RESUMO
This case study explores foodborne botulism, a severe illness caused by botulinum neurotoxin-contaminated food. It leads to bilateral descending paralysis, involving the diaphragm. We highlight diaphragmatic ultrasound as a non-invasive diagnostic tool. A 50-year-old obese male developed diplopia and weakness after consuming contaminated food, rapidly progressing to severe symptoms. Mechanical ventilation became necessary due to respiratory failure. Diaphragmatic ultrasound confirmed bilateral diaphragm paralysis despite early antitoxin treatment. The patient experienced complications, requiring tracheostomy and rehabilitation. After five months, he fully recovered diaphragmatic function. This study underscores botulism's life-threatening nature and the vital role of supportive care. Diaphragmatic ultrasound is a safe and effective method for assessing diaphragmatic function in such cases, obviating ionizing radiation exposure. We recommend its routine use for evaluating botulism-induced paralysis.
Assuntos
Toxinas Botulínicas , Botulismo , Insuficiência Respiratória , Paralisia Respiratória , Masculino , Humanos , Pessoa de Meia-Idade , Botulismo/diagnóstico por imagem , Botulismo/etiologia , Paralisia Respiratória/diagnóstico por imagem , Paralisia Respiratória/complicações , Paralisia/etiologia , Insuficiência Respiratória/etiologia , Antitoxina Botulínica/uso terapêuticoAssuntos
Calcinose , Transtornos Respiratórios , Paralisia Respiratória , Doenças Torácicas , Humanos , Paralisia Respiratória/etiologia , Paralisia Respiratória/complicações , Calcinose/complicações , Calcinose/diagnóstico por imagem , Debilidade Muscular/complicações , Doenças Torácicas/complicaçõesRESUMO
Crotalic envenomation is responsible for approximately 8%-13% of ophidism cases in Brazil, yet it is associated with the highest mortality among snakes. We describe the case of a patient bitten by a rattlesnake who developed ventilatory muscle paralysis within hours after envenomation. While diaphragmatic paralysis is a rare late neurotoxic event following crotalic envenomation, in this case, paralysis occurred early but was rapidly reversed after antivenom administration. This report discusses potential contributing factors based on a comprehensive literature review.
Assuntos
Paralisia Respiratória , Mordeduras de Serpentes , Animais , Humanos , Mordeduras de Serpentes/complicações , Paralisia Respiratória/complicações , Antivenenos/uso terapêutico , Paralisia/etiologia , CrotalusRESUMO
BACKGROUND: Diaphragm plication remains the only effective treatment for diaphragm paralysis. Robot-assisted thoracoscopic (RATS) diaphragm plication combines advantages of open and thoracoscopic techniques. We present our experiences focussing on lung-function improvement and surgical outcome. METHODS: In this single-center retrospective study with comparative analysis, perioperative data of all patients who underwent RATS or thoracoscopic (VATS) diaphragm plication between 2015 and 2022 at our institution were assessed. Functional outcome was analysed with pre- and postoperative pulmonary function tests in sitting and supine position. RESULTS: We included 43 diaphragm plications, of which 31 were performed via RATS. Morbidity in the RATS- and VATS-cohort were 13 and 8%, respectively (p = 0.64), without any major complication (Clavien-Dindo ≥ III, 0%). Surgical time for RATS diaphragm plication was reduced drastically with a median operating time for the first 16 patients of 136 min (range 84-185) and 84 min (range 56-122) for the most recent 15 patients (p < 0.0001). Pulmonary function testing after RATS-plication showed a mean increase in vital capacity (VC) of 9% (SD 8, p < 0.0001) and of 7% (SD 9, p = 0.0009) in forced expiratory volume in 1 s (FEV1) when sitting and 9% (SD 8, p < 0.0001) for VC as well as 10% (SD 8, p = 0.0001) for FEV1 when in supine position. CONCLUSION: RATS diaphragm plication is a very safe and feasible approach, yielding good results in improving patients' pulmonary function. Further studies are required to elucidate possible advantages over VATS or open approaches.
