Paralysis of the diaphragm symptoms. Diaphragm dysfunction clinic. Hernias of the natural openings of the diaphragm

Diaphragm, "abdominal barrier" - a powerful muscular organ that delimits the cavity chest from the abdominal cavity and supporting with its tone intra-abdominal pressure. This tone is maintained both at low (enteroptosis) and at high standing of the diaphragm (ascites, flatulence, pregnancy), ensuring the effectiveness of active contraction of the diaphragm during inspiration. The diaphragm is the main respiratory muscle involved in blood circulation. Rhythmic respiratory movements The diaphragms contribute to respiration from the moment of birth and do not stop completely, as established radiologically, even during a pause in Cheynstokes breathing. Particularly large aperture value for ventilation lower divisions lungs, where atelectasis most often develops, for example, after surgery. The diaphragm, contracting, brings together the edges of the lower opening of the chest, being to a certain extent an antagonist of the intercostal muscles, which raise the lowered arches of the ribs and thereby expand the lower opening of the chest. Interaction with the intercostal muscles is provided especially effective increase lung volume. With paralysis of the diaphragm during inspiration, the false ribs diverge to the sides, and epigastric region swells.
The participation of the diaphragm in blood circulation is also significant. Closely braiding the liver with its legs and dome, the diaphragm during inhalation squeezes venous blood out of the liver and at the same time rarefies intrathoracic pressure, thus facilitating suction venous blood from the main venous collectors to the heart.
The diaphragm performs its complex function of the muscular organ of respiration and blood circulation due to complex innervation, which also determines numerous neuroreflex reactions of the diaphragm in violation of the central nervous and autonomic regulation.
With pulmonary emphysema, a prolonged increase in diaphragm function initially leads to its hypertrophy, and then to degenerative changes (fat degeneration) with function decompensation, which has great importance in the development of respiratory and pulmonary heart failure in lung diseases. Atrophy of the muscular layers of the diaphragm is found with paralysis of the phrenic nerve, for example, after therapeutic frenic exeresis for pulmonary tuberculosis.
The height of standing and the movements of the diaphragm in the clinic are judged by visible movement diaphragmatic shadow during breathing (Litten's phenomenon), along the percussion border of the lungs with organs abdominal cavity, as well as by the respiratory movements of the false ribs, "partly by the rhythmic change of retraction and bulging of the epigastric region. Low standing of the diaphragm is observed with emphysema, effusion pleurisy, pericarditis, etc., high with ascites, flatulence, intra-abdominal tumors. The most distinct the data is revealed by fluoroscopy.
Painful diaphragmatic syndrome is associated with the fact that central part diaphragm innervates n. phrenicus, why pain is transmitted through the fourth cervical nerve in the neck and in the area trapezius muscle(brachial, acromial sign) and there are pain points along the intercostal space at the sternum (especially on the right) and between the legs of the sternocleidomastoid muscle. The peripheral part of the diaphragm is innervated from the intercostal nerves, and the pain is related to the lower part of the chest, to the epigastric region and the abdominal wall; there are also pains of a reflex nature, such as angina pectoris, transmitted through n. vagus.

Diaphragmatitis

Clonic spasm of the diaphragm (hiccups)

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Clonic spasm of the diaphragm (hiccups) is usually a harmless phenomenon, sometimes life-threatening, more often occurs reflexively in response to irritation of neighboring organs, with stomach overload, with incipient peritonitis, with irritation of the phrenic nerve by a mediastinal tumor, aortic aneurysm, or from excitation of a center located nearby with respiratory, -agonal hiccups, which has such a poor prognostic value, uremic hiccups, hiccups with cerebral apoplexy, encephalitis, with venous congestion brain.
Treatment. Skin irritation (mustard plasters, rubbing the skin with brushes, ether under the skin), distracting the patient's attention, arousal respiratory center(inhalation of carbon dioxide in pure form or In the form of carbogen), lobelia, quinidine (as a decrease in the excitability of the diaphragmatic muscle), alcoholism and in last resort transection of the phrenic nerve.
Tonic spasm of the diaphragm observed with tetany, tetanus, with peritonitis. Therapy-chloroform, ether.

