Diaphragmatic paralysis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2] [3] [4] [5]

Diaphragmatic paralysis was first suggested by Steurtz, in 1911 during a simple phrenicotomy for treatment of lung disease. Diaphragmatic paralysis may be classified according to involvement of leaflets into unilateral or bilateral. It is thought that diaphragmatic paralysis is the result of paralysis of cervical nerve roots( C3-C5). Common causes of unilateral diphragmatic paralysis include idiopathic, phrenic nerve injury in cardiac surgery and viral infection. Common causes of bilateral diphragmatic paralysis include idiopathic, cervical spinal cord disease and motor neuron disease. Unilateral diaphragmatic paralysis must be differentiated from eventration of the diaphragm. Eventration of the diaphragm is an abnormal elevation of the hemidiaphragm. Bilateral diaphragmatic paralysis must be differentiated from other diseases that cause elevation of the diaphragm such as pleural adhesions, subpulmonic effusions, obesity, ascites, abdominal organomegaly and ileus. Other differential diagnosis are dermatomyositis, polymyositis, rib fracture, pleural effusions, amyotrophic lateral sclerosis.The incidence of diaphragmatic paralysis is unknown, but incidence of diaphragmatic paralysis after cardiac surgery is approximately 30,000 to 75,000 per 100,000 individuals. Prevalence of diaphragmatic paralysis after cardiac surgery is 1,600 per 100,000 in children. The most potent risk factor in the development of diaphragmatic paralysis is cooling or stretching in cardiac surgery. Common complication of diaphragmatic paralysis includes severe pulmonary dysfunction in bilateral diaphragmatic paralysis. Studies of choice for unilateral diaphragmatic paralysis include upright chest radiograph and fluoroscopic sniff test. Studies of choice for bilateral diaphragmatic paralysis include measurement of transdiaphragmatic pressure (Pdi). The majority of patients with unilateral diaphragmatic paralysis are asymptomatic.  Dyspnea in supine position and orthopnea are common symptoms of bilateral diphragmatic paralysis. Laboratory findings consistent with the diagnosis of diaphragmatic paralysis include reduced oxygen saturation in the supine position in unilateral and bilateral diaphragmatic paralysis and elevated arterial partial pressure of carbon dioxide (PaCO2) in bilateral diaphragmatic paralysis. An x-ray and ultrasound are helpful in the diagnosis of diaphragmatic paralysis. No treatment is required for unilateral diaphragmatic paralysis because most patients are asymptomatic. In bilateral diaphragmatic paralysis treatment options are ventilatory support and diaphragmatic pacing. Surgery is usually reserved for patients with either dyspnea in strenous physical activity and patients with underlying severe pulmonary disease. Surgical plication of the involved hemidiaphragm can be considered for unilateral diaphragmatic paralysis. surgery in bilateral diaphragmatic paralysis can be done via neurolysis and nerve grafting.

Diaphragmatic paralysis was first suggested by Steurtz, in 1911 during simple phrenicotomy for treatment of lung disease. In 1946, a case of poliomyelitiswith respiratory paralysis was explained in Romania.

Diaphragmatic paralysis may be classified according to involvement of leaflets into unilateral or bilateral. Bilateral diaphragmatic paralysis is a medical emergency. Unilateral diaphragmatic paralysis is often discovered incidentally on chest x-ray for other reasons.

It is thought that diaphragmatic paralysis is the result of paralysis of cervical nerve roots( C3-C5 ). Diaphragmatic paralyses can be unilateral or bilateral according to involvemnet of one or two leaflets of diaphragm. In the case of unilateral diaphragm paralysis, it is compensated by other hemidiaphragm or accessory muscles of respiration. In bilateral diaphragmatic paralysis, accessory muscles do all of the work of breathing and finally it may lead to ventilatory failure. Early diaphragmatic paralysis may be one of the manifestations of genetic neuromuscular disorders such as spinal muscular atrophy (Werdnig-Hoffmann disease) and acid maltase deficiency. On gross and microscopic pathology, there are no characteristic findings of diaphragmatic paralysis. left untreated, patients with unilateral diaphragmatic paralysis may recover fully or partially.

