Diaphragm Paresis – Causes, Symptoms and Treatment
Diaphragm paresis is a partial or complete paralysis of the diaphragm, the main breathing muscle, which can significantly impair respiratory function. It is most commonly caused by nerve damage.
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Diaphragm paresis is a partial or complete paralysis of the diaphragm, the main breathing muscle, which can significantly impair respiratory function. It is most commonly caused by nerve damage.
What Is Diaphragm Paresis?
Diaphragm paresis refers to a partial (paresis) or complete (paralysis) loss of function of the diaphragm, the dome-shaped muscle that separates the chest cavity from the abdominal cavity and serves as the primary muscle of breathing. With each breath, the diaphragm contracts downward to expand the lungs. When this muscle is weakened or paralyzed, breathing can become significantly compromised.
The condition may affect one side of the diaphragm (unilateral) or both sides (bilateral). Bilateral diaphragm paresis is considerably more serious and can lead to severe respiratory failure.
Causes
Diaphragm paresis is most commonly caused by damage to the phrenic nerve, which is the primary nerve controlling the diaphragm. Known causes include:
- Traumatic injury: Surgeries involving the neck, chest, or heart, as well as accidents or penetrating wounds
- Neurological diseases: Amyotrophic lateral sclerosis (ALS), multiple sclerosis, poliomyelitis, or Guillain-Barre syndrome
- Malignancies: Lung cancer, lymphomas, or other tumors that compress or infiltrate the phrenic nerve
- Infectious causes: Viral neuritis, such as following herpes zoster infection
- Idiopathic causes: In a proportion of cases, no identifiable cause is found
- Birth trauma: Phrenic nerve injury during difficult delivery in newborns
Symptoms
Symptoms vary depending on whether one or both sides of the diaphragm are affected:
Unilateral Diaphragm Paresis
- Often mild or asymptomatic
- Exertional dyspnea (shortness of breath during physical activity)
- Incidental finding on chest X-ray (elevated hemidiaphragm)
- Mild reduction in lung capacity
Bilateral Diaphragm Paresis
- Severe breathlessness, particularly when lying flat (orthopnea)
- Hypoxia (low blood oxygen levels)
- Hypercapnia (elevated carbon dioxide levels in the blood)
- Sleep-disordered breathing
- In severe cases: acute respiratory failure
Diagnosis
Several diagnostic tools are used to evaluate diaphragm paresis:
- Chest X-ray: Reveals an elevated hemidiaphragm on the affected side
- Ultrasound: Real-time assessment of diaphragm movement and thickness
- Fluoroscopy (sniff test): Detects paradoxical upward movement of the diaphragm during rapid inhalation
- Pulmonary function testing (spirometry): Measures lung volumes and detects restrictive breathing patterns
- Electromyography (EMG) and nerve conduction studies: Assess phrenic nerve function
- MRI or CT scan: Identifies structural causes such as tumors or nerve compression
Treatment
Treatment of diaphragm paresis depends on the underlying cause, the severity of respiratory impairment, and the overall health of the patient.
Conservative Management
- Treatment of the underlying condition (e.g., oncological therapy, antiviral medications)
- Respiratory physiotherapy to strengthen accessory breathing muscles
- Weight management, as excess body weight can worsen symptoms
Ventilatory Support
- Non-invasive ventilation (NIV): Particularly beneficial in bilateral paresis with nocturnal hypoventilation
- Invasive mechanical ventilation: Reserved for severe acute respiratory failure
Surgical Options
- Diaphragm plication: Surgical tightening of the paralyzed diaphragm to improve breathing mechanics
- Diaphragm pacing: Electrical stimulation of the phrenic nerve in selected patients
Prognosis
The outlook for diaphragm paresis depends largely on the underlying cause. Traumatically induced paresis may partially or fully resolve over time. Paresis associated with progressive neurological diseases generally carries a poorer prognosis. Regular medical follow-up and appropriate ventilatory support can significantly improve quality of life for affected individuals.
References
- McCool F.D., Tzelepis G.E. - Dysfunction of the Diaphragm. New England Journal of Medicine, 2012; 366:932-942.
- Ricoy J. et al. - Diaphragmatic dysfunction. Pulmonology, 2019; 25(4):223-235.
- Boon A.J. et al. - Two-dimensional ultrasound imaging of the diaphragm: quantitative values in normal subjects. Muscle and Nerve, 2013; 47(6):884-889.
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