Evaluación de la parálisis diafragmática con ultrasonido y espirometría: comparación del bloqueo supraclavicular vs bloqueo interescalénico en cirugía de hombro / Evaluation of diaphragmatic paralysis with ultrasound and spirometry: comparison of supraclavicular vs interscalene block in shoulder surgery

Resumen: Introducción: la cirugía artroscópica de hombro ha ganado popularidad recientemente; sin embargo, el dolor postquirúrgico se reporta de moderado a severo. La anestesia regional es útil para el control del dolor postquirúrgico. El bloqueo interescalénico y supraclavicular produce parálisis diafragmática en diferente proporción. Se busca encontrar cuál es el porcentaje y duración de la parálisis hemidiafragmática mediante mediciones ultrasonográficas, correlacionadas con espirometría comparando el abordaje supraclavicular con interescalénico. Material y métodos: ensayo clínico, controlado y aleatorizado. Se incluyeron 52 pacientes entre 18 y 90 años, programados para cirugía artroscópica de hombro, divididos en dos grupos (bloqueo interescalénico y supraclavicular). Se midió la excursión diafragmática y se realizó una espirometría previo al ingreso al quirófano y a las 24 horas de instalación del bloqueo, el estudio concluyó a las 24 horas del evento anestésico. Resultados: la capacidad vital se redujo en 0.7% en el grupo del bloqueo supraclavicular y 7.7% en el grupo interescalénico, el VEF1 se redujo en 0.2% en el supraclavicular y 9.5% en el interescalénico con una diferencia estadísticamente significativa (p = 0.001). La parálisis diafragmática en ventilación espontánea se presentó en ambos abordajes a los 30 minutos, sin diferencia significativa. A las seis y ocho horas continuó la parálisis en el grupo interescalénico, mientras que en el abordaje supraclavicular se mantuvo en comparación con la basal. Conclusiones: el bloqueo supraclavicular resulta tan efectivo como el bloqueo interescalénico en la cirugía artroscópica de hombro, con menor bloqueo diafragmático (1.5 veces más parálisis diafragmática en el interescalénico).

Abstract: Introduction: arthroscopic shoulder surgery has recently gained popularity, however, postoperative pain is reported as moderate to severe. Regional anesthesia is useful for the control of postoperative pain. Interscalene and supraclavicular blocks produce diaphragmatic paralysis in different proportions. The aim of this study is to find the percentage and duration of hemidiaphragmatic paralysis, by means of ultrasonographic measurements, correlated with spirometry, comparing the supraclavicular approach with interscalene. Material and methods: clinical, controlled and randomized trial. Fifty-two patients, between 18 and 90 years of age, scheduled for arthroscopic shoulder surgery were included, divided into 2 groups (interscalene or supraclavicular block). Diaphragmatic excursion was measured and spirometry was performed prior to admission to the operating room and 24 hours after installation of the block, the study concluded 24 hours after the anesthetic event. Results: vital capacity was reduced by 0.7% in the supraclavicular block and 7.7% for the interscalene, FEV1 was reduced by 0.2% for the supraclavicular and 9.5% in the interscalene with a statistically significant difference (p = 0.001). Diaphragmatic paralysis in spontaneous ventilation appeared in both approaches at 30 minutes, without significant difference. At 6 and 8 hours, paralysis continued in the interscalene group, while in the supraclavicular approach it remained preserved compared to the baseline. Conclusions: supraclavicular block is as effective as interscalene block in arthroscopic shoulder surgery, with less diaphragmatic block (1.5 times more diaphragmatic paralysis in interscalene).

Clinical efficacy of diaphragmatic plication in the treatment of diaphragmatic paralysis after congenital heart defect operation / 中国胸心血管外科临床杂志

