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1.
Am J Physiol Gastrointest Liver Physiol ; 318(1): G77-G83, 2020 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-31589467

RESUMO

BACKGROUND: Endoscopic intrasphincteric injection of Botox (ISIB) is used routinely for the treatment of achalasia esophagus and other spastic motor disorders. Studies show that the ISIB reduces the smooth muscle lower esophageal sphincter (LES) pressure. The esophageal hiatus, formed by the right crus of diaphragm, surrounds the cranial half of the LES and works like an external LES. We studied the effects of ISIB on the LES and hiatal contraction and gastroesophageal reflux (GER). Fourteen patients treated with ISIB were studied. Esophageal manometry-impedance recordings were performed before and after the ISIB. Hiatal contraction was assessed during tidal inspiration, forced inspiration, Müller's maneuver, and straight leg raise. In 6 subjects, the manometry were repeated 6-12 mo after the ISIB. The esophagogastric junction (EGJ) pressure was measured at end expiration (LES pressure) and at the peak of maneuvers (hiatal contraction). Transdiaphragmatic pressure (pdi; force of diaphragmatic contraction) was measured at the peak of forced inspiration. GER was measured from the impedance recordings. The EGJ pressure at end expiration (LES pressure) decreased significantly after the Botox injection. The peak EGJ pressure at tidal inspiration, forced inspiration, Müller's maneuver, and straight leg raise was also dramatically reduced by the ISIB. There was no effect of Botox on the pdi during forced inspiration. Seven of 10 subjects demonstrated GER during maneuvers following the ISIB. Six to 12 mo after ISIB, the LES and hiatal contraction pressure returned to the pre-ISIB levels. ISIB, in addition to decreasing LES pressure, paralyzes the esophageal hiatus (crural diaphragm) and induces GER.NEW & NOTEWORTHY The sphincter mechanism at the lower end of the esophagus comprises smooth muscle lower esophageal sphincter (LES) and skeletal muscle crural diaphragm (hiatus). Current thinking is that the endoscopic intrasphincteric injection of Botox (ISIB), used routinely for the treatment of achalasia esophagus, reduces LES pressure. Our study shows that ISIB, even though injected into the LES, diffuses into the hiatus and causes its paralysis. These findings emphasize the importance of esophageal hiatus as an important component of the antireflux barrier and that the ISIB is refluxogenic.


Assuntos
Inibidores da Liberação da Acetilcolina/efeitos adversos , Toxinas Botulínicas Tipo A/efeitos adversos , Diafragma/efeitos dos fármacos , Acalasia Esofágica/tratamento farmacológico , Esfíncter Esofágico Inferior/efeitos dos fármacos , Refluxo Gastroesofágico/induzido quimicamente , Contração Muscular/efeitos dos fármacos , Paralisia Respiratória/induzido quimicamente , Inibidores da Liberação da Acetilcolina/administração & dosagem , Adulto , Idoso , Toxinas Botulínicas Tipo A/administração & dosagem , Diafragma/fisiopatologia , Acalasia Esofágica/diagnóstico , Acalasia Esofágica/fisiopatologia , Esfíncter Esofágico Inferior/fisiopatologia , Feminino , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/fisiopatologia , Humanos , Injeções Intramusculares , Masculino , Pessoa de Meia-Idade , Pressão , Paralisia Respiratória/diagnóstico , Paralisia Respiratória/fisiopatologia , Fatores de Risco
4.
Rev Mal Respir ; 36(2): 197-203, 2019 Feb.
Artigo em Francês | MEDLINE | ID: mdl-30711345