Assuntos
Paralisia Respiratória , Procedimentos Cirúrgicos Robóticos , Robótica , Humanos , Diafragma/cirurgia , Estudos Retrospectivos , Resultado do Tratamento , Paralisia Respiratória/cirurgia , Paralisia Respiratória/complicaçõesRESUMO
Coronavirus disease 2019 (COVID-19) continues to be a disease of global importance, with an increasing array of sequelae attributed to infection by the severe acute respiratory syndrome coronavirus-2. One such complication that has been rarely documented thus far is diaphragmatic dysfunction. Here, we report the cases of 2 individuals who developed diaphragmatic paralysis post COVID-19, which failed to respond to conservative management. Both patients proceeded to undergo robot-assisted thoracoscopic plication of the diaphragm reinforced with a bovine acellular dermal matrix. In both cases, there was significant improvement in symptomatology, namely dyspnoea and fatigue. We conclude that robot-assisted diaphragmatic plication should be considered for the treatment of refractory diaphragmatic paralysis post COVID-19.
Assuntos
Derme Acelular , COVID-19 , Paralisia Respiratória , Robótica , Humanos , Animais , Bovinos , Paralisia Respiratória/cirurgia , Paralisia Respiratória/complicações , COVID-19/complicações , Diafragma/cirurgiaRESUMO
A man in his fifties was injured in a traffic accident and diagnosed with traumatic subarachnoid haemorrhage, liver injury, and fractures of the rib, right clavicle, right scapula and right femur. He also presented with motor and sensory disturbances of the right upper extremity and was suspected of having a brachial plexus injury. After undergoing mechanical ventilation due to multiple traumas, he was extubated. However, he developed acute respiratory failure and required reintubation. Respiratory symptoms were not clear until just before reintubation. The diagnosis of right diaphragm paralysis was made using point-of-care ultrasound with no other findings that could cause respiratory failure. MRI led to the diagnosis of brachial plexus injury, which likely caused diaphragm paralysis. Point-of-care ultrasound provided a clear visualisation and rapid bedside diagnosis of diaphragm paralysis, which can be challenging to diagnose while ruling out other causes of respiratory failure.
Assuntos
Plexo Braquial , Insuficiência Respiratória , Paralisia Respiratória , Plexo Braquial/lesões , Diafragma/diagnóstico por imagem , Humanos , Masculino , Paralisia/etiologia , Sistemas Automatizados de Assistência Junto ao Leito , Insuficiência Respiratória/complicações , Insuficiência Respiratória/etiologia , Paralisia Respiratória/complicações , Paralisia Respiratória/etiologiaRESUMO
RATIONALE: Hemidiaphragmatic paralysis (HDP) is a frequent complication of the brachial plexus block, caused by unintentional blockade of ipsilateral phrenic nerve. HDP did not rise enough alarm and attention to most anesthesiologists, because most patients with no coexisting comorbid diseases are asymptomatic and able to tolerate it. However, it may cause severe respiratory complication for patients with preexisting compromised cardiorespiratory function. PATIENT CONCERNS: A 67-year-old woman with morbidly obesity was planned to receive opening reduction and internal fixation of right humeral shaft fracture under regional anesthesia considering less respiratory and cardiovascular system interference compared with general anesthesia. DIAGNOSES: After ultrasound guided supraclavicular brachial plexus block, the patient developed severe hypoxia and hypercapnia.Unintentional block of phrenic nerve and diaphragm paralysis was diagnosed by diaphragm ultrasound, which was considered as the main reason of severe hypoxia. INTERVENTIONS: It led to a conversion from regional anesthesia to general anesthesia with endotracheal intubation for patient's safety and smooth operation. OUTCOMES: The unintentional phrenic nerve block leads to a prolonged ventilation time, length of stay in intensive care unit and length of stay in hospital. LESSONS: This case report highlights the risk of diaphragm paralysis in morbidly obese patients. Though new diaphragm sparing brachial plexus block (BPB) methods were developed intended to reduce the risk of HDP, no approaches could absolutely spare phrenic nerve involvement. Therefore, clinicians should always consider the risk of HDP associated with BPBs. For each individual, a detailed preoperative evaluation and sufficient preparation are paramount to avoid serious complications.
