Difference between revisions of "Diaphragmatic plication"
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{{Infobox surgical case reference | {{Infobox surgical case reference | ||
| anesthesia_type =General | | anesthesia_type = General | ||
| airway =ETT with lung isolation | | airway = ETT with lung isolation | ||
| lines_access =PIV | | lines_access = PIV | ||
| monitors =Standard | Arterial line | ||
| considerations_preoperative =Possible hypoxia/hypercapnia | | monitors = Standard | ||
| considerations_intraoperative = | ABP | ||
| considerations_preoperative = Possible hypoxia/hypercapnia | |||
Baseline atelectasis with possible dyspnea while supine | |||
| considerations_postoperative = | | considerations_intraoperative = Lung isolation required | ||
}} | Lateral decubitus positioning | ||
Ensure optimal respiratory mechanics prior to extubation | |||
| considerations_postoperative = Consider ICU given possibility of respiratory decompensation | |||
}}'''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.<ref name=":0">{{Cite journal|date=2021-04-03|title=Plication of the Diaphragm: Background, Indications, Contraindications|url=https://emedicine.medscape.com/article/1970326-overview}}</ref> | |||
Causes of diaphragmatic paralysis<ref name=":1">{{Cite web|title=UpToDate|url=https://www.uptodate.com/contents/causes-and-diagnosis-of-unilateral-diaphragmatic-paralysis-and-eventration-in-adults|access-date=2021-06-24|website=www.uptodate.com}}</ref>: | Causes of diaphragmatic paralysis<ref name=":1">{{Cite web|title=UpToDate|url=https://www.uptodate.com/contents/causes-and-diagnosis-of-unilateral-diaphragmatic-paralysis-and-eventration-in-adults|access-date=2021-06-24|website=www.uptodate.com}}</ref>: | ||
| Line 21: | Line 22: | ||
*Malignancy | *Malignancy | ||
*Idiopathic | *Idiopathic | ||
Diaphragmatic paralysis has many clinical implications including<ref name=":0" />: | Diaphragmatic paralysis has many clinical implications including<ref name=":0" />: | ||
* | *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<ref name=":0" />. | 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<ref name=":0" />. | ||
| Line 41: | Line 40: | ||
!System | !System | ||
!Considerations | !Considerations | ||
|- | |||
|Airway | |||
| | |||
|- | |- | ||
|Neurologic | |Neurologic | ||
| Line 48: | Line 50: | ||
|Possible transthoracic approach with standard intrathoracic considerations | |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 | |||
* | * | ||
| Line 77: | Line 78: | ||
*ABG | *ABG | ||
*PFTs | * PFTs | ||
*CXR | *CXR | ||
*CT scan | *CT scan | ||
| Line 91: | Line 92: | ||
*Consider pre-induction a-line on room air | *Consider pre-induction a-line on room air | ||
*Premedication with midazolam as needed, consider avoidance of opioids for premedication given possible tenuous respiratory status | * Premedication with midazolam as needed, consider avoidance of opioids for premedication given possible tenuous respiratory status | ||
===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | ===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | ||
| Line 106: | Line 107: | ||
*2 large bore IVs | *2 large bore IVs | ||
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ||
*Lung isolation technique available: either DLT or SLT with bronchial blocker<ref name=":1" /><ref name=":2">{{Cite journal|last=Kara|first=H. Volkan|last2=Roach|first2=Michael J.|last3=Balderson|first3=Stafford S.|last4=D’Amico|first4=Thomas A.|date=2015-11|title=Thoracoscopic diaphragm plication|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4669248/|journal=Annals of Cardiothoracic Surgery|volume=4|issue=6|pages=573–575|doi=10.3978/j.issn.2225-319X.2015.08.11|issn=2225-319X|pmc=4669248|pmid=26693159}}</ref> | *Lung isolation technique available: either DLT or SLT with bronchial blocker<ref name=":1" /><ref name=":2">{{Cite journal|last=Kara|first=H. Volkan|last2=Roach|first2=Michael J.|last3=Balderson|first3=Stafford S.|last4=D’Amico|first4=Thomas A.|date=2015-11|title=Thoracoscopic diaphragm plication|url=https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4669248/|journal=Annals of Cardiothoracic Surgery|volume=4|issue=6|pages=573–575|doi=10.3978/j.issn.2225-319X.2015.08.11|issn=2225-319X|pmc=4669248|pmid=26693159}}</ref> | ||
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*Consider epidural or ESP catheter for chest tubes | *Consider epidural or ESP catheter for chest tubes | ||
