Obstructive Lung Diseases: Student/Resident Case Report Poster - Obstructive Lung Diseases |

Thinking Outside the Lungs: Asthma Due to a Displaced Diaphragm FREE TO VIEW

Chidinma Ezeonu, MD; Deborah Goss, MD; Angelo Reyes, MD
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Rutgers New Jersey Medical School, Bloomfield, NJ

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):930A. doi:10.1016/j.chest.2016.08.1030
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SESSION TITLE: Student/Resident Case Report Poster - Obstructive Lung Diseases

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: While non-pulmonary causes of asthma, such as valvular heart disease and gastroesophageal reflux are commonly recognized, the mechanical causes of asthma are often over looked. We now present a case of adult onset asthma due to diaphragm elevation.

CASE PRESENTATION: The patient is a 51 year old woman with a history of asthma, sleep apnea, GERD and obesity who presented for further evaluation of progressively worsening asthma. It was first diagnosed 10 years ago. She complained of wheezing, chest tightness, and severe dyspnea with minimal exertion minimally relieved by bronchodilators and inhaled corticosteroids. She reported that her symptoms were triggered by dust and cold air. On examination, she had diminished breath sounds, most notable on the right. Her symptoms first appeared after her C-section and spirometry at that time showed an FVC of 53%, FEV1 of 53% and FEV1/FVC of 116%. Computed tomography of the chest revealed an elevation of the right diaphragmatic cupola to the T4-T5 level, with the liver entering into the chest cavity and marked volume loss. The patient was referred for diaphragm plication and had surgical correction of the diaphragm to its expected position. There was full expansion of the affected lung leading to near complete resolution of her symptoms.

DISCUSSION: Eventration of the diaphragm is a rare entity. It can be congenital or acquired. Congenital cases, which are more common, can remain undiagnosed until symptoms occur in the setting of increased intra-abdominal pressure, such as in pregnancy or increased body mass1. Acquired cases are often due to interruption or injury to the phrenic nerve due to mass effect (such as neoplasm), or surgical injury1. The surgical repair consists of moving the diaphragm to its original position and adhering it via sutures to the chest wall. Appropriate tension must be placed on the diaphragm to allow the lung to fully re-expand without tearing this thin and often weakened muscle2. Improvement in chest wall mechanics and subsequently respiratory symptoms following diaphragm plication can occur along with documented improvement in both FEV1 and FVC3.

CONCLUSIONS: Asthma is a clinical diagnosis, but it is important to remember that this is also a diagnosis of exclusion. Symptoms such as wheezing, chest tightness and coughing require a complete and thorough evaluation for non-pulmonary causes of asthma prior to the institution of chronic therapy.

Reference #1: Kansal AP, Chopra V, Chahal AS, Grover CS, Singh H, Kansal S. Right-sided diaphragmatic eventration: A rare entity. Lung India. 2009;26(2):48-50.

Reference #2: Watanabe S, Shimokawa S, Fukueda M, Kinjyo T, Taira A. Large Eventration of Diaphragm in an Elderly Patient Treated With Emergency Plication. The Annals of Thoracic Surgery. 2016;65(6):1776-1777.

Reference #3: Elshafie G, Acosta J, Aliverti A, et al. Chest wall mechanics before and after diaphragm plication. Journal of Cardiothoracic Surgery. 2016;11:25.

DISCLOSURE: The following authors have nothing to disclose: Chidinma Ezeonu, Deborah Goss, Angelo Reyes

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