Diaphragm paralysis

Paralysis of the diaphragm is characterized by its high standing. When breathing, there is a discrepancy to the sides of the lower ribs, the epigastric region does not swell, as is normal, and the liver does not descend. Shortness of breath develops during work and excitement. There is a change in voice, weakness of coughing, sneezing. Tension drops out during the act of defecation. With complete paralysis, after minimal stress, fatal asphyxia can occur.
Diaphragmatic hernia (false and true). Diaphragmatic hernia is usually called a false traumatic hernia (hernia diaphragmatica spuria, traumatica; evisceratio), when in typical cases after stab wound or blunt trauma, as a rule, on the left through the gap is the diaphragm protrude into chest cavity stomach and intestines. Severe shortness of breath, vomiting, hiccups develop, and death from shock may even occur. The study finds tympanitis in the chest, the absence of respiratory noise, displacement of the heart, especially characteristic iridescent bowel sounds in the chest or hemothorax, concomitant pleurisy, peritonitis, sharp radiological changes.
The general practitioner often deals with long-term consequences trauma, about which the patient does not always find it necessary to tell without special questioning.
The patient usually has only nausea, vomiting, or symptoms intestinal obstruction. There may be signs of compression of the mediastinal organs. When examining, it is important to pay attention to the scar from the wound. Find also an unusual area of ​​a tympanic sound in a thorax; respiratory mobility of the chest is limited (usually on the left), respiratory sounds are weakened or not heard, the heart is displaced. In contrast to pneumothorax, there is no bulging of the intercostal spaces, but a devastated epigastric region is characteristic, especially the intestinal sounds of a prolapsed stomach and intestines heard in hailstones. An X-ray examination after taking barium clarifies the picture in detail.
The most severe, sometimes fatal complication - intestinal obstruction. Treatment is surgical and technically difficult.
Less often emb. a true diaphragmatic hernia (hernia diaphragmatica vera) is supplied, when, due to a congenital defect in the development of the diaphragm (usually due to xiphoid process) the stomach or large intestine is in the anterior or posterior mediastinum, in a bag of one or all sheets of diaphragm.
AT last years with a wide x-ray examination patients are not so rarely found small diaphragmatic hernia at the hiatus oesophageus itself, and top part stomach protrudes above the diaphragm. The patient makes vague dyspeptic complaints, sometimes he suffers from more severe reflex angina pectoris due to irritation of the person passing by. vagus nerve and coronary spasm. From diaphragmatic hernia, one should also distinguish rare unilateral relaxation, relaxation or insufficiency of the diaphragm, which is opened by chance, when, in the absence of complaints, percussion tympanitis is found, and an X-ray examination reveals a high standing of the diaphragm.

Relaxation of the diaphragm is a pathology that is characterized by a sharp thinning or total absence muscle layer of the organ. It occurs due to anomalies in the development of the fetus or due to pathological process, which led to the protrusion of the organ into the chest cavity.

In fact, this term in medicine means two pathologies at once, which, however, have similar clinical symptoms and both are due to the progressive protrusion of one of the domes of the organ.

A congenital anomaly of development is characterized by the fact that one of the domes is devoid of muscle fibers. It is thin, transparent, consists mainly of sheets of the pleura and peritoneum.

In the case of acquired relaxation we are talking about paralysis of muscles and their subsequent atrophy. In this case, two variants of the development of the disease are possible: the first is a lesion with total loss tone, when the diaphragm looks like a tendon sac, and muscle atrophy is quite pronounced; the second is violations motor function while maintaining tone. The appearance of the acquired form is facilitated by damage to the nerves of the right or left dome.

Causes of pathology

A congenital form of relaxation can be provoked by abnormal laying of diaphragm myotomes, as well as impaired muscle differentiation, and intrauterine injury/aplasia of the phrenic nerve.

The acquired form (secondary muscle atrophy) can be caused by inflammatory and traumatic injuries organ.

Also, an acquired ailment occurs against the background of damage to the phrenic nerve: traumatic, surgical, inflammatory, scar damage with lymphadenitis, tumor.

