Diaphragmatic plication

Diaphragmatic plication

Anesthesia type	General
Airway	ETT with lung isolation
Lines and access	PIV Arterial line
Monitors	Standard ABP
Primary anesthetic considerations
Preoperative	Possible hypoxia/hypercapnia Baseline atelectasis with possible dyspnea while supine
Intraoperative	Lung isolation required Lateral decubitus positioning Ensure optimal respiratory mechanics prior to extubation
Postoperative	Consider ICU given possibility of respiratory decompensation
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Diaphragmatic plication is a surgical procedure indicated for the treatment of diaphragmatic paralysis. The diaphragm is the primary muscle of inspiration, but its contribution varies based on position and sleep. The diaphragm is responsible for 56% of the tidal volume in the awake, supine patient and up to 81% during periods of deep sleep.

Causes of diaphragmatic paralysis:

• Phrenic nerve injury due to stretching or cooling during cardiac surgery
• Herpes zoster, poliomyelitis and other viral infections
• Cervical spondylosis, cervical compressive tumors, blunt neck trauma, neck surgery, pneumonia, and iatrogenic embolization
• Motor neuron disease, myopathy, inflammatory myositis
• Malignancy
• Idiopathic

Diaphragmatic paralysis has many clinical implications including:

• Respiratory derangements (hypercapnia, hypoxia)
• Reduced energy levels
• Sleep disordered breathing during REM
• Inability to fully expand lungs resulting in higher risk of pleural effusions, pneumonia, atelectasis
• With unilateral diaphragmatic paralysis, patients are usually asymptomatic at rest, but may have exertional dyspnea and decreased exercise performance or when in lateral recumbent position with paralyzed side down
• Orthopnea sometimes occurs, especially in patients with bilateral diaphragmatic paralysis

The goal of diaphragm plication is to flatten the dome of the diaphragm, which increases the volume of expansion. The surgical technique for these procedures can be robotic, laparoscopic, VATS, or open with either transthoracic or transabdominal approaches described in the literature.

Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic	Sleep disturbances, possible cervical spine disease as etiology of diaphragmatic paralysis
Cardiovascular	Possible transthoracic approach with standard intrathoracic considerations
Pulmonary	PFTs: Diaphragmatic paralysis is usually associated with a mild-to-moderate restrictive deficit on spirometry testing, with a reduction in forced expiratory volume, forced vital capacity, and maximum voluntary ventilation. ABGs: these patients may present with chronic hypercapnia or hypoxia CXR: atelectasis, hemidiaphragm elevation may be present Risk of cor pulmonale and pulmonary hypertension in setting of chronic hypercapnia and/or hypoxia
Gastrointestinal	Possible laparoscopic approach
Hematologic	Possible polycythemia given chronic hypoxemia
Renal
Endocrine
Other

Labs and studies

• ABG
• PFTs
• CXR
• CT scan
• Depending on the degree and chronicity of hypoxia, may consider an echo for evaluation of pulmonary hypertension

Operating room setup

• Lung isolation technique available: either DLT or SLT with bronchial blocker
• Fiberoptic bronchoscope for lung isolation
• Arterial line

Patient preparation and premedication

• Consider pre-induction a-line on room air
• Premedication with midazolam as needed, consider avoidance of opioids for premedication given possible tenuous respiratory status

Regional and neuraxial techniques

• General anesthesia is required given the need for lung isolation, duration of the procedure, and invasiveness of the procedure
• Consider epidural or ESP catheter for postoperative pain control due to chest tube placement

Intraoperative management

Monitoring and access

• Standard monitors
• Arterial line
• 2 large bore IVs

Induction and airway management

• Lung isolation technique available: either DLT or SLT with bronchial blocker
• Fiberoptic bronchoscope for lung isolation
• Consider HOB 30° induction to optimize FRC
• Higher risk of atelectasis and mucus plug, consider early recruitment and frequent suctioning

Positioning

• Lateral decubitus with paralyzed diaphragm up

Maintenance and surgical considerations

• GETA
• Possible approaches: thorascopic, laparoscopic, robotically assisted thorascopic, open thoracotomy
• Chest tube will be placed at the end of the procedure
• Consider epidural or ESP catheter for chest tubes

Emergence

• Ensure complete reversal of muscle relaxant
• Would closely monitor tidal volumes during emergence given that this patient population is at high risk of respiratory compromise
• Lower threshold to maintain the patient on the ventilator due to high risk of respiratory compromise

Postoperative management

Disposition

• Floor or ICU depending if postoperative mechanical ventilation is required
  • In one study, mechanical ventilation was discontinued from 2 to 12 days after plication with dramatic improvement in respiratory mechanics
• The patients are generally discharged following chest tube removal.
• On follow-up, success is indicated by either the repositioning of the diaphragm caudally on radiograph and resolution or improvement in symptoms.

Pain management

• Consider epidural or ESP catheter for chest tubes

Potential complications

• Respiratory failure in setting of no improvement in diaphragm
• Pneumonia

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications