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Diaphragmatic Function , Diaphragmatic paralysis, and Eventratio

n of the Diaphragm

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• 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.

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• 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 th

e rib.• The crural portion causes downward placement of

the diaphragm( less effective in breathing.)

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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.

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PARALYSIS OF THE DIAPHRAGM

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

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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 thoracoscop

ic approach.

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• 48-1

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