Pulmonary Physiology |

Bilateral Diaphragmatic Paralysis: An Unusual Cause of Acute Respiratory Failure FREE TO VIEW

Aaron Mulhall, MD; Mitchell Rashkin, MD; Elsira Pina, DO
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University of Cincinnati, Cincinnati, OH

Chest. 2015;148(4_MeetingAbstracts):890A. doi:10.1378/chest.2243058
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SESSION TITLE: Pulmonary Physiology Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Bilateral diaphragmatic paralysis is a rare cause of respiratory failure that is poorly recognized. We report a case of bilateral diaphragmatic paralysis as a complication of endoscopic ultrasound (EUS) guided celiac plexus neurolysis.

CASE PRESENTATION: An 83-year-old white male with pancreatic adenocarcinoma presented with acute respiratory failure. Earlier that day he had undergone EUS-guided celiac plexus neurolysis for cancer-related pain. An extensive evaluation for a cause of his respiratory failure was negative. Tracheostomy was performed and the patient was transferred to a long-term acute care hospital. Pulmonology was consulted for ventilator weaning. His exam was significant for diminished bilateral breath sounds and a grossly normal neurologic exam. Chest x-ray revealed bibasilar atelectasis. His negative inspiratory force was -10cmH20 and his forced vital capacity was 150mL. There was high suspicion for diaphragmatic paralysis. A tube detecting diaphragm contractility signals was placed in the esophagus, showing no evidence of diaphragm contraction. Ultrasound of the diaphragm showed paradoxical movement bilaterally with deep inspiration. Electromyography of the diaphragm confirmed the diagnosis. MRI of the cervical spine showed no abnormalities and a para-neoplastic panel was negative. The patient's repiratory failure persisted and he ultimately entered inpatient Hospice.

DISCUSSION: Bilateral diaphragmatic paralysis is a rare complication of celiac plexus neurolysis. Time to recovery varies from months to permanent loss of function. The celiac plexus is located at the level of T12 and L1 vertebrae, anterior to the diaphragmatic crura, encasing the anterior abdominal aorta (Figure 1). The right phrenic nerve enters the diaphragm anterolateral to the aortic hiatus. The left phrenic nerve enters the diaphragm anterolateral to the esophageal hiatus. Both phrenic nerves penetrate the diaphragm and innervate it from below (Figure 2). The proposed mechanism in our case is thought to be anterocrural spread of bupivacaine and alcohol from the celiac plexus towards the diaphragm, contacting both phrenic nerves as they innervate the diaphragm.1

CONCLUSIONS: Bilateral diaphragmatic paralysis is a rare, but significant, complication of celiac plexus neurolysis potentially leading to ventilator dependent respiratory failure.

Reference #1: Kim JH, et al. Diaphragmatic paralysis following alcohol celiac plexus neurolysis and a review of literature−A case report.Anesthesia and Pain Medicine 2009 Oct; 4(04): 290-3.

DISCLOSURE: The following authors have nothing to disclose: Aaron Mulhall, Mitchell Rashkin, Elsira Pina

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