From the Guidelines
Diaphragm plication is a crucial consideration in double lung transplant patients with significant diaphragmatic dysfunction or paralysis, and it should be performed concurrently with the transplant surgery to optimize postoperative respiratory mechanics and ventilator weaning. When considering diaphragm plication in patients undergoing double lung transplant, it is essential to assess the patient's diaphragmatic function preoperatively, using imaging studies and fluoroscopy or ultrasound sniff tests to identify any diaphragmatic elevation or abnormal movement [no direct evidence provided]. The decision to perform diaphragm plication is typically based on the presence of significant diaphragmatic dysfunction or paralysis that could compromise respiratory function post-transplantation.
- The procedure involves flattening and tightening the diaphragm to restore proper position and function, which improves lung expansion and ventilation.
- Diaphragm plication is especially important in lung transplant recipients because they already have compromised respiratory function and cannot afford additional mechanical disadvantages.
- By addressing diaphragmatic dysfunction early, plication can reduce the risk of atelectasis, pneumonia, and prolonged mechanical ventilation, ultimately improving transplant outcomes and patient survival. However, the provided evidence does not directly address the significance of left diaphragm plication during double lung transplant, and therefore, the recommendation is based on general knowledge of diaphragm plication in lung transplant patients 1.
From the Research
Diaphragm Plication in Double Lung Transplant
- Diaphragm plication is considered in patients undergoing double lung transplant to improve posttransplant ventilation, especially in cases of diaphragmatic paralysis or dysfunction 2.
- The procedure can be performed for anatomic or functional indications, such as sizing or spacing issues, or symptomatic diaphragmatic dysfunction 3.
Indications for Diaphragm Plication
- Diaphragmatic dysfunction is common among lung transplant candidates, with a frequency of 52.2% on pre-transplant fluoroscopy 3.
- Diaphragm plication may be performed to address donor-recipient size mismatch or to improve ventilatory mechanics 2, 3.
- The procedure can be done during or after lung transplantation, with 11.4% of lung transplant patients undergoing diaphragm plication in one study 3.
Outcomes of Diaphragm Plication
- Patients undergoing diaphragm plication have acceptable and comparable early and late outcomes, despite having lower spirometry values throughout the 3-year follow-up period 3.
- Diaphragm dysfunction can lead to difficult weaning after bilateral lung transplant, and diaphragm thickening fraction and neuroventilatory efficiency can predict weaning outcome 4.
- The duration of mechanical ventilation before the first spontaneous breathing trial is associated with diaphragm dysfunction, highlighting the importance of early assessment and intervention 4.
Comparison with Single Lung Transplant
- Double lung transplantation improves lung function over single lung transplantation, with higher forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) values 5.
- However, the advantage of spirometry values alone may not justify double lung transplantation, and the benefit of double lung transplantation varies depending on the underlying diagnosis 5.