Management of residual pleural space after lung resection: Fully controllable paralysis of the diaphragm through continuous phrenic nerve block

Abstract

Background: Residual pleural space after lung resection associated with air leak is a challenging issue, potentially causing serious complications. We report a new, postoperative technique to reduce the pleural space, inducing a controlled reversible paralysis of the diaphragm. Methods: Ten patients were enrolled (7 lobectomies, 2 bilobectomy, 1 wedge resection). Inclusion criteria were: digitally detected air flow >200 mL/min at post-op day 3, presence of empty pleural space at chest x-ray, absence of restrictive lung disease, absence of known arrhythmias. A 22G nerve-block catheter was place under ultrasound guidance in proximity to the phrenic nerve, between the sternocleidomastoid muscle the anterior scalene muscle at the level of 6th cervical vertebra. Continuous infusion of ropivacaine 0.2% 3 mL/h was started. Fluoroscopy was used to confirm significant reduction in hemidiaphragm movements. Monitoring of vital signs intense respiratory physiotherapy were enhanced. The infusion was stopped at air leak cessation the catheter was removed along with the chest drain. Results: No peri-post-procedural complications occurred. In all patients, we observed an immediate reduction of the empty pleural space resolution of the air leak within few days (3?1.16 days). After suspension of local anaesthetic, complete restoration of the hemidiaphragm function has been documented. Conclusions: This is an effective minimally invasive method to reduce the residual pleural space after lung resections. Narrowing of the pleural space facilitates the contact between the lung the chest wall promoting the resolution of the air leak. Diaphragm paralysis is controlled temporary with no residual disabilities.