Assuntos
Anestésicos Locais/efeitos adversos , Bloqueio do Plexo Braquial/efeitos adversos , Plexo Braquial/efeitos dos fármacos , Dispneia/etiologia , Bloqueio Nervoso/efeitos adversos , Obesidade Mórbida , Paralisia/induzido quimicamente , Paralisia/diagnóstico , Nervo Frênico/efeitos dos fármacos , Paralisia Respiratória/complicações , Idoso , Clavícula/efeitos dos fármacos , Feminino , Humanos , Hipóxia , Obesidade Mórbida/complicações , Obesidade Mórbida/cirurgia , Ultrassonografia de IntervençãoRESUMO
CASE PRESENTATION: An 84-year-old woman with a medical history of hypertension, hypothyroidism, and transient ischemic attacks presented with right-sided upper and lower extremity weakness for 1 day. She was a lifetime nonsmoker with no known heart disease or chronic lung disease. She had no occupational exposure or pertinent family history. She denied any fevers, chills, rashes, or shortness of breath. There was no history of recent travel.
Assuntos
Forame Oval Patente/complicações , Hipóxia/etiologia , Ataque Isquêmico Transitório/etiologia , Posicionamento do Paciente , Paralisia Respiratória/complicações , Idoso de 80 Anos ou mais , Pressão Atrial , Cateterismo Cardíaco , Ecocardiografia Transesofagiana , Feminino , Forame Oval Patente/diagnóstico , Forame Oval Patente/fisiopatologia , Humanos , Paralisia Respiratória/diagnóstico , Paralisia Respiratória/fisiopatologiaRESUMO
RATIONALE: Respiratory muscle paralysis due to low cervical spinal cord injury (CSCI) can lead to dysphagia. Noninvasive positive airway pressure (PAP) therapy can effectively treat this type of dysphagia. High-flow nasal cannula (HFNC) oxygen therapy can generate a low level of positive airway pressure resembling PAP therapy, it may improve the dysphagia. PATIENT CONCERNS: The patient was an 87-year-old man without preexisting dysphagia. He suffered a CSCI due to a dislocated C5/6 fracture, without brain injury, and underwent emergency surgery. Postoperatively (day 2), he complained of dysphagia, and the intervention was initiated. DIAGNOSIS: Based on clinical findings, dysphagia in this case, may have arisen due to impaired coordination between breathing and swallowing, which typically occurs in patients with CSCI who have reduced forced vital capacity. INTERVENTIONS: HFNC oxygen therapy was started immediately after the surgery, and swallowing rehabilitation was started on Day 2. Indirect therapy (without food) and direct therapy (with food) were applied in stages. HFNC oxygen therapy appeared to be effective because swallowing function temporarily decreased when the HFNC oxygen therapy was changed to nasal canula oxygen therapy. OUTCOMES: Swallowing function of the patient improved and he did not develop aspiration pneumonia. LESSONS: HFNC oxygen therapy improved swallowing function in a patient with dysphagia associated with respiratory-muscle paralysis following a CSCI. It may have prolonged the apnea tolerance time during swallowing and may have improved the timing of swallowing. HFNC oxygen therapy can facilitate both indirect and direct early swallowing therapy to restore both swallowing and respiratory function.