Common causes of unilateral diphragmatic paralysis include idiopathic, phrenic nerve injury in cardiac surgery and viral infection and less common causes include cervical spondylosis, cervical compressive tumors and blunt neck trauma. Common causes of bilateral diphragmatic paralysis include idiopathic, cervical spinal cord disease and motor neuron disease. Less common causes of bilateral diphragmatic paralysis include parsonage turner syndrome and malnutrition.

Unilateral diaphragmatic paralysis must be differentiated from eventration of the diaphragm. Eventration of the diaphragm is an abnormal elevation of the hemidiaphragm. Bilateral diaphragmatic paralysis must be differentiated from other diseases that cause elevation of the diaphragm such as pleural adhesions, subpulmonic effusions, obesity, ascites, abdominal organomegaly and ileus. Diaphragmatic paralysis must be differentiated from other disease that cause dyspnea such as dermatomyositis, polymyositis, rib fracture, pleural effusions, and amyotrophic lateral sclerosis.

The incidence of diaphragmatic paralysis is unknown, but incidence of diaphragmatic paralysis after cardiac surgery is approximately 30,000 to 75,000 per 100,000 individuals. Prevalence of diaphragmatic paralysis after cardiac surgery is 1,600 per 100,000 in children.The morbidity and mortality of the unilateral diaphragmatic paralysis is related to underlying pulmonary function and etiology. Most of the bilateral diaphragmatic paralysis are symptomatic and may develop ventilatory failure. Patients of all age groups may develop diaphragmatic paralysis. There is no racial predilection to diaphragmatic paralysis. Men are more commonly affected.

The most potent risk factor in the development of diaphragmatic paralysis is cooling or streching in cardiac surgery. Other risk factors include viruses, spinal cord transection and malnutrition.

There is insufficient evidence to recommend routine screening for diaphragmatic paralysis.

 If left untreated, patients with unilateral diaphragmatic paralysis may recover fully or partially. Common complications of diaphragmatic paralysis includes severe pulmonary dysfunction in bilateral diaphragmatic paralysis. Prognosis is generally excellent in unilateral diaphragmatic paralysis. Bilateral diaphragmatic paralysis is a medical emergency.

Studies of choice for unilateral diaphragmatic paralysis include upright chest radiograph and fluoroscopic sniff test. Studies of choice for bilateral diaphragmatic paralysis include measurement of transdiaphragmatic pressure (Pdi).

The majority of patients with unilateral diaphragmatic paralysis are asymptomatic. Exertional dyspnea and decreased exercise performance are common symtoms of unilateral diaphragmati paralysis. Less common symtoms of unilateral diaphragmatic paralysis include dyspnea at rest and orthopnea. Dyspnea in supine position and orthopnea are common symtoms of bilateral diphragmatic paralysis. Less common symtoms of bilateral diaphragmatic paralysis include daytime fatigue and confusion.

Patients with unilateral diphragmatic paralysis usually appear normal. Patients with bilateral diaphragmatic paralysis usually are in respiratory distress. The severe forms of bilateral diaphragmatic paralysis would lead to pulmonary hypertension.

Laboratory findings consistent with the diagnosis of diaphragmatic paralysis include reduced oxygen saturation in the supine position in unilateral and bilateral diaphragmatic paralysis and elevated the arterial partial pressure of carbon dioxide (PaCO2) in bilateral diaphragmatic paralysis. Hypoxemia may be seen in arterial blood gas in bilateral diaphragmatic paralysis.

There are no ECG findings associated with diaphragmatic paralysis.