The congenital form leads to the fact that after the birth of a child, the organ cannot bear the load placed on it. It gradually stretches, which leads to relaxation. Stretching can occur with different speed, that is, it can manifest itself both in early childhood and in the elderly.

It should be noted that the congenital form of pathology is often accompanied by other anomalies. prenatal development, for example, cryptorchidism, heart defects, etc.

The acquired form differs from the congenital one not by the absence, but by paresis / paralysis of the muscles and their subsequent atrophy. In this case, complete paralysis does not occur, so the symptoms are less pronounced than with the congenital form.

Acquired relaxation of the diaphragm may occur after secondary diaphragmitis, such as in pleurisy or subphrenic abscess, as well as after an organ injury.

Stretching of the stomach with pyloric stenosis can provoke the disease: constant trauma from the stomach provokes degenerative changes muscles and their relaxation.

Symptoms

The manifestations of the disease may differ from case to case. For example, they are very pronounced congenital pathology, and with acquired, especially partial, segmental, they may be completely absent. This is due to the fact that the acquired is characterized by a lower degree of tissue stretching, a lower standing of the organ.

In addition, the segmental localization of the pathology on the right is more favorable, since the adjacent liver, as it were, tampons the damaged area. Limited relaxation on the left can also be covered by the spleen.

With diaphragm relaxation, symptoms rarely occur in childhood. The disease is more often manifested in people aged 25-30, especially in those who are engaged in heavy physical labor.

The main cause of complaints is the displacement of the peritoneal organs into the chest. For example, a part of the stomach rising, provokes a bend in the esophagus and its own, as a result of which the motility of the organs is disturbed, respectively, there are pain. The kinking of the veins can lead to internal bleeding. These signs of the disease are aggravated after a meal and physical activity. In this situation pain syndrome provokes an inflection of the vessels feeding the spleen, kidney and pancreas. Attacks of pain can reach high intensity.

As a rule, the pain syndrome manifests itself acutely. Its duration varies from several minutes to several hours. It ends just as quickly as it starts. Nausea often precedes an attack. It is noted that the pathology may be accompanied by difficulty in passing food through the esophagus, as well as bloating. These two phenomena are often leading place in the pathology clinic.

Most patients complain of attacks of pain in the region of the heart. These can be due to both vagal reflux and direct pressure on the organ exerted by the stomach.

Diagnostic methods

The main method for detecting relaxation is x-ray examination. Sometimes during relaxation there is a suspicion of a hernia, but to conduct differential diagnosis without x-ray examination is almost impossible. Only sometimes the features of the course of the disease and the nature of its development make it possible to accurately determine the pathology.

The doctor, conducting a physical examination, detects the following phenomena: bottom line left lung; the zone of subdiaphragmatic tympanitis extends upwards; in the area of ​​pathology, intestinal peristalsis is heard.

treatment

In this situation, only one way to eliminate the disease is possible - surgical.

However, not all patients are operated on. To do so, evidence is required.

Surgical intervention is performed only in cases where a person has pronounced anatomical changes, clinical symptoms incapacitating, causing severe discomfort.

Diaphragm is the main muscle that provides pulmonary ventilation, and its value can be compared to a certain extent with the value of the cardiac muscle that carries out blood circulation. Decompensation of the diaphragm function is the most important mechanism of thanatogenesis in patients dying from respiratory failure in acute or chronic pathology lungs. Only those ventilation disorders that arise as a result of the pathology of the diaphragm itself will be considered here. This pathology includes paralysis of the diaphragm, relaxation of the diaphragm, diaphragmatic hernia of various origins, and some other conditions.

Unilateral paralysis of the diaphragm

The most common cause of unilateral diaphragmatic paralysis is invasion of the phrenic nerve by a malignant lung tumor or mediastinum. There is accidental damage to the nerve during surgery, trauma, or a violation of its function as a result of a viral infection. Operations specifically aimed at creating unilateral paralysis of the diaphragm in tuberculosis (phrenicotomy, frenitripsy, phrenic exeresis, phrenic alcoholization) are practically not used at present. Bilateral diaphragmatic paralysis is usually the result of a lesion cervical spinal cord. Cold injuries of both phrenic nerves during local cooling of the heart during intracardiac interventions are described. Paralysis of the diaphragm leads to a sharp unilateral or bilateral decrease in lung volumes and a corresponding violation of ventilation.