RESUMO

INTRODUCTION: Lyme disease is not uncommon and can sometimes progress to neurological complications. We report here an unusual case of bilateral diaphragmatic paralysis secondary to Lyme neuroborreliosis. CASE REPORT: A 79-year-old man was admitted to the intensive care unit for acute respiratory distress requiring intubation and the long-term use of nocturnal non-invasive ventilation. Three months beforehand he had been bitten by a tick and developed erythema migrans which was treated with Doxycycline for 10 days. This clinical presentation became complicated a few days later by the progressive onset of severe dyspnoea. At admission, chest radiography revealed bilateral elevation of the diaphragm. Pulmonary function tests revealed a severe restrictive disorder aggravated by decubitus. A diaphragmatic electromyogram showed bilateral axonal polyneuropathy of the phrenic nerves. IgG and IgM antibodies to Borrelia burgdorferi were detectable in serum and cerebrospinal fluid, leading to the diagnosis of Lyme disease. He was treated with intravenous ceftriaxone 2g per day for 21 days, leading to a substantial improvement in symptoms. CONCLUSION: In the presence of unilateral or bilateral diaphragmatic paralysis of undetermined aetiology, it seems relevant to perform Lyme serology in the blood and, in positive cases, to follow up with a lumbar puncture in order to detect intrathecal IgG synthesis.


Assuntos
Neuroborreliose de Lyme/complicações , Síndrome do Desconforto Respiratório do Adulto/etiologia , Paralisia Respiratória/etiologia , Idoso , Grupo Borrelia Burgdorferi/efeitos dos fármacos , Grupo Borrelia Burgdorferi/isolamento & purificação , Ceftriaxona/uso terapêutico , Doxiciclina/uso terapêutico , Humanos , Neuroborreliose de Lyme/diagnóstico , Neuroborreliose de Lyme/tratamento farmacológico , Masculino , Síndrome do Desconforto Respiratório do Adulto/diagnóstico , Síndrome do Desconforto Respiratório do Adulto/tratamento farmacológico , Paralisia Respiratória/diagnóstico , Paralisia Respiratória/tratamento farmacológico
6.
BMJ Case Rep ; 11(1)2018 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-30567185

RESUMO

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/cirurgia
7.
Tex Heart Inst J ; 45(4): 270-272, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-30374244

RESUMO

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/diagnóstico
11.
Rev Esp Anestesiol Reanim ; 65(10): 593-596, 2018 Dec.
Artigo em Inglês, Espanhol | MEDLINE | ID: mdl-30033043

RESUMO

Phrenic nerve block is a complication that can occur after brachial plexus anaesthesia above the clavicle. The main consequence of this blockage is ipsolateral diaphragmatic paralysis, which can sometimes lead to the appearance of post-operative respiratory complications. A case is presented on a woman, who after having undergone a total shoulder prosthesis, presented with dyspnoea in the post-operative recovery unit. A diaphragmatic ultrasound was performed that enabled a rapid diagnosis to be made of a complete paralysis of the ipsolateral hemi-diaphragm. Given the suspicion of phrenic nerve block, ultrasound has proven to be a rapid diagnostic tool with high sensitivity and specificity. Its use can anticipate the possible development of immediate complications, and act as a guide in choosing the appropriate therapeutic strategy for each case in an early manner. In this case it enabled us to treat early with oxygen therapy, interscalene catheter removal, and intensive surveillance.


Assuntos
Artroplastia do Ombro , Diafragma/diagnóstico por imagem , Doenças do Sistema Nervoso Periférico/diagnóstico , Nervo Frênico/fisiopatologia , Complicações Pós-Operatórias/diagnóstico , Paralisia Respiratória/diagnóstico , Idoso , Anestésicos Locais/efeitos adversos , Bloqueio do Plexo Braquial/efeitos adversos , Remoção de Dispositivo , Dispneia/etiologia , Dispneia/terapia , Diagnóstico Precoce , Feminino , Humanos , Levobupivacaína/efeitos adversos , Oxigenoterapia , Doenças do Sistema Nervoso Periférico/etiologia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/terapia , Paralisia Respiratória/diagnóstico por imagem , Paralisia Respiratória/etiologia , Ultrassonografia
12.
Cardiol Young ; 28(5): 776-778, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29490711