An x-ray is helpful in the diagnosis of diaphragmatic paralysis. Findings on an x-ray suggestive of unilateral diaphragmatic paralysis include elevated hemidiaphragm on the paralysed side and small lung volumes. Findings on an x-ray suggestive of bilateral diaphragmatic paralysis include smooth elevation of the hemidiaphragms and atelectasis at the lung base.

Ultrasound may be helpful in the diagnosis of diaphragmatic paralysis. Findings on an ultrasound suggestive of diaphragmatic paralysis include abnormal paradoxical movement during inspiration and Less than 20% thickening of the diaphragm.

Chest CT scan may be helpful in the diagnosis of tumors as causes of diaphragmatic paralysis. Findings on CT scan suggestive of diaphragmatic paralysis include patchy areas of atelectasis and elevation of one or both hemidiaphragm.

Cervical spine MRI may be helpful in the diagnosis of diaphragmatic paralysis. Findings on MRI suggestive of diaphragmatic paralysis include spinal column or nerve roots pathologic conditions as causes of diaphragmatic paralysis.

Fluoroscopic sniff test may be helpful in the diagnosis of diaphragmatic paralysis. Findings on sniff test suggestive of diaphragmatic paralysis include paradoxical elevation of the paralyzed hemidiaphragm during inspiration.

Other diagnostic studies for diphragmatic paralysis include pulmonary function test which demonstrates decrease in vital capacity in diaphragmatic paralysis. Maximal inspiratory pressure (MIP) can be decreaed. Electromyography and polysomnography are other diagnostic studies.

No treatment is required for unilateral diaphragmatic paralysis because most patients are asymptomatic. In bilateral diaphragmatic paralysis treatment options are ventilatory support and diaphragmatic pacing.

Surgery is not the first-line treatment option for patients with unilateral diaphragmatic paralysis. Surgery is usually reserved for patients with either dyspnea in strenous physical activity and patients with underlying severe pulmonary disease. Surgical plication of the involved hemidiaphragm can be considered for unilateral diaphragmatic paralysis. surgery in bilateral diaphragmatic paralysis can be done via neurolysis and nerve grafting.

There are no established measures for the primary prevention of diaphragmatic paralysis. However, the incidence of diaphragmatic paralysis is less in off-pump coronary artery bypass grafting (OPCAB) compared to conventional CABG.

Effective measures for the secondary prevention of diaphragmatic paralysis include chest physiotherapy following post cardiac surgery diaphragmatic paralysis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

Diaphragmatic paralysis was first suggested by Steurtz, in 1911 during simple phrenicotomy for treatment of lung disease. In 1946, a case of poliomyelitis with respiratory paralysis was explained in Rumania.

• Diaphragmatic paralysis was first suggested by Steurtz, in 1911 during simple phrenicotomy for treatment of lung disease.^[1]
• Thomas Harris, in 1892, stated that depression of the epigastric and hypochondriac regions on deep inspiration not always indicative of diaphragmatic paralysis.
• In 1946, a case of poliomyelitis with respiratory paralysis was explained in Rumania ^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

Diaphragmatic paralysis may be classified according to involvement of leaflets into unilateral or bilateral. Bilateral diaphragmatic paralysis is a medical emergency. Unilateral diaphragmatic paralysis is often discovered incidentally on chest x-ray for other reasons.

• Diaphragmatic paralysis may be classified according to involvement of leaflets into unilateral or bilateral.^[1][2][3]
• Unilateral diaphragmatic paralysis is more common than bilateral diaphragmatic paralysis. It is often discovered incidentally on chest x-ray for other reasons.^[3]
• Bilateral diaphragmatic paralysis can be considered a medical emergency.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

It is thought that diaphragmatic paralysis is the result of paralysis of cervical nerve roots( C3-C5 ). Diaphragmatic paralyses can be unilateral or bilateral according to involvemnet of one or two leaflets of diaphragm. In the case of unilateral diaphragm paralysis, it is compensated by other hemidiaphragm or accessory muscles of respiration. In bilateral diaphragmatic paralysis, accessory muscles do all of the work of breathing and finally it may lead to ventilatory failure. Early diaphragmatic paralysis may be one of the manifestations of genetic neuromuscular disorders such as spinal muscular atrophy (Werdnig-Hoffmann disease) and acid maltase deficiency. On gross and microscopic pathology, there are no characteristic findings of diaphragmatic paralysis.

