Diaphragmatic Function , Diaphragmatic paralysis, and Eventration of the Diaphragm

1
Diaphragmatic Function , Diaphragmatic paralysis,
and Eventration of the Diaphragm
2

• With quite breathing, the diaphragm accounts
  about 75 to 80 of ventilation.
• The vertical movement of the diaphragm is 1 to 2
  cm during quite breathing and 6 to 7 cm during
  deep breathing.
• Each cm of vertical movement contributes 300 to
  400 ml of air during normal breathing.

3

• The diaphragm comprise 2 parts costal and crural
  portions.
• The costal portion is thinner and the crural
  portion is thicker.
• Both portions are innervated by the phrenic
  nerve.
• The costal portion flatten the diaphragm and lift
  the rib.
• The crural portion causes downward placement of
  the diaphragm( less effective in breathing.)

4
PARALYSIS OF THE DIAPHRAGM

• In the adult, unilateral diaphragmatic paralysis
  does not cause significant respiratory
  embarrassment.
• But 20 to 30 of reduction of vital capacity and
  total lung capacity occurs.
• Fackler et al reported these lung volumes become
  normal 6 months later.

5
PARALYSIS OF THE DIAPHRAGM

• In normal adults, bilateral diaphragmatic
  paralysis may be tolerated. However, excessive
  movement of accessory muscles of respiration may
  be seen.

6
PARALYSIS OF THE DIAPHRAGM

• In infants and young children, unilateral
  diaphragmatic paralysis may cause severe
  respiratory embarrassment and mechanical
  ventilation is indicated. Bilateral diaphragmatic
  paralysis is more lethal.
• Paradoxical movement of the lower rib cage can be
  seen in these infants and young children.

7
PARALYSIS OF THE DIAPHRAGM

• When these patients are in the lateral decubitus
  position with paralyzed diaphragm leaf up, inward
  movement of the subcostal area of the upper
  abdomen can be seen.

8
PARALYSIS OF THE DIAPHRAGM

• Paralysis of the hemidiaphragm may be seen by
  elevation the diaphragm leaf on CXR.
• Sniff test sudden inspiratory movement causes
  the paralyzed hemidiaphragm to ascend by the
  fluoroscopic observation.
• In patients with mechanical ventilation,
  electrophysiologic evaluation of the phrenic
  nerve is needed.

9
Etiology of Diaphragmatic Paralysis

• In infants, most unilateral diaphragmatic
  paralysis are caused by injury of the phrenic
  nerve during a cardiac procedure.
• The Mustard and Glenn procedures had the
• highest incidences.
• Birth trauma and removal of the
• mediastinal tumor are another causes.

10
Etiology of Diaphragmatic Paralysis

• In adults, most injury of the phrenic nerve
  during a cardiac procedure is caused by the use
  of topical hypothermia with ice slush.
• The left side is usually the involved nerve.
• The cold injury can be prevented by avoidance of
  entering the pleural space and inflation of the
  lung.

11
Etiology of Diaphragmatic Paralysis

• Helps et al reported a right thoracotomy with a
  low submammary incision had higher incidence of
  phrenic nerve injury than a midline sternal
  approach in the repair of secundum atrial defect

12
Etiology of Diaphragmatic Paralysis

• Other causes of diaphragmatic paralysis are
  tumor, mediastinotomy, resection in the thorax
  and the neck, and even placement of a subclavian
  or jugular vein catheter or electrode.
• Idiopathic paralysis of the diaphragm is not
  uncommon and it is the result of viral infection.
  The paralysis is often unilateral.

13
Management of Diaphragmatic Paralysis

• In infants and young children, mechanical
  ventilation is the initial treatment with the
  involved side down.
• If continued support is required beyond 2 weeks,
  operative plication is indicated.
• The plication does not require muscle resection.

14
Management of Diaphragmatic Paralysis

• The plication can immobilize the paralyzed
  diaphragm in the flat position to reduce the
  paradoxic movement with associated shift of the
  mediastinum to the contralateral side.
• In adults and children older than 2 years,
  conservative treatment is often indicated.
• Celli et al reported the use of intermittent
  external negative-positive pressure to treat
  idiopathic paralysis of the diaphragm.

15
Therapy Use of the Phrenic Nerve Paralysis

• Therapeutic temporary paralysis of a phrenic
  nerve has been used to treat TB in the past.
• It can obtained by percutaneous infiltration
  about the nerve trunk in the neck with local
  anesthetic.
• Additional elevation of the paralyzed diaphragm
  can be obtained by a temporary pneumoperitoneum.

16
EVENTRATION OF THE DIAPHRAGM

• It is a rare anomaly and the cause is not known
  completely.
• Eventration of a newborn is a true congenital
  defect and severe cardiorespiratory distress may
  occur because of associated hypoplasia of the
  lung of the same side.
• After the newborn is stable, operative correction
  is indicated.

17
EVENTRATION OF THE DIAPHRAGM

• The surgery is usually through a thoracic
  approach.
• In adults and old children, eventration is caused
  by acquired complete or incomplete paralysis of
  the diaphragm.
• Localized eventration, usually on the right side,
  with protrusion of the liver, does not require
  surgery.

18
EVENTRATION OF THE DIAPHRAGM

• With a major hernia or a complete eventration,
  the patient may have cardiorespiratory or GI
  symptoms.
• Surgery is indicated for symptomatic older
  patients.

19
EVENTRATION OF THE DIAPHRAGM

• A thoracic approach with entering through the 8th
  ICS is preferred.
• After entering the pleural space, the the
  diaphragm is repaired by plication.
• The 2nd method is by incision of the leaf and
  repair with silks or other nonabsorbable sutures
  interruptedly.
• However, plication is preferred.
• Mouroux et al reported video-assisted
  thoracoscopic approach.

20

• 48-1

21

• 48-2

22

• 48-3

23
Thank You!