Assuntos
Medula Cervical/lesões , Transtornos de Deglutição/terapia , Oxigenoterapia/instrumentação , Insuficiência Respiratória/complicações , Paralisia Respiratória/complicações , Traumatismos da Medula Espinal/complicações , Idoso de 80 Anos ou mais , Cânula , Medula Cervical/diagnóstico por imagem , Transtornos de Deglutição/diagnóstico , Transtornos de Deglutição/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/terapia , Paralisia Respiratória/diagnóstico , Paralisia Respiratória/terapia , Traumatismos da Medula Espinal/diagnóstico , Vértebras TorácicasRESUMO
Dermatomyositis (DM) is an idiopathic inflammatory disorder that presents with proximal muscle weakness and typical DM skin changes. DM can involve other organs such as the lung, esophagus, and heart. Diaphragmatic muscle paralysis is an unrecognized clinical presentation of acute DM exacerbation. A 58-year-old man with a history of DM presented to the hospital after sustaining a cardiorespiratory arrest. Before arrest, he had been suffering from progressive dyspnea and muscle weakness. Immunosuppressive therapy of tacrolimus for DM was recently discontinued due to renal toxicity. Bedside ultrasound of the diaphragm while intubated revealed evidence of bilateral diaphragmatic paralysis. After extubation, supine and upright pulmonary function tests (PFT) and sniff test results strengthened the diagnosis of diaphragmatic paralysis. The patient was worked up for an acute DM exacerbation as the likely etiology of the severe diaphragmatic muscle weakness (diaphragmatic paralysis) and ventilatory failure. Skin and muscle biopsy confirmed the diagnosis of active DM. The patient was treated with high dose steroids and mycophenolate mofetil, following which he soon recovered.
Assuntos
Dermatomiosite/complicações , Insuficiência Respiratória/etiologia , Paralisia Respiratória/etiologia , Dermatomiosite/diagnóstico , Dermatomiosite/patologia , Diagnóstico Diferencial , Humanos , Masculino , Pessoa de Meia-Idade , Paralisia Respiratória/complicaçõesRESUMO
Infantile tremor syndrome (ITS) owing to vitamin B12 deficiency usually presents with tremors, anaemia, pigmentary skin changes, neuro-regression and hypotonia. A 10-month-old boy with ITS and respiratory failure owing to bilateral diaphragmatic palsy who responded to high parenteral doses of vitamin B12 is presented. As far as we are aware, this is the first report of diaphragmatic palsy associated with ITS and vitamin B12 deficiency.
Assuntos
Insuficiência Respiratória/tratamento farmacológico , Paralisia Respiratória/complicações , Tremor/tratamento farmacológico , Deficiência de Vitamina B 12/complicações , Vitamina B 12/uso terapêutico , Humanos , Lactente , Masculino , Insuficiência Respiratória/etiologia , Tremor/etiologiaRESUMO
BACKGROUND: Paralysis of the diaphragm in newborn infants can lead to recurrent infections and life-threatening respiratory insufficiency. The clinical diagnosis of unilateral diaphragmatic paralysis has been reported in infants with laboratory evidence of congenital Zika virus infection and/or the congenital Zika syndrome (CZS) phenotype but no evaluation of phrenic nerve function has been described. All reported infants have had accompanying arthrogryposis. High infant mortality is reported. METHODS: The causal mechanism of congenital diaphragmatic paralysis was evaluated in three infants with arthrogryposis as a manifestation of CZS (two of the three infants had laboratory evidence of ZIKV infection shortly after birth; the remaining infant had negative serology for ZIKV when first tested at 7 months of age). Electromyography and phrenic nerve compound muscle action potential (CMAP) were performed in all infants with diaphragmatic paralysis demonstrated on imaging studies. RESULTS: All infants had evidence of moderate chronic involvement of peripheral motor neurons. Phrenic nerve CMAP was reduced on the side of the diaphragmatic paralysis in two infants and reduced bilaterally in the remaining infant who had primarily anterior involvement of the diaphragm. All three infants had multiple medical complications and one infant died at 18 months of age. CONCLUSION: Evaluation of three infants with CZS and diaphragmatic paralysis demonstrated phrenic nerve dysfunction. In these and other affected infants, arthrogryposis appears to be a constant co-occurring condition and health problems are significant; both conditions are likely due to involvement of the peripheral nervous system in some infants with CZS.