The main muscles of inspiration include:

• Diaphragm (most important)

• Scalenes
• External intercostals
• Sternomastoids

The muscles of expiration:

• Internal intercostals
• Muscles of the abdominal wall
  • Rectus abdominus
  • Internal and external obliques
  • Transversus abdominus

• The diaphragm is the musculo-fibrous membrane. It has two parts: non-contractile central fibrous  and peripheral muscular components. ^[1][2][3]
• Peripheral muscular section has two fibers:
  • Type 1: slow and fatigue resistant fibers: play roles in low intensity, continual cycle of breathing
  • Type 2: fast fibers: play roles in rapid and intense situations such as:
    • Talking
    • Singing,
    • Sneezing,
    • Defecation
    • Acute hyperventilation

The diaphragm create negative intrathoracic pressure and facilitates movement of air into the lungs. It is innervated by cervical nerve roots ( C3-C5 ) via the phrenic nerves.^[4][5]

Diaphragmatic paralysis can be unilateral or bilateral according to involvemnet of one or two leaflets of diaphragm.

Diaphragmatic paralysis is an uncommon cause of dyspnea.

It is understood that diaphragmatic paralysis is the result of paralysis of cervical nerve roots (C3-C5 ).

In the case of unilateral diaphragm paralysis, it is compensated by other hemidiaphragm or accessory muscles of respiration.

In bilateral diaphragmatic paralysis, accessory muscles do all of the work of breathing and finally it may lead to ventilatory failure.

Bilateral diaphragmatic paralysis is usually seen with generalized muscle weakness. In some cases, the diaphragm is the only muscle involved. 

Early diaphragmatic paralysis may be one of the manifestations of genetic neuromuscular disorders such as spinal muscular atrophy (Werdnig-Hoffmann disease) and acid maltase deficiency.^[6]

• On gross pathology, there are no characteristic findings of diaphragmatic paralysis.

• On microscopic histopathological analysis, there are no characteristic findings of diaphragmatic paralysis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

Common causes of unilateral diphragmatic paralysis include idiopathic, phrenic nerve injury in cardiac surgery and viral infection and less common causes of it include cervical spondylosis, cervical compressive tumors and blunt neck trauma. Common causes of bilateral diphragmatic paralysis include idiopathic, cervical spinal cord disease and motor neuron disease. Less common causes of bilateral diphragmatic paralysis include parsonage turner syndrome and malnutrition.

• Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. There are no life-threatening causes of diaphragmatic paralysis

• Idiopathic in many cases

• Phrenic nerve injury in cardiac surgery due to cooling or streching ^[2]
• Viral infections such as:
  • Herpes zoster
  • Poliomyelitis

• Idiopathic in many cases
• Cervical spinal cord disease such as
  • Large tumors
  • Spinal cord transection

• Motor neuron disease such as: ^[4]
  • Amyotrophic lateral sclerosis

• Neuropathy
  • Post-polio syndrome
  • Guillain-Barré syndrome
  • Post-viral neuropathy ( West Nile virus )^[5]
  • Thyroid Disease
  • Autoimmune diseases

• Neuromuscular junction disease 
  • Myasthenia gravis^[6]
  • Lambert-Eaton myasthenic syndrome ^[7]
  • Systemic botulism 
• Muscle disease 
  • Polymyositis
  • Dermatomyositis
  • Inclusion body myopathy
  • Limb-girdle muscular dystrophy
  • Acid maltase deficiency 
  • Hypothyroidism
  • Hyperthyroidism

