Treatment for an elevated diaphragm ranges from simple breathing exercises and sleep adjustments to surgical repair, depending on what’s causing the elevation and how much it affects your breathing. Many cases, particularly when only one side is elevated, can be managed without surgery. More severe cases, especially those causing significant shortness of breath or digestive symptoms, often benefit from a procedure called diaphragmatic plication.
Why the Diaphragm Rises
The most common cause of an elevated diaphragm is damage to the phrenic nerve, the nerve that controls diaphragm movement. This can happen after cardiac surgery, neck surgery, trauma, cervical spine compression fractures, or even a nerve block used during shoulder surgery. When the phrenic nerve stops working properly, the diaphragm on that side weakens or becomes paralyzed, and it drifts upward into the chest cavity.
Not all cases involve nerve damage, though. Pressure from below can push the diaphragm up. An enlarged liver, liver tumors, or a liver abscess commonly elevate the right side. On the left, a distended stomach, enlarged spleen, abdominal tumors, or a bloated abdomen can be responsible. Some people are born with a condition called diaphragmatic eventration, where part of the diaphragm never fully develops its muscle tissue. Most congenital cases affect the right side, particularly the front portion of the diaphragm.
Understanding the cause matters because treatment targets the underlying problem. If an enlarged liver is pushing the diaphragm up, treating the liver condition is the priority. If the phrenic nerve was injured during surgery, the approach focuses on the diaphragm itself.
How It’s Diagnosed
An elevated diaphragm often shows up incidentally on a chest X-ray, but confirming whether the diaphragm is actually paralyzed requires a more specific test. The standard method is a fluoroscopic “sniff test,” where you breathe normally and then sniff sharply while a radiologist watches the diaphragm move in real time on a live X-ray. In a healthy person, both sides of the diaphragm pull downward when you sniff. If one side moves upward instead, that paradoxical motion is highly suggestive of paralysis on that side. Nerve conduction studies can also measure whether the phrenic nerve is still functioning, which becomes important when deciding between treatment options.
Non-Surgical Management
If your symptoms are mild, or if your doctor expects the nerve to recover on its own (which sometimes happens after surgical injury), conservative management is the first step. This typically involves breathing exercises, physical conditioning, and adjustments to daily habits.
Breathing Exercises
Two techniques form the foundation of conservative care. Diaphragmatic breathing involves consciously engaging the diaphragm during slow, deep breaths, which helps strengthen the muscle and improve ventilation efficiency without triggering the sensation of breathlessness. Pursed-lip breathing, where you inhale through your nose and exhale slowly through pursed lips, prevents the small airways from collapsing too early and improves gas exchange.
Inspiratory muscle training takes this further by using a handheld device that creates resistance when you inhale, forcing the diaphragm and other breathing muscles to work harder. Typical programs run 8 to 12 weeks, with sessions three to five times per week. The resistance is usually set at 15 to 50 percent of your maximum inhalation pressure, a level that improves strength without causing excessive strain. Aerobic exercise, at least three times a week, and resistance training at least twice a week complement these breathing-specific exercises.
Sleep and Positioning
Many people with an elevated diaphragm notice that breathlessness worsens when lying flat, because gravity allows abdominal organs to press further into the chest. Sleeping with your head elevated makes a significant difference. You can use a few pillows or rolled towels under your head and neck, sleep in a recliner, or use an adjustable bed. Placing a pillow under your knees reduces back strain in this propped-up position. Side sleeping also helps, and for some people it’s the most comfortable option, particularly with a pillow between the knees for alignment.
During the day, when breathlessness hits, sitting with your feet flat on the floor and leaning slightly forward with your elbows on your knees takes pressure off the diaphragm. If you’re standing, leaning your elbows or hands on a piece of furniture at just below shoulder height while relaxing your neck and shoulders achieves a similar effect.
Diaphragmatic Plication Surgery
When an elevated diaphragm causes persistent shortness of breath, exercise intolerance, or digestive problems, and conservative measures aren’t enough, the main surgical option is diaphragmatic plication. The surgeon essentially folds and stitches the loose, elevated portion of the diaphragm to flatten it back down and prevent it from ballooning into the chest. This restores more space for the lung to expand.
The procedure is typically done using minimally invasive techniques with small incisions and a camera, either through the chest (thoracoscopic) or through the abdomen (laparoscopic), using three to four small ports. The choice between approaches often depends on surgeon preference and the patient’s medical history, though studies in children suggest laparoscopic plication may have a slightly higher rate of recurrence.
Results and Recovery
Plication delivers meaningful improvements for most patients. In a long-term study published in the Journal of Thoracic Disease, 86 percent of patients reported improvement in their symptoms after surgery, with digestive complaints seeing particularly strong relief. Lung function testing showed an average 27 percent increase in the amount of air patients could inhale, peaking around six months after surgery. However, lung function gradually declined after 18 months and returned to preoperative levels by the fourth year, suggesting the benefits to measurable lung capacity may not be permanent even though symptom relief can persist.
Recovery is relatively quick. Most people stay in the hospital for up to two nights. You can expect to return to work and normal routines within about two weeks, though it may take up to six weeks to feel fully back to your usual energy levels.
Phrenic Nerve Pacing
For people whose diaphragm elevation stems from a neurological condition rather than nerve damage at the chest level, phrenic nerve pacing is another option. This involves implanting a small device that sends electrical signals to the phrenic nerve, stimulating the diaphragm to contract rhythmically the way it normally would. The clearest candidates are people with spinal cord injuries above the C3 vertebra, where the phrenic nerve itself is intact but the brain’s signal can no longer reach it. Other conditions that may qualify include certain brainstem disorders and some lower motor neuron diseases.
Phrenic nerve pacing is not appropriate for everyone. If the phrenic nerve itself is damaged or nonfunctional, as confirmed by nerve conduction studies, stimulating it won’t produce a contraction. The nerve has to be intact for the device to work.
When One Side Affects the Other
Even when only one side of the diaphragm is elevated, the healthy side doesn’t always compensate perfectly. Evidence suggests that changes in abdominal pressure from the elevated side can impair the function of the opposite, healthy half of the diaphragm. This helps explain why some people with a unilateral problem feel more short of breath than you might expect from losing function on just one side. It also means that treating the elevated side, whether through plication or rehabilitation, can improve overall breathing function beyond what the affected side alone would account for.