Combined suprascapular and axillary nerve blocks are another alternative to consider in scenarios in which avoiding phrenic nerve palsy is critical, particularly in arthroscopic shoulder surgery. Interestingly, injection of local anesthesia through a catheter appears to produce a less dramatic change in diaphragmatic sonographic excursion than if the same large-volume bolus was injected directly through a needle, possibly supporting a benefit of titrated injection.66 This suggests that injection dynamics may play an important role in development of diaphragmatic dysfunction and should be investigated further. Unilateral phrenic nerve injury often results in symptomatic hemidiaphragm paralysis. Neuropathy is damage to or dysfunction of a nerve or group of nerves. I was having a heart attack. The sural nerve is then harvested from the leg to be used as an interposition, or bypass, graft. Regional anesthesia continues to be of value in providing analgesia for shoulder surgery, but its benefits must be weighed against the risks, including phrenic nerve palsy. About Phrenic Nerve Contact us today to learn more about the Phrenic Nerve Program at UCLA. Once a view of the curved, hyperechoic diaphragmatic line has been obtained, M-mode sonography is used to quantify the extent of diaphragmatic excursion. The Center of Peripheral Nerve Surgery is a multidisciplinary center specializing in the research, diagnosis, and treatment of a variety of peripheral nerve problems. We also review the various techniques that seek to provide adequate regional anesthesia of the shoulder while minimizing the risk of phrenic nerve palsy, as well as methods for assessing their impact on diaphragmatic function, and thus provide a comprehensive narrative of their value in achieving these two objectives. The axillary nerve is a terminal branch of the posterior cord of the brachial plexus. The loss of functionality occurs when patients use ventilators for breathing. The most common method involves placing a 3- to 5-MHz curved array transducer inferior to the costal margin and in a longitudinal parasagittal orientation in the anterior axillary line on the left or in the midclavicular line on the right (fig. Contact us today and let us guide you toward a solution for your condition. The specific nerves to be targeted will depend in part on the surgical approach that is used (fig. The diaphragm, the fundamental muscle of respiration, is innervated by the phrenic nerve which originates from the cervical ventral horn of C3-C5 roots, and it is supplied mainly by C4 [].Injury to the phrenic nerve and/or one of its roots may lead to diaphragmatic paralysis (DP) and dysfunction [].The spinal level mostly affected in cervical spondylosis is C5-C6, C6-C7, and C4-C5. Patients are often misdiagnosed because the . (A) Preblock sniff test assessment for phrenic nerve palsy. For additional information on Phrenic Nerve Paralysis and Paralyzed Diaphragm treatment in Los Angeles, CA, call our office at (310) 423-2129 to schedule a consultation today! Find a Doctor Find a Doctor. In 1948, Lurje 3 suggested that the phrenic nerve may be used as a source of motor axons, but it is not recorded whether he ever used it clinically. Dr. Onders and his team discovered implanting electrodes into the muscle near the phrenic nerve, which controls the diaphragm, and stimulating the electrodes with a small battery-powered external pulse generator causes the diaphragm to contract. Reza Jarrahy, MD earned his bachelor's degree from Stanford University and his medical degree from the State University of New York's Stony Brook School of the Medicine. When breathing in, the diaphragm drops to allow the lungs to bring air in. I am on oxygen 24/7. Image reproduced with permission from Maria Fernanda Rojas Gomez and Ultrasound for Regional Anesthesia (USRA; http://www.usra.ca). Implanting the diaphragm pacing technology is an outpatient laparoscopic procedure. The pacing and other settings are optimized for each patient. If nerve damage is left for over a year, there is a good chance the nerve will permanently lose its connection to the diaphragm. Once we determine you are an ideal candidate, we may perform additional diagnostic testing to determine the cause, if possible, and to decide which procedure would be best for you. Taking that into account, and the fact that a repaired nerve heals at 1 mm a day, surgery is offered by 6 to 9 months. On a chest X-ray, the diaphragm will appear elevated. To determine if our revolutionary treatment options can help you, we will begin with a consultation. We have vast experience in combining pacemakers with nerve reconstruction to optimize recovery in the most complex cases of diaphragm paralysis. New indications and a safer technique. A new nerve block procedure for the suprascapular nerve based on a cadaveric study. A