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The case of a 15-month-old boy with bilateral diaphragm paralysis after simultaneous cardiac surgery for tetralogy of Fallot, and Nuss procedure for pectus excavatum, is presented. Extubated one day after his first operation, the boy suffered severe respiratory distress soon after, due to bilateral diaphragmatic paralysis. Diaphragm paralysis restricted abdominal respiration, while thoracic respiration was inhibited by metallic bar after the Nuss Procedure, which combined prevented extubation for 47 days. Thoracoplasty, such as the Nuss Procedure, should not be performed simultaneously with cardiac surgery because abdominal and thoracic respiration can be restricted in infants, causing prolonged, severe, post-surgical respiratory failure.

Introduction: Acute hypercapnic respiratory failure is a medical emergency that can have numerous underlying causes, including central nervous system issues, lung and airway diseases, and diaphragmatic dysfunction. In recent years, immune checkpoint inhibitors (ICIs) have become a widely used treatment for solid organ malignancies, offering promising results for patients. However, ICIs can also cause autoimmune toxicities, including rare but severe neurologic toxicities, such as bilateral diaphragmatic paralysis. Case: A 70-year-old male patient with chronic obstructive pulmonary disease (COPD) was hospitalised for total gastrectomy. His past medical history was left upper lobectomy due to melenoma metastatis, primary was BRAF negative malignant melanoma of gastric fundus. He was given 2 courses of nivolumab immunotherapy. The patient, who developed hypercarbic respiratory failure after admission to surgical ward, was intubated. After our multiple weaning attempts were unsuccessful, we performed further examinations and treatments. Multiple tests were conducted to rule out other possible causes of the patient’s condition, including phrenic nerve involvement, nerve-muscle junction diseases, limbic encephalitis, and paraneoplastic panels, which all returned negative results. The patient was diagnosed with bilateral diaphragmatic paralysis by fluoroscopy. The patient with elevated creatine kinase and antitin antibody positivity was diagnosed with subacute progressive diaphragmatic paralysis after nivolumab. To manage the patient’s condition, the patient was given pulse steroid, intravenous immunoglobulin and underwent plasmapheresis. Despite the treatment, the patient required mechanical ventilation support. The patient who underwent tracheostomy due to prolonged intubation. Finally he was discharged with intermittent use of a home type mechanical ventilator. Discussion: It is important to note that diaphragmatic dysfunction as a side effect of ICI treatment may occur weeks after administration and may be mistaken for other causes of hypercarbic respiratory failure [ABSTRACT FROM AUTHOR]

The case of a 15-month-old boy with bilateral diaphragm paralysis after simultaneous cardiac surgery for tetralogy of Fallot, and Nuss procedure for pectus excavatum, is presented. Extubated one day after his first operation, the boy suffered severe respiratory distress soon after, due to bilateral diaphragmatic paralysis. Diaphragm paralysis restricted abdominal respiration, while thoracic respiration was inhibited by metallic bar after the Nuss Procedure, which combined prevented extubation for 47 days. Thoracoplasty, such as the Nuss Procedure, should not be performed simultaneously with cardiac surgery because abdominal and thoracic respiration can be restricted in infants, causing prolonged, severe, post-surgical respiratory failure. [ABSTRACT FROM AUTHOR]

