Diaphragmatic paralysis differential diagnosis: Difference between revisions
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Latest revision as of 21:22, 29 July 2020
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahda Alihashemi M.D. [2]
Overview
Unilateral diaphragmatic paralysis must be differentiated from eventration of the diaphragm. Eventration of the diaphragm is an abnormal elevation of the hemidiaphragm. Bilateral diaphragmatic paralysis must be differentiated from other diseases that cause elevation of the diaphragm such as pleural adhesions, subpulmonic effusions, obesity, ascites, abdominal organomegaly and ileus. Diaphragmatic paralysis must be differentiated from other disease that cause dyspnea such as dermatomyositis, polymyositis, rib fracture, pleural effusions, amyotrophic lateral sclerosis.
Differentiating diaphragmatic paralysis from other Diseases
Unilateral diaphragmatic paralysis must be differentiated 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 manifestations of eventration of the diaphragm include asymptomatic, infection and respiratory distress.[1]
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:
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[2] | - | + | - | - | +/- | + | - | - | + | - | - | - | 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, | ||
Bronchitis[3] | - | - | - | + | + | + | - | - | - | - | - | - | Rhonchi | ↑WBC | Normal | Normal | Normal | Physical exam | Rhonchi relieved by cough | |||
Bronchiolitis[4] | - | - | - | + | +/- | + | - | - | - | - | - | - | Wheeze and Crackles | ↑WBC | Normal | Bronchovascular markings | ↓Vt | Clinical assessment | Respiratory syncytial virus (RSV) | |||
Lung carcinoma[5] | - | - | + | - | - | + | - | - | + | + | - | - | Wheeze and Crackles | Normal | Normal | Mass lesion, hilar lymphadenopathy | ↓Vt, ↑RV | Bronchoscopy | Paraneoplastic syndromes, such as SIADH and lambert-Eaton | |||
Pneumonia[6] | - | - | - | + | + | + | - | - | - | - | - | - | Wheeze, Rhonchi, and Crackles | ↑WBC, neutrophilia | Normal | Lobar consolidation | Normal | Chest X-ray and CT Scan | productive cough | |||
Pneumothorax[7] | - | - | - | - | + | - | - | - | - | - | +/- | - | Diminished breath sounds | Normal | ↓O2, ↑CO2 | Radiolucency without lung marking | ↓Vt | CXR and Chest CT scan | Tracheal deviation | |||
Pulmonary embolism[8] | - | - | - | - | + | - | - | +/- | - | - | - | - | Normal | Normal | Respiratory alkalosis | Normal | Normal | Pulmonary CT angiography | Pleuritic chest pain | |||
Rib fractures (flail chest)[9] | - | + | - | - | + | - | - | - | - | - | - | - | Normal | Normal | Respiratory acidosis | Fracture marks | Normal | Chest X-ray | Pneumothorax | |||
Cardiovascular system | Pericardial tamponade[10] | +/- | - | - | - | + | - | +/- | +/- | - | - | + | - | Muffled heart sounds | Normal | Normal | Water bottle appearance enlarged heart | Normal | Echocardiography | Fluid accumulation in pericardium | ||
Pulmonary edema[11] | +/- | + | - | + | + | + | + | + | + | + | + | + | 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[12] | + | + | - | + | - | - | - | - | - | - | - | - | Normal | ↑WBC, neutrophilia | Normal | Normal | Normal | CSF PCR | Confusion | |||
Traumatic brain injury[13] | + | +/- | - | - | - | - | - | - | - | - | - | - | 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[14] | - | - | - | - | - | - | - | - | - | - | - | + | Normal | Normal | Normal | Normal | Normal | Blood test (TSH, T4) | Weight gain |
