From the Guidelines
Diaphragmatic spasm due to phrenic nerve injury during intubation should be managed with supportive care and symptomatic relief using medications such as baclofen, benzodiazepines, or gabapentin, as the most recent and highest quality study suggests that neuromuscular blockade can provide ideal intubating conditions and reduce complications 1.
Management of Diaphragmatic Spasm
The management of diaphragmatic spasm due to phrenic nerve injury during intubation involves:
- Supportive care while the nerve heals, which may take several weeks to months
- Symptomatic relief using medications such as:
- Baclofen (10-25 mg three times daily)
- Benzodiazepines like diazepam (2-10 mg three times daily)
- Gabapentin (300-1200 mg three times daily)
- Monitoring for respiratory compromise, particularly in patients with underlying pulmonary disease
Prevention Strategies
Prevention strategies for phrenic nerve injury during intubation include:
- Careful positioning during intubation
- Avoiding excessive neck extension
- Using appropriate tube size
Advanced Management Options
In severe cases that don't respond to medication, advanced management options may be necessary, such as:
- Ultrasound-guided phrenic nerve blocks using lidocaine 1-2% or botulinum toxin injections (50-100 units)
- Consultation with a neurologist or pain specialist for further evaluation and management, as suggested by guidelines for the management of tracheal intubation in critically ill adults 1.
From the Research
Diaphragmatic Spasm due to Phrenic Nerve Injury during Intubation
- Diaphragmatic spasm can occur due to phrenic nerve injury during intubation, which can lead to respiratory dysfunction 2.
- Phrenic nerve injury can cause diaphragmatic paresis, which is associated with severe respiratory dysfunction 2, 3.
- The diagnosis of diaphragmatic dysfunction can be made using various techniques, including respiratory system pressures, oesophageal manometry, diaphragm ultrasound, and electromyography 4, 5, 3.
Causes and Symptoms of Diaphragmatic Palsy
- Diaphragmatic palsy can be caused by various factors, including injury to the phrenic nerve during thoracic surgeries, neuromuscular disorders, trauma, and tumor compression 5, 3.
- The symptoms of diaphragmatic palsy can vary from asymptomatic to disabling dyspnea requiring mechanical ventilation 3.
- Pulmonary function tests can show a decrease in maximum respiratory muscle power, and spirometry can show reduced lung functions 3.
Treatment and Prevention of Diaphragmatic Dysfunction
- Treatment of diaphragmatic palsy depends on the cause and can include surgical repair of the diaphragm or non-invasive ventilation 5, 3.
- Phrenic nerve stimulation can prevent diaphragm atrophy in patients with respiratory failure on mechanical ventilation 6.
- Diaphragm protection is an important consideration in optimizing ventilator management in patients with acute respiratory failure 4.