Bilateral diaphragmatic paralysis (BDP) can occur in the course of motor neuron disease, myopathy, or from mechanical damage or the use of ‘ice slush’ during cardiac surgery. BDP has been observed during and after infections, associated with systemic lupus erythematosus and mediastinal tumors, or may have idiopathic etiology. It is a serious and life-threatening condition. A 62-yr-old man presented with slowly progressive dyspnoea that worsened in the supine position and on bending forward. Chest X-rays, fluoroscopy, lung-function parameters and blood-gas analysis revealed respiratory failure. BDP was confirmed from a phrenic nerve stimulation test and measurement of transdiaphragmatic pressure (Pdi). Since there was no evidence of an obvious etiology, BDP was considered idiopathic. Other muscles were not involved. The pathological basis was probably focal demyelination in segments of the phrenic nerve. Because of increasing diaphragmatic muscle fatigue, the patient was treated with a nasal mask providing bilevel positive airway pressure (BiPAP) ventilation during the night. Clinical suspicion of BDP should always be raised in patients suffering slowly progressive dyspnoea without any obvious cardiac, metabolic or traumatic predisposing factors, and orthopnoea and dyspnoea on bending forward. Electromyographic tests and measurement of Pdi can reveal the correct diagnosis. [ABSTRACT FROM AUTHOR]

Abstract: Daily inspiratory muscle strength and endurance training (IMT) was performed in a 44-year-old patient with idiopathic bilateral diaphragmatic paralysis (BDP) in addition to nocturnal non-invasive ventilation (NIV). After 4 months of training inspiratory muscle function improved satisfactorily whereas phrenic nerve latency remained pathological. Due to the improvement of inspiratory muscle capacity nocturnal NIV could be stopped without inducing nocturnal respiratory insufficiency. [Copyright &y& Elsevier]

Diaphragmatic paralysis following phrenic nerve injury is a major complication following congenital cardiac surgery. In contrast to unilateral paralysis, patients with bilateral diaphragmatic paralysis present a higher risk group, require different management methods, and have poorer prognosis. We retrospectively analysed seven patients who had bilateral diaphragmatic paralysis following congenital heart surgery during the period from July, 2006 to July, 2014. Considerations were given to the time to diagnosis of diaphragm paralysis, total ventilator days, interval after plication, and lengths of ICU and hospital stays. The incidence of bilateral diaphragmatic paralysis was 0.68% with a median age of 2 months (0.6-12 months). There was one neonate and six infants with a median weight of 4 kg (3-7 kg); five patients underwent unilateral plication of the paradoxical diaphragm following recovery of the other side, whereas the remaining two patients who did not demonstrate a paradoxical movement were successfully weaned from the ventilator following recovery of function in one of the diaphragms. The median ventilation time for the whole group was 48 days (20-90 days). The median length of ICU stay was 46 days (24-110 days), and the median length of hospital stay was 50 days (30-116 days). None of the patients required tracheostomy for respiratory support and there were no mortalities, although all the patients except one developed ventilator-associated pneumonia. The outcome of different management options for bilateral diaphragmatic paralysis following surgery for CHD is discussed.

Background. Brachial neuritis (BN) is a rare inflammatory condition of peripheral nerves, usually involving the cervicobrachial plexus. These patients present with sudden onset of shoulder and arm pain that evolves into muscle weakness and atrophy.. Case Report. A 33-year-old woman presented with a 1-month history of diffuse pain in her thorax. She had no trauma or inciting incident prior to the onset of this pain and was initially treated for muscle spasms. The patient was seen in the emergency room multiple times and was treated with several courses of antibiotics for pneumonia on the basis of clinical symptoms and abnormal x-rays. The pleuritic chest pain persisted for at least 4 months, and the patient was eventually admitted for worsening pain and dyspnea. On physical examination, crackles were heard at both lung bases, and chest inspection revealed increased expansion in the upper thorax but poor expansion of the lower thorax and mild paradoxical respiration. "Sniff" test revealed no motion of the left hemidiaphragm and reduced motion on the right hemidiaphragm. Her computed tomography scan revealed bilateral atelectasis, more severe at the left base. She reported no symptoms involving her joints or skin or abdomen. Her presentation and clinical course are best explained by BN with a bilateral diaphragmatic weakness. However, she had a positive ANA, RF, anti-RNP antibody, and anti SS-A. Conclusion. Patients with BN can present with diffuse thoracic pain, pleuritic chest pain, and diaphragmatic weakness. Our patient may represent a case of connective tissue disease presenting with brachial plexus neuritis.