significant reduction in costs for the long-term care of ventilator-dependent patients is one of the advantages of the Avery Diaphragm Pacing System over a mechanical ventilator. In a subsequent study, the same authors reported that the minimum effective anesthetic volume to achieve complete sensory block of C5 and C6 dermatomes within 30 min in 50% of patients using this technique was 2.9 ml ropivacaine 0.75%. However, isolated testing after block performance may be compared with predicted values based on patient demographics, although this is less accurate than a comparison with baseline values. Ultrasound-guided suprascapular nerve block, description of a novel supraclavicular approach. Indeed, the patient no longer needs to reside in an ICU hospital setting. Paralyzed diaphragm caused by neurological disorders, spinal cord disorders and trauma to the phrenic nerve from surgery, radiation or a tumor. Patients usually stay awake, but are drowsy during the procedure. People with injuries at C3, C4 and C5 may have compromised diaphragmatic function, but are unlikely to be . Your doctor will need to determine your type and severity of sleep apnea. Phrenic nerve injury (PNI) is a complication of ablation that pulmonologists should be familiar with, due to its increasing incidence (3). Hip replacement. High volume and low concentration of anaesthetic solution in the perivascular interscalene sheath determines quality of block and incidence of complications. Phrenic Nerve Repair Reconstructive Services Our team is made up of experts and leaders in the art and science of plastic surgery. Advice Media. Cervical spine disease is a risk factor for persistent phrenic nerve paresis following interscalene nerve block. In men, the normal displacement of an unaffected diaphragm is 1.8 0.3, 7.0 0.6, and 2.9 0.6 cm in quiet breathing, deep breathing, and sniffing, respectively, and 1.6 0.3, 5.7 1.0, and 2.6 0.5 cm in women.60 Once again, it is ideal to obtain baseline measures of diaphragmatic excursion before block performance. Long-term follow-up after phrenic nerve reconstruction for diaphragmatic paralysis: a review of 180 patients [published correction appears in. A recent study compared the effect of performing an ultrasound-guided intraplexus injection on the anterior versus posterior aspect of the C5C6 nerve roots with 15 ml ropivacaine 1%.35 There was a similar reduction of 12 to 28% in all pulmonary function parameters in both groups. Copyright 2017, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. A novel technique using ICG for contralateral phrenic nerve identification is also described. Reza Jarrahy, MD (left) and Matthew Kaufman, MD (right), Diaphragm Paralysis Caused by Transverse Cervical Artery Compression of the Phrenic Nerve: The Red Cross Syndrome. To expedite the process, we ask that you come prepared with a confirmed diagnosis for a paralyzed diaphragm. Partial early recovery can sometimes occur and reveals itself by an increase in lung aeration by one to two rib spaces, suggestive of increased tone in the diaphragm. Patients should understand that there isnt an unlimited time that you can wait to fix the nerves. CINAHL = Cumulative Index to Nursing and Allied Health Literature. Dr. Matthew Kaufman of The Institute for Advanced Reconstruction has performed over 500 Phrenic Nerve surgeries, for patients all over the country and the world! They also present a comprehensive review of the strategies for reducing phrenic nerve palsy and its clinical impact while ensuring adequate analgesia for shoulder surgery. The diagnosis of phrenic nerve block on chest X-ray by a double-exposure technique. Key landmarks to identify proximity to the phrenic nerve include the posterior border of the sternocleidomastoid muscle medially, the brachial plexus laterally, and the anterior scalene muscle, upon which the phrenic nerve courses. Phrenic Nerve Paralysis may occur during birth, following trauma, or from radiation, tumor, or a virus. Inspire improves airflow and reduces obstructive sleep apnea . Accessory phrenic nerve: A rarely discussed common variation with clinical implications. In addition, scar tissue can form in the neck and compress the nerve. Untreated phrenic nerve paralysis will likely end with the patient being required to use a mechanical ventilator to breathe, and no one likes the thought of that. Our goal is to improve the treatments available to patients with peripheral nerve pathologies. Consequently, there is reduced lung ventilation on the affected side, particularly of the lower lobe.28,30 In healthy individuals, however, tidal volumes remain unchanged due to a greater contribution from the rib cage.11,28 In higher-risk patient groups, hypoxia and dyspnea may ensue and require treatment by sitting the patient upright and administering supplemental oxygen therapy or, in severe