• Cervical spondylosis
• Cervical compressive tumors
• Blunt neck trauma
• Neck surgery
• Pneumonia
• Iatrogenic embolization such as bronchial artery embolization for treatment of hemoptysis
• Neuralgic amyotrophy (inflammatory disorder of brachial plexus)^[9]

Less common causes of diaphragmatic paralysis include:

• Parsonage Turner syndrome (brachial neuritis or neuralgic amyotrophy)
• Malnutrition^[10]

• Diaphragmatic paralysis due to spinal muscular atrophy caused by a mutation in the survival motor neuron 1 (SMN1) gene on chromosome 5q13.2.^[11]
• Acid maltase deficency as a cause of diaphragmatic paralysis caused by a mutation in GAA gene on chromosome band 17q23.^[12]

Cardiovascular	No underlying causes
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	Hypothyroidism, Hyperthyroidism
Environmental	No underlying causes
Gastroenterologic	Systemic botulism, Malnutrition
Genetic	Acid maltase deficiency
Hematologic	No underlying causes
Iatrogenic	Phrenic nerve injury in cardiac surgery, Neck surgery, Iatrogenic embolization
Infectious Disease	Herpes zoster, Poliomyelitis
Musculoskeletal/Orthopedic	Polymyositis, Dermatomyositis, Inclusion body myopathy, Limb-girdle muscular dystrophy, Acid maltase deficiency, Cervical spondylosis,
Neurologic	Large tumors, Spinal cord transection, Amyotrophic lateral sclerosis, Guillain-Barré syndrome, Post-viral neuropathy, Myasthenia gravis, Systemic botulism, Neuralgic amyotrophy, Parsonage Turner syndrome
Nutritional/Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	Cervical compressive tumors,
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	Pneumonia
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	Autoimmune diseases,Lambert-Eaton myasthenic syndrome , Polymyositis, Dermatomyositis
Sexual	No underlying causes
Trauma	Blunt neck trauma,
Urologic	No underlying causes
Miscellaneous	Idiopathic

List the causes of the disease in alphabetical order.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

Unilateral diaphragmatic paralysis must be differentiated from eventration of the diaphragm. Eventration of the diaphragm is an abnormal elevation of the hemidiaphragm. Bilateral diaphragmatic paralysis must be differentiated from other diseases that cause elevation of the diaphragm such as pleural adhesions, subpulmonic effusions, obesity, ascites, abdominal organomegaly and ileus. Diaphragmatic paralysis must be differentiated from other disease that cause dyspnea such as dermatomyositis, polymyositis, rib fracture, pleural effusions, amyotrophic lateral sclerosis.

Unilateral diaphragmatic paralysis must be differentiated from eventration of the diaphragm. Eventration of the diaphragm is an abnormal elevation of the hemidiaphragm that some parts of hemidiaphragm are replaced by fibrous tissue. Clinical manifestations of eventration of the diaphragm include asymptomatic, infection and respiratory distress.^[1]

Bilateral diaphragmatic paralysis must be differentiated from other diseases that cause elevation of the diaphragm such as:

• Pleural adhesions
• Subpulmonic effusions
• Obesity with decreased chest wall compliance
• Ascites
• Abdominal organomegaly
• Ileus

Diaphragmatic paralysis must be differentiated from other disease that cause dyspnea such as:

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); DOE (dyspnea on exercise); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell);

