Phrenic Nerve palsy Unilateral right side

[Blastman4444]

HI,
Back in 2011 I got the bends flying on a commercial plane after a delay of 21 hours after my last dive no one could explain why I got the bends. Prior to that happening in 2009 routine xray a doctor once told me I had an elevated right diaphragm but if it wasn't bothering me don't worry about it. Fast forward 9 years now I'm having some issues breathing and another doctor sent me for a sniff test told me I have phrenic Nerve palsy my right lung is not really working because the diaphragm on that side doesn't move they used a fluoroscopic xray it was like a video I could see my heart beating breathing. The new doctor said when I first was told about the elevated diaphragm in 2009 I was only running on one lung. Could this be why I got the bends flying on the plane? If the lung isn't working right not going to be able to get rid of the nitrogen in the time limits which are normally used by a healthy person.

 

[Duke Dive Medicine]

HI,
Back in 2011 I got the bends flying on a commercial plane after a delay of 21 hours after my last dive no one could explain why I got the bends. Prior to that happening in 2009 routine xray a doctor once told me I had an elevated right diaphragm but if it wasn't bothering me don't worry about it. Fast forward 9 years now I'm having some issues breathing and another doctor sent me for a sniff test told me I have phrenic Nerve palsy my right lung is not really working because the diaphragm on that side doesn't move they used a fluoroscopic xray it was like a video I could see my heart beating breathing. The new doctor said when I first was told about the elevated diaphragm in 2009 I was only running on one lung. Could this be why I got the bends flying on the plane? If the lung isn't working right not going to be able to get rid of the nitrogen in the time limits which are normally used by a healthy person.

Hi kell490, what were your symptoms of DCS and who diagnosed you? Were you treated for it?

Best regards,
DDM

 

[Blastman4444]

My symptoms were intimidate severe tingling, and weakness in legs and arms after taking off in a plane from Fort Lauderdale Airport around labor day weekend in 2011 I was treated at St. Mary's Medical Center in West Palm Beach. I don't remember the doctors name I know they gave me a CT scan other test I'm not sure how they exactly diagnosed me. I was given 6 hours of Hyperbaric treatment in a larger chamber where I wore plastic hood over my head that was on 100% o2 I was told. There was enough room for one tech to be in the chamber it was still small had to sit Then I was then kept overnight and the next day I was put in a small chamber that was like a glass tube you lay down in and that one they told me had no hood the entire chamber was pressurized to 100% O2. I don't remember the doctors name I know it took sometime for the operators of the chamber to be called in they said it was a as needed program not staffed 100% of the time. I have posted here back then when it happend we might have discussed this before you can search my userID. After the treatments I still had the tingling in my lower legs for some months after returning home the doctor said that was normal inflammation it would go away with in 6 month which it did. I have not had any issues with it again I dove one more time in 2012 on a trip to Cozumel but didn't fly out for 3 days after diving 2 longer dives I felt some minor tingling in my left arm shortly after surfacing which went away after about an hour I can't say that had anything to do with DCS. I haven't done any diving since 2012 when I went to Cozumel now that I have had this diagnoses of the problem with the phrenic Nerve I wonder if that could be the reason why it happened possibly not able to off gas nitrogen at the same rate someone both diaphragms working.

 

[Duke Dive Medicine]

Hi kell490,

That's an interesting story, I'm glad you got treated and recovered. I'm trying to figure out a way that phrenic nerve palsy could have played a role in this. If you have one lung that's chronically under-ventilated, your other lung would probably have compensated. If you can oxygenate and get rid of carbon dioxide normally (including with exercise) then you should on-gas and off-gas nitrogen normally too, but maybe "normally" for you is slower than average. If you had a long week of diving and had built up a considerable nitrogen load, that likely factored in. Another thing I wonder about is post-dive venous gas emboli. In normally functioning lungs, VGE are trapped in the pulmonary circulation and eliminated. If one lung is under-ventilated this would not happen as efficiently. This is a bit of a reach, but I wonder if there could have been some venous gas emboli remaining in the circulation of your right lung. If there were, they'd have expanded as the plane climbed. If they were trapped in the pulmonary capillaries, maybe part of the gas was shunted through to the pulmonary veins and then into the arterial circulation. Or, maybe they went retrograde back through the right pulmonary artery and were passed through an intracardiac shunt. Do you know if you have a PFO? @Dr Simon Mitchell, @Dr. Doug Ebersole, and any other medical types, your opinions would be welcome.

