Paralyzed diaphragm—Effect of plication on respiratory mechanics

doi:10.1016/0022-4804(74)90078-X

Journal of Surgical Research

Volume 16, Issue 5, May 1974, Pages 523-526

https://doi.org/10.1016/0022-4804(74)90078-X Get rights and content

Abstract

The results of this experiment indicate that mediolateral plication of the paralyzed diaphragm improves vital capacity and maximum breathing capacity up to 4 wk postoperative. Although the respiratory mechanics in plicated animals never returned to preoperative control levels, there was a statistically significant improvement over animals without plication. One patient is reported that underwent this procedure.

References (6)

A.K. Dutt
Diaphragmatic paralysis caused by herpes zoster
Amer. Rev. Respir. Dis.
(1970)
G.W. Parker et al.
Paralysis of phrenic nerve following herpes zoster
JAMA J. Amer. Med. Ass.
(1962)
N. Schifrin
Unilateral paralysis of the diaphragm in the newborn infant due to phrenic nerve injury
Pediatrics
(1952)

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Cited by (17)

The advantage of early plication in children diagnosed with diaphragm paresis
2017, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Affected patients with DP may be supported with positive-pressure ventilation for a longer period in the hope of functional recovery and the avoidance of further surgery; however, recovery is unpredictable, and prolonged ICU admission can expose these fragile patients to additional risk and morbidity.3 Plication of the affected diaphragm can improve the work of breathing and facilitate separation from positive-pressure support.8 This variability in clinical condition also leads to variability and uncertainty when trying to determine the best management strategy at the individual patient level.
In this single-center study, we sought to determine the frequency of phrenic nerve injury leading to diaphragm paresis (DP) in children following open cardiac surgery over the last 10 years, and to identify possible variables that predict the need for plication and associated clinical outcomes.
Patients diagnosed with DP were identified from departmental databases and a review of clinical diaphragm ultrasound images. A cohort was analyzed for predictors of diaphragm plication and associations with clinical outcomes. Cumulative proportion graphs modeled the association between plication and length of stay.
DP was diagnosed in 161 of 6448 patients (2.5%) seen between January 2002 and December 2012. All diagnoses but 1 were confirmed by ultrasound. Plication of the diaphragm was performed in 30 patients (19%); compared with patients who did not undergo plication, these patients were younger (median age, 10 days vs 138 days; P < .001), more likely to have undergone deep hypothermic circulatory arrest (47% vs 18%; P = .005), had a longer duration of positive pressure ventilation (median, 15 days vs 7 days; P < .001), and had longer lengths of stay in both the intensive care unit (median, 23 days vs 8 days; P < .0001) and the hospital (median, 37 days vs 15 days; P < .0001). Early plication was associated with reduction in all intervals of care.
Early plication should be considered for patients with diaphragm paresis requiring prolonged respiratory support after cardiac bypass surgery. Longer follow-up evaluation is required to better define the long-term implications of plication.
Is video-assisted thoracoscopic diaphragmatic plication a widespread technique for diaphragmatic hernia in adults?: Review of the literature and results of a national survey
2014, Cirugia Espanola
La plicatura diafragmática es el tratamiento más aceptado para la eventración diafragmática sintomática en adultos. La infrecuencia de esta dolencia y la escasa difusión de este procedimiento hacen que esta técnica sea excepcional en nuestro medio. Para estimar la difusión en la literatura, realizamos una revisión estructurada en lenguas inglesa y castellana a la que sumamos nuestra casuística: encontramos solo 6 series que aportan un total de 59 plicaturas diafragmáticas en adultos asistidas por toracoscopia. Ninguna en castellano. Nuestra serie sería la segunda mayor: 18 casos, con resultados satisfactorios similares a los publicados.
Finalmente efectuamos una encuesta a todos los servicios españoles de cirugía torácica: ninguno tiene más de 10 casos operados por toracoscopia en los últimos 8 años (a excepción del nuestro) y la mayoría continúa utilizando la toracotomía como abordaje.