Unilateral diaphragmatic paralysis usually causes no symptoms or is manifested by a decrease in tolerance to significant loads. With bilateral paralysis, shortness of breath is noted with the participation of auxiliary muscles in breathing. Respiratory failure worsens horizontal position when the diaphragm rises even higher. In this case, the paradoxical movement of the anterior abdominal wall sinking during inhalation. Fluoroscopy reveals a high standing dome(s) of the diaphragm, immobility, or a paradoxical rise during inhalation, especially when the upper airway is closed. functional study with bilateral paralysis reveals a sharp decrease in the total volume and vital capacity lung and additional inspiratory volume; with one-sided - the corresponding volumes are reduced by only 20-25%. In the position of the patient lying down, volume indicators further worsen.

Treatment and prognosis for diaphragmatic paralysis depend on its cause. Unilateral paralysis special treatment do not require. For bilateral paralysis associated with spinal cord injury, permanent electrical stimulation of one of the phrenic nerves in the neck with an implantable pacemaker is recommended. Nerve damage associated with viral infection or cold injury during cardiac operations, often spontaneously eliminated after 6-8 months.

Diaphragm relaxation

Relaxation of the diaphragm (idiopathic relaxation of the diaphragm, eventration of the diaphragm) is a rare congenital defect consisting in the underdevelopment of the diaphragmatic muscle; occurs more often in men, it is one- or two-sided, and relaxation is usually total on the left, and partial on the right. Ventilation disturbances are similar to those in diaphragmatic paralysis. The most common unilateral relaxations are almost asymptomatic.

Radiologically, a high standing dome (domes) of the diaphragm is detected, and on the right, partial relaxation, filled with a protruding dome of the liver, sometimes requires differentiation with a tumor (diaphragm, lung, liver). The diagnosis is specified with the help of pneumoperitoneum, in which the protruding part of the dome is contrasted with air.

Treatment for unilateral lesions is most often unnecessary, although operations have been described that reduce the area of ​​the relaxed dome of the diaphragm and increase the volume of the corresponding hemithorax (diaphragmatic application, plastic synthetic fabric). Total bilateral relaxation, apparently, is not compatible with life, and its treatment is almost not developed.

Hernias of the natural openings of the diaphragm

Hernias natural holes aperture ( esophageal opening, holes of Morgagni and Bochdalek) rarely cause pronounced violations ventilation. Gastroesophageal reflux characteristic of sliding hernias esophageal opening, may cause repeated aspiration of gastric contents, especially at night, and be related to the pathogenesis of acute and chronic bronchopulmonary diseases, including bronchial asthma. Surgical treatment of these hernias (Nissen's operation) in some cases favorably affects the course of pulmonary pathology.

Congenital defects (false hernias) of the diaphragm in newborns, which are observed more often on the left, cause a massive displacement of the abdominal organs into the pleural cavity, compression collapse of the lung and displacement of the mediastinum in opposite side, which causes acute respiratory failure, manifested by severe shortness of breath, cyanosis and restlessness of the child. The diagnosis is confirmed by X-ray examination, in which the left pleural cavity the stomach and intestinal loops are revealed, and the mediastinum is displaced to the right. The situation calls for immediate surgical intervention aimed at restoring the continuity of the dome of the diaphragm.

Traumatic ruptures (false hernias) of the diaphragm

Traumatic ruptures (false hernias) of the diaphragm are observed with thoracoabdominal wounds, as well as with closed injuries(compression of the chest, abdomen, fall from a height). More often they are observed on the left, since the liver plays the role of a pelota on the right. With massive ruptures as a result of the movement of the abdominal organs into the pleural cavity, acute respiratory disorders as a result lung collapse and mediastinal displacement (shortness of breath, cyanosis, tachycardia, etc.). Small tears, especially in severe concomitant trauma, often go unrecognized.