cases, instituting noninvasive or invasive ventilatory support to augment tidal volumes. It therefore falls to the individual anesthesiologist to assess the likely impact of phrenic nerve palsy in any given patient undergoing shoulder surgery and to select the appropriate regional anesthetic technique accordingly. The phrenic nerve often is injured in infants undergoing congenital heart procedures. Hernia repair. Prolonged diaphragm dysfunction after interscalene brachial plexus block and shoulder surgery: A prospective observational pilot study. The left phrenic nerve was blocked using the method described by Moore. Among his nerve surgery expertise which he performs together with his partners at the Institute for Advanced Reconstruction in Shrewsbury, NJ, Dr. Kaufman is the only known surgeon to perform specialized phrenic nerve surgery. The phrenic nerve controls function of the diaphragm muscle; the primary muscle involved in breathing. Most patients adjust to the therapy within the first 3 months. Eric Vallieres. Effect of hemidiaphragmatic paresis caused by interscalene brachial plexus block on breathing pattern, chest wall mechanics, and arterial blood gases. Surgical treatment of permanent diaphragm paralysis after interscalene nerve block for shoulder surgery. Leg, ankle or foot operations. Local injection of liposomal bupivacaine combined with intravenous dexamethasone reduces postoperative pain and hospital stay after shoulder arthroplasty. Journal of Reconstructive Microsurgery , 2016; DOI: 10.1055/s-0036-1588018 Cite This . The remed system is indicated for moderate to severe Central Sleep Apnea in adult patients. The phrenic nerve is a bilateral nerve, and its left and right counterparts have some important differences in terms of course and relations with surrounding structures. Kaufman MR, Willekes LJ, Elkwood AI, et al. Eligible trials included randomized or quasirandomized controlled trials, controlled trials, case series, or pertinent correspondence that were deemed relevant or providing new knowledge on the subject in question. That's a savings of up to $20,000 per year. If your doctor determines that you have central sleep apnea you should discuss with your physician if the remed System is right for you. Extrafascial injection for interscalene brachial plexus block reduces respiratory complications compared with a conventional intrafascial injection: A randomized, controlled, double-blind trial. The incidence and aetiology of phrenic nerve blockade associated with supraclavicular brachial plexus block. Phrenic nerve breathing pacemaker surgeryIn this procedure, surgeons implant a breathing pacemaker to control the diaphragm muscle. My right phrenic nerve was damaged (paralyzed) during surgery to remove a Thymic tumor. Alexander Farivar. Learn More Share With Friends Request Information Suprascapular nerve block. The superior trunk is formed by the union of C5 and C6 roots and is an appealing alternative target for local anesthetic injection, given that the phrenic nerve has diverged a considerable distance away from the brachial plexus at this level. The authors describe the anatomical, physiologic, and clinical principles relevant to phrenic nerve palsy in this context. However, there may be some correlation between these parameters. Please consult with your doctor for additional information. endobj xref 95 37 0000000016 00000 n 0000001537 00000 n 0000001683 00000 n 0000002186 00000 n 0000002622 00000 n 0000003188 00000 n 0000003821 00000 n 0000004362 00000 n 0000004476 00000 n 0000004588 00000 n 0000004695 00000 n 0000005073 00000 n 0000005551 00000 n 0000006615 00000 n 0000007502 00000 n 0000007852 00000 n . Kaufman MR, Elkwood AI, Brown D, et al. There are additional risks associated with removing your system. Surgery can cost $20,000-$90,000 or more, depending on the facility and the type of surgery. Comparison between ultrasound-guided supraclavicular and interscalene brachial plexus blocks in patients undergoing arthroscopic shoulder surgery: A prospective, randomized, parallel study. This review aims to summarise the available literature on the diagnosis and management of . Minimum effective volume of local anesthetic for shoulder analgesia by ultrasound-guided block at root C7 with assessment of pulmonary function. Learn more about the Avery Diaphragm Pacing System System, Published Article: Diaphragm Pacing Using the Minimally Invasive Cervical Approach. Diaphragmatic paralysis: The use of M mode ultrasound for diagnosis in adults. The reduction in local anesthetic concentration and dose decreased duration of sensory blockade by 34% and increased postoperative opioid requirements by up to 50%.43,44 Zhai et al.56 demonstrated that there is no significant difference in the incidence of phrenic nerve palsy with a fixed 50-mg dose of ropivacaine for ultrasound-guided