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
*Ensure complete reversal of muscle relaxant | *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 | * 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 | *Lower threshold to maintain the patient on the ventilator due to high risk of respiratory compromise | ||
==Postoperative management== | == Postoperative management== | ||
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | ===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
* Floor or ICU depending if postoperative mechanical ventilation is required | * 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 <ref>{{Cite journal|last=Kuniyoshi|first=Yukio|last2=Yamashiro|first2=Satoshi|last3=Miyagi|first3=Kazufumi|last4=Uezu|first4=Toru|last5=Arakaki|first5=Katsuya|last6=Koja|first6=Kageharu|date=2004-06|title=Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery|url=https://pubmed.ncbi.nlm.nih.gov/15312011/|journal=Annals of Thoracic and Cardiovascular Surgery: Official Journal of the Association of Thoracic and Cardiovascular Surgeons of Asia|volume=10|issue=3|pages=160–166|issn=1341-1098|pmid=15312011}}</ref><ref>{{Cite journal|last=Versteegh|first=Michel I. M.|last2=Braun|first2=Jerry|last3=Voigt|first3=Pieter G.|last4=Bosman|first4=Daniël B.|last5=Stolk|first5=Jan|last6=Rabe|first6=Klaus F.|last7=Dion|first7=Robert A. E.|date=2007-09|title=Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea|url=https://pubmed.ncbi.nlm.nih.gov/17658265/|journal=European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery|volume=32|issue=3|pages=449–456|doi=10.1016/j.ejcts.2007.05.031|issn=1010-7940|pmid=17658265}}</ref> | **In one study, mechanical ventilation was discontinued from 2 to 12 days after plication with dramatic improvement in respiratory mechanics <ref>{{Cite journal|last=Kuniyoshi|first=Yukio|last2=Yamashiro|first2=Satoshi|last3=Miyagi|first3=Kazufumi|last4=Uezu|first4=Toru|last5=Arakaki|first5=Katsuya|last6=Koja|first6=Kageharu|date=2004-06|title=Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery|url=https://pubmed.ncbi.nlm.nih.gov/15312011/|journal=Annals of Thoracic and Cardiovascular Surgery: Official Journal of the Association of Thoracic and Cardiovascular Surgeons of Asia|volume=10|issue=3|pages=160–166|issn=1341-1098|pmid=15312011}}</ref><ref>{{Cite journal|last=Versteegh|first=Michel I. M.|last2=Braun|first2=Jerry|last3=Voigt|first3=Pieter G.|last4=Bosman|first4=Daniël B.|last5=Stolk|first5=Jan|last6=Rabe|first6=Klaus F.|last7=Dion|first7=Robert A. E.|date=2007-09|title=Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea|url=https://pubmed.ncbi.nlm.nih.gov/17658265/|journal=European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery|volume=32|issue=3|pages=449–456|doi=10.1016/j.ejcts.2007.05.031|issn=1010-7940|pmid=17658265}}</ref> | ||
* The patients are generally discharged following chest tube removal. <ref name=":2" /> | * The patients are generally discharged following chest tube removal. <ref name=":2" /> | ||
* On follow-up, success is indicated by either the repositioning of the diaphragm caudally on radiograph and resolution or improvement in symptoms.<ref name=":2" /> | *On follow-up, success is indicated by either the repositioning of the diaphragm caudally on radiograph and resolution or improvement in symptoms.<ref name=":2" /> | ||
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
* Consider epidural or ESP catheter for chest tubes | *Consider epidural or ESP catheter for chest tubes | ||
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ||
* Respiratory failure in setting of no improvement in diaphragm | *Respiratory failure in setting of no improvement in diaphragm | ||
* Pneumonia | *Pneumonia | ||
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ||
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|- | |- | ||
|Postoperative disposition | | Postoperative disposition | ||
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<references /> | <references /> | ||
[[Category:Thoracic surgery]] | |||
Latest revision as of 12:40, 5 April 2022
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 |
| Article quality | |
| Editor rating | |
| User likes | 0 |
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.[1]
Causes of diaphragmatic paralysis[2]:
- 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[1]:
- 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[1].