@#Objective    To investigate the timing and clinical efficacy of diaphragmatic plication in the treatment of diaphragmatic paralysis after congenital heart disease (CHD) operation. Methods    From January 2013 to February 2019, 30 children with CHD who were treated in Fuwai Hospital were collected, including 17 males and 13 females with a median age of 19.5 (3, 72) months. There were 6 patients with bilateral diaphragmatic paralysis (bilateral group) and 24 patients with unilateral diaphragmatic paralysis (unilateral group). The clinical data of the two groups were compared. Results    Among the 6 bilateral diaphragmatic paralysis patients, 2 underwent bilateral diaphragmatic plication, and the other 4 patients continued their off-line exercise after unilateral diaphragmatic plication. Patients in the unilateral group had shorter ventilator use time (266.77±338.34 h vs. 995.33±622.29 h, P=0.001) and total ICU stay time (33.21±23.97 d vs. 67.33±28.54 d, P=0.008) than those in the bilateral group. One patient died in the bilateral group, and there was no statistical difference between the two groups (P=0.363). There was no statistical difference in the ICU stay time after diaphragm plication between the two groups (11.68±10.28 d vs. 29.83±27.73 d, P>0.05). Conclusion    Diaphragmatic plication is an effective treatment for diaphragmatic paralysis after CHD operation once the conservative treatment failed. The prognosis of bilateral diaphragmatic paralysis is worse than that of unilateral diaphragmatic paralysis. Strict control of indications for surgery is beneficial to the early recovery of patients.

Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study / Paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom: um estudo coorte prospectivo

Abstract Background and objectives: The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block. Methods: Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed. Results: Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale numerical rating scale (NRS) at 24 hours did not differ between groups. Conclusions: Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.

Resumo Justificativa e objetivos: O aparecimento frequente de paralisia hemidiafragmática durante o bloqueio interescalênico restringe seu uso em pacientes com insuficiência respiratória. O bloqueio supraclavicular pode ser uma opção segura e eficaz. Nosso objetivo primário foi avaliar a incidência de paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom e compará-lo com o bloqueio interescalênico. Métodos: Os adultos agendados para cirurgia eletiva do ombro sob anestesia regional (Hospital Universitário de Toulouse) foram prospectivamente incluídos neste estudo observacional, de maio de 2016 a maio de 2017. Vinte mililitros de ropivacaína a 0,375% foram injetados, preferencialmente objetivando a interseção da primeira costela e da artéria subclávia. A excursão diafragmática foi medida por ultrassonografia antes e 30 minutos após a anestesia regional. Uma redução ≥ 25% na excursão diafragmática durante um sniff test definiu a paralisia hemidiafragmática. Dispneia e hipoxemia foram registradas na sala de recuperação. Fatores preditivos de paralisia hemidiafragmática (sexo, idade, peso, tabagismo, capacidade funcional) foram explorados. A dor pós-operatória também foi avaliada. Resultados: Quarenta e dois e 43 pacientes dos grupos bloqueio supraclavicular e bloqueio interescalênico, respectivamente, foram avaliados. A incidência de paralisia hemidiafragmática foi de 59,5% no grupo bloqueio supraclavicular em comparação com 95,3% no grupo bloqueio interescalênico (p < 0,0001). O movimento paradoxal do diafragma foi mais comum no grupo bloqueio interescalênico (RR = 2, 95% IC 1,4-3; p = 0,0001). Uma variação semelhante na saturação de oxigênio foi registrada entre os pacientes com e sem paralisia hemidiafragmática (p = 0,08). Nenhum fator preditivo de paralisia hemidiafragmática pôde ser identificado. O consumo de morfina e o maior escore na escala numérica (NRS) em 24 horas não diferiram entre os grupos. Conclusão: Devido à frequente incidência de paralisia hemidiafragmática após bloqueio supraclavicular, essa técnica não pode ser recomendada para pacientes com função respiratória alterada.

Evaluación del movimiento diafragmático por ultrasonografía mediante la medición del índice de excursión en perros / Evaluation of diaphragmatic movement measuring the excursion index with ultrasonography in dogs / Avaliação do movimento diafragmático pela ultrassonografia através da mensuração do índice de excursão em cães

