2011 Annual Conference

Barr, Kelly

Phrenic nerve damage can occur concurrently with brachial plexus injury during traumatic deliveries.  In this case the male infant had mild symptoms of respiratory, sleep and feeding problems that progressed over 8 months after a traumatic birth resulting in a clavicular fracture and Erb’s palsy.  Physical therapy was ordered to manage the secondary impairments during the awaited recovery of innervation.  During this period, respiratory sequellae developed which the therapist communicated to the primary care physician resulting in radiographs and a diagnosis of phrenic nerve damage with right hemidiaphragm paresis and mediastinal shift. The child was treated with plication of the diaphragm due to the severity of the elevation of the diaphragm and respiratory sequellae resolved.  It is important to include respiratory examination in the evaluation for Erb’s palsy and to continuously reassess respiratory function during the first few months of life after traumatic birth.

This is a case study and therefore includes only one client with a brachial plexus injury at birth which included damage to the phrenic nerve and hemidiaphragmatic paresis.  The case study describes the physical therapist screen and referral back to the medical team for further diagnostic work.

The Appendix A evaluation was used for Brachial plexus injury which revealed a Erb-Duchenne⁸ palsy presentation during the evaluation.  Assessment was done of the respiratory status. At this time his breathing was tachypneic and effortful or labored.  His abdomen and ribcage were observed for symmetry during respiration.  The right side had decreased excursion and decreased volume of the abdomen during inspiration compared to the left due to the paradoxical motion of the diaphragm during inspiration.  His respirations were shorter and shallower in appearance. Lung sounds were deficient over the right lower lung with auscultation.  He did not demonstrate any coughing during the examination over the entire hour of time.  Position changes did improve the symmetry of the abdominal excursions in supported upright positions.  The baby tended to move less vigorously than a typically developing 6 month old even in the 3 uninvolved extremities and seemed to be content with just quiet visual exploration. Fatigue is difficult to assess in infancy, however, with an absence of muscle tone abnormality combined with paucity of vigorous motion in a 6 month old, fatigue or lethargy were suspected.  The infant had no fever and his coloring was pale.  His regulatory state was good throughout the examination with no crying.

With the suspicion of respiratory problems, a call was made to his physician who promptly referred him directly from the clinic to radiology for chest images.   He followed the next day with examination in his clinic where he revealed the radiological results. These results included right hemidiaphragmatic paresis with mediastinal shift to the left affecting the space of the left lung in addition to the right involved side.  On return to our facility for physical therapy he was given a reflux wedge to help with upright positioning during sleep which helped to increase his sleep to several hours at a time. His respiratory status was constantly monitored during sessions until he saw a specialist and received plication of the diaphragm which took about 6 weeks to get started. By this time he was almost 8 months old and spontaneous return of the diaphragm was not expected.  The mediastinal shift was one of the great concerns because the right diaphragm insufficiency was not able to preserve the heart and left lung spatial orientation. 

The infant returned to physical therapy about a week after the plication of the diaphragm and resumed treatment for BPI.  He was able to sleep through the night by this time and had resumed typical respiratory patterns of a 6 month old infant.  He was followed by the specialist for several months and referred to a BPI specialist in Houston for surgical intervention.  This infant had no complications with 2 separate brachial plexus surgeries after his plication surgery.  He was able to develop normal running and cardiovascular skills through age 5 when he moved out of the area.  His right upper extremity still had some motor impairment but, throughout the 4 and half years of care, never had further respiratory symptoms. 

Literature review reveals that brachial plexus surgery is best performed after the diaphragm is repaired or after spontaneous recovery of the phrenic nerve palsy⁶ because there is significant morbidity associated with surgical recovery including difficulty weaning from ventilation after surgery⁴ and infection or even death (10-14%)⁶.  This infant did not have a respiratory infection but often cases of PNI will have repeated respiratory infections⁴. It is important that PNI be identified early for the purpose of providing mechanical support when necessary or support such as wedges and positioning advice. Once the PNI is identified it should be carefully monitored for complications until it resolves spontaneously or surgically. While the literature reveals this to be a rare manifestation of birth trauma (1/15,000 births)⁶, PNI affects a critical respiratory muscle.  As physical therapists the respiratory examination should be included in evaluation of BPI. The presence of dyspnea, tachypnea, sleep disorders, or failure to thrive⁶ combined with the birth trauma should prompt respiratory assessment to include auscultation of each lung, visual inspection of the respiratory muscles at the ribcage and abdomen for symmetry and pace, questions about sleep patterns, feeding patterns, coughing, stridor, and grunting. Radiological images (AP chest) often diagnose the elevated diaphragm and orientation of the mediastinum but sometimes ultrasound may be required and can use height as well as thinning to identify paresis⁹.  Ultrasound is preferred over fluoroscopy^{6, 9} because of radiation exposure and has high specificity for diagnosis of elevated diaphragm prior to scheduling of plication.

This case study describes the importance of vital signs and respiratory evaluation of newborns with brachial plexus injury and birth trauma.