Scientific letter
Morgagni Hernia as a Reversible Cause of Hypercapnic Respiratory Failure
Hernia diafragmática de Morgagni como causa reversible de insuficiencia respiratoria hipercápnica
Patrícia Dionísio
, Susana Moreira, Rita Pinto Basto, Paula Pinto
Corresponding author
Pulmonology Department, Centro Hospitalar Lisboa Norte, Portugal
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There was no history of recent trauma or surgery.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On admission, she was started on non-invasive ventilation (NIV) for hypercapnic respiratory failure (pH 7.35, PaCO<span class="elsevierStyleInf">2</span> 72.4 and PaO<span class="elsevierStyleInf">2</span> 40.2<span class="elsevierStyleHsp" style=""></span>mmHg). The initial chest radiographs showed an hypotransparency on the right pulmonary lower lobe. The chest CT scan identified a large Morgagni hernia on the right side, with the compromise of the right lung volume and contralateral mediastinal deviation, as well as signs of pulmonary hypertension. The echocardiogram confirmed mild pulmonary hypertension (PSAP 49<span class="elsevierStyleHsp" style=""></span>mmHg). She was referred to Cardiothoracic Surgery but was refused because of her surgery-related risk. She was discharged on long-term supplemental oxygen therapy and domiciliary NIV. Between 2008 and 2012 she was admitted three times for decompensated hypercapnic respiratory failure and for oxygen and ventilatory parameters adjustment. Diaphragmatic hernia was also bigger on the chest radiographs. In 2013 she was admitted five times in the context of emesis and gastroparesis. Despite a significant weight loss (BMI 50 to 41<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>), she maintained the need for both long-term supplemental oxygen therapy and NIV. At that time her lung function test showed a moderately severe obstructive pattern (FVC 1.05<span class="elsevierStyleHsp" style=""></span>mL (67%); FEV<span class="elsevierStyleInf">1</span> 0.64<span class="elsevierStyleHsp" style=""></span>mL (52%); FEV<span class="elsevierStyleInf">1</span>/FVC ratio 61.14%; TLC 2.87<span class="elsevierStyleHsp" style=""></span>mL (82%); RV 1.76<span class="elsevierStyleHsp" style=""></span>mL (106%); ITGV 2.50 (112%)). A new CT scan showed increased volume of the Morgagni hernia, which contained part of the transverse colon, all the ascending colon, loops of ileum and distal jejunum, with the insinuation of gastric antrum, leading to passive atelectasis of the middle lobe and right lower lobe and deviation of the mediastinal structures to the left hemithorax.</p><p id="par0020" class="elsevierStylePara elsevierViewall">At the end of the year 2013, she was submitted to reduction and repair of the hernia and gastropexy, with a favourable expansion of the right lung (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and gradual resolution of global respiratory failure. Despite regaining weight (BMI 43<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>) it was possible to discontinue domiciliary NIV and supplemental oxygen therapy (pH 7.39, PaCO<span class="elsevierStyleInf">2</span> 47.8 and PaO<span class="elsevierStyleInf">2</span> 75.0<span class="elsevierStyleHsp" style=""></span>mmHg in room air). The echocardiogram showed a reduction in PSAP from 49 to 39<span class="elsevierStyleHsp" style=""></span>mmHg. There was a remarkable improvement in her lung volumes, that are now within the normal range (FVC 2.29<span class="elsevierStyleHsp" style=""></span>mL (157%); FEV<span class="elsevierStyleInf">1</span> 1.71<span class="elsevierStyleHsp" style=""></span>mL (150%); FEV<span class="elsevierStyleInf">1</span>/FVC ratio 74.75; TLC 4.47<span class="elsevierStyleHsp" style=""></span>mL (127%); RV 2.01<span class="elsevierStyleHsp" style=""></span>mL (117%); ITGV 2.45<span class="elsevierStyleHsp" style=""></span>mL (110%)).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In 2014, she did a polysomnography which showed severe obstructive sleep apnea with a respiratory disturbance index (RDI) of 39.3/H and time oxygen saturation <90% (T90) of 19.9%. The patient was started on long-term positive airway pressure treatment with good adherence.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In our literature review, we could only find ten reported cases of MH with respiratory failure in adults.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a> It is a rare aetiology for respiratory failure. It is usually asymptomatic or it presents with non-specific chronic symptoms. Because of these characteristics, the diagnosis of MH it is not often considered when changes in chest radiographs are present. Sometimes the typical radiological images of intra-thoracic gas-filled loops of the bowel are not present and it can appear as an opacity mimicking pneumonia, intrathoracic tumour, atelectasis, pericardial cyst or simulate a pneumothorax.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,4</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Hypoventilation is a result of lung parenchyma compression by the abdominal viscera and diaphragm impairment, which causes a restrictive ventilatory defect.