Resumen El ultrasonido es una técnica portátil y repetible, que permite evaluar de forma dinámica los movimientos del diafragma. Existen muchas causas que pueden generar disfunción diafragmática y parálisis diafragmática como anestésicos, injuria del nervio frénico, postoperatorio de cirugía cardíaca, torácica o abdominal, enfermedades neuromusculares, metabólicas e infecciosas y causas relacionadas al paciente crítico como sepsis y ventilación mecánica prolongada. Se tuvieron en cuenta cuarenta y ocho perros, entre internados y programados para cirugía electiva, sin signos clínicos cardiorrespiratorios a los cuales se les realizó ultrasonido Global FAST, se evaluó el movimiento del diafragma en modo M en tres posiciones y se registró la medida del índice de excursión diafragmática. Tres de los perros internados fueron excluidos, debido a hallazgos en el ultrasonido, los perros programados para cirugía electiva fueron sometidos al mismo protocolo preanestésico en los mismos tiempos. No se presentaron diferencias estadísticas entre las posiciones. Al comparar la medida del índice de excursión diafragmática entre los perros internados y anestesiados en la posición DLD (decúbito lateral derecho) y DD (decúbito dorsal), se observaron diferencias significativas (p<0,01). El ultrasonido en modo M es una buena herramienta para medir el índice de excursión diafragmática, proporciona información cuantitativa para la evaluación de la función dinámica diafragmática, la anestesia puede llegar a causar una disminucion significativa en el índice de excursión diafragmático, el cual puede permanecer oculto y generar complicaciones anestésicas.

Abstract The ultrasonographic examination is a portable, non-invasive, repeatable technique that can assess the dynamic movements of the diaphragm. There are several causes for diaphragmatic dysfunction or paralysis, including anesthetic drugs, phrenic nerve injury, postoperative cardiac, thoracic or abdominal surgery; neuromuscular, infectious or metabolic diseases, critical patient comorbidities such as sepsis or prolonged mechanical ventilation complications. The study included forty-eight dogs that where either hospitalized or admitted for elective surgery without cardiorespiratory disease signs. They were evaluated following Global FAST protocol. The diaphragmatic movement was evaluated in M mode and the excursion diaphragmatic index was measured in three different positions. Three dogs were excluded due to their ultrasonographic findings. The same anesthetic protocol was used for the dogs admitted for elective surgery. There was no statistical difference between the dogs evaluated in the three different positions. The excursion diaphragmatic index of the hospitalized dogs compared to anesthetized dogs in right lateral recumbency (RLR) and dorsal recumbency (DR) was significantly different (p <0,01). Mode M ultrasonographic examination is a useful tool to measure the excursion diaphragmatic index in dogs because it provides quantitative information for the evaluation of the dynamic function of the diaphragm. Anesthetic drugs can cause a significant reduction of the excursion diaphragmatic index which, if not evaluated and detected promptly, can cause complications anesthetic.

Resumo O ultra-som é uma técnica portátil e repetível, que permite avaliar de forma dinâmica os movimentos do diafragma. Muitas causas podem gerar disfunção do diafragma e paralisia diafragmática como anestésicos, lesão do nervo frénico, cirurgia cardíaca, torácica ou abdominal, doenças neuromusculares, e infecciosa e metabólica relacionados para paciente crítico como sepsia e faz com que a ventilação mecânica prolongada. Quarenta e oito cães foram tidos em conta, incluindo estágios e agendada para cirurgia electiva sem sinais clínicos cardio-respiratórias que foram submetidos a ultrasons RÁPIDO global, o movimento do diafragma no modo-M foi avaliada em três posições e medição do índice foi gravado de excursão diafragmática. Três dos cães de embarque foram excluídos porque os resultados de ultrasom, cães agendados para cirurgia eletiva foram submetidos ao mesmo protocolo pré-anestésica, ao mesmo tempo. Não houve diferenças estatísticas entre as posições para a medição. Ao comparar a medida do índice de excursão diafragmática entre os cães admitidos e anestesiados na posição DLD (decúbito lateral direito) e DD (decúbito dorsal), foram observadas diferenças significativas (p <0,01), sendo este valor menor em cães anestesiado. A ultrassonografia modo-M para medir o índice de excursão diafragmática é uma boa ferramenta, pois fornece informações quantitativas para a avaliação da função dinâmica diafragmática. A anestesia pode causar uma diminuição significativa no índice de excursão diafragmática, que pode permanecem escondidos e geram complicações anestésicas.