interscalene block using concentrations of 0.25, 0.5, or 0.75%, with minimal effect on analgesic outcomes. Many patients with phrenic nerve injuries have been told that they must simply learn to live with this deficit. In the event of respiratory compromise due to phrenic nerve palsy, cessation of the infusion should result in a more rapid return of phrenic nerve function.87 It also may be possible to speed up the resolution of phrenic nerve palsy by administering a bolus of 0.9% sodium chloride through the catheter to wash off residual local anesthetic.86, As discussed previously, the use of ultra-low volumes and doses of local anesthetic will minimize the risk of phrenic nerve palsy but at the expense of reduced duration of analgesia. It is made to last a lifetime. For most nerve procedures, patients may only need an overnight hospital stay and are discharged home the following morning. A cause of long-term hiccups is damage to, or irritation of, the vagus nerves or phrenic nerves. Phrenic nerve injury, such as may occur from cardiothoracic surgery, can lead to diaphragmatic paralysis or dysfunction. Cervical variations of the phrenic nerve. How Much Does Herniated Disc Surgery Cost, 7 Lesser-Known Discounts for the 50+ Crowd, 7 Ways to Stretch Your Reduced Food Budget. Contact your doctor with questions regarding the use of MRI and theremed System. Neurostimulation of the phrenic nerve is a new technology that has demonstrated improvement. This site is not optimized for Internet Explorer 8 (or older). With any surgery there are risks, but the alternative of not having your nerve damage addressed has far more downsides. Just like any other muscle in your body, you can strengthen it with exercises. Or, the American Academy of Neurology offers a neurologist locator[. Subjectively, dyspnea is the cardinal symptom of phrenic nerve palsy after interscalene block. Transient phrenic nerve palsy after regional anesthesia for shoulder surgery results from a direct inhibitory effect of local anesthetic on the phrenic nerve or its roots (C3C5), and thus minimizing its occurrence depends on reducing the dose of local anesthetic reaching these neural structures. (B) Postblock sniff test assessment for phrenic nerve palsy. In the past, treatment options for phrenic nerve injury were limited to either nonsurgical therapy or diaphragm plication, neither of which attempts to restore normal function to the paralyzed diaphragm. The late August sun can leave a mark. Patients will be followed closely by physical therapists, who will use electrical stimulation to gently help the nerves turn back on. Although diaphragmatic plication is a treatment option, phrenic nerve repair may also be considered in an attempt to restore function of the paralyzed hemidiaphragm and it may be the optimal first line treatment when feasible. The system is a battery powered device placed under the skin in the upper chest area with two small thin wires (leads), one to deliver the therapy (stimulation lead) and one to sense breathing (sensing lead). Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis. Looking for help to take care of your garden? The patient was instructed to lie in the supine position and to move the head away from the side where the block was to be performed. Less equipment = less money. Patient concerns: An 88-year-old man presented himself to the emergency geriatric unit with intermittent painless abdominal contraction due to phrenic nerve stimulation.He has a history of transcatheter aortic valve . We believe the choice becomes obvious. Advances in nerve decompression and transplant allow reconstructive plastic surgeons to reverse diaphragm paralysis. Chest fluoroscopy is an even more detailed X-ray and can show the right and left side of the diaphragm in motion as the patient breathes in and out. Reza Jarrahy, MD Cadaveric (left) and corresponding sonographic images (right) demonstrating the course of the right phrenic nerve as it emerges beneath the lateral margin of the sternocleidomastoid muscle (SCM), between the middle scalene muscle (MSM) and the anterior scalene muscle (ASM). For more information, please call 713.363.7310 . Once theremed System is implanted and the therapy is turned on, some patients may experience discomfort from stimulation and/or from the presence of the device. Injection with 20 to 30 ml local anesthetic is associated with a 25 to 51% incidence of phrenic nerve palsy in both landmark- and ultrasound-guided studies.11,40,41,59 Nonetheless, inferior sensory block and greater analgesic requirements in shoulder surgery have been reported with supraclavicular brachial plexus block compared with interscalene block.37,59 This may reflect incomplete blockade of the suprascapular nerve, which has left the brachial plexus at this point. Decreasing the local anesthetic volume from 20 to 