A small volume of abdominal organs initially displaced through a defect in the diaphragm may not have a significant effect on ventilation, and only if it is infringed in the defect, when the volume hollow organs, located in the pleural cavity, increases sharply, can, along with acute phenomena from the side gastrointestinal tract (sharp pains in the right hypochondrium, vomiting, collapse), there are pronounced ventilation disorders (dyspnea, cyanosis, hypoxemia). In any case, a traumatic diaphragm defect is an indication for urgent or planned operation aimed at its elimination after the reduction of the abdominal organs.

Flattening of the diaphragm in emphysema

Of great importance in obstructive pathology of the lungs is a sharp flattening of the diaphragm in emphysema, associated with an increase in lung volume and an increase in intrathoracic pressure due to the disappearance of elastic retraction of the lungs and valvular disorders. bronchial patency. A flattened diaphragm during contraction is not able to increase the intrathoracic volume and, moreover, does not lift, but tightens lower ribs, to which it is attached and thus prevents inhalation. This phenomenon is observed in the terminal phases of respiratory failure, and the impact on it seems problematic.

Aperture flutter

The so-called diaphragmatic flutter (diaphragmatic myoclonus, Leeuwenhoek's syndrome) is an extremely rare suffering characterized by paroxysmal frequent (about 100 per minute) contractions of the diaphragm, as if superimposed on its respiratory excursions. During the attacks, shortness of breath, a feeling of twitching in the lower chest and a pulsation visible to the eye are noted. epigastric region. The frequency of seizures is reduced by taking antihistamines.

Hello, my question is 26146. Yes, they examined the diaphragm, did a thoracoscopy under local anesthesia, these defects (thin spots) were found on the dome of the diaphragm. I am most interested in what I need to do in my case: suturing thin places on the diaphragm, doing a pleurectomy or some kind of gynecological intervention, or all together? P.s. I want children.

Can a hernia of the diaphragm be on the right and on x-ray overlap half a lung

We observed a giant cardiodiaphragmatic lipoma of this size and effectively removed it from the preperitoneal approach, other diaphragmatic hernias on the right are rare, unless it is a relaxation of the diaphragm.

A year ago, the child underwent 2 heart surgeries to correct CHD "Phalo's tetralogy". On re-examination, a diagnosis of "Paresis of the left dome of the diaphragm" was made. What treatment is needed? Where given treatment you can go?

Hello. I'm 36 years old. In November, she was ill with pneumonia. After treatment, the cough continues to this day, but it is of this nature - dry, strong, paroxysmal, appears as a result of the appearance of sourness in the throat, along with the cough, sneezing immediately appears, and lacrimation. I take a sip of water and everything calms down. Please tell me what it is and how to treat it?

Hello! In April, I was diagnosed with myasthenia and 25.08.2008. performed surgery to remove thymus/tumor 24*18/. After the operation, the x-ray showed that it was highly elevated with right side diaphragm and I myself felt short of breath. Now he is often worried about shortness of breath and sometimes pain from the bottom of the Robert on the right side. Can I somehow fix this? Maybe some exercise?

Most likely the right phrenic nerve was damaged. It is necessary to adapt to this state, as there will most likely not be a restoration of diaphragmatic movement. A rather complicated method of recovery is electrical stimulation of the phrenic nerve, but as far as I know, these operations have not been put on stream.

Paralysis and paresis of the diaphragm

Diaphragm paralysis is characterized by its high standing and lack of respiratory movements. Unlike a hernia, there is no hernial orifice or sac. The musculoskeletal component was preserved throughout (especially in the early stages of the disease), when its atrophy had not yet begun.

Diaphragmatic paralysis in newborns usually occurs during birth trauma as a result of damage to the cervical spinal roots related to the phrenic nerve. Similar isolated birth injury rare, more often all roots are damaged brachial plexus with the development of paralysis upper limb, while the phrenic nerve is sometimes involved in the process.

Approximately 5% of newborns who have undergone neonatal trauma have diaphragmatic paresis. varying degrees, which in most cases is combined with Erb's palsy. At infants and older children, paresis of the diaphragm occurs as a result of damage to the phrenic nerve during surgery, during puncture of the subclavian veins, or due to the involvement of the nerve in the inflammatory process with empyema of various origins, tumor lesions.