Assuntos
Paralisia Respiratória/complicações , Paralisia Respiratória/etiologia , Paralisia Respiratória/fisiopatologia , Artrogripose/fisiopatologia , Artrogripose/virologia , Brasil , Diafragma/inervação , Diafragma/fisiopatologia , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Nervo Frênico/metabolismo , Nervo Frênico/virologia , Gravidez , Complicações Infecciosas na Gravidez/virologia , Zika virus/patogenicidade , Infecção por Zika virus/complicaçõesAssuntos
Dispneia/etiologia , Paralisia Respiratória/complicações , Paralisia Respiratória/diagnóstico , Idoso , Pressão Positiva Contínua nas Vias Aéreas , Diafragma/diagnóstico por imagem , Dispneia/terapia , Humanos , Masculino , Testes de Função Respiratória , Paralisia Respiratória/terapia , UltrassonografiaRESUMO
Patent foramen ovale (PFO) is a congenital abnormality present in 25%-30% of healthy adults and rarely leads to any sequelae. 1 2 It is associated with a left-to-right shunt which usually does not lead to any haemodynamic compromise. Occasionally, the shunt can get reversed; that is, right-to-left shunt occurs due to worsening pulmonary hypertension and can lead to persistent hypoxia. It is rare for the shunt reversal to happen in the absence of pulmonary hypertension. Here, we present an exceedingly rare case in a 61-year-old man presenting with hypoxia, was found to have shunt reversal due to unilateral diaphragmatic paralysis. He was successfully treated with PFO closure. The purpose of this report is to consider rare possibilities of PFO shunt reversal when the right-sided heart pressure is normal and to highlight that a simple chest X-ray can be a clue to the diagnosis.
Assuntos
Forame Oval Patente/diagnóstico , Paralisia Respiratória/diagnóstico , Adulto , Diagnóstico Diferencial , Ecocardiografia Transesofagiana , Forame Oval Patente/complicações , Forame Oval Patente/diagnóstico por imagem , Forame Oval Patente/cirurgia , Humanos , Hipertensão Pulmonar/etiologia , Hipóxia/etiologia , Masculino , Paralisia Respiratória/complicações , Paralisia Respiratória/diagnóstico por imagem , Paralisia Respiratória/cirurgiaRESUMO
Diaphragmatic eventration in old age is a rare phenomenon. Typically, it is thought to originate as a result of failure of development of the muscles of the diaphragm. Less commonly, it can occur secondary to acquired conditions resulting from spinal cord or phrenic nerve injury and is only detected incidentally when the patient presents with dyspnea, chest infection, or cardiac compression symptoms. Herein, we report a case of right diaphragmatic paralysis in a 58-year-old man with a presentation of marked elevation of the right hemidiaphragm and ascites causing a picture compatible with cardiac tamponade.
Assuntos
Tamponamento Cardíaco/etiologia , Eventração Diafragmática/complicações , Paralisia Respiratória/complicações , Ascite/diagnóstico por imagem , Tamponamento Cardíaco/diagnóstico por imagem , Eventração Diafragmática/diagnóstico por imagem , Ecocardiografia Transesofagiana , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios XRESUMO
Charcot-Marie-Tooth disease comprises a vast array of defects in myelin integrity that causes progressive peripheral sensorimotor neuropathy. It is the most prevalent inherited peripheral neuropathy, and it can affect the management of coexisting medical conditions. We report the case of a 25-year-old woman who had undergone successful Fontan surgery during childhood, but her Fontan circulation failed as a result of diaphragmatic paresis caused by Charcot-Marie-Tooth disease type 1A. This diagnosis precluded cardiac transplantation.