Organ system			Diseases	Clinical manifestations													Diagnosis					Other features
				Symptoms								Physical exam
				Loss of consciousness	Agitation	Weight loss	Fever	Chest pain	Cough	Orthopnea	DOE	Cyanosis	Clubbing	JVD	Peripheral edema	Auscultation	CBC	ABG	Imaging	Spirometry	Gold standard
Acute Dyspnea	Respiratory system	Head and Neck, Upper airway	Aspiration[2]	–	+	–	–	+/-	+	–	–	+	–	–	–	Diminished breath sounds	Normal	Normal	Atelectasis	↓Vt, ↑RV	Bronchoscopy	Choking
		Chest and Pleura, Lower airway	Atelectasis	–	–	–	+/-	+/-	+/-	–	–	+/-	–	–	–	Diminished breath sounds, Wheeze	Normal	↓O2, Normal/↓CO2	Collapsed lung lobe, fissuresdisplacement	↓ FVC	Chest CT scan	Surgical procedure, Aspiration, Mechanical ventilation
			Bronchitis[3]	–	–	–	+	+	+	–	–	–	–	–	–	Rhonchi	↑WBC	Normal	Normal	Normal	Physical exam	Rhonchi relieved by cough
			Bronchiolitis[4]	–	–	–	+	+/-	+	–	–	–	–	–	–	Wheeze and Crackles	↑WBC	Normal	Bronchovascular markings	↓Vt	Clinical assessment	Respiratory syncytial virus (RSV)
			Lung carcinoma[5]	–	–	+	–	–	+	–	–	+	+	–	–	Wheeze and Crackles	Normal	Normal	Mass lesion, hilar lymphadenopathy	↓Vt, ↑RV	Bronchoscopy	Paraneoplastic syndromes, such as SIADH and lambert-Eaton
			Pneumonia[6]	–	–	–	+	+	+	–	–	–	–	–	–	Wheeze, Rhonchi, and Crackles	↑WBC, neutrophilia	Normal	Lobar consolidation	Normal	Chest X-ray and CT Scan	productive cough
			Pneumothorax[7]	–	–	–	–	+	–	–	–	–	–	+/-	–	Diminished breath sounds	Normal	↓O2, ↑CO2	Radiolucency without lung marking	↓Vt	CXR and Chest CT scan	Tracheal deviation
			Pulmonary embolism[8]	–	–	–	–	+	–	–	+/-	–	–	–	–	Normal	Normal	Respiratory alkalosis	Normal	Normal	Pulmonary CT angiography	Pleuritic chest pain
			Rib fractures (flail chest)[9]	–	+	–	–	+	–	–	–	–	–	–	–	Normal	Normal	Respiratory acidosis	Fracture marks	Normal	Chest X-ray	Pneumothorax
	Cardiovascular system		Pericardial tamponade[10]	+/-	–	–	–	+	–	+/-	+/-	–	–	+	–	Muffled heart sounds	Normal	Normal	Water bottle appearance enlarged heart	Normal	Echocardiography	Fluid accumulation in pericardium
			Pulmonary edema[11]	+/-	+	–	+	+	+	+	+	+	+	+	+	Basal crackle	Normal	Respiratory alkalosis	Bat wing pattern, air bronchograms	↓Vt, ↑RV	Cardiac Catheterization	Tachypnea
	Central nervous system		Stroke	+	–	–	+/-	–	–	–	–	–	–	–	–	Normal	Normal	Normal	Intracranial infarct or hemorrhage	Normal	Brain MRI	Paralysis or paresthesia
			Encephalitis[12]	+	+	–	+	–	–	–	–	–	–	–	–	Normal	↑WBC, neutrophilia	Normal	Normal	Normal	CSF PCR	Confusion
			Traumatic brain injury[13]	+	+/-	–	–	–	–	–	–	–	–	–	–	Normal	Normal	Respiratory acidosis	Intracerebral hemorrhage	Normal	Brain CT scan	Lucid interval
Organ system			Diseases	Clinical manifestations													Diagnosis					Other features
				Symptoms								Physical exam
				Loss of consciousness	Agitation	Weight loss	Fever	Chest pain	Cough	Orthopnea	DOE	Cyanosis	Clubbing	JVD	Peripheral edema	Auscultation	CBC	ABG	Imaging	Spirometry	Gold standard
Chronic Dyspnea	Respiratory system	Head and Neck, Upper airway	Goiter[14]	–	–	–	–	–	–	–	–	–	–	–	+	Normal	Normal	Normal	Normal	Normal	Blood test (TSH, T4)	Weight gain
