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ЛЕЧЕНИЕ ПАРАЛИЧЕЙ И ПАРЕЗОВ ДИАФРАГМЫ
In rare cases, diaphragmatic paralysis is reversible, but in most cases it is not. There are several options for the treatment of diaphragmatic weakness, and the treatment of choice depends on the severity and the etiology. For patients with daytime and/or nocturnal hypoventilation, noninvasive positive pressure ventilation may be used at night. In one study of patients with neuromuscular disease, symptoms of poor sleep quality, such as headache, daytime fatigue, and cognitive impairment, are improved by the use of nocturnal continuous positive airway pressure. In addition, in this study, daytime arterial PO2 and PCO2 improved with therapy.31 In another study, transdiaphragmatic pressures improved after a period of ventilatory support.32 Permanent positive pressure ventilation via tracheostomy is used for high cervical spine injuries.
Diaphragmatic pacing is another option for the treatment of diaphragmatic paralysis. In cervical spinal cord lesions above C3, the C3-C5 motor neurons and the phrenic nerve remain intact. Therefore, phrenic nerve pacing is a feasible treatment option. Before placement of the device, an EMG should be performed to ensure that the phrenic nerve is functionally intact. The pacer is then implanted into the phrenic nerves in the neck or the chest and controlled by a stimulating unit that is external to the body. There is a conditioning period, during which the diaphragm regains function after its period of paralysis, and this may be complicated by hypercapnia. If successful, diaphragmatic pacing may provide normal pulmonary function and arterial blood gases as well as a decreased incidence of respiratory infections. Theoretical concerns about nerve damage resulting from pacing have not been borne out in the literature.33 In spinal cord lesions affecting the C3-C5 motor neurons, the efficacy of diaphragmatic pacing depends on the level of the lesion. Unfortunately, when these motor neurons are damaged, the phrenic nerve is damaged, and denervation leads to atrophy of the diaphragm muscle.
Unilateral diaphragmatic paralysis is usually asymptomatic, but when it produces symptoms in the setting of strenuous exertion or underlying lung disease, it may be treated. Diaphragmatic plication has been shown to result in improvements in oxygenation and lung volumes as well as symptoms, and is associated with little morbidity.34,35 The procedure prevents the paralyzed diaphragm from being pulled up into the thorax by the negative pressure generated by the healthy diaphragm. This improves ventilation to the ipsilateral lung and reduces the workload of the contralateral diaphragm, preventing fatigue.
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