Diaphragmatic paralysis differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

[Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].

OR

[Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

Differentiating diaphragmatic paralysis from other Diseases

Unilateral diaphragmatic paralysis must be diffrentiated from eventration of the diaphragm. Eventration of the diaphragm is an abnormal elevation of the hemidiaphragm that some parts of hemidiaphragm are replaced by fibrous tissue. Clinical manifetations of eventration of the diaphragm include asymptomatic, infection and respiratory distress.

Bilateral diaphragmatic paralysis must be differentiated from other diseases that cause elevation of the diaphragm such as

• Pleural adhesions
• Subpulmonic effusions
• Obesity with decreased chest wall compliance
• Ascites
• Abdominal organomegaly
• Ileus

Diaphragmatic paralysis must be differentiated from other disease that cause dyspnea such as:

The differential diagnosis of bilateral diaphragmatic elevation on the plain chest radiograph includes subpulmonic effusions, pleural adhesions, obesity with decreased chest wall and abdominal compliance, and subdiaphragmatic processes such as ascites, organomegaly, and ileus.

EVENTRATION OF THE DIAPHRAGM — Eventration of the diaphragm is a disorder in which all or part of the diaphragmatic muscle is replaced by fibroelastic tissue, leading to a thinned and pliable central portion of the diaphragm.

Etiology — Eventration may be congenital or acquired; the congenital form reflects a failure of the fetal diaphragm to muscularize, whereas the acquired form is associated with phrenic nerve injury or is idiopathic [4,25]. The continuity of the diaphragm and normal attachments to the costal margin are maintained. (See "Eventration of the diaphragm in infants".)

Clinical manifestations — In adults, diaphragmatic eventration is rarely symptomatic. When present, the symptoms associated with diaphragmatic eventration include dyspnea, palpitations, chest pain, dyspepsia, and recurrent pneumonia [26]. The degree of respiratory impairment ranges from the more common asymptomatic elevation of the diaphragmatic dome to the much less common degree of respiratory impairment seen in unilateral diaphragmatic paralysis. (See 'Clinical manifestations'above.)

The severe congenital diaphragmatic eventration seen in newborns is discussed separately. (See "Eventration of the diaphragm in infants".)

• [Disease name] must be differentiated from other diseases that cause [clinical feature 1], [clinical feature 2], and [clinical feature 3], such as [differential dx1], [differential dx2], and [differential dx3].
• [Disease name] must be differentiated from [[differential dx1], [differential dx2], and [differential dx3].

• As [disease name] manifests in a variety of clinical forms, differentiation must be established in accordance with the particular subtype. [Subtype name 1] must be differentiated from other diseases that cause [clinical feature 1], such as [differential dx1] and [differential dx2]. In contrast, [subtype name 2] must be differentiated from other diseases that cause [clinical feature 2], such as [differential dx3] and [differential dx4].

Preferred Table

Diseases	History and Symptoms				Physical Examination				Laboratory Findings				Other Findings
	Finding 1	Finding 2	Finding 3	Finding 4	Physical Finding 1	Physical Finding 2	Physical Finding 3	Physical Finding 4	Lab Test 1	Lab Test 2	Lab Test 3	Lab Test 4
Differential Diagnosis 1			+
Differential Diagnosis 2	↑			-
Differential Diagnosis 3		↓
Differential Diagnosis 4
Differential Diagnosis 5

Use if the above table can not be made

Differential Diagnosis	Similar Features	Differentiating Features
Differential 1	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
Differential 2	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
Differential 3	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
Differential 4	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].
Differential 5	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] also observed in [disease name].	On [physical exam; history; diagnostic test; imaging], [Differential 1] {has; demonstrates} [feature 1], [feature 2], [feature 3] that distinguish it from [disease name].

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); BMI (body mass index); CBC (complete blood count); CSF (cerebrospinal fluid); CXR (chest X-ray); DOE (dyspnea on exercise); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FVC (forced vital capacity); JVD (jugular vein distention); MCV (mean corpuscular volume); Plt (platelet); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); TSH (thyroid stimulating hormone); Vt (tidal volume); WBC (white blood cell);