Laryngeal adenocarcinoma[15] | - | - | + | - | - | +/- | - | - | - | - | - | - | Stridor | Normal | ↓O2, ↑CO2 | Retropharyngeal tissue thickness | Normal | Laryngoscopy | Choking sensation | |||
Chest and Pleura,
Lower airway |
COPD[16] | - | - | +/- | - | - | + | + | + | + | + | + | +/- | Expiratory wheeze | ↑ RBC | Respiratory alkalosis, Metabolic acidosis | ↑ Bronchovascular markings, Cardiomegaly | ↓ FEV1/FVC | Physical exam and | Heavy smoking history | ||
Emphysema[17] | - | - | - | - | - | +/- | - | - | + | + | - | - | Expiratory wheeze, Hyperinflation | Normal | Respiratory alkalosis, Metabolic acidosis | Flattening of diaphragm, vertical heart | ↓ FEV1/FVC | Physical exam and | Barrel chest | |||
Pulmonary hypertension[18] | - | - | - | - | +/- | +/- | - | - | +/- | +/- | + | + | Accentuated S2 | Normal | Hypoxia and acidosis | Enlarged pulmonary arteries | ↑Physiologic RV | Cardiac catheterization | Syncope, | |||
Sarcoidosis[19] | - | - | +/- | - | +/- | + | - | - | + | - | - | - | Crackles | Normal | ↓O2, ↑CO2 | Hilar adenopathy | ↑ FEV1/FVC | High resolution computed tomography (HRCT) | Hypercalcemia, high ACE | |||
Pleural effusion[20] | - | +/- | + | - | + | - | +/- | - | - | - | +/- | +/- | 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[21] | - | - | - | +/- | +/- | +/- | + | + | - | - | - | - | Normal | Normal | Normal | Unilateral or bilateral diaphragmatic flattening | ↓Vt, ↑RV | CXR confirmed by fluoroscopic sniff test | Respiratory insufficiency | |||
Tuberculosis[22] | - | - | + | + | + | + | - | - | +/- | - | - | - | Rhonchi, Wheezing, Crackles | ↑WBC | ↓O2, ↑CO2 | Patchy consolidation or poorly defined linear and nodular opacities | Restrictive, obstructive, or mixed | IFN-γ release assay (IGRA) | Night sweat | |||
Cardiovascular system | Constrictive pericarditis[10] | - | - | - | - | + | - | + | + | - | - | + | - | Muffled heart sounds | Normal | Normal | Calcifications | Normal | Chest CT scan | Syncope | ||
Pericardial effusion[23] | - | - | - | +/- | + | + | +/- | +/- | - | - | + | - | 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[24] | +/- | - | +/- | - | - | - | - | - | - | - | - | - | Normal | ↑WBC | Normal | Normal | ↓Vt, ↑RV | Revised El Escorial criteria (clinical) | Muscle weakness, Dysphagia | ||
Polymyositis/dermatomyositis[25] | - | - | +/- | - | + | - | - | - | - | - | - | +/- | Normal | ↑WBC | Normal | Normal | ↓Vt, ↑RV | Muscle biopsy | Muscle weakness, Heliotrope | |||
Mitochondrial diseases[26] | - | - | +/- | - | - | - | - | - | - | - | - | - | Wheeze | ↓WBC, Plt | Normal | Normal | ↓Vt, ↑RV | Muscle biopsy | Muscle pain | |||
Glycolytic enzyme defects (e.g., McArdle)[27] | +/- | - | - | - | - | - | - | - | - | - | - | +/- | Normal | Normal | Normal | Normal | ↓Vt, ↑RV | Muscle biopsy (ragged red fibers) | Myoglobinuria, | |||
Systemic | Ascites[28] | - | - | - | - | - | - | - | - | - | - | - | - | Normal | Normal | Normal | Peritoneal fluid accumulation | ↓Vt, ↑RV | Abdominal ultrasound | Abdominal distention | ||
Kyphoscoliosis[29] | - | - | - | - | - | - | - | - | - | - | - | - | Wheeze | Normal | Normal | Deviated vertebral column | ↓Vt, ↑RV | Standing lateral spine radiograph | Low back pain | |||
Obesity[30] | - | - | - | - | - | - | - | - | - | - | - | - | Normal | Normal | ↓O2 | Normal | ↓Vt, ↑RV | BMI | Low stamina, |
References
- ↑ O'Horo JC, Rogus-Pulia N, Garcia-Arguello L, Robbins J, Safdar N (2015). "Bedside diagnosis of dysphagia: a systematic review". J Hosp Med. 10 (4): 256–65. doi:10.1002/jhm.2313. PMC 4607509. PMID 25581840.
