Grigoris Chrysocherakis, Christos Papagoras, Nikolaos Papanikolaou, Emmanouil Zachariades
Objective: We present an unusual cause of diaphragm elevation related to prior anesthetic procedure.
Case presentation: Patient 50 years old, obese, ex-smoker (40 p/y) with history of chronic obstructive pulmonary disease (COPD), hypertension and dyslipidemia was admitted to the Euroclinic complaining of dyspnoea mainly on exertion. Few years before the admission, the patient underwent a surgical treatment of left shoulder assisted by regional anesthetic procedure (interscalene brachial plexus block).
Clinical and laboratory findings: SpO2: 94%. After exertion: 97%. Auscultation: no breathing sounds at the left lower lobe. Chest X-ray (CXR) and Chest CT-scan: Left diaphragm elevation. Abdomen CT scan: normal. Radioscopy: delayed movement of the left diaphragm compared to the right. Normal contraction at sniff test: spirometry: mixed type (mixed pattern) with good response to bronchodilation of obstructive component. Plethysmography: TLC at lower normal limits. RV and RV/TLC increased. Nocturnal oxymetry: average SpO2: 92%, desaturation index: 4.6/h. Neurologic evaluation: normal. The patient was treated with bronchodilators. We suggested weight control, magnetic resonance imaging (MRI) of spinal cervical tract and pulmonary and neurological following.
Discussion: Several studies focus on respiratory complications due to regional anesthetic procedures especially on brachial plexus. The complication rate increases in case of obese and “short neck” patients. The phrenic nerve blockade is usually temporary but some patients might suffer from permanent phrenic disfunction and concomitant shortness of breath. Special attention is needed in case of COPD, obesity or sleep apnoea syndrome. The procedure is contraindicated in severe chronic respiratory obstructive or restrictive disease. Moreover, newest surgical and anesthetic procedures (such as robotic surgery of the abdomen), have an increased pulmonary adverse events in above mentioned population.
Conclusions: Pulmonary complications in anesthesiology and surgery are increasingly present even in modern regional procedures. The need for pulmonary consultation is of great importance in the preoperative evaluation of the patient.