Organ system			Diseases	Clinical manifestations													Diagnosis					Other features
				Symptoms								Physical exam
				Loss of consciousness	Agitation	Weight loss	Fever	Chest pain	Cough	Orthopnea	DOE	Cyanosis	Clubbing	JVD	Peripheral edema	Auscultation	CBC	ABG	Imaging	Spirometry	Gold standard
Acute Dyspnea	Respiratory system	Head and Neck, Upper airway	Aspiration	-	+	-	-	+/-	+	-	-	+	-	-	-	Diminished breath sounds	Normal	Normal	Atelectasis	↓Vt, ↑RV	Bronchoscopy	Choking
		Chest and Pleura, Lower airway	Atelectasis	-	-	-	+/-	+/-	+/-	-	-	+/-	-	-	-	Diminished breath sounds, Wheeze	Normal	↓O2, Normal/↓CO2	Collapsed lung lobe, fissuresdisplacement	↓ FVC	Chest CT scan	Surgical procedure, Aspiration, Mechanical ventilation
			Bronchitis	-	-	-	+	+	+	-	-	-	-	-	-	Rhonchi	↑WBC	Normal	Normal	Normal	Physical exam	Rhonchi relieved by cough
			Bronchiolitis	-	-	-	+	+/-	+	-	-	-	-	-	-	Wheeze and Crackles	↑WBC	Normal	Bronchovascular markings	↓Vt	Clinical assessment	Respiratory syncytial virus (RSV)
			Lung carcinoma	-	-	+	-	-	+	-	-	+	+	-	-	Wheeze and Crackles	Normal	Normal	Mass lesion, hilar lymphadenopathy	↓Vt, ↑RV	Bronchoscopy	Paraneoplastic syndromes, such as SIADH and lambert-Eaton
			Pneumonia	-	-	-	+	+	+	-	-	-	-	-	-	Wheeze, Rhonchi, and Crackles	↑WBC, neutrophilia	Normal	Lobar consolidation	Normal	Chest X-ray and CT Scan	productive cough
			Pneumothorax	-	-	-	-	+	-	-	-	-	-	+/-	-	Diminished breath sounds	Normal	↓O2, ↑CO2	Radiolucency without lung marking	↓Vt	CXR and Chest CT scan	Tracheal deviation
			Pulmonary embolism	-	-	-	-	+	-	-	+/-	-	-	-	-	Normal	Normal	Respiratory alkalosis	Normal	Normal	Pulmonary CT angiography	Pleuritic chest pain
			Rib fractures (flail chest)	-	+	-	-	+	-	-	-	-	-	-	-	Normal	Normal	Respiratory acidosis	Fracture marks	Normal	Chest X-ray	Pneumothorax
	Cardiovascular system		Pericardial tamponade	+/-	-	-	-	+	-	+/-	+/-	-	-	+	-	Muffled heart sounds	Normal	Normal	Water bottle appearance enlarged heart	Normal	Echocardiography	Fluid accumulation in pericardium
			Pulmonary edema	+/-	+	-	+	+	+	+	+	+	+	+	+	Basal crackle	Normal	Respiratory alkalosis	Bat wing pattern, air bronchograms	↓Vt, ↑RV	Cardiac Catheterization	Tachypnea
	Central nervous system		Stroke	+	-	-	+/-	-	-	-	-	-	-	-	-	Normal	Normal	Normal	Intracranial infarct or hemorrhage	Normal	Brain MRI	Paralysis or paresthesia
			Encephalitis	+	+	-	+	-	-	-	-	-	-	-	-	Normal	↑WBC, neutrophilia	Normal	Normal	Normal	CSF PCR	Confusion
			Traumatic brain injury	+	+/-	-	-	-	-	-	-	-	-	-	-	Normal	Normal	Respiratory acidosis	Intracerebral hemorrhage	Normal	Brain CT scan	Lucid interval
Organ system			Diseases	Clinical manifestations													Diagnosis					Other features
				Symptoms								Physical exam
				Loss of consciousness	Agitation	Weight loss	Fever	Chest pain	Cough	Orthopnea	DOE	Cyanosis	Clubbing	JVD	Peripheral edema	Auscultation	CBC	ABG	Imaging	Spirometry	Gold standard
Chronic Dyspnea	Respiratory system	Head and Neck, Upper airway	Goiter	-	-	-	-	-	-	-	-	-	-	-	+	Normal	Normal	Normal	Normal	Normal	Blood test (TSH, T4)	Weight gain
			Laryngeal adenocarcinoma	-	-	+	-	-	+/-	-	-	-	-	-	-	Stridor	Normal	↓O2, ↑CO2	Retropharyngeal tissue thickness	Normal	Laryngoscopy	Choking sensation
