Surgical management of symptomatic diaphragm paralysis*

DPT: diaphragm physical therapy; EMG: electromyography.
* For potential candidates for phrenic nerve reconstruction, refer to a center of excellence for best outcomes. Favorable candidates for nerve reconstruction include those with a recent injury (<5 years) who are physically fit and have minimal comorbidities. Conversely, unfavorable candidates are those with a remote injury (>5 years) or obesity or who are older, unable to exercise, or have multiple medical comorbidities.
¶ Iatrogenic or traumatic.
Δ Following acute transection, motor units remain viable for 18 to 24 months.
◊ DPT is not uniformly available, and where unavailable, the patient's medical status should be optimized. The ability to participate with DPT in the postoperative period following phrenic nerve reconstruction is important for recovery.
§ Minimum of 6 to 8 months.
¥ The availability of high-quality electrodiagnostic testing for phrenic nerve injury may be limited to centers that specialize in treating this condition. When performed by clinicians with limited experience, there is a high rate of false positive results (ie, reporting no motor units detectable), particularly in patients who are overweight or with obesity.
‡ For patients with superimposed pulmonary disease, dyspnea that is disproportionate to physical activity.
† Preoperative electrodiagnostic testing is corroborated with intraoperative testing, which is more precise since the nerve is contacted directly and diaphragm movement can be seen directly in response to nerve stimulation.
** Supportive care includes respiratory support and ongoing DPT.
¶¶ Whether phrenic nerve reconstruction is feasible depends on the mechanism of injury (eg, sharp transection, stretching), location of the injury (eg, neck, chest), hostility of the surgical field, and the patient's surgical risk.
ΔΔ Complex presentations include remote injury (>5 years), hostile surgical field (eg, prior radiation), obesity, and poor functional status.