			Laryngeal adenocarcinoma[15]	–	–	+	–	–	+/-	–	–	–	–	–	–	Stridor	Normal	↓O2, ↑CO2	Retropharyngeal tissue thickness	Normal	Laryngoscopy	Choking sensation
		Chest and Pleura, Lower airway	COPD[16]	–	–	+/-	–	–	+	+	+	+	+	+	+/-	Expiratory wheeze	↑ RBC	Respiratory alkalosis, Metabolic acidosis	↑ Bronchovascular markings, Cardiomegaly	↓ FEV1/FVC	Physical exam and Spirometry	Heavy smoking history
			Emphysema[17]	–	–	–	–	–	+/-	–	–	+	+	–	–	Expiratory wheeze, Hyperinflation	Normal	Respiratory alkalosis, Metabolic acidosis	Flattening of diaphragm, vertical heart	↓ FEV1/FVC	Physical exam and Spirometry	Barrel chest
			Pulmonary hypertension[18]	–	–	–	–	+/-	+/-	–	–	+/-	+/-	+	+	Accentuated S2	Normal	Hypoxia and acidosis	Enlarged pulmonary arteries	↑Physiologic RV	Cardiac catheterization	Syncope, Ascites, Pleural effusion
			Sarcoidosis[19]	–	–	+/-	–	+/-	+	–	–	+	–	–	–	Crackles	Normal	↓O2, ↑CO2	Hilar adenopathy	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Hypercalcemia, high ACE
			Pleural effusion[20]	–	+/-	+	–	+	–	+/-	–	–	–	+/-	+/-	Egophony (“E-to-A” change)	Normal	Normal	Blunting of the costophrenic and cardiophrenic angle	↓Vt, ↑RV	Light’s criteria	↓Tactile fremitus, Asymmetrical chest expansion
			Diaphragmatic paralysis[21]	–	–	–	+/-	+/-	+/-	+	+	–	–	–	–	Normal	Normal	Normal	Unilateral or bilateral diaphragmatic flattening	↓Vt, ↑RV (anatomical)	CXR confirmed by fluoroscopic sniff test	Respiratory insufficiency
			Tuberculosis[22]	–	–	+	+	+	+	–	–	+/-	–	–	–	Rhonchi, Wheezing, Crackles	↑WBC	↓O2, ↑CO2	Patchy consolidation or poorly defined linear and nodular opacities	Restrictive, obstructive, or mixed	IFN-γ release assay (IGRA) Acid-fast staining	Night sweat
	Cardiovascular system		Constrictive pericarditis[10]	–	–	–	–	+	–	+	+	–	–	+	–	Muffled heart sounds	Normal	Normal	Calcifications	Normal	Chest CT scan	Syncope
			Pericardial effusion[23]	–	–	–	+/-	+	+	+/-	+/-	–	–	+	–	Muffled heart sounds	Normal	Normal	Fluid density around the heart	Normal	M-mode and 2-dimensional Doppler echocardiography	Hoarseness, Palpitation
	Neuromuscular disease		Amyotrophic lateral sclerosis[24]	+/-	–	+/-	–	–	–	–	–	–	–	–	–	Normal	↑WBC	Normal	Normal	↓Vt, ↑RV	Revised El Escorial criteria (clinical)	Muscle weakness, Dysphagia
			Polymyositis/dermatomyositis[25]	–	–	+/-	–	+	–	–	–	–	–	–	+/-	Normal	↑WBC	Normal	Normal	↓Vt, ↑RV	Muscle biopsy	Muscle weakness, Heliotrope
			Mitochondrial diseases[26]	–	–	+/-	–	–	–	–	–	–	–	–	–	Wheeze	↓WBC, Plt	Normal	Normal	↓Vt, ↑RV	Muscle biopsy	Muscle pain
			Glycolytic enzyme defects (e.g., McArdle)[27]	+/-	–	–	–	–	–	–	–	–	–	–	+/-	Normal	Normal	Normal	Normal	↓Vt, ↑RV	Muscle biopsy (ragged red fibers)	Myoglobinuria, Muscle weakness
	Systemic		Ascites[28]	–	–	–	–	–	–	–	–	–	–	–	–	Normal	Normal	Normal	Peritoneal fluid accumulation	↓Vt, ↑RV	Abdominal ultrasound	Abdominal distention
			Kyphoscoliosis[29]	–	–	–	–	–	–	–	–	–	–	–	–	Wheeze	Normal	Normal	Deviated vertebral column	↓Vt, ↑RV (anatomical)	Standing lateral spine radiograph	Low back pain
			Obesity[30]	–	–	–	–	–	–	–	–	–	–	–	–	Normal	Normal	↓O2	Normal	↓Vt, ↑RV (anatomical)	BMI	Low stamina, Sweating

