Chest
Volume 134, Issue 6, December 2008, Pages 1336-1339
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Postgraduate Education Corner
Pulmonary and Critical Care Pearls
A 78-Year-Old Man With an Elevated Hemidiaphragm Following Trauma

https://doi.org/10.1378/chest.08-0503Get rights and content

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Physical Examination

Physical examination revealed a frail elderly man. Vital signs were as follows: pulse rate, 70 beats/min; BP, 118/59 mm Hg; respiratory rate, 18 breaths/min; peripheral oxygen saturation, 100% on 2 L by nasal cannula. Neurologic examination revealed a patient oriented to person and place, Glasgow coma scale of 14, right conjunctival hemorrhage, and bilateral raccoon eyes. Lung examination revealed equal air entry bilaterally with symmetric chest expansion and clear breath sounds bilaterally.

Laboratory Investigations

Laboratory investigation were as follows: hemoglobin, 12.4 g/dL; WBC count, 7,550/μL; and platelets, 172,000/μL. Electrolytes, renal parameters, and coagulation profile were normal. A portable chest radiograph showed significant elevation of the left hemidiaphragm (Fig 1). There were no prior radiographs for comparison. ECG showed a normal sinus rhythm.

Initial Clinical Course

On hospital day 2, the patient underwent head CT for routine surveillance of the intracranial hemorrhage. The patient became tachypneic and hypoxic, with peripheral oxygen saturations of 70%, and required endotracheal intubation. Chest radiography performed 24 h after intubation and positive pressure ventilation demonstrated only minimal elevation of the left hemidiaphragm (Fig 2). The patient was extubated after 6 days of mechanical ventilation. Immediately prior to extubation the patient was

Discussion

First described by Jean Louis Petit in 1774, eventration is the abnormal elevation of all or a portion of a diaphragmatic leaf, which then does not participate in respiratory activity. Total eventration of a hemidiaphragm is a rare anomaly in adults. This condition usually results from primary or acquired phrenic nerve palsy but often presents as a pure degenerative muscular disease without evident signs of denervation. Generally, the disease is a true congenital defect acquired during the

Clinical Pearls

  • 1.

    Diaphragmatic eventration in adults can occur following head and neck and cardiovascular surgery, trauma, motor neuron disease, infection, and malignancy.

  • 2.

    Normal chest radiograph findings on positive pressure ventilation cannot exclude diaphragmatic eventration.

  • 3.

    CT of the thorax with fine cuts and reformatted images is the diagnostic modality of choice for the evaluation of diaphragmatic pathology when a chest radiograph is indeterminate.

  • 4.

    Surgical repair of diaphragmatic eventration is reserved

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The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).

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