Imagen en trauma toracoabdominal.Un diagnóstico diferencial difícil / Image in thoracoabdominal trauma. A difficult differential diagnosis

Resumen Hombre de 70 años de edad, quien ingresó en el área de urgencias con antecedente de atropellamiento. Refería dolor torácico bilateral y disnea. Al examen físico lo encontramos con vía aérea permeable, ausencia de murmullo vesicular en porción inferior de hemitórax derecho asociada con pérdida de la matidez hepática, hemodinámicamente estable, consciente, con puntaje de 15 en la escala de coma de Glasgow. Se obtuvo radiografía de tórax, la cual reveló una imagen radiolúcida por encima del hígado, por lo cual se solicitó tomografía de abdomen con contraste, la que permitió corroborar la integridad del diafragma. Este tipo de imagen radiológica puede sugerir una ruptura diafragmática traumática; sin embargo, sólo se trata de un hallazgo radiográfico.

Abstract A 70-year-old male entered the emergency department after being hit by a car. He had bilateral thoracic pain and dyspnea. On the physical examination we found him with patent airway, absence of vesicular murmur in the lower portion of the right hemithorax in association with loss of hepatic dullness, hemodinamic stability, conscious with 15 points on the Glasgow coma scale. We obtained a plain thoracic x-ray, which revealed a radiolucent image over the liver; for that reason, we obtained a contrasted CT-scan which showed diaphragmatic integrity. This image finding may suggest a traumatic diaphragmatic rupture; however, it may be only a radiological finding.

Diagnosis of diaphragmatic paralysis for mechanical ventilation patients after congenital heart disease surgery by ultrasound: A case crossover study / 中国胸心血管外科临床杂志

@#Objective    To explore the feasibility of ultrasound diagnosis of diaphragmatic paralysis in patients with ventilation after congenital heart disease surgery. Methods    There were 542 patients with congenital heart disease after surgery, difficult to be weaned off the ventilator or suspected diaphragmatic paralysis of the patients, respectively, in the ventilator continous positive pressure breathing (CPAP) mode and completely independent breathing state, whose ultrasound examination of diaphragm function was conducted to determine the presence of diaphragmatic paralysis in our hospital between January 1, 2013 and April 30, 2016. There were 327 males and 215 females at age of 14±32 months. The results of ultrasound diagnosis between ventilator CPAP mode and completely spontaneous breathing mode were compared. Results    Five hundred and forty-two patients underwent ultrasound diaphragmatic examination. The results of bedside ultrasound were completely diagnosed: in completely spontaneous breathing, 82 patients who were diagnosed as diaphragmatic paralysis, including 39 on the right, 25 on the left, 18 on both sides; in CPAP mode, 82 patients who were diagnosed as diaphragmatic paralysis, 38 on the right, left 25, bilateral 19. Using ultrasound in CPAP mode to diagnose diaphragmatic paralysis after congenital heart disease surgery, compared with the completely spontaneous breathing state, the sensitivity was 100.0% and the specificity was 99.9%. Conclusion    It is accurate and feasible to diagnose the presence of diaphragmatic paralysis in patients with ventilation after congenital heart disease surgery.

Bedside ultrasound for the diagnosis of postoperative diaphragmatic paralysis after congenital cardiac surgery in infant / 中华超声影像学杂志

Objective To investigate the diagnostic performance of bedside ultrasound for postoperative diaphragmatic paralysis after congenital cardiac surgery in infant . Methods A total of 47 postoperative infants presented dyspnea after congenital cardiac surgery were collected . The diaphragmatic motion was detected by bedside ultrasound as an indirect indicator to reflect the condition of the phrenic nerve . The diagnostic performance of the combination of paradoxical and hypokinetic motion in parallel tests were assessed according to the final diagnostic results . The proportion of confirmed diaphragmatic paralysis in patients with different diaphragmatic motion was calculated respectively and compared . Ten cases were randomly selected for the estimation of the repeatability by calculating the weighted Kappa value based on the results in two different doctors . Results Utilizing the combination of paradoxical and hypokinetic motion in parallel tests as the diagnostic criteria ,the sensitivity was 100％ and the specificity was 40％ . After observation period , all the 14 patients presented with diaphragmatic paradoxical motion were confirmed as diaphragmatic paralysis ;while in the 23 patients presented with hypokinetic motion ,8 cases were confirmed as diaphragmatic paralysis ,there was significant difference between them ( P = 0 .000) . The reproducibility for bedside ultrasound was good ( Kappa value was 0 .891) . Conclusions Utilizing the bedside ultrasound for the diagnosis of diaphragmatic paralysis in infant is sensitive and reliable . For reducing the time for definite diagnosis and avoiding over-treatment ,paradoxical diaphragmatic motion can be considered as a direct diagnostic criteria ,however follow-up estimation for hypokinetic diaphragmatic motion is necessary before the confirmation of final diagnosis .

