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83 year old female presents to the ED with left hip fracture. She has no significant PMHx. takes an aspirin daily, EKG is normal. Chest Xray reveals an elevated right hemidiaphragm. What do I tell the ortho resident consulting me about this isolated finding? . Diaprhagmatic Paralysis.

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Presentation Transcript
slide1
83 year old female presents to the ED with left hip fracture. She has no significant PMHx. takes an aspirin daily, EKG is normal. Chest Xray reveals an elevated right hemidiaphragm. What do I tell the ortho resident consulting me about this isolated finding?
diaprhagmatic paralysis

Diaprhagmatic Paralysis

The Significance to the Medicine

Consultant

normal diaphragm function
Normal Diaphragm Function
  • Ventilation depends on the ability of the respiratory pump to move air in and out of the gas exchange portion of the lungs. The respiratory muscles serve as the link between the different components of the pump: the respiratory centers, the conducting nerves and the rib cage and abdomen.
the diaphragm
The Diaphragm
  • The most important of the respiratory muscles is the diaphragm. Contraction of the diaphragm has the following effects that promote air movement into the lungs:
  • It decreases intrapleural pressure
  • It raises or inflates the rib cage using the abdomen as a fulcrum on which to lean.
  • It expands the rib cage through its zone of apposition by generating positive intraabdominal pressure.
alterations with diaphragmatic paralysis
Alterations with diaphragmatic paralysis
  • Diaphragmatic paralysis can involve either the whole diaphragm(bilateral) or only one leaflet(unilateral). In this setting, the accessory muscles of respiration assume some or all the work of breathing, depending upon the degree of diaphragmatic compromise.
unilateral diaphragmatic paralysis
Unilateral Diaphragmatic Paralysis
  • Unilateral diaphragmatic paralysis is seen as the “elevated hemidiaphragm” so commonly noted on chest radiograph. This brings to mind the clinical question, what is the significance?
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Pulmonary function tests in unilateral diaphragm paralysis show moderate to no reductions in vital capacity while upright but usually some decrease when supine. Studies have shown that total lung capacity is reduced about 20 percent.
differential diagnosis of elevated hemidiaphragm
Most common cause is phrenic nerve invasion from bronchogenic CA

Idiopathic

Trauma

Surgery

Phrenic nerve cooling seen after cardiac surgery

Cervicle spondylosis

Poliomyelitis

Intubation for surgery probably from neck hyperextension

Other causes are very rare and more common in Bilateral diaphragmatic paralysis, these inclued :spinal cord transection, Multiple sclerosis,Guillain-Barre Syndrom,Phrenic nerve dysfunction,throid dysfunction,Malnutrion, Acid maltase deficiency, CTD, Amyloidosis

Differential diagnosis of elevated hemidiaphragm
clinical manifestations
Clinical manifestations
  • Patients without underlying lung disease are usually asymptomatic at rest, but may have dyspnea with exertion.
  • Orthopnea may also occur but is not as intense as with bilateral diaphragmatic paralysis.
  • Patients with PFO are found to have increased incidence of R to L shunts.
so what do we do with the radiographic finding
So what do we do with the radiographic finding
  • The prognosis of unilateral diaphragmatic paralysis is determined by the cause. If it is idiopathic, some cases recover spontaneously. For those that do not, patients are still usually able to lead a normal life.
treatment options
Treatment options
  • For those patients with significant exercise intolerance or morbidity, surgical plication will improve both the physiology and symptoms in patients with significant symptoms.
surgical plication
Surgical Plication
  • Before plication, the healthy hemidiaphragm generates pressure to the affected side. This pressure pulls up the paralyzed leaflet. This ineffective motion does not allow appropriate expansion of the ipsilateral lung.
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Plication repairs the flail segment by stretching the paralyzed diaphragm as a semi-taught sheet between the lower borders of the rigid chest wall.
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After plication there is improvement in static lung mechanics, exercise performance, blood gas exchange and respiratory muscle function.
evidence for plication
Evidence for Plication
  • One study showed at fourteen year follow up, improvement of patient spirometry in all lung function tests.
in conclusion
In conclusion...
  • An isolated finding of elevated hemidiaphragm should prompt the consultant to consider the differential diagnosis. If determined to be idiopathic or from non malignant causes then the patient’s symptoms should be reviewed. If the patient is
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symptomatic then surgical plication should be considered, otherwise the prognosis is good and no additional therapy is necessary.
back to original case
Back to original case
  • Review of systems revealed no significant orthopnea or dyspnea on exertion. Old radiograph from two years previous showed no change. Most importantly no mass was seen on chest radiograph. It was concluded that this was idiopathic and no further work up needed.