Diagnosis and Management of Diaphragmatic Paralysis

Diagnostic Approaches

Chest radiography can assess the relative position of the diaphragm and provide clues to diaphragmatic paralysis, as recommended by the American College of Radiology 1
Fluoroscopy is considered a reference standard for diagnosis, allowing for accurate assessment of diaphragmatic motion, according to the American College of Radiology 1
Ultrasound of the chest is highly recommended for diagnosing diaphragmatic paralysis, as it shows concordant results with fluoroscopic imaging, can evaluate diaphragmatic excursion amplitude, thickness, and contraction, and identify paralysis as paradoxical movement during respiration, with high sensitivity and specificity, as stated by the American College of Radiology 1
CT scan is the gold standard for diagnosing diaphragmatic hernia but has limited value in assessing diaphragmatic dysfunction, as noted by the American College of Radiology and the World Journal of Emergency Surgery 1, 2
Cine dynamic MRI sequences allow for direct visualization of diaphragm motion and comprehensive analysis of both diaphragm and chest wall muscle movement, according to the American College of Radiology 1

For diaphragmatic hernia associated with paralysis, primary repair should be attempted when possible using non-absorbable sutures, and for larger defects (>3 cm), mesh reinforcement is recommended to prevent recurrence, as suggested by the World Journal of Emergency Surgery 3, 4
Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates, higher resistance to infections, and lower risk of displacement, as recommended by the World Journal of Emergency Surgery 3
Minimally invasive approach (laparoscopic) is preferred for stable patients, while open laparotomy approach is recommended for unstable patients, according to the World Journal of Emergency Surgery and Praxis Medical Insights 3, 4, 5

For patients with congenital central hypoventilation syndrome using diaphragm pacing, spare antennae should be available at home, a backup diaphragm pacer transmitter is mandatory, and diaphragm pacers should only be implanted by surgeons with extensive expertise, as recommended by the American Journal of Respiratory and Critical Care Medicine 6
Patients with oral intake difficulties may benefit from percutaneous endoscopic gastrostomy (PEG), gastrostomy, or jejunostomy, as suggested by the World Journal of Emergency Surgery and Praxis Medical Insights 3, 5