- ↑ Cantin, Luce; Bankier, Alexander A.; Eisenberg, Ronald L. (2009). "Bronchiectasis". American Journal of Roentgenology. 193 (3): W158–W171. doi:10.2214/AJR.09.3053. ISSN 0361-803X.
- ↑ Holbro A, Lehmann T, Girsberger S, Stern M, Gambazzi F, Lardinois D, Heim D, Passweg JR, Tichelli A, Bubendorf L, Savic S, Hostettler K, Grendelmeier P, Halter JP, Tamm M (2013). "Lung histology predicts outcome of bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation". Biol. Blood Marrow Transplant. 19 (6): 973–80. doi:10.1016/j.bbmt.2013.03.017. PMID 23562737.
- ↑ Dela Cruz CS, Tanoue LT, Matthay RA (2011). "Lung cancer: epidemiology, etiology, and prevention". Clin Chest Med. 32 (4): 605–44. doi:10.1016/j.ccm.2011.09.001. PMC 3864624. PMID 22054876.
- ↑ Simonetti AF, Viasus D, Garcia-Vidal C, Carratalà J (2014). "Management of community-acquired pneumonia in older adults". Ther Adv Infect Dis. 2 (1): 3–16. doi:10.1177/2049936113518041. PMC 4072047. PMID 25165554.
- ↑ Currie GP, Alluri R, Christie GL, Legge JS (2007). "Pneumothorax: an update". Postgrad Med J. 83 (981): 461–5. doi:10.1136/pgmj.2007.056978. PMC 2600088. PMID 17621614.
- ↑ Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.
- ↑ Swart E, Laratta J, Slobogean G, Mehta S (February 2017). "Operative Treatment of Rib Fractures in Flail Chest Injuries: A Meta-analysis and Cost-Effectiveness Analysis". J Orthop Trauma. 31 (2): 64–70. doi:10.1097/BOT.0000000000000750. PMID 27984449.
- ↑ 10.0 10.1 van Steijn JH, Sleijfer DT, van der Graaf WT, van der Sluis A, Nieboer P (2002). "How to diagnose cardiac tamponade". Neth J Med. 60 (8): 334–8. PMID 12481882.
- ↑ Martindale, Jennifer L.; Noble, Vicki E.; Liteplo, Andrew (2013). "Diagnosing pulmonary edema". European Journal of Emergency Medicine. 20 (5): 356–360. doi:10.1097/MEJ.0b013e32835c2b88. ISSN 0969-9546.
- ↑ Debiasi RL, Tyler KL (2004). "Molecular methods for diagnosis of viral encephalitis". Clin Microbiol Rev. 17 (4): 903–25, table of contents. doi:10.1128/CMR.17.4.903-925.2004. PMC 523566. PMID 15489354.
- ↑ McAllister TW (2011). "Neurobiological consequences of traumatic brain injury". Dialogues Clin Neurosci. 13 (3): 287–300. PMC 3182015. PMID 22033563.
- ↑ Stang MT, Armstrong MJ, Ogilvie JB, Yip L, McCoy KL, Faber CN, Carty SE (July 2012). "Positional dyspnea and tracheal compression as indications for goiter resection". Arch Surg. 147 (7): 621–6. doi:10.1001/archsurg.2012.96. PMID 22430090.
- ↑ Schwenk NR, Schapira RM, Byrd JC (November 1994). "Laryngeal carcinoma presenting as platypnea". Chest. 106 (5): 1609–11. PMID 7956433.