Influence of different volumes of ropivacaine with the same solubility on diaphragmaticparalysis following ultrasound-guided supraclavicular brachial plexus block / 临床麻醉学杂志

Objective To investigate the effects of different volumes of ropivacaine with the same solubility in supraclavicular brachial plexus block(SCBPB) under ultrasound guidance on ipsilateral diaphragmaticparalysis.Methods Seventy two patients (32 males,40 females, aged 18-65 years, of ASA Ⅰ or Ⅱ, scheduled for the right upper limb fracture internal fixation removal were randomized into group A (0.375% ropivacaine 20 ml) and group B (0.375% ropivacaine 30 ml), 36 cases in each group.The onset and duration of sensory and motor block were observed as well as complication.Diaphragmatic excursion were evaluated by M type ultrasound before and 30 min after drug injection under eupnea and forced respiration through observing diaphragmatic excursion to study diaphragmatic paralysis.Results The onset time of sensory block and maintaining time of sensory block or motor block had no significant difference between the two groups.Compared with group A,the onset time of motor block in group B was significantly shorter (P<0.05).Twelve cases (33.3%) in group A and 22 cases (61.1%) in group B respectively showed complete or partial hemidiaphragmatic paralysis 30 min after drug injection.Compared with group A, the rate of diaphragmatic paralysis in group B was significantly higher (P<0.05).Conclusion Supraclavicular brachial plexus block under ultrasound guidance with 0.375% ropivacaine 20 ml or 30 ml both can provide excellent anesthetic effect.0.375% ropivacaine 20 ml is less likely to lead to diaphragmatic paralysis.

Spinal muscular atrophy combined with respiratory distress type Ⅰ but no respiratory failure:a case report / 临床儿科杂志

Objective To explore the diagnosis and differential diagnosis of spinal muscular atrophy with respiratory distress type Ⅰ (SMARD1). Method The clinical data, results of gene detection, and follow-up information of a girl diagnosed with SMARD1 were retrospectively analyzed, and related literatures were reviewed. Results The girl was born by cesarean section due to oligohydramnios. After birth, she was transferred to neonatology department for poor feeding and response, and diagnosed with neonatal sepsis, infectious shock, disseminated inravascular coagulation and atypical purulent meningitis. She was discharged after one month of treatment. However, at 2 months old, she presented contracture of ankle joint, abnormal liver function, and myocardial damage. At 6 months old, she had obvious reduced muscular tension and development retardation. At 8 months old, the SMA gene was detected and it was normal. At 9 months old, The panel gene of peripheral neuropathy was detected and found 2 heterozygosis mutations in IGHMBP2 gene, exon8 c.1061-2A>G and exon12 c.1708C>T, which came from her father and mother respectively. Locus of exon12 c.1708C>T has been reported to be associated with the disease, and the other is a shear mutation. The diagnosis of SMARD1 was confirmed by the clinical and gene detection. The girl, 2-year-old now, suffered with recurrent respiratory tract infections, but had no respiratory distress or no respiratory failure yet. Conclusion The clinical phenotype of SMARD1 is complex and diverse. This case is the first domestic case comfirmed by gene detection.

Parálisis diafragmática bilateral idiopática tratada con ventilación mecánica no invasiva / Idiopathic bilateral diaphragmatic paralysis with noninvasive mechanical ventilation

Resumen La parálisis diafragmática bilateral es infrecuente y puede ser idiopática o más comúnmente asociada a varias entidades. Describimos el caso de un varón de 61 años con antecedentes de asma bronquial quien desarrolló parálisis difragmática bilateral sin causa evidente, la cual es excepcional. El paciente presentó disnea progresiva y ortopnea, que no mejoraban con antibioterapia ni esteroides sistémicos, por lo que se descartaron diversas etiologías como neuralgia lateral amiotrófica y finalmente se le diagnosticó parálisis diafragmática lateral en base a la exploración física y las pruebas de imagen. Se inició ventilación mecánica no invasiva con gran mejoría clínica.