10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis. Kaufman MR, Elkwood AI, Colicchio AR, et al. For example, Drugstore.com charges about $10-$12 for a one-month supply of a generic tricyclic antidepressant such as nortriptyline [ 1] or amitripyline, which have been shown to relieve nerve pain in some patients. It winds through C3-C5 and makes its way down towards the diaphragm. Phrenic nerve damage may occur after a major operation such as neck dissection for head and neck cancer, lung surgery, coronary bypass surgery, heart valve or other vascular surgery and thymus gland surgery. From our vast experience in evaluating thousands, and treating hundreds of patients over the last fifteen years, we have clearly identified that most cases of Idiopathic Diaphragm Paralysis are actually a result of chronic peripheral nerve compression in the neck region. The suprascapular nerve provides sensory fibers to approximately 70% of the shoulder joint capsule, and blocking this peripheral nerve can be performed with either a landmark-guided7173 or ultrasound-guided technique.4,74,75 The suprascapular nerve can either be blocked in the suprascapular fossa or in the root of the neck distal to where it arises from the superior trunk of the brachial plexus.76 However, large volumes of injection in the latter approach may still potentially lead to local anesthetic spread to the phrenic nerve and its roots. Specific conditions we treat include: Refining the ultrasound-guided interscalene brachial plexus block: The superior trunk approach. Inflammatory scarring causing nerve entrapment has been reported with both landmark-guided and ultrasound-guided interscalene block, and although it has been suggested that this scarring may be related to local anesthetic myotoxicity,24,25 these are postulated mechanisms without direct supporting evidence at present. Strategies that have been proposed to reduce phrenic nerve palsy while preserving analgesic efficacy include limiting infusion rates to 2 ml/h.85 In a letter to the editor, Tsui and Dillane86 reported that using an intermittent bolus regimen reduces phrenic nerve palsy; however, this has yet to be confirmed in a formal clinical trial. Fewer upper airway infections means fewer expensive hospital stays. The Phrenic Nerve Program is a collaboration between Reza Jarrahy, MD at the UCLA Division of Plastic & Reconstructive Surgery and Matthew Kaufman, MD at The Institute for Advanced Reconstruction. Comparison of tissue distribution, phrenic nerve involvement, and epidural spread in standard- vs low-volume ultrasound-guided interscalene plexus block using contrast magnetic resonance imaging: A randomized, controlled trial. To learn more about our services, call 310-825-5510. The rem ed System is an implantable system that stimulates a nerve in the chest (phrenic nerve) to send signals to the large muscle that controls breathing (the diaphragm). Curved array transducer (1) position for scanning the diaphragm in the midclavicular, right subcostal margin using the liver as an acoustic window, and linear array transducer (2) on the left in the midaxillary line at the level of ribs eight to nine. These signals stimulate breathing in the same way that the brain signals breathing. Despite this, the vast majority of patients in clinical trials of interscalene block exhibit few symptoms and require no specific treatment.1517 Thus, on the surface, transient phrenic nerve palsy appears to have little clinical significance in terms of both objective (respiratory support) and subjective (dyspnea) features. Phrenic nerve injury is a common complication of cardiac and thoracic surgical procedures, with potentially severe effects on the health of a child. MT = middle trunk; ST = superior trunk. We read with interest the case series "Surgical Treatment of Permanent Diaphragm Paralysis after Interscalene Nerve Block for Shoulder Surgery." 1 We agree with the conclusion made by authors that the current practice of regional anesthetic blocks should continue to focus on technical accuracy, including use of ultrasound guidance. The phrenic nerve originates primarily from the fourth cervical ventral ramus but also receives contributions from both third and fifth ventral rami, as well as the cervical sympathetic ganglia or thoracic sympathetic plexus.5 This small nerve forms at the upper lateral border of the anterior scalene muscle and descends obliquely across the anterior surface of the muscle toward its medial border (fig. The other authors declare no competing interests. Infusion rates of 4 to 6 ml/h will invariably lead to phrenic nerve palsy over the first 24 h, regardless of the concentration of the local anesthetic.84 Similarly, Renes et al.15 found that although there was no evidence of phrenic nerve palsy 2 h after a small bolus injection of 0.75% ropivacaine at the C7 