In any event, you should see a diving medical specialist if you plan on diving again. If you'd like a referral, I can give you information on physicians in your area.

Best regards,
DDM

 

[Blastman4444]

At this point I don't plan on diving again until I figure out if this could be a problem I do know at some point in my past my resting o2 reading using a pulse/ox meter started to read around 91-94% I guessing that happened at the time when the phrenic Nerve damage happend because I can remember going to doctors in years past and seeing 98% resting. Sometime in 2009 I was told from an xray that I had an elevated right diaphragm that it wasn't a concern because I had no other symptoms the lower o2 reading didn't see alarming to them I do know if I breath deeper the reading goes up to 98% like you said it's possible my other lung has compensated. I'm in Phoenix AZ if you could refer me to a diving Medical specialist in my area. I have never been checked for a PFO as far as I know I am going to a Pulmonary specialist this month now I have had some reoccurring coughing and wheezing while laying down I'm wondering if this is related. Thank you for your detailed insight into a possible connection the event back in 2011 I think had a lot of factors lack of sleep, stress, and dehydration still didn't fully explain it maybe the underlying medical condition was factor as they are lot of times. Another idea I had was would it be possible for the pressurized tank and regulator to inflate that bad lung more while at depth then after returning to the surface I would be off gassing at a lower rate then normal but took on a higher then normal loading causing an imbalance between the two in the end I would have a larger amount of nitrogen still in my blood compared to a normal person.

 

[Norwegian Cave Diver]

Would this also mean that your CNS central nervious system loading would be artificially high?

 

[Dr Simon Mitchell]

Hello,

Like DDM I very much doubt that phrenic nerve palsy would materially affect inert gas exchange in diving. I would be more concerned that it might compromise your exercise capacity and ability to swim your way out of trouble during a dive.

Whatever the breathing issues you allude to are, that needs to be well characterized and discussed with a diving physician before you dive again.

Good luck with it all.

Simon M

 

[Duke Dive Medicine]

At this point I don't plan on diving again until I figure out if this could be a problem I do know at some point in my past my resting o2 reading using a pulse/ox meter started to read around 91-94% I guessing that happened at the time when the phrenic Nerve damage happend because I can remember going to doctors in years past and seeing 98% resting. Sometime in 2009 I was told from an xray that I had an elevated right diaphragm that it wasn't a concern because I had no other symptoms the lower o2 reading didn't see alarming to them I do know if I breath deeper the reading goes up to 98% like you said it's possible my other lung has compensated. I'm in Phoenix AZ if you could refer me to a diving Medical specialist in my area. I have never been checked for a PFO as far as I know I am going to a Pulmonary specialist this month now I have had some reoccurring coughing and wheezing while laying down I'm wondering if this is related. Thank you for your detailed insight into a possible connection the event back in 2011 I think had a lot of factors lack of sleep, stress, and dehydration still didn't fully explain it maybe the underlying medical condition was factor as they are lot of times. Another idea I had was would it be possible for the pressurized tank and regulator to inflate that bad lung more while at depth then after returning to the surface I would be off gassing at a lower rate then normal but took on a higher then normal loading causing an imbalance between the two in the end I would have a larger amount of nitrogen still in my blood compared to a normal person.

Hi Kell, the coughing and wheezing could result from a lung that is chronically under-inflated. It's good to hear that you're seeing a pulmonologist.

The question about the diving gear is an interesting one. Your open-circuit scuba gear is designed to deliver breathing gas to you at a pressure that will allow you to inflate your lungs (mostly the left, in your case) against the ambient water pressure, but not higher. The diaphragm of the regulator must be drawn inward in order to crack the inlet valve and allow air to flow from the tank, and that requires negative inspiratory pressure. As long as your gear was functioning correctly, any positive pressure in your airway would have resulted in the regulator diaphragm moving out and the air flow stopping. Expiration would also have occurred normally, that is, the slight positive pressure produced by the relaxation of your diaphragm would have caused the air to flow back out through your airways and the regulator exhaust valve. The pressure required to open the mushroom valve in a normally functioning regulator is negligible.

Best regards,
DDM