Bilateral paralysis of the diaphragm is uncommon and can be either idiopathic or more frequently associated with several medical conditions. We describe the case of a 61-year-old man with a history of asthma who developed severe bilateral diaphragmatic paralysis without any obvius cause, which is exceptional. The patient manifested progressive dyspnea and debilitating orthopnea with no improvement with antibiotics or systemic steroids. Different etiologies were discarded as amyotrophic lateral neuralgia, and he was diagnosed of bilateral diaphragmatic paralysis based on physical examination and imaging tests. Noninvasive mechanical ventilation was started with great clinical improvement.

Delayed Onset Transient Diaphragmatic Paralysis after Pacemaker Implantation

A 77-year-old woman presented with exertional dyspnea six days after left pectoral pacemaker implantation. Chest radiography at presentation showed that her left diaphragm was elevated when compared to earlier films. A fluoroscopic sniff test confirmed left diaphragmatic paralysis. Thoracic computed tomography did not reveal any major vascular or lung parenchymal injury; however, phrenic nerve injury on direct needle puncture during the original surgery was suspected. The patient's small body size may have increased the risk of this injury. Delayed-onset unilateral diaphragmatic paralysis appears to be a rare complication of cardiac device implantation.

Influence of different volumes of ropivacaine with isodosage on diaphragmatic excursion following ultra-sound-guided interscalene brachial plexus block / 临床麻醉学杂志

Objective To investigate the influence of different volumes of ropivacaine with isod-osage on diaphragmatic excursion following ultrasound-guided interscalene brachial plexus block. Methods Sixty ASA Ⅰ-Ⅱ patients scheduled for right ulnoradial fracture internal fixation removal were randomized into group A (0.5% ropivacaine 20 ml)and group B (0.75% ropivacaine 13.3 ml) (n=30,each).Diaphragmatic excursion were evaluated by M type ultrasound before,1 5 min and 30 min after drug injection. The degree and duration of sensory and motor block were recorded. Results The anesthetic effect and maintain time had no significant difference between groups;Com-pared with group A,group B had lower incidence of diaphragmatic paralysis (P <0.05).There were 28 (93%)and 22 (73%)cases of patients in group A and group B respectively showed reduction of diaphragmatic excursion more than 50% or even complete paralysis 30 min after drug injection (P <0.05).Conclusion Ultrasound-guided interscalene brachial plexus with 0.5% ropivacaine 20 ml or 0.75% ropivacaine 13.3 ml both can provide excellent block.Compared with 0.75% ropivacaine 13.3 ml,0.5% ropivacaine 20 ml is more likely to lead to diaphragmatic paralysis.

Parálisis diafragmática en el post operatorio de cirugía cardiovascular, trasplantes cardíaco y pulmonar / Diaphragmatic paralysis in the postoperative period after cardiovascular surgery, and heart and lung transplantation

Objetivo principal: Describir la incidencia, evolución y tratamiento de los pacientes con parálisis diafragmática (PD) en los postoperatorios (POP) de cardiopatías congénitas (CC), trasplante cardiaco (TC) y trasplante pulmonar (TP) en la Unidad de Cuidados Intensivos 35 (UCI 35) del Hospital de Pediatría Juan P. Garrahan. Método: Se estudiaron 43 pacientes POP de CC, TC y TP que cursaron con PD durante los años 2010 al 2013. Se estudiaron datos demográficos como edad expresada en meses, sexo, peso en kilos, la existencia de sindromes genéticos, internación prequirúrgica, mala condición previa presencia de cirugía, circulación extracorpórea (CEC), días en ARM, fracaso de extubación, plicatura diafragmática, defecto residual cardiaco, obstrucción de VAS post extubación, atelectasias (ATL), episodios en ventilación no invasiva (VNI), traqueotomía (TQT), entre otros días de internación, tipo de egreso y sobrevida. Resultados: La incidencia de PD fue del 2,35%, de los 43, 22 fueron niñas, la edad M = 9 meses (0,5-204), con un peso M = 6,8 (2,3-65); 34 pacientes POP de CC, 4 POP de TC y 5 de TP. El 95% de la cirugías fue con CEC, 18 pacientes tenían cirugía previa, 21 con mala condición preoperatoria, los días de ARM M = 10 (0-109), el 55% tuvo al menos un fracaso de extubación, se realizaron 21 plicaturas, dentro de los 5 días del diagnóstico de PD en un 50%, se practicaron 6 TQT, el 83% de los pacientes tuvo por lo menos un episodio en VNI, la sobrevida al alta, de 88%. Conclusiones: Si bien la PD es poco frecuente en nuestra población, aumenta considerablemente la morbilidad de estos pacientes.