Clinic and diagnostics

The most severe clinical picture noted with paralysis of the diaphragm in newborns: expressed respiratory failure with shortness of breath and cyanosis, breathing is often arrhythmic with retraction of compliant places of the chest, the borders of the heart are displaced in healthy side, on the side of the lesion, breathing is heard worse. Most children show symptoms of cardiovascular disorders.

Diagnosis can only be made with x-ray examination. Characteristic is the high standing of the dome of the diaphragm, its contour has a clear hemispherical shape, the mediastinal organs are displaced to the healthy side. There are no synchronous respiratory movements of the diaphragm, more often it is motionless, but paradoxical movements are also possible.

Treatment

Treatment depends on the severity of the condition, the severity of hypoxia and respiratory disorders. Usually start with conservative therapy aimed at maintaining cardiac activity, adequate pulmonary ventilation. In addition to constant oxygenation, breathing is periodically carried out with increased resistance on exhalation.

If there is no effect, an auxiliary or artificial respiration. Provide stimulation to improve recovery processes, muscle trophism and conductivity nerve impulses. Must be applied cervical electrophoresis with prozerin, aloe, lidase, prescribe vitamins and anticholinesterase drugs (prozerin).

If there is no effect after 2-3 weeks, apply surgery, which consists in performing a thoracotomy and applying mattress gathering sutures in such a way that a flattening of the dome of the diaphragm occurs. At the same time, it must be remembered that the phrenic nerve and its main branches should not get into the seams, since in the long term it is possible to restore the function of the diaphragm. The results are largely determined by the degree of damage to the central nervous system and expressiveness of those who joined inflammatory changes in the lungs. Usually after the operation, the condition of children begins to improve rapidly.

Foreign bodies of the trachea and bronchi

Foreign body aspiration (FB) in children is quite common. All researchers note that this species pathology is characteristic of childhood(more than 90% of cases); while most often this pathology occurs in children aged 1 to 3 years. According to the results of survey statistics, the frequency of aspiration of foreign bodies is 3.7 per 1000 children. It should be noted that all over the world, otolaryngologists deal mainly with this pathology in children and, as a rule, only in acute period(during the day) after aspiration IT. This circumstance explains the significant frequency of unnoticed aspirations, especially in young children.

Are celebrated various options mechanical obstruction (according to G.I. Lukomsky):

• through or partial;
• valve;
• complete

All children with late dates diagnosis of IT of the tracheobronchial tree, partial obstruction is noted, which determines the possibility of long-term carriage of IT. Most ITs (mostly of organic origin) are eliminated by coughing or mucociliary transport, but some are retained in the airways and may cause chronic inflammatory process in the lungs.

Clinic

The clinic depends on the size of the IT, its location and origin (organic or inorganic). Aspiration of several foreign bodies at once, aspiration of liquid or food can also be observed, which also affects clinical symptoms. Complete blockage of the bronchus can lead to atelectasis of the segment or lobe ventilated by this bronchus. Obturation of the trachea causes an acute attack of suffocation, which, if not provided timely help, can lead to severe complications, including death.

However, IT may not completely obturate Airways, leading to a partial violation of ventilation in this area, or, creating a valve mechanism with the subsequent development of emphysema, which captures various volumes of the affected lung. Clinical and radiological characteristic, of course, depends on the period that has elapsed since the aspiration of IT. auscultatory there is a weakening of breathing, wheezing of various nature, as well as uncharacteristic respiratory noises. In children with early dates from the moment of aspiration to radiographs revealed:

• emphysema of a segment or lobe,
• reduction of pneumatization of the lung area,
• segment or lobe atelectasis.

Very effective method research for suspected aspiration of IT is chest x-ray with the detection of pathological mobility of the median shadow ( positive symptom Goltznecht-Jakobson).

Treatment

The main method of treatment is endoscopic extraction of a foreign body using a rigid respiratory bronchoscope with optical forceps with various form working parts. Only in rare cases in case of failure of bronchological removal of a foreign body, due to the nature of IT or the development of suppuration, one has to resort to thoracotomy with bronchotomy or resection of the interested area of ​​the lung.

Bychkov V.A., Manzhos P.I., Bachu M. Rafik Kh., Gorodova A.V.