1 Diaphragmatic Function, Diaphragmatic paralysis, and Eventration of the Diaphragm.
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Transcript of 1 Diaphragmatic Function, Diaphragmatic paralysis, and Eventration of the Diaphragm.
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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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• 48-2
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• 48-3
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