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Aggressive treatment of acquired phrenic nerve paralysis in infants and small children
Insights
Early diagnosis and treatment of diaphragmatic paralysis from phrenic nerve injury in children significantly improve outcomes. Transthoracic diaphragmatic plication is an effective surgical intervention for these pediatric patients.
Area of Science:
- Pediatric Surgery
- Thoracic Surgery
- Critical Care Medicine
Background:
- Phrenic nerve injury can lead to diaphragmatic paralysis, causing significant respiratory distress in infants.
- Congenital heart disease surgery is a risk factor for phrenic nerve injury in pediatric patients.
- Delayed diagnosis and treatment of diaphragmatic paralysis are associated with prolonged ventilation and increased morbidity.
Purpose of the Study:
- To evaluate the efficacy of transthoracic diaphragmatic plication for treating pediatric diaphragmatic paralysis secondary to phrenic nerve injury.
- To assess the impact of early diagnosis and intervention on patient outcomes.
Main Methods:
- Retrospective review of pediatric patients who sustained phrenic nerve injury during congenital heart disease surgery.
- Analysis of diagnostic methods (fluoroscopy), time to diagnosis, and treatment with transthoracic diaphragmatic plication.
- Comparison of outcomes before and after 1980, reflecting changes in diagnostic and treatment timing.
Main Results:
- Seven pediatric patients experienced phrenic nerve injury over five years, primarily infants undergoing congenital heart surgery.
- Patients diagnosed and treated earlier (average 7.8 days) had shorter ventilation durations post-plication (mean 3.7 days) compared to those diagnosed later (average 16 days).
- Six out of seven patients survived and showed good recovery after transthoracic diaphragmatic plication; the one death occurred in a complex case with delayed diagnosis.
Conclusions:
- Transthoracic diaphragmatic plication is a safe and effective treatment for pediatric diaphragmatic paralysis.
- Prompt diagnosis and surgical intervention are crucial for optimizing respiratory function and survival in children with phrenic nerve injury.
- Establishing an early diagnosis and initiating timely treatment are vital components of managing symptomatic pediatric diaphragmatic paralysis.
Abstract:
Transthoracic diaphragmatic plication is a simple and effective means of treatment for phrenic nerve injury and resultant diaphragmatic paralysis, and should be undertaken as soon as the diagnosis of diaphragmatic paralysis is established in a child with substantial respiratory difficulty. Seven of more than 1,500 patients sustained phrenic nerve injury during operation for congenital heart disease at our institution over the past five years. All but 1 patient were less than 5 months old, and the average weight was 3.8 kg. Five of the 7 could not be weaned from the ventilator, and the other 2 had persistent postoperative tachypnea and stridor. Before 1980, 3 patients were intubated for an average of 16 days prior to diagnosis by fluoroscopy. Since then, 4 patients have been intubated for an average of 7.8 days before diagnosis. All 7 underwent transthoracic diaphragmatic plication and were extubated by 6 days after operation (mean, 3.7 days). Six patients survived and are doing well. The 1 death occurred in 1976 in a premature infant with multiple congenital cardiac lesions; diagnosis was delayed until the twenty-eighth day after intubation and transthoracic diaphragmatic plication, until the sixty-second day. This infant died of pneumonia one month after extubation. These data support our policy of establishing an early diagnosis of phrenic nerve injury and early treatment utilizing transthoracic diaphragmatic plication in symptomatic children.