Progress of Spinal muscular atrophy with respiratory distress type 1 / 中华实用儿科临床杂志

Spinal muscular atrophy with respiratory distress type 1 (SMARD1) is a rare autosomal recessive neuromuscular disease.It is caused by mutations in the gene immunoglobulin μ-binding protein 2 which resides on chromosome 11 q13.3 and encodes the immunoglobulin μ-binding protein 2.This disorder is characterized by degeneration of anterior horn α-motoneurons and manifesting as irreversible diaphragmatic paralysis,respiratory distress associated with progressive symmetrical muscular weakness,distal lower limbs mainly involved,and muscle atrophy between the first 6 weeks and 6 months of life.Overall,SMARD1 is a poor-prognosis disease that artificial ventilation is needed for the whole life.

Clinical diagnosis and surgical treatment of diaphragmatic paralysis in infants with congenital heart disease after cardiac surgery / 中华实用儿科临床杂志

Objective To investigate the clinical manifestations,diagnosis and treatment of diagrammatic paralysis in infants with congenital heart disease (CHD) after cardiac surgery.Methods Thirty-one cases of diaphragmatic paralysis after cardiac surgery were selected from Jan.2006 to Jun.2012,including 23 cases were male and 8 cases were female.The age at operation was 20 days to 25 months,(8.0 ± 5.5) months on the average.The body weight at operation was 3.1-12.2 kg,(6.8 ± 2.3) kg on the average.All children received machine auxiliary breathing,and they had breathing difficulty without the machine.Diaphragmatic plication via 6-8 intercostal was performed under general anesthesia and endotracheal intubation.Lateral position,with uninjured side downward,was taken to perform chest posterolateral incision or chest lateral incision.Relaxing and weak diaphragm muscles were resected or directly sutured after folding.The clinical manifestations and diagnosis of children were summarized,and the effectiveness of diaphragmatic plication was evaluated.Results In 31 cases with diaphragmatic paralysis,there were 15 cases with left diaphragmatic paralysis,12 cases with right diaphragmatic paralysis,and 4 cases with bilateral diaphragmatic paralysis.Thirty-one cases had dyspnea after weaning of ventilator,and 28 cases received reintubation,23 cases with ventilator-as-sociated pneumonia,and 10 cases with tracheotomy.Diaphragmatic plication was performed in 28 cases,and all of them were weaned off ventilator successfully after the placation.The time of preoperative mechanical ventilation lasted 119-827 hours [(447 ± 225) hours],postoperative ventilator assistance time was 12-206 hours [(71 ± 52) hours],which showed significant difference in time of ventilation(P ＜0.05).Conservative treatment was given to the remaining 3 cases,and they were weaned off ventilation successfully with a better recovery.Conclusions Diaphragmatic paralysis in infants after CHD surgery affects their recovery.Diaphragm plication is a safe and effective method to treat the diaphragm paralysis.

Evaluación por imágenes del diafragma en el niño / Image evaluation of diaphragm in children

The anatomy, embriology andfunctions of the neonate 's diaphragm, as well as its anatomical and functional oddities were reviewed. And, in a deeper way, imaging studies were also reviewed; these have an important role in functional and anatomic evaluation of the diaphragm, each one with its own advantages and limitations. Chest X-rays allow an anatomic two dimensional evaluation of the diaphragm and constitutes the first approach in the study of diaphragm pathology in children; hence, the normal anatomy and the most common pathological signs are reviewed. Digestive tube studies using contrast media still are the best choice for diagnosis of hiatal hernia and of herniation through the foramen of Morgagni, where the colon is ascended. Ultrasound use is highlighted for the evaluation of diaphragmatic motility, as well as some of its advantages over fluoroscopy, which is and has been the method of choice in the diagnosis of diaphragmatic paralysis in children. Multiplanar images are the most complete method for the anatomic evaluation of the diaphragm, since they show its spatial orientation and allow the detailed evaluation of those pahologies where the anatomy is altered, such as diaphragmatic hernias, trauma and tumors.