RESUMO

Diaphragm excursion method is unsuitable for diagnosis of diaphragm paralysis during positive pressure ventilation. We diagnosed diaphragm paralysis in a neonate, without interrupting positive pressure respiratory support after cardiac surgery, using the diaphragm thickness fraction, which could be evaluated during mechanical ventilation and was unaffected by bowel gases. The diaphragm thickness fraction method can help diagnose diaphragm dysfunction using only echography.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Cardiopatias Congênitas/cirurgia , Respiração Artificial/efeitos adversos , Paralisia Respiratória/diagnóstico , Ultrassonografia/métodos , Humanos , Recém-Nascido , Masculino , Período Pós-Operatório , Paralisia Respiratória/etiologia
13.
Korean J Radiol ; 19(1): 111-118, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29354007

RESUMO

Objective: To evaluate the technical feasibility of four-dimensional (4D) CT for the functional evaluation of the pediatric diaphragm. Materials and Methods: In 22 consecutive children (median age 3.5 months, age range 3 days-3 years), 4D CT was performed to assess diaphragm motion. Diaphragm abnormalities were qualitatively evaluated and diaphragm motion was quantitatively measured on 4D CT. Lung density changes between peak inspiration and expiration were measured in the basal lung parenchyma. The diaphragm motions and lung density changes measured on 4D CT were compared between various diaphragm conditions. In 11 of the 22 children, chest sonography was available for comparison. Results: Four-dimensional CT demonstrated normal diaphragm (n = 8), paralysis (n = 10), eventration (n = 3), and diffusely decreased motion (n = 1). Chest sonography demonstrated normal diaphragm (n = 2), paralysis (n = 6), eventration (n = 2), and right pleural effusion (n = 1). The sonographic findings were concordant with the 4D CT findings in 90.9% (10/11) of the patients. In diaphragm paralysis, the affected diaphragm motion was significantly decreased compared with the contralateral normal diaphragm motion (-1.1 ± 2.2 mm vs. 7.6 ± 3.8 mm, p = 0.005). The normal diaphragms showed significantly greater motion than the paralyzed diaphragms (4.5 ± 2.1 mm vs. -1.1 ± 2.2 mm, p < 0.0001), while the normal diaphragm motion was significantly smaller than the motion of the contralateral normal diaphragm in paralysis (4.5 ± 2.1 mm vs. 7.6 ± 3.8 mm, p = 0.01). Basal lung density change of the affected side was significantly smaller than that of the contralateral side in diaphragm paralysis (89 ± 73 Hounsfield units [HU] vs. 180 ± 71 HU, p = 0.03), while no significant differences were found between the normal diaphragms and the paralyzed diaphragms (136 ± 66 HU vs. 89 ± 73 HU, p = 0.1) or between the normal diaphragms and the contralateral normal diaphragms in paralysis (136 ± 66 HU vs. 180 ± 71 HU, p = 0.1). Conclusion: The functional evaluation of the pediatric diaphragm is feasible with 4D CT in select children.


Assuntos
Diafragma/diagnóstico por imagem , Tomografia Computadorizada Quadridimensional , Paralisia Respiratória/diagnóstico , Eventração Diafragmática/diagnóstico , Eventração Diafragmática/diagnóstico por imagem , Feminino , Humanos , Lactente , Recém-Nascido , Pulmão/diagnóstico por imagem , Pulmão/fisiopatologia , Masculino , Paralisia Respiratória/diagnóstico por imagem , Estudos Retrospectivos , Ultrassonografia
16.
BMJ Case Rep ; 20172017 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-28720601

RESUMO

A 45-year-old man with a raised body mass index presented with an acute history of right lower chest pain and increasing breathlessness. C reactive protein, D dimer and cardiac echocardiography were negative, with mild bibasal atelectasis the only positive reported finding from erect chest X-ray and CT pulmonary angiogram. He was discharged with antibiotics for a chest infection. He remained severely breathless and was referred to the sleep-related breathing disorders clinic. He described shoulder pain, daytime tiredness and sleeping upright due to a ââ'¬Ëœsuffocatingââ'¬â"¢ sensation. The video demonstrates the clinical findings. The CT topogram confirmed bilateral diaphragmatic paralysis. Spirometry demonstrated an 80% reduction in forced vital capacity in the supine position, when compared with erect. Consultation with a neurologist yielded the diagnosis of neuralgic amyotrophy, leading to bilateral diaphragmatic paralysis. The respiratory symptoms have been controlled with night-time non-invasive ventilation, allowing him to sleep supine.


