An unusual case of orthopnea

Abstract

Bilateral diaphragmatic paralysis is a known cause of respiratory failure. Diagnosis can be difficult, particularly in the acute setting. We present the case of a gentleman diagnosed with bilateral diaphragmatic paralysis secondary to phrenic neuropathy in the setting of cervical spondylosis. KEYWORDS :Cervical spondylosis , diaphragmatic paralysis , orthopnea , phrenic neuropathy Case presentationA 63-year-old man presented to the emergency department with a 2-day history of orthopnea. He reported lifting heavy iron tables 3 days prior to presentation. Bilateral shoulder and neck discomfort were described 1 day prior to the onset of orthopnea. He reported no chest pain, cough, wheeze, sputum, haemoptysis, fevers or ankle oedema. He was a nonsmoker whose past medical history included osteoarthritis, hypercholesterolaemia and hypertension.Cardiovascular and respiratory examinations were normal. Bilateral tenderness of the trapezius muscles was present, increasing with shoulder abduction. No cervical spinal tenderness was evident and neurological examination was normal. Further examination revealed significant positional orthopnea. Differential diagnosisOrthopnea is a common manifestation of pulmonary oedema secondary to left ventricular failure and in those suffering from asthma, neuromuscular disease, sleep apnoea or panic disorders. Given this patient's symptoms of neck and back pain, consideration must be given to neuromuscular pathologies. Initial managementInflammatory markers, troponin, d-dimer and N-terminal pro b-type natriuretic peptide were normal. Electrocardiogram revealed left ventricular hypertrophy, documented as long standing. Initial chest X-rays demonstrated a small left pleural ABSTRACT An unusual case of orthopnea effusion, making assessment of the left hemidiaphragm difficult. A transthoracic echocardiogram was normal. A computerised tomography pulmonary angiogram (CTPA) was performed because of the patient's ongoing symptoms. This required two attempts because of the patient's orthopnea. CTPA showed bibasal atelectasis with no evidence of pulmonary embolism. Diazepam was required to allow for completion of the CTPA and consideration was given to a panic disorder. However, the patient demonstrated no other features in keeping with this.Pulmonary function tests revealed a restrictive pathology with forced expiratory volume at first second (FEV1) of 3.01 L (57% predicted), forced vital capacity (FVC) 3.84 L (60% predicted) and a FEV1/FVC ratio of 78%. Mean inspiratory and expiratory pressures were reduced and a marked decrease in vital capacity was noted with sitting and supine values of 2.13 L and 0.9 L, respectively. Bedside thoracic ultrasonography revealed limited diaphragmatic movement bilaterally. Fluoroscopic sniff test showed reduced maximum inspiratory and expiratory pressures. Chest radiographs completed in both lying (Fig 1 ) and standing (Fig 2 ) positions demonstrated elevated bilateral hemidiaphragms while supine. DiagnosisA presumptive diagnosis of diaphragmatic paralysis was con...

Cervical Spine Stenosis Causing Diaphragmatic Paralysis: A Case Study and Narrative Review of Clinical Presentations and Outcomes

“…Only articles that documented radiologic evidence of myelopathy or radiculopathy were included. [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Across the cases, the average age was 64 years old, with 16 male and 3 female patients (Table 2). The most common etiology (n = 6, 32%) involved cervical trauma from a motor vehicle accident, lifting heavy objects, and iatrogenic injury.…”

“…In the 19 case reports reviewed, all patients who underwent a decompressive spinal procedure (n = 14, 74%) experienced improvement in dyspnea and increased diaphragmatic movement. 1,2,[5][6][7]10,[12][13][14][15][16][17][18][19] The first signs of respiratory improvement among surgical cases ranged from same-day postoperative recovery to 2 years postsurgery (Table 2). Of the 2 patients who did not receive surgical treatment, 1 patient was successfully weaned off mechanical ventilation and was breathing independently after 6 months, while the other patient ultimately expired from a fatal heart attack.…”

“…6 Of the 3 patients who received physiotherapy or bilevel positive airway pressure (BiPAP), 1 patient had improved PFTs and orthopnea after 9 months, while the other 2 patients experienced no improvement. 10,11,13 One of the patients who did not experience any improvement in their dyspnea eventually developed right ventricular failure and pulmonary hypertension and was transitioned to hospice care. 10 However, it is important to note the patient was not adherent to his BiPAP or medical therapy for his preexisting conditions.…”

“…After reviewing the cases presented in each article and performing an independent literature review, 7 more cases were added to the review for a total of nineteen cases of diaphragmatic paralysis secondary to foraminal and central stenosis (Table 2). Only articles that documented radiologic evidence of myelopathy or radiculopathy were included 2–19 . Across the cases, the average age was 64 years old, with 16 male and 3 female patients (Table 2).…”

“…In the 19 case reports reviewed, all patients who underwent a decompressive spinal procedure (n=14, 74%) experienced improvement in dyspnea and increased diaphragmatic movement 1,2,5–7,10,12–19 . The first signs of respiratory improvement among surgical cases ranged from same-day postoperative recovery to 2 years postsurgery (Table 2).…”