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Oxygenation decreases due to alveolar collapse in the atelectatic lung.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> These changes in pulmonary mechanics and respiratory muscle performance tend to have worse outcomes in obese patients as they already breathe at abnormally low lung volumes. NIV is a useful tool as it improves alveolar recruitment of the affected area, while simultaneously increasing the functional residual capacity and minute ventilation.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> Nevertheless, NIV may also lead to deterioration of MH and consequently of respiratory status by causing aerophagia and abdominal distension.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> Another possible mechanism is by increasing intra-abdominal pressure when using high positive end-expiratory pressure.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> We think that in our patient the volume increase of the MH since 2007, when she was started on NIV, can potentially be explained by these mechanisms, complicated by the severe obesity.</p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand, there is no consensus or guidelines on surgical timing in non-acute cases. Although the majority of these hernias are asymptomatic, repair is recommended to avoid future complications<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,3</span></a> and may improve lung function<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> as we were able to demonstrate. Surgical intervention may also reverse chronic respiratory failure as Tone et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> report and we also found in this case. It is important to stress that the first lung function tests were carried out less than a month before surgery and that the patient regained weight after the surgical intervention. Another aspect to be mentioned is that our laboratory uses the ERS Quanjer 1993 lung function reference values<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> which were validated to patients with a minimum height of 154<span class="elsevierStyleHsp" style=""></span>cm tall. Since our patient height is only 141<span class="elsevierStyleHsp" style=""></span>cm tall, her measured values as percent of predicted are globally overestimated and we should focus on the absolute volumes.</p><p id="par0045" class="elsevierStylePara elsevierViewall">This case demonstrates the benefit of surgical reduction of this type of hernia, even in cases of chronic respiratory failure and additional causes for increased surgical risk.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 860 "Ancho" => 2083 "Tamanyo" => 223099 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computer tomography scan before and immediately after surgery showing the right lung expansion (at the right).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A review of Morgagni and Bochdalek hernias in adults" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 4 | 9 |
| 2024 October | 43 | 28 | 71 |
| 2024 September | 32 | 28 | 60 |
| 2024 August | 70 | 53 | 123 |
| 2024 July | 51 | 31 | 82 |
| 2024 June | 65 | 27 | 92 |
| 2024 May | 80 | 21 | 101 |
| 2024 April | 51 | 23 | 74 |
| 2024 March | 47 | 22 | 69 |
| 2024 February | 49 | 19 | 68 |
| 2023 June | 1 | 0 | 1 |
| 2023 March | 14 | 2 | 16 |
| 2023 February | 52 | 28 | 80 |
| 2023 January | 47 | 34 | 81 |
| 2022 December | 70 | 31 | 101 |
| 2022 November | 92 | 32 | 124 |
| 2022 October | 60 | 40 | 100 |
| 2022 September | 56 | 31 | 87 |
| 2022 August | 53 | 52 | 105 |
| 2022 July | 56 | 54 | 110 |
| 2022 June | 55 | 39 | 94 |
| 2022 May | 62 | 48 | 110 |
| 2022 April | 89 | 40 | 129 |
| 2022 March | 89 | 50 | 139 |
| 2022 February | 85 | 34 | 119 |
| 2022 January | 77 | 38 | 115 |
| 2021 December | 56 | 34 | 90 |
| 2021 November | 49 | 53 | 102 |
| 2021 October | 47 | 45 | 92 |
| 2021 September | 38 | 48 | 86 |
| 2021 August | 31 | 37 | 68 |
| 2021 July | 29 | 30 | 59 |
| 2021 June | 43 | 42 | 85 |
| 2021 May | 36 | 35 | 71 |
| 2021 April | 122 | 132 | 254 |
| 2021 March | 50 | 43 | 93 |
| 2021 February | 62 | 27 | 89 |
| 2021 January | 61 | 28 | 89 |
| 2020 December | 39 | 25 | 64 |
| 2020 November | 40 | 32 | 72 |
| 2020 October | 53 | 45 | 98 |
| 2020 September | 38 | 20 | 58 |
| 2020 August | 50 | 24 | 74 |
| 2020 July | 33 | 32 | 65 |
| 2020 June | 32 | 15 | 47 |
| 2020 May | 71 | 23 | 94 |
| 2020 April | 6 | 0 | 6 |
| 2020 March | 17 | 16 | 33 |
| 2020 February | 51 | 19 | 70 |
| 2020 January | 47 | 21 | 68 |
| 2019 December | 38 | 18 | 56 |
| 2019 November | 54 | 22 | 76 |
| 2019 October | 28 | 9 | 37 |
| 2019 September | 26 | 15 | 41 |
| 2019 August | 30 | 18 | 48 |
| 2019 July | 63 | 20 | 83 |
| 2019 June | 43 | 21 | 64 |
| 2019 May | 59 | 13 | 72 |
| 2019 April | 61 | 9 | 70 |
| 2019 March | 73 | 23 | 96 |
| 2019 February | 44 | 23 | 67 |
| 2019 January | 61 | 32 | 93 |
| 2018 December | 59 | 32 | 91 |
| 2018 November | 57 | 38 | 95 |
| 2018 October | 7 | 7 | 14 |
| 2018 September | 5 | 0 | 5 |
| 2018 May | 10 | 8 | 18 |
| 2018 January | 0 | 1 | 1 |
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