Video-assisted thoracoscopic diaphragmatic plication in a ventilator-dependent patient with an elevated and dysfunctional hemidiaphragm.

Unilateral hemidiaphragm dysfunction can reduce ventilatory reserve, but its contribution to weaning failure is difficult to isolate in a critically ill patient. A 61-year-old woman with asthma and a chronically elevated left hemidiaphragm developed severe pneumonia and acute hypercapnic respiratory failure, with an arterial partial pressure of carbon dioxide (PaCO2) of 164.9 millimeters of mercury (mmHg), followed by recurrent extubation failure and tracheostomy. Pulmonary embolism was excluded. Bronchoscopy, microbiological treatment, nutritional support, and treatment for suspected autoimmune disease improved several reversible problems, yet hypercapnia recurred during ventilator reduction. Prior imaging showed that the elevation predated the acute illness. Formal fluoroscopic sniff testing, diaphragm ultrasound, phrenic nerve studies, and complete ventilator-setting records were unavailable; the condition is therefore described cautiously as an elevated and dysfunctional hemidiaphragm, most consistent clinically with acquired paralysis rather than a true hernia. After multidisciplinary reassessment, three-port left video-assisted thoracoscopic diaphragmatic plication was performed under low-pressure capnothorax. The diaphragm was flattened with six rows of continuous nonabsorbable braided polyester suture, using repeated mattress-type bites reinforced with polytetrafluoroethylene pledgets. Operative time was 180 minutes. PaCO2 was 36.0 mmHg on postoperative day 1. Spontaneous-breathing trials began on postoperative day 2, and sustained side-arm oxygen through the tracheostomy began on postoperative day 7. Hypercapnic acidosis recurred on postoperative days 11-12 during ongoing pulmonary infection. She was transferred for rehabilitation off the ventilator on postoperative day 15 and remained off ventilatory support at last contact, with the tracheostomy still in place. This case does not establish that plication alone produced ventilator liberation. It shows how a familiar operation may be used after cautious selection to remove one potentially reversible mechanical burden in multifactorial weaning failure.