What is the treatment for unilateral diaphragmatic palsy?

Treatment for Unilateral Diaphragmatic Palsy

Surgical plication of the diaphragm is the most effective treatment for symptomatic unilateral diaphragmatic paralysis when conservative measures fail to provide adequate relief. 1

Initial Assessment and Conservative Management

• Unilateral diaphragmatic paralysis is often well-tolerated if there is no underlying lung or ribcage pathology, but can cause dyspnea and hypoxemia under increased respiratory loads 2
• Initial evaluation should include chest radiography and fluoroscopic or ultrasound assessment to confirm paradoxical movement of the affected hemidiaphragm 3
• Conservative management should be attempted first:
  • Respiratory muscle training to strengthen accessory muscles of respiration 3
  • Positioning strategies (supported upright sitting with pillows) to reduce work of breathing 3
  • For patients with significant symptoms, non-invasive ventilation (NIV) may provide symptomatic relief 2

Indications for Surgical Intervention

• Persistent lifestyle-limiting dyspnea despite conservative management 1
• Decreased forced vital capacity (FVC), especially when lying down 1
• Moderate hypoxemia (typically PaO2 <80 mmHg) 4
• No evidence of spontaneous recovery after an appropriate waiting period (typically 6-12 months) 1

Surgical Management

• Diaphragmatic plication is the procedure of choice for symptomatic unilateral diaphragmatic paralysis 4

  • The procedure involves flattening and tensing the paralyzed hemidiaphragm through a thoracotomy or thoracoscopic approach 4
  • This prevents paradoxical movement during respiration and improves lung expansion 1

• Surgical approach options:

  • Traditional thoracotomy with plication has excellent long-term results 4
  • Video-assisted thoracoscopic surgery (VATS) is preferred in stable patients due to lower morbidity and shorter hospital stays 3
  • Minimally invasive approaches have a reported in-hospital mortality rate of only 0.14% 3

Expected Outcomes

• Most patients show both subjective and objective improvement after plication 4
• Benefits include:
  • Improved respiratory symptoms and exercise capacity 1
  • Increased lung volumes and forced vital capacity 4
  • Better quality of life 1
  • Long-term maintenance of improvement (documented up to 7 years post-procedure) 4

Special Considerations

• In patients with bilateral diaphragmatic paralysis, surgical options are more limited and continuous positive airway pressure (CPAP) or mechanical ventilation may be required 5
• For patients with traumatic causes (such as post-surgical injury), the possibility of spontaneous recovery should be considered before proceeding to surgical intervention 6
• Patients with underlying pulmonary disease may have poorer outcomes and require more aggressive management 5

Common Pitfalls

• Failure to recognize unilateral diaphragmatic paralysis as a cause of unexplained dyspnea 5
• Inadequate diagnostic evaluation (fluoroscopy or ultrasound "sniff test" should be performed to confirm paradoxical movement) 3
• Premature surgical intervention before allowing adequate time for potential spontaneous recovery 1
• Not considering diaphragmatic plication in symptomatic patients, especially those with decreased quality of life 1