Assuntos
Neurite do Plexo Braquial/complicações , Diafragma/patologia , Dispneia/etiologia , Paralisia Respiratória/etiologia , Dor de Ombro/etiologia , Neurite do Plexo Braquial/diagnóstico , Diafragma/inervação , Dispneia/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva , Nervo Frênico , Paralisia Respiratória/diagnóstico , Dor de Ombro/diagnóstico , Espirometria
17.
Anesth Analg ; 125(1): 313-319, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28609340

RESUMO

BACKGROUND: The effect of interscalene block (ISB) on pulmonary function of obese participants has not been investigated. The goal of this study is to assess the association of obesity (body mass index [BMI] >29 kg/m vs BMI <25 kg/m) and change in forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) after ISB in participants undergoing outpatient shoulder surgery. METHODS: This prospective, observational cohort study compared obese (BMI >29 kg/m) and normal-weight (BMI <25 kg/m) groups undergoing ISB for ambulatory shoulder surgery, on preblock and postblock FVC and FEV1, at 30 minutes postblock and in the postanesthesia care unit (PACU). The primary outcome in this study was FVC% change (percentage change from preblock to postblock values of FVC) at 30 minutes postblock in the supine position. Secondary outcomes included FVC% change at PACU and in the sitting position, FEV1% change (percentage change from preblock to postblock values of FEV1), FVC, FEV1, incidence of diaphragmatic paresis, modified Borg scale for perceived dyspnea, Richmond Agitation-Sedation Scale scores for sedation, and intraoperative airway events. RESULTS: Fourteen participants were recruited to each group. The mean (standard deviation) BMI in the normal-weight and obese groups was 23 (1.7) and 33 (3.1) kg/m, respectively. ISB success rate was 100%. All participants demonstrated hemidiaphragmatic paresis after ISB. Compared to the normal-weight group, in the sitting position, the obese group had a significant decrease in FVC% change at 30 minutes (-30 [10.5] vs -23 [7.2], P = .046) and an FEV1% change in the PACU (-40 [12.6] vs -27 [13.9], P = .02). No difference was found for measurements taken in the supine position. A repeated-measures analysis demonstrated that, adjusted for position, there is no significant group effect on FVC% change or FEV1% change from 30 minutes to PACU. The 2 groups were not different in terms of breathlessness and sedation at 30 minutes (P = .67, P = .48, respectively) and in the PACU (P = .69, P > .99, respectively) nor in the occurrence of intraoperative airway events (P > .99). CONCLUSIONS: ISB is associated with greater FVC and FEV1 reductions in obese participants undergoing shoulder surgery compared to normal-weight participants. Neither time (30 minutes versus PACU) nor position (sitting versus supine) affected this relationship. Despite these changes, obesity was not associated with increased clinical respiratory symptoms or events.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Bloqueio do Plexo Braquial/efeitos adversos , Pulmão/fisiopatologia , Obesidade/complicações , Paralisia Respiratória/etiologia , Ombro/cirurgia , Adulto , Período de Recuperação da Anestesia , Índice de Massa Corporal , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/diagnóstico , Obesidade/fisiopatologia , Posicionamento do Paciente , Estudos Prospectivos , Recuperação de Função Fisiológica , Paralisia Respiratória/diagnóstico , Paralisia Respiratória/fisiopatologia , Fatores de Risco , Ombro/inervação , Decúbito Dorsal , Fatores de Tempo , Resultado do Tratamento , Capacidade Vital , Adulto Jovem
18.
Ann Thorac Surg ; 104(1): e9-e11, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28633275

RESUMO

A 49-year-old man with left phrenic nerve paralysis caused by mediastinal tumor resection 28 years earlier was found to have a nodule in the right upper lobe. The right phrenic nerve was severed during right upper lobectomy but was reconstructed along with bilateral plication of the diaphragm. The patient was weaned from the ventilator during the daytime on postoperative day 13 and was discharged home on postoperative day 48. Three months postoperatively, chest fluoroscopic imaging showed recovery of movement of the right diaphragm. Nerve conduction studies showed improvement of function of the reconstructed right phrenic nerve.


