What is the appropriate management for an elevated hemidiaphragm?

Management of Elevated Hemidiaphragm

Surgical intervention with diaphragmatic plication is indicated for symptomatic patients with elevated hemidiaphragm, particularly when associated with disabling dyspnea or respiratory compromise. 1

Diagnostic Evaluation

The first step in managing an elevated hemidiaphragm is determining its etiology:

Initial Imaging

• Chest X-ray (PA and lateral): First-line imaging that can detect approximately 200 ml of pleural fluid. Lateral views can detect as little as 50 ml of fluid 2
  • Sensitivity varies: 2-60% for left-sided abnormalities and 17-33% for right-sided abnormalities 3
  • Look for characteristic findings:
    • Lateral peaking of an apparently raised hemidiaphragm with steep lateral slope
    • Flat appearance of posterior hemidiaphragm on lateral view 2

Advanced Imaging

• CT scan with contrast: Gold standard for diagnosing diaphragmatic abnormalities 2

  • Sensitivity 14-82% and specificity 87% 2
  • Key findings include:
    • Diaphragmatic discontinuity
    • Segmental non-recognition of the diaphragm
    • "Dangling diaphragm" sign
    • "Dependent viscera" sign
    • "Collar sign" in cases of hernia 2

• Ultrasound: Useful for guiding aspiration if pleural effusion is present

  • More accurate than plain radiography for estimating pleural fluid volume 2
  • Better visualization of fibrinous septations than CT 2

• Fluoroscopic sniff test: Essential for differentiating between paralysis and eventration 4

  • Paralysis: Paradoxical motion during sniffing
  • Eventration: No paradoxical motion 1
  • The shape/radius of curvature on lateral chest radiograph can help predict paralysis 4

Etiologic Considerations

Several conditions can cause elevated hemidiaphragm:

1. Diaphragmatic paralysis: Due to phrenic nerve injury, stroke, or neuromuscular disease 5
2. Diaphragmatic eventration: Congenital or acquired thinning of diaphragm muscle 1
3. Diaphragmatic hernia: Abdominal contents herniate through diaphragmatic defect 2
4. Pleural effusion: Fluid accumulation in pleural space 2
5. Subpulmonic effusion: Fluid accumulates in subpulmonic location 2
6. Post-surgical complication: Following thoracic surgery 6

Management Algorithm

1. Asymptomatic Patients

• Observation with periodic imaging follow-up
• No specific intervention required unless progression or development of symptoms 1

2. Symptomatic Patients

• Surgical intervention: Diaphragmatic plication is indicated for all symptomatic patients 1
  • Approach options:
    • Minimally invasive thoracoscopic plication (preferred by most thoracic surgeons)
    • Open thoracotomy approach
    • Abdominal approach 1
  • Goals of plication:
    • Improve lung volumes
    • Decrease paradoxical elevation of hemidiaphragm
    • Relieve compression of lung tissue
    • Return mediastinum to normal position 7

3. Patients with Diaphragmatic Hernia

• Surgical repair: Recommended for symptomatic hernias or those with complications 2
  • Laparoscopic approach for stable patients (Strong recommendation, moderate-quality evidence) 2
  • Laparotomy for unstable patients (Weak recommendation, low-quality evidence) 2
  • Repair techniques:
    • Primary repair with non-absorbable sutures for small defects
    • Mesh reinforcement for defects >3 cm (Weak recommendation, low-quality evidence) 2
    • Biosynthetic, biologic, or composite meshes are preferred 2

4. Patients with Respiratory Failure

• Non-invasive ventilation: For patients with hypercapnic respiratory failure 5
• Antibiotics: If secondary pneumonia develops 5
• Oxygen therapy: As needed for hypoxemia

Special Considerations

• Post-surgical patients: Consider diaphragmatic hernia in patients with persistent ipsilateral chest pain and elevated hemidiaphragm following thoracic surgery, especially in cases of previous catamenial pneumothorax 6

• Robotic-assisted surgery: For patients requiring minimally invasive repair

  • Patient selection considerations:
    • Body habitus (tall, thin patients are ideal)
    • Absence of obstruction in right hemithorax
    • No severe adhesions from prior procedures 2
  • Challenges with elevated hemidiaphragm during robotic procedures:
    • Can obstruct visualization
    • Makes passage of right-arm instruments difficult
    • May require reverse-Trendelenburg position, diaphragmatic retention suture, or bariatric port for the right instrument arm 2

Outcomes and Prognosis

Diaphragmatic plication is generally safe with excellent outcomes and is associated with significant symptom improvement 1. Successful plication eliminates lung compression and restores normal mediastinal position 7.

Potential Complications

• Recurrence of diaphragmatic hernia (2-12% with proper technique) 3
• Post-surgical complications including dysphagia and gas bloat syndrome 3
• Higher complication risk in emergency surgery and elderly patients with comorbidities 3

By following this structured approach to diagnosis and management, patients with elevated hemidiaphragm can experience significant improvement in respiratory function and quality of life.