		Chest and Pleura, Lower airway	COPD	-	-	+/-	-	-	+	+	+	+	+	+	+/-	Expiratory wheeze	↑ RBC	Respiratory alkalosis, Metabolic acidosis	↑ Bronchovascular markings, Cardiomegaly	↓ FEV1/FVC	Physical exam and Spirometry	Heavy smoking history
			Emphysema	-	-	-	-	-	+/-	-	-	+	+	-	-	Expiratory wheeze, Hyperinflation	Normal	Respiratory alkalosis, Metabolic acidosis	Flattening of diaphragm, vertical heart	↓ FEV1/FVC	Physical exam and Spirometry	Barrel chest
			Pulmonary hypertension	-	-	-	-	+/-	+/-	-	-	+/-	+/-	+	+	Accentuated S2	Normal	Hypoxia and acidosis	Enlarged pulmonary arteries	↑Physiologic RV	Cardiac catheterization	Syncope, Ascites, Pleural effusion
			Sarcoidosis	-	-	+/-	-	+/-	+	-	-	+	-	-	-	Crackles	Normal	↓O2, ↑CO2	Hilar adenopathy	↑ FEV1/FVC	High resolution computed tomography (HRCT)	Hypercalcemia, high ACE
			Pleural effusion	-	+/-	+	-	+	-	+/-	-	-	-	+/-	+/-	Egophony ("E-to-A" change)	Normal	Normal	Blunting of the costophrenic and cardiophrenic angle	↓Vt, ↑RV	Light's criteria	↓Tactile fremitus, Asymmetrical chest expansion
			Diaphragmatic paralysis	-	-	-	+/-	+/-	+/-	+	+	-	-	-	-	Normal	Normal	Normal	Unilateral or bilateral diaphragmatic flattening	↓Vt, ↑RV (anatomical)	CXR confirmed by fluoroscopic sniff test	Respiratory insufficiency
			Tuberculosis	-	-	+	+	+	+	-	-	+/-	-	-	-	Rhonchi, Wheezing, Crackles	↑WBC	↓O2, ↑CO2	Patchy consolidation or poorly defined linear and nodular opacities	Restrictive, obstructive, or mixed	IFN-γ release assay (IGRA) Acid-fast staining	Night sweat
	Cardiovascular system		Constrictive pericarditis	-	-	-	-	+	-	+	+	-	-	+	-	Muffled heart sounds	Normal	Normal	Calcifications	Normal	Chest CT scan	Syncope
			Pericardial effusion	-	-	-	+/-	+	+	+/-	+/-	-	-	+	-	Muffled heart sounds	Normal	Normal	Fluid density around the heart	Normal	M-mode and 2-dimensional Doppler echocardiography	Hoarseness, Palpitation
	Neuromuscular disease		Amyotrophic lateral sclerosis	+/-	-	+/-	-	-	-	-	-	-	-	-	-	Normal	↑WBC	Normal	Normal	↓Vt, ↑RV	Revised El Escorial criteria (clinical)	Muscle weakness, Dysphagia
			Polymyositis/dermatomyositis	-	-	+/-	-	+	-	-	-	-	-	-	+/-	Normal	↑WBC	Normal	Normal	↓Vt, ↑RV	Muscle biopsy	Muscle weakness, Heliotrope
			Mitochondrial diseases	-	-	+/-	-	-	-	-	-	-	-	-	-	Wheeze	↓WBC, Plt	Normal	Normal	↓Vt, ↑RV	Muscle biopsy	Muscle pain
			Glycolytic enzyme defects (e.g., McArdle)	+/-	-	-	-	-	-	-	-	-	-	-	+/-	Normal	Normal	Normal	Normal	↓Vt, ↑RV	Muscle biopsy (ragged red fibers)	Myoglobinuria, Muscle weakness
	Systemic		Ascites	-	-	-	-	-	-	-	-	-	-	-	-	Normal	Normal	Normal	Peritoneal fluid accumulation	↓Vt, ↑RV	Abdominal ultrasound	Abdominal distention
			Kyphoscoliosis	-	-	-	-	-	-	-	-	-	-	-	-	Wheeze	Normal	Normal	Deviated vertebral column	↓Vt, ↑RV (anatomical)	Standing lateral spine radiograph	Low back pain
			Obesity	-	-	-	-	-	-	-	-	-	-	-	-	Normal	Normal	↓O2	Normal	↓Vt, ↑RV (anatomical)	BMI	Low stamina, Sweating

Related Chapters

• Air hunger - The sensation of an urgent need to breathe, sensation that you cannot take in a full breath
• Tachypnea - Breathing rapidly
• Bradypnea - Breathing slowly
• Eupnea - Normal unlabored breathing
• Orthopnea - Dyspnea that occurs with lying flat
• Trepopnea - An abnormal awareness of one's own breathing that is seen in one lateral position but not in the other
• Paroxysmal nocturnal dyspnea - Sudden, severe shortness of breath at night that awakens a person from sleep, often with coughing and wheezing.