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General overview

The thoracic diaphragm is a thick layer of skeletal muscle which divides the thorax from the abdomen. It's main function is to aid in respiration. When the diaphragm contracts, pressure in the thoracic cavity decreases as the thorax expands which then results in air being drawn into the lungs. Anatomically, the right half is slightly higher than the left due to the liver situated under the right side. 

Other functions of the diaphragm include helping with vomiting, urination and bowel movement by increasing intra-abdominal pressure. It's also involved with preventing gastric acid reflux by applying pressure on the oesophagus which passes through it. 

Diaphragm paralysis

Paralysis of the diaphragm occurs when there's damage to the phrenic nerve, the cervical spine or to the brainstem.

The most common issue associated with paralysis of the diaphragm is damage to the phrenic nerve. The most common cause of phrenic nerve involvement includes bronchial cancer (which usually affects one side). Other causes include lung cancer, lymph node cancer, surgical trauma, neuromuscular disorders, spinal cord disorders, Guillain-Barre syndrome and systemic lupus erythematosis (SLE).

Symptoms and signs

Patients with one-sided (unilateral) diaphragmatic paralysis may have little to no symptoms and the finding is usually incidental. In bilateral diaphragmatic paralysis, the symptoms can be more severe which will result in the patient seeking medical attention.

The symptoms of this condition may include the following:

  • Shortness of breath and overall difficulty in breathing.
  • Cyanosis (blue discolouration of the lips and/or fingers).
  • Headaches.
  • Fatigue.
  • Insomnia. 

How is this condition diagnosed?

  • Chest X-rays can show a clearly flattened diaphragm when it is paralyzed.
  • Lung function tests will show a severely reduced lung capacity.
  • Phrenic nerve stimulation will determine whether the nerve is functioning properly or not. 
  • A CT scan of the chest will also show the anatomical effect of the paralysis and if there are any causes to the problem.
  • An MRI scan will be helpful in determining whether there's any spinal column or nerve root involvement.

Management of the condition

The main area to deal with first is to treat and manage the underlying cause of the paralysis of the diaphragm. 

Treatment protocols will also include the following procedures:

  • Diaphragmatic plication - this is a surgical technique done to pull the diaphragm down. This procedure results in the diaphragm being able to work properly and therefore improves respiratory function. This procedure also helps patients struggling with asthma, respiratory infections and COPD. This procedure can also be done using a thoracoscope which is used in high-risk patients and allows for a shorter hospital stay.
  • Breathing pacemakers - this device is used in patients who have functional phrenic nerves and in whom the cause of the paralysis is due to spinal cord or neuromuscular disorders. It helps to improve respiratory function and lower infection rates.
  • Tracheostomy - this procedure is reserved for patients with life-threatening conditions or who have a high quadriplegia. This procedure is done by making a surgical incision in the trachea to allow flow of air into the lungs.  

Patients with unilateral diaphragmatic paralysis usually need no treatment and the issue resolves without any medical intervention.

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