En nuestra opinión muchos pacientes con eventración diafragmática sintomática podrían beneficiarse con la difusión de estas técnicas.
Diaphragmatic plication is the most accepted treatment for symptomatic diaphragmatic hernia in adults. The fact that this pathology is infrequent and this procedure not been widespread means that this is an exceptional technique in our field.
To estimate its use in the literature, we carried out a review in English and Spanish, to which we added our series. We found only six series that contribute 59 video-assisted mini-thoractomy for diaphragmatic plications in adults, and none in Spanish. Our series will be the second largest with 18 cases.
Finally, we conducted a survey in all the Spanish Thoracic Surgery units in Spain: none reported more than 10 cases operated by thoracoscopy in the last 8 years (except our series) and most continue employing thoracotomy as the main approach.
We believe that many patients with symptomatic diaphragmatic hernia could benefit from the use of such techniques.
Subdiaphragmatic venous hemodynamics in patients with biventricular and Fontan circulation after diaphragm plication
2007, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Unilateral diaphragm paralysis reduces inspiratory muscle force. Combined with its paradoxical upward displacement, this leads to inability of the patient to inspire to total lung capacity and substantially decreases pulmonary function.15,16 By eliminating paradoxical movement and increasing kinetics of the unaffected hemidiaphragm, plication of the paralyzed diaphragm improves tidal volume and maximum breathing capacity.
Diaphragm paralysis owing to phrenic nerve injury can result in significant morbidity in children undergoing surgical management of congenital cardiac defects. Diaphragm plication is the accepted therapy for diaphragm paralysis. We have investigated subdiaphragmatic venous hemodynamics in patients with biventricular and Fontan circulation after diaphragm plication.
Doppler ultrasound was used to evaluate flows in the hepatic vein, portal vein, and subhepatic inferior vena cava under respiratory monitoring and with a tilt table. Twenty-nine patients with biventricular circulation were studied: 19 with normal diaphragms and 10 after diaphragm plication. Twenty-eight patients with total cavopulmonary connections after the Fontan procedure were also studied: 19 with normal diaphragms and 9 with plicated diaphragms. Inspiratory/expiratory flow ratios in supine and upright positions were calculated to investigate respiratory effects, and upright/supine flow ratios were calculated to assess gravity effects.
In patients with biventricular circulation and normal diaphragms, hepatic venous flow was augmented by inspiration; this effect was reduced in patients with a plicated diaphragm (upright inspiratory/expiratory flow ratios: 2.4 vs 1.4, respectively; P = .01). Portal venous flow was higher during expiration; this effect was lost in patients with a plicated diaphragm (supine inspiratory/expiratory flow ratios: 0.8 and 1.0; P < .05). In Fontan patients with normal diaphragms, hepatic venous flow depended heavily on inspiration. This effect was blunted in patients with a plicated diaphragm (supine inspiratory/expiratory flow ratios: 3.2 vs 2.3; P < .05). Expiratory augmentation of portal flow was absent in Fontan patients with normal diaphragms and reversed in patients a plicated diaphragm (supine inspiratory/expiratory flow ratios: 1.0 vs 1.6; P = .02). Gravity reduced Fontan portal venous flow; having a plicated diaphragm did not alter this effect (upright/supine flow ratios: 0.7 vs 0.7).
In patients with biventricular and those with Fontan circulation with a paralyzed diaphragm, plication does not completely restore normal subdiaphragmatic venous hemodynamics. In Fontan patients with a plicated diaphragm, important inspiration-derived hepatic venous flow is suppressed, and portal venous flow loses its normal expiratory augmentation. These flow dynamics share similarities with those observed in patients with failing Fontan circulation. This suboptimal splanchnic circulation may contribute to early problems of prolonged pleural effusions and ascites and potentially may promote late Fontan failure. Phrenic nerve injury should consequently be avoided at all costs before or at the time of the Fontan operation.
