Here's one from a recent fellow, now out in the real world...
I saw a 57 year old man in Southern Delaware, referred to me for abnormal CT thorax (a pneumatocele). I noticed that his left diaphragm was elevated, and that was not the case on a previous CXR 6 years earlier. Sniff test confirmed left diaphragmatic paralysis. No history of thoracic surgery or trauma. His medical problems includes severe COPD, hypertension and hypercholesterolemia. The CT thorax does not show any masses/tumors. He has emphysematous changes, and calcified granulomas.What is the differential diagnosis and the next step, if any needed?
Thanks for your input.......
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In the absence of structural disease such as tumor compression, the most common etiology for unilateral diaphragmatic paralysis in recent cardiac surgery (due to cardioplegia). As you did not mention it, I'll assume the patient has not had recent cardiac surgery.
So, next on the list would be neurologic disease from variable causes (post-polio, Guillan-Barre, MS, etc) or possilbe collagen-vascular diseases/vasculitites causing an unfortunate mononeuritis. Post-viral etiologies are possible.
A large proportion of these end up idiopathic.
So, I suppose that in the absence of any systemic signs/symptoms to suggest neurologic disease or myopathy, or a history suggestive of any of these, than observation is in order.
Now, we do need to consider the underlying emphysema. He should have PFT's (including MIPS and MEPS) to assess for significant restriction or obstruction. Phrenic nerve conduction studies are apparently not incredibly helpful.
If he is asymptomatic, than typically no treatment is required. But depending on the severity of his underlying lung disease he could develop hypercapnea or significant dyspnea (especially when laying down...). In that case, nocturnal NIPPV may be helpful.
Jeff H has provided a great discussion. I seem to get a lot of these patients in practice as well: older men with COPD with mixed restriction who have a non-functioning diaphragm. Many of the idiopathic cases are postulated to be viral (like a lot of idiopathic problems) with Parsonage-Turner syndrome being a more acute form.
Usually healthy patients with unilateral diaphragmatic paralysis are not supposed to be very symptomatic but I seldom see any healthy people...
It is very hard to get some insurances to pay for NIPPV in this cases, they will pay for BiPAP for BILATERAL but not unilateral paralysis...
An ABG and a sleep study may identify ways to get him NIPPV/BiPAP if he is very symptomatic.
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