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 |
|
| Gastrointestinal | Possible laparoscopic approach |
| Hematologic | Possible polycythemia given chronic hypoxemia[3][4] |
| 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[2][5]
- 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[6]
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
- The patients are generally discharged following chest tube removal. [5]
- On follow-up, success is indicated by either the repositioning of the diaphragm caudally on radiograph and resolution or improvement in symptoms.[5]
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 |
References
- ↑ 1.0 1.1 1.2 "Plication of the Diaphragm: Background, Indications, Contraindications". 2021-04-03. Cite journal requires
|journal=(help) - ↑ 2.0 2.1 "UpToDate". www.uptodate.com. Retrieved 2021-06-24.
- ↑ "Diaphragmatic plication for unilateral diaphragmatic paralysis: A 10-year experience". The Annals of Thoracic Surgery. 49 (2): 248–252. 1990-02-01. doi:10.1016/0003-4975(90)90146-W. ISSN 0003-4975.
- ↑ "Neuromuscular Disorders Affecting the Thorax: Diaphragm Paralysis". Pulmonology Advisor. 2019-01-23. Retrieved 2021-06-24.
- ↑ 5.0 5.1 5.2 Kara, H. Volkan; Roach, Michael J.; Balderson, Stafford S.; D’Amico, Thomas A. (2015-11). "Thoracoscopic diaphragm plication". Annals of Cardiothoracic Surgery. 4 (6): 573–575. doi:10.3978/j.issn.2225-319X.2015.08.11. ISSN 2225-319X. PMC 4669248. PMID 26693159. Check date values in:
|date=(help) - ↑ Kara, H. Volkan; Roach, Michael J.; Balderson, Stafford S.; D’Amico, Thomas A. (2015-11). "Thoracoscopic diaphragm plication". Annals of Cardiothoracic Surgery. 4 (6): 573–575. doi:10.3978/j.issn.2225-319X.2015.08.11. ISSN 2225-319X. PMC 4669248. PMID 26693159. Check date values in:
|date=(help) - ↑ Kuniyoshi, Yukio; Yamashiro, Satoshi; Miyagi, Kazufumi; Uezu, Toru; Arakaki, Katsuya; Koja, Kageharu (2004-06). "Diaphragmatic plication in adult patients with diaphragm paralysis after cardiac surgery". Annals of Thoracic and Cardiovascular Surgery: Official Journal of the Association of Thoracic and Cardiovascular Surgeons of Asia. 10 (3): 160–166. ISSN 1341-1098. PMID 15312011. Check date values in:
|date=(help) - ↑ Versteegh, Michel I. M.; Braun, Jerry; Voigt, Pieter G.; Bosman, Daniël B.; Stolk, Jan; Rabe, Klaus F.; Dion, Robert A. E. (2007-09). "Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea". European Journal of Cardio-Thoracic Surgery: Official Journal of the European Association for Cardio-Thoracic Surgery. 32 (3): 449–456. doi:10.1016/j.ejcts.2007.05.031. ISSN 1010-7940. PMID 17658265. Check date values in:
|date=(help)
Top contributors: Libing Wang and Chris Rishel