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

The incidence of diaphragmatic paralysis is unknown, but the incidence of diaphragmatic paralysis after cardiac surgery, radiologically, is approximately 30,000 to 75,000 per 100,000 individuals. Prevalence of diaphragmatic paralysis after cardiac surgery is 1,600 per 100,000 in children. The morbidity and mortality of the unilateral diaphragmatic paralysis is related to underlying pulmonary function and etiology. Most of the bilateral diaphragmatic paralysis are symptomatic and may develop ventilatory failure. Patients of all age groups may develop diaphragmatic paralysis. There is no racial predilection to diaphragmatic paralysis. Men are more commonly affected.

• The incidence of diaphragmatic paralysis is unknown, but the incidence of diaphragmatic paralysis after cardiac surgery is approximately 30,000 to 75,000 per 100,000 individuals.^[1]

The prevalence of diaphragmatic paralysis is unknown, but prevalence of diaphragmatic paralysis after cardiac surgery is 1,600 per 100,000 in children. ^[2]

• The morbidity and mortality of the unilateral diaphragmatic paralysis is related to underlying pulmonary function and etiology.^[3]

• Most of the unilateral diaphragmatic paralysis are asymptomatic and are discovered incidentally during imaging and mortality rate are low.
• Most of the bilateral diaphragmatic paralysis are symptomatic and may develop ventilatory failure.

• Patients of all age groups may develop diaphragmatic paralysis.

• There is no racial predilection to diaphragmatic paralysis.

• Men are more commonly affected by diaphragmatic paralysis than women.^[4]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

The most potent risk factor in the development of diaphragmatic paralysis is cooling or streching in cardiac surgery. Other risk factors include viruses, spinal cord transection and malnutrition.

• Common risk factors in the development of diphragmatic paralysis include:^[1]
  • Cooling or streching in cardiac surgery^[2]
  • Virus
  • Spinal cord transection

• Less common risk factors in the development of diaphragmatic paralysis include:
  • Malnutrition^[3]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

There is insufficient evidence to recommend routine screening for diaphragmatic paralysis.

There is insufficient evidence to recommend routine screening for diaphragmatic paralysis.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]

If left untreated, patients with unilateral diaphragmatic paralysis may recover fully or partially. Common complication of diaaphragmatic paralysis includes severe pulmonary dysfunction in bilateral diaphragmatic paralysis. Prognosis is generally excellent in unilateral diaphragmatic paralysis and bilateral diaphragmatic paralysis is a medical emergency.

• If left untreated, patients with unilateral diaphragmatic paralysis may recover fully or partially. Most of the bilateral diaphragmatic paralysis are symptomatic and may develop ventilatory failure. ^[1]

• Common complication of diaphragmatic paralysis include:
  • Severe pulmonary dysfunction in bilateral diaphragmatic paralysis.

• Prognosis is generally excellent in unilateral diaphragmatic paralysis.^[2]
• Bilateral diaphragmatic paralysis is a medical emergency. 

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