- ↑ Qureshi H, Sharafkhaneh A, Hanania NA (2014). "Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications". Ther Adv Chronic Dis. 5 (5): 212–27. doi:10.1177/2040622314532862. PMC 4131503. PMID 25177479.
- ↑ Sharafkhaneh A, Hanania NA, Kim V (2008). "Pathogenesis of emphysema: from the bench to the bedside". Proc Am Thorac Soc. 5 (4): 475–7. doi:10.1513/pats.200708-126ET. PMC 2645322. PMID 18453358.
- ↑ Sajkov D, Petrovsky N, Palange P (June 2010). "Management of dyspnea in advanced pulmonary arterial hypertension". Curr Opin Support Palliat Care. 4 (2): 76–84. doi:10.1097/SPC.0b013e328338c1e0. PMID 20407377.
- ↑ Moher D, Cole CW, Hill GB (November 1992). "Epidemiology of abdominal aortic aneurysm: the effect of differing definitions". Eur J Vasc Surg. 6 (6): 647–50. PMID 1451823.
- ↑ Thomas R, Jenkins S, Eastwood PR, Lee YC, Singh B (July 2015). "Physiology of breathlessness associated with pleural effusions". Curr Opin Pulm Med. 21 (4): 338–45. doi:10.1097/MCP.0000000000000174. PMC 5633324. PMID 25978627.
- ↑ Dubé BP, Dres M (2016). "Diaphragm Dysfunction: Diagnostic Approaches and Management Strategies". J Clin Med. 5 (12). doi:10.3390/jcm5120113. PMC 5184786. PMID 27929389.
- ↑ Campbell IA, Bah-Sow O (2006). "Pulmonary tuberculosis: diagnosis and treatment". BMJ. 332 (7551): 1194–7. doi:10.1136/bmj.332.7551.1194. PMC 1463969. PMID 16709993.
- ↑ Jung HO (2012). "Pericardial effusion and pericardiocentesis: role of echocardiography". Korean Circ J. 42 (11): 725–34. doi:10.4070/kcj.2012.42.11.725. PMC 3518705. PMID 23236323.
- ↑ Lechtzin N, Lange DJ, Davey C, Becker B, Mitsumoto H (January 2007). "Measures of dyspnea in patients with amyotrophic lateral sclerosis". Muscle Nerve. 35 (1): 98–102. doi:10.1002/mus.20669. PMID 17029274.
- ↑ Schwarz MI, Matthay RA, Sahn SA, Stanford RE, Marmorstein BL, Scheinhorn DJ (January 1976). "Interstitial lung disease in polymyositis and dermatomyositis: analysis of six cases and review of the literature". Medicine (Baltimore). 55 (1): 89–104. PMID 1246203.
- ↑ Heinicke K, Taivassalo T, Wyrick P, Wood H, Babb TG, Haller RG (2011). "Exertional dyspnea in mitochondrial myopathy: clinical features and physiological mechanisms". Am J Physiol Regul Integr Comp Physiol. 301 (4): R873–84. doi:10.1152/ajpregu.00001.2011. PMC 3197343. PMID 21813873.
- ↑ Tarui S (1995). "Glycolytic defects in muscle: aspects of collaboration between basic science and clinical medicine". Muscle Nerve Suppl. 3: S2–9. PMID 7603522.
- ↑ Perri GA (2013). "Ascites in patients with cirrhosis". Can Fam Physician. 59 (12): 1297–9, e538–40. PMC 3860926. PMID 24336542.
- ↑ Qiabi M, Chagnon K, Beaupré A, Hercun J, Rakovich G (2015). "Scoliosis and bronchial obstruction". Can Respir J. 22 (4): 206–8. PMC 4530852. PMID 26083538.
- ↑ Sin DD, Jones RL, Man SF (July 2002). "Obesity is a risk factor for dyspnea but not for airflow obstruction". Arch. Intern. Med. 162 (13): 1477–81. PMID 12090884.