nerve root, all patients developed either partial or complete phrenic nerve palsy after a 24-h infusion of 0.2% ropivacaine at 6 ml/h. Bony and capsular components are innervated by the suprascapular, axillary, lateral pectoral (C5C7), musculocutaneous (C5C7), and long thoracic (C5C7) nerves (fig. With this device, electrodes are placed on the phrenic nerve in the neck or chest and connect to an external device that creates radio waves. The technical storage or access that is used exclusively for statistical purposes. Insurance Reimbursment Avery Diaphragm Pacing Systems are approved by the Center for Medicare & Medicaid Services for Medicare reimbursement and by most private and government insurance plans throughout the world. So that is one of the paths of the right and left-sided pairs of the phrenic nerve. I was told the damaged nerve can regenerate at one mm per month. Phrenic nerve reconstruction may involve neurolysis, interposition nerve grafting, and/or neurotization, depending on the extent of the injury. For this narrative review, we systematically searched electronic databases including MEDLINE, PubMed-not-MEDLINE, Excerpta Medica database (Embase), Cochrane Central Controlled Trials Database Register, and Cumulative Index to Nursing and Allied Health Literature (CINAHL), supplemented by a manual search. If you have been diagnosed with a paralyzed diaphragm, you may be a candidate for phrenic nerve repair. Once the therapy is adjusted for you, you will need check-up visits every 3-6 months. It is small and unobtrusive. Read full indications for use. Kaufman MR, Elkwood AI, Rose MI, et al. Costanzo MR, Javaheri S, Ponikowski P, et al. Causes, Symptoms, and Treatment of Phrenic Nerve Damage. Suprascapular nerve block prolongs analgesia after nonarthroscopic shoulder surgery but does not improve outcome. Cartography of human diaphragmatic innervation: Preliminary data. It's essential to breathing. The conventional ultrasound-guided interscalene block is a direct carryover from the landmark-guided approach, which relied on the interscalene groove and the anterior tubercle of the C6 transverse process as key landmarks, and thus necessitated a needle approach to the brachial plexus at the root level. Filters applied included (1) publication date January 1, 1946, to November 1, 2016; (2) English language; (3) human studies; and (4) adult studies. What side(s) of your diaphragm is paralyzed? Cutaneous innervation is provided by the axillary (C5C6), suprascapular nerve (C5C6), and supraclavicular nerves of the cervical plexus (C3C4). It causes problems with breathing, which is thoroughly uncomfortable on its own. Surgical treatment focuses on healing the injured nerve(s). (A) The distribution of cutaneous innervation of the shoulder. Functional restoration of diaphragmatic paralysis: an evaluation of phrenic nerve reconstruction. In avulsion-type injuries the nerve is directly pulled off its electrical source in the spinal cord. Introduction: Phrenic nerve lesion is a known complication of thoracic surgical intervention, but it is rarely described following thymectomy and lung surgery. In humans, the right and left phrenic nerves are primarily supplied by the C4 spinal nerve, but there is also a contribution from the C3 and C5 spinal nerves. In addition, its system of using small implanted radiofrequency receivers rather than electrode wires that pass directly through the skin may decrease a patients risk of infection and ongoing wound care management issues. Incidence of phrenic nerve block after interscalene brachial plexus block. These include the intercostal nerves, 4,5 the spinal accessory nerve, 2 and the motor branches of the cervical plexus. In rupture-type injuries, the nerve completely snaps and leaves two free ends that are no longer talking to each other. Then 3 weeks after surgery, I went to the ER by ambulance for chest pains which went across my back. On deep inspiration, caudal descent of the liver or spleen precedes descent of the bright pleural line (fig. Three major nerves (given the symbols C3, C4, C5) exit from the spinal cord in the neck and combine to form the phrenic nerve. They were often told by their physicians that they would simply have to live with it. Although there is clearly some correlation between pulmonary function test changes and ultrasound evidence of unilateral diaphragmatic paresis, no study has explicitly and specifically assessed the correlation between ultrasound, pulmonary function test, oxygen saturations, and subjective symptoms of dyspnea. Phrenic nerve injury can result in paralysis of the . Linear array transducer ultrasound image of the pleura in the right midaxillary line at the level of the seventh and eighth ribs in (A) early inspiration; (B) mid-inspiration; and (C) end-inspiration.
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