Answers: C. Diaphragmatic paralysis
Discussion
The patient’s symptoms, imaging, and pulmonary function testing (PFT)
were consistent with diaphragmatic paralysis, with low lung volumes and
bibasilar atelectasis. Fluoroscopy demonstrated minimal movement of
both hemidiaphragms, consistent with bilateral diaphragmatic paralysis.
Peripheral electromyography showed decreased amplitude of the right
median sensory response and prolonged peak latency and decreased
amplitude of the right radial sensory response. Motor units throughout
the right arm were noted to be of high amplitude with long duration and
reduced muscle recruitment. These findings were most consistent with
mild to moderate, right-sided cervical radiculopathies. MRI of the spine
was normal. Diagnosis was made of neuralgic amyotrophy with involvement
of the bilateral phrenic nerves.
Answer A is incorrect as the patient had a normal echocardiogram and
BNP. Answer B is incorrect as there was no obstruction on spirometry.
Answer D is incorrect as there is no evidence of interstitial lung
disease (ILD) on his chest x-ray nor crackles on exam to suggest an
interstitial process. Additionally, an elevated RV to TLC ratio would
argue against an ILD.
There are several causes of diaphragmatic paralysis (DP), including
trauma, surgery, radiation, cervical manipulation, central nervous
system lesions (amyotrophic lateral sclerosis, multiple sclerosis,
poliomyelitis), peripheral nervous system lesions (brachial plexus
neuropathy, Guillain-Barre, chronic inflammatory demyelinating
polyneuropathy, post-viral or idiopathic phrenic neuropathy), and
myopathies (1). Neuralgic amyotrophy is an inflammatory neuropathy that
generally affects the brachial plexus with occasional involvement of the
phrenic nerve(s). It is often characterized by sudden onset of severe
neuropathic pain involving the shoulders and upper extremities followed
by weakness and/or sensory loss in the affected areas. There are both
hereditary and idiopathic forms of neuralgic amyotrophy with relapse
rates of around 25% and 75% for idiopathic and hereditary forms,
respectively (2). There is no treatment of neuralgic amyotrophy, though
patients generally experience resolution of symptoms over months to
years (3).
DP can be unilateral or bilateral and range from asymptomatic to
having severe orthopnea and resting dyspnea with chronic respiratory
failure. DP is characterized by restrictive physiology on PFTs with
forced vital capacity (FVC) generally less than 50% of predicted in
bilateral diaphragmatic paralysis (BDP). Supine spirometry can be
helpful in diagnosis and generally shows a 10-30% decline in FVC in
patients with unilateral diaphragmatic paralysis (UDP) and as much as a
50% decline in BPD. While functional residual capacity (FRC) is often
mildly decreased, this is contrary to the significant reduction seen in
ILD. DLCO is also frequently reduced, though this reduction is due to
reduced alveolar volume and should improve when this correction is
factored in, contrary to the fixed reduction seen in ILD (4).
Diaphragmatic fluoroscopy, or sniff test, shows paradoxical upward
movement of the affected diaphragm with inspiration. Maximal inspiratory
force (MIP) is relatively preserved in UDP (generally >60%) but is
often severely reduced (<30%) in BDP (5). Physical exam may show
paradoxical inward movement of the abdomen with inspiration due to
negative pleural pressures generated by accessory muscles pulling the
diaphragm superiorly, though this is generally only seen in BDP. Chest
imaging often shows elevation of the affected diaphragm(s) with
associated lower lobe atelectasis (6). More recently, ultrasound has
been shown to be an effective and noninvasive way to accurately assess
diaphragm function (7). Treatment of DP is often supportive, though
patients with symptomatic DP may benefit from diaphragm plication to
limit upward movement of the affected diaphragm with inspiration and
nocturnal noninvasive ventilation if hypercapnia develops (8). Phrenic
nerve pacing can be considered in patients who require mechanical
ventilation, particularly in patients with BPD secondary to cervical
spine injuries (9).
Our patient had severe symptoms initially with resting hypoxemia. He
was started on nocturnal noninvasive positive pressure ventilation
(NIPPV) and supplemental oxygen. He noted slow improvement in his
symptoms over time. Sniff test was repeated at 10 months and showed
improved diaphragm excursion. Repeat PFT at 12 months showed improvement
in FVC to 77% of predicted. He has since been weaned from both NIPPV as
well as supplemental oxygen.
References
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Billings ME, Aitken ML, Benditt JO. Bilateral diaphragm paralysis: a challenging diagnosis. Respir Care 2008; 53(10): 1368-71.
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van Alfen N. The neuralgic amyotrophy consultation. J Neurol 2007; 254(6):695-704.
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van Alfen N, van Engelen BG, Hughes RA. Treatment for idiopathic and
hereditary neuralgic amyotrophy (brachial neuritis). Cochrane Database
Syst Rev 2009(3): CD006976.
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Dube BP, Dres M. Diaphragm Dysfunction: Diagnostic Approaches and Management Strategies. J Clin Med 2016; 5(12). pii: E113.
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Koo P, Oyieng'o DO, Gartman EJ, et. al. The Maximal
Expiratory-to-Inspiratory Pressure Ratio and Supine Vital Capacity as
Screening Tests for Diaphragm Dysfunction. Lung 2017; 195(1): 29-35.
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Sferrazza Papa GF, Pellegrino GM, Di Marco F, et. al. A Review of the
Ultrasound Assessment of Diaphragmatic Function in Clinical Practice.
Respiration 2016; 91(5): 403-11.
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Welvaart WN, Jak PM, van de Veerdonk MC, et. al. Effects of diaphragm
plication on pulmonary function and cardiopulmonary exercise
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DiMarco AF. Diaphragm Pacing. Clin Chest Med 2018; 39(2): 459-71.