A 43-year-old woman with end-stage idiopathic pulmonary fibrosis underwent a right lung transplant. A right thoracotomy incision was made to implant the lung, and the operation was completed without any complications. She was brought to the ICU and ventilated, with plans to extubate the following morning. On postoperative day one, a spontaneous breathing trial (SBT) is aborted within five minutes after she becomes tachypneic at a respiratory rate of 44 breaths/min and desaturates to 89% on FIO2 0.4.
After a week of failed SBT, a tracheostomy tube is placed and she is able to ambulate. Bronchoscopy shows well-healing bronchial anastomosis without debris in the airways. Breath sounds are clear. She is able to participate in physical rehabilitation, but attempts to wean her from the ventilator are met with hypercapnia and tachypnea. The chest radiograph shown below has been unchanged since postoperative day two.
Further work-up should include which of the following tests?
A. Edrophonium test
B. Chest fluoroscopy (sniff test)
C. Flexible fiberoptic bronchoscopy
D. Tacrolimus trough levels
该患者有右侧膈肌功能障碍，这可能是其手术的并发症。在胸外科手术中，膈神经可被拉伸、压碎或无意中横断。测量膈肌偏移的无创方法是透视sniff test，指导患者深呼吸，然后以直立位sniff test，再次以侧卧位sniff test。深吸气时受累膈肌缺乏尾侧运动，sniff test时出现反常运动是阳性发现。该试验在单侧膈肌功能障碍中的假阳性率约为6%，对双侧膈肌功能障碍没有帮助。潜在治疗包括临时呼吸机支持、膈肌折叠术和膈神经起搏。术中非脱色神经肌肉阻滞的半衰期为数小时，而不是数天。虽然粘液栓可导致肺不张和肺叶塌陷，但在膈肌升高和呼吸音清晰的情况下，最后一次光纤检查是干净的。他克莫司毒性与膈肌无力无关。
References:
- McCool FD, Tzelepis GE. Dysfunction of the diaphgram. N Engl J Med. 2012 Mar 8;366(10):932-942.
- Nason LK, Walker CM, McNeeley MF, Burivong W, Fligner CL, Godwin JD. Imaging of the diaphgram: anatomy and function. Radiographics. 2012 Mar-Apr;32(2):E51-E70.
- Laghi F, Tobin MJ. Disorders of the respiratory muscles. Am J Respir Crit Care Med. 2003 Jul 1;168(1):10-48.
B
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