Assuntos
Doença de Charcot-Marie-Tooth/complicações , Técnica de Fontan/efeitos adversos , Doenças do Sistema Nervoso Periférico/complicações , Complicações Pós-Operatórias , Atresia Pulmonar/cirurgia , Insuficiência Respiratória/etiologia , Paralisia Respiratória/complicações , Adulto , Feminino , Humanos , Doenças do Sistema Nervoso Periférico/diagnóstico , Radiografia Torácica , Insuficiência Respiratória/diagnóstico , Paralisia Respiratória/diagnósticoRESUMO
AIM: To develop examination algorithm and to determine the indications for various options for surgical treatment. MATERIAL AND METHODS: It is presented analysis of surgical treatment of 25 patients with unilateral diaphragm relaxation for the period from 1963 to 2016. There were 15 men and 10 women aged from 39 to 65 years. Diagnosis included predominantly radiological methods. All patients were operated openly through thoracotomy. Procedure consisted of creation of new diaphragmatic cupola at the usual level with two flaps of diaphragm and prosthesis between them. In 12 (48%) patients who were operated before 1990 xenopericardial patch was used. Further, synthetic materials (Teflon, polypropylene) were preferred. RESULTS: Postoperative morbidity and mortality was 20% (n=6) and 4% (n=1) respectively. Long-term results were followed-up within terms from 8 months to 12 years. Recurrent relaxation was absent. Most of patients had improved dyspnea, increased vital capacity and FEV1 in long-term period. Certain and general values of SF-36 life quality questionnaire were high in long-term postoperative period and similar to those in general population.
Assuntos
Diafragma/cirurgia , Paralisia Respiratória/cirurgia , Adulto , Idoso , Algoritmos , Dispneia/etiologia , Dispneia/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Paralisia Respiratória/complicações , Retalhos Cirúrgicos , ToracotomiaRESUMO
BACKGROUND: Topical cooling with ice slush as an adjunct for myocardial protection during cardiac surgery has been shown to cause freezing injury of the phrenic nerves. This can cause diaphragmatic dysfunction and respiratory complications. METHODS: Twenty (n=20) male patients between the ages of 40 and 60 years were equally randomised to undergo elective coronary artery bypass grafting (CABG) with either cold cardioplegic arrest with topical ice slush cooling or cold cardioplegic arrest without the use of ice slush. The sniff nasal inspiratory force (SNIF) was used to compare inspiratory muscle strength. RESULTS: There was no difference in the preoperative SNIF in the two randomised groups. In the immediate postoperative period, the ice slush group had worse SNIF (33.5±9.6cm H2O versus 47.8±12.2cm H2O; p=0.009). The pre-home discharge SNIF was still significantly lower for the ice slush group despite a noted improvement in SNIF recovery in both groups (38.3±10.6cm H2O versus 53.5±13.2cm H2O; p=0.011). Two patients in the ice slush group had left diaphragmatic dysfunction with none in the control group. CONCLUSION: The use of topical ice slush is associated with freezing injury of the phrenic nerves. This will adversely affect the inspiratory muscle force which may lead to respiratory complications after surgery.
Assuntos
Ponte de Artéria Coronária , Diafragma/inervação , Hipotermia Induzida/efeitos adversos , Capacidade Inspiratória/fisiologia , Nervo Frênico/lesões , Insuficiência Respiratória/etiologia , Paralisia Respiratória/complicações , Administração Tópica , Adulto , Doença da Artéria Coronariana/cirurgia , Humanos , Hipotermia Induzida/métodos , Gelo , Masculino , Pessoa de Meia-Idade , Nariz , Período Pós-Operatório , Insuficiência Respiratória/fisiopatologia , Paralisia Respiratória/fisiopatologiaRESUMO
Cough is a fundamental defense mechanism for keeping the airway free of foreign elements. Life-threatening situations may arise when cough proves ineffective as a result of muscle weakness or altered mucociliary function. When a patient is unable to cough effectively, techniques are required to either reinforce or replace cough capacity. The use of mechanical systems that facilitate or substitute cough function is increasingly common in Intensive Care Units, where it is relatively frequent to find situations of ineffective cough due to different clinical causes. This review examines the current clinical practice recommendations referred to the indication and use of mechanical cough assist and intrapulmonary percussive ventilation systems.