Plication of the diaphragm for infants and young children with phrenic nerve palsy
1988, Journal of Pediatric Surgery
Phrenic nerve palsy (PNP) is seen in infants and young children usually resulting from operative trauma or birth injury. Spontaneous recovery usually occurs, but occasionally surgical plication is necessary. Twenty-three cases of PNP over a 10-year period were managed surgically. Patient ages ranged from 1 day to 30 months (median, 4 months), 18 were male and five female. Cause was operative trauma in 18 (17 cardiac surgery, one neuroblastoma), birth trauma in two, and idiopathic in three. The right side was involved in 14, the left in eight, and both in one. Indications for plication were inability to wean from the ventilator (group 1, 16 patients), recurrent pneumonia (group 2, four patients), and respiratory distress (group 3, three patients). The 16 patients in group 1 were intubated for a median of 18.5 days from onset of PNP to plication. Postoperatively, three had continuing congestive heart failure (one died at 16 days of age, one was still chronically ventilated at 22 months, one was extubated at nine days); the other 13 were extubated at a median of two days postoperatively. All the patients in groups 2 and 3 were extubated within two days of surgery. Twelve plications were transthoracic and 11 were transabdominal. Postoperative complications included pneumonia (2), wound infection (1), pneumothorax (2), and mucous plug with pulmonary collapse (1). One patient died of cardiac failure at 16 days. One patient in group 3 developed recurrent respiratory distress 4 months postoperatively; he had a recurrent elevated hemidiaphragm requiring a second plication. Mean follow-up for all surviving patients is 23.5 months, and no patients have had recurrent respiratory problems. Plication of the diaphragm is safe and effective in patients with persistent PNP who have recurrent pneumonia, respiratory distress, or ventilator dependence.
Phrenic Nerve Injury Complicating Closed Cardiovascular Surgical Procedures for Congenital Heart Disease
1985, Annals of Thoracic Surgery
Phrenic nerve injury (PNI) with resulting hemidiaphragmatic paralysis occurred in 19 (2.1 ± 0.5%) of 891 closed cardiac surgical procedures during a twenty-three-year period. Diagnosis was confirmed by standard radiographic criteria. Phrenic nerve injury was most commonly noted following systemic-pulmonary artery anastomosis, ligation of persistent ductus arteriosus plus pulmonary artery banding, and atrial septectomy. Most patients were managed conservatively (nasotracheal or orotracheal intubation and positive end-expiratory pressure). Although no deaths were a direct result of PNI, major complications occurred in 15 of the 19 instances of PNI (79% ± 10%). The serious morbidity and the hospital costs associated with this complication, however, underscore the cardinal importance of prevention. If injury does occur, early surgical intervention (diaphragmatic plication) in very young infants may reduce the attendant morbidity, but the complete role of diaphragmatic plication remains to be defined.
Results of diaphragmatic plication for unilateral diaphragmatic paralysis
1985, Journal of Thoracic and Cardiovascular Surgery
Seven adult patients with dyspnea resulting from nonmalignant unilateral diaphragmatic paralysis underwent plication of the affected hemidiaphragm. Preoperatively, the patients complained of exertional dyspnea and orthopnea and had a reduced arterial oxygen tension, total lung capacity, vital capacity, expiratory reserve volume, and functional residual capacity. Plication was performed by imbricating the diaphragm in layers through a thoracotomy. After plication there was a significant increase in arterial oxygen tension and all lung volumes except residual volume. The patients’ symptoms were improved with plication and a significant decrease was recorded in breathlessness on a visual analogue scale. There were no postoperative complications and mean hospital stay was 12 days.

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Paralyzed diaphragm—Effect of plication on respiratory mechanics

Abstract

Diaphragmatic paralysis caused by herpes zoster

Amer. Rev. Respir. Dis.

Paralysis of phrenic nerve following herpes zoster

JAMA J. Amer. Med. Ass.

Unilateral paralysis of the diaphragm in the newborn infant due to phrenic nerve injury

Pediatrics