Revisamos la embriología, anatomía y funciones del diafragma, sus particularidades anatómicas y funcionales en los neonatos y, en forma más profunda, los estudios por imágenes, que en la actualidad tienen un importante rol en su evaluación anatómica y funcional, cada uno de ellos con sus ventajas y limitaciones. La radiografía de tóraxpermite una evaluación anatómica en dos planos del diafragma y constituye la primera aproximación en el estudio de la patología del diafragma en los niños, por lo que se describe la anatomía normal y los signos de las patologías más frecuentes. Los estudios contrastados del tubo digestivo siguen siendo de elección para el estudio de las hernias hiatales y hernias de Morgagni en donde está ascendido el colon. Destacamos el uso del ultrasonido en la evaluación de la motilidad diafragmática, y algunas de sus ventajas sobre la fluoroscopia, que es y ha sido el método de elección en el diagnóstico de la parálisis diafragmática en los niños. Las imágenes multiplanares son un método más completo en la evaluación anatómica del diafragma, muestran mejor su orientación espacial y permiten la evaluación detallada de las patologías donde la anatomía está alterada, como hernias diafragmáticas congénitas, trauma y tumores.

Parálisis diafragmática y de cuerda vocal en un paciente cón Síndrome de Churg-Strauss: reporte de un caso / Diaphragmatic and vocal cord paralysis in Churg-Strauss syndrome: a case report

El Síndrome de Churg-Strauss es una vasculitis sistémica que afecta vasos de pequeño y mediano calibre y que suele presentarse con asma, fiebre, hipereosinofilia, insuficiencia cardiaca, daño renal y neuropatía periférica. esta última se observa en el 65 por ciento al 80 por ciento de los casos, siendo el compromiso de nervios craneales en una minoría, y aún más excepcional la parálisis de cuerdas vocales y el diafragma. Las neuropatías por vasculitis sistémicas pueden resultar en morbilidad grave e incluso la muerte, por esto la necesidad de instaurar un tratamiento temprano. Reportamos el caso de un paciente que padeció parálisis diafragmática y de cuerda vocal por síndrome de Churg-Strauss.

Churg-Strauss syndrome is a systemic vasculitis of the small and medium sized vessels that usually occurs with asthma, fever, hypereosinophilia, cardiac failure, renal damage and peripheral neuropathy. The latter affects 65 percent to 80 percent of patients, cranial nerves involvement is rare while vocal cord and diaphragmatic paralysis are exceptional. Neuropathies due to systemic vasculitis may result in significant disability and death, therefore the importance to institute an early treatment. We report here a patient who suffered diaphragmatic and vocal cord paralysis due to Churg-Strauss syndrome.

Myasthenia gravis: A rare cause of orthopnoea due to bilateral diaphragmatic paralysis.

A case of a 68-year-old patient with bronchial asthma who presented with orthopnoea and respiratory failure in supine position is presented.

Pure Motor Function Loss of Bilateral Upper Extremities after Anterior Spinal Cord Infarction: A case report

Anterior spinal artery syndrome refers to the paralysis of the bilateral upper extremities, bladder dysfunction and the sensory deficit of pain and temperature below the level of injury. A 64 year-old female got a cardiac arrest event after stent insertion into the coronary artery. After CPR, she underwent the motor deficit (Z-T) of the bilateral upper extremities without any sensory deficit; proprioception, vibration and pain. The brain MRI showed no abnormality, but high signal intensity was detected in C3-C7 level by T2 sagittal plane and at the anterior horn area of gray matter by axial view of spine MRI. The ventilator has been applied after CPR. By the fluoroscopy, the movement of the diaphragm was decreased, and the nerve conduction study of both phrenic nerves showed no responses.

Diaphragmatic paralysis following alcohol celiac plexus neurolysis and a review of literature: A case report

A 54-year-old man who had metastasis of gastric cancer was referred to pain clinic to control his severe epigastric pain.After the confirmation of the effect of the diagnostic celiac plexus block, c-arm-guided neurolysis of celiac plexus using alcohol was performed without any sensory or motor change.Five days after the chemical neurolysis, elevated hemidiaphragm and basal atelectasis of right lung were noted at routine chest X-ray follow-up without any respiratory symptoms such as dyspnea.There was no evidence of diaphragmatic metastasis. Two months after the neurolysis, the radiographic finding did not show any change.