Assuntos
Diafragma/cirurgia , Neoplasias Pulmonares/cirurgia , Doenças do Sistema Nervoso Periférico/cirurgia , Nervo Frênico/cirurgia , Pneumonectomia/efeitos adversos , Procedimentos Cirúrgicos Reconstrutivos/métodos , Paralisia Respiratória/cirurgia , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Diafragma/inervação , Humanos , Neoplasias Pulmonares/diagnóstico , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso Periférico/complicações , Doenças do Sistema Nervoso Periférico/diagnóstico , Nervo Frênico/lesões , Radiografia Torácica , Paralisia Respiratória/diagnóstico , Paralisia Respiratória/etiologia , Tomografia Computadorizada por Raios X
19.
Ned Tijdschr Geneeskd ; 161: D1135, 2017.
Artigo em Holandês | MEDLINE | ID: mdl-28659200

RESUMO

BACKGROUND: Neuralgic amyotrophy is characterised by pain in the neck or shoulder region, followed by neuropathy of both motor and sensory nerves of the brachial plexus. The incidence of this condition is estimated at 1/1000 per year. In a rare variant of the syndrome, involvement of both phrenic nerves can occur, leading to diaphragmatic paralysis and severe orthopnoea. CASE DESCRIPTION: A 67-year-old woman was referred to us with acute orthopnoea. Imaging studies showed bilateral diaphragmatic paralysis, and electromyography (EMG) confirmed neuropathy of both phrenic nerves. The diagnosis was bilateral neuralgic amyotrophy. The patient received nocturnal ventilation support via nasal high flow oxygen therapy. This symptomatic treatment had a positive effect. CONCLUSION: Isolated phrenic nerve neuropathy is a rare variant of neuralgic amyotrophy, leading to orthopnoea. Recovery is slow and frequently incomplete. Supportive treatment with non-invasive ventilation support is necessary to improve the patient's quality of life.


Assuntos
Neurite do Plexo Braquial/diagnóstico , Dispneia/diagnóstico , Idoso , Neurite do Plexo Braquial/epidemiologia , Dispneia/etiologia , Feminino , Humanos , Nervo Frênico , Qualidade de Vida , Paralisia Respiratória/diagnóstico
20.
BMJ Case Rep ; 20172017 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-28249882

RESUMO

A 61-year-old man who was an ex-heavy smoker presented to our ambulatory care centre with a 4-week history of dyspnoea on mild exertion. 2 weeks prior to his symptoms, he had developed right-sided cervical herpes zoster for which he was prescribed oral acyclovir by his general practitioner. On examination, a rash over the right C4-5 dermatomes was noted and dullness on percussion of the right mid and lower zones with markedly reduced air entry. His chest radiograph showed a raised right hemi-diaphragm with associated right middle and lower lobe collapse. Further investigation with CT and bronchoscopy did not identify a cause and showed no evidence of underlying malignancy or endobronchial obstruction. An ultrasound 'sniff test' was performed to confirm diaphragmatic paralysis. We present a rare case of cervical herpes-induced diaphragmatic paralysis, and summarise our approach and the current understanding of this interesting condition.


Assuntos
Diafragma/fisiologia , Exantema/etiologia , Herpes Zoster/tratamento farmacológico , Paralisia Respiratória/diagnóstico , Aciclovir/administração & dosagem , Amitriptilina/administração & dosagem , Herpes Zoster/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Neuralgia/tratamento farmacológico , Paralisia Respiratória/etiologia , Paralisia Respiratória/virologia , Resultado do Tratamento
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