Diaphragm function in acute respiratory failure and the potential role of phrenic nerve stimulation

Reardon, Peter M.; Wong, Jonathan L.; Fitzpatrick, Aisling M; Goligher, Ewan C.

doi:10.1097/mcc.0000000000000828

Cited by 3 publications

(2 citation statements)

References 58 publications

(76 reference statements)

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“…It may slow the biological mechanisms responsible for ventilator induced diaphragmatic dysfunction and have a consequent impact on morbidity and mortality. In the future, temporary phrenic stimulation may help optimise ventilator management in patients with respiratory failure ( 23 ). We previously published a pilot study of unilateral phrenic nerve neurostimulation in an ovine model and showed reduced muscle atrophy and muscle fiber injury in the neurostimulated hemi-diaphragm ( 12 ).…”

Section: Discussionmentioning

confidence: 99%

Phrenic nerve stimulation in an ovine model with temporary removable pacing leads

Etienne¹,

Dres²,

Piquet³

et al. 2022

J Thorac Dis

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Background: The objective of this study was to assess the feasibility and safety of a novel, removable, surgically implanted, temporary neurostimulation approach involving the distal portion of the phrenic nerve.Methods: Temporary phrenic nerve pacing electrodes were implanted surgically using an ovine model (4 animals). The primary endpoint was the ability to successfully match the animal's minute-ventilation upon implantation of both phrenic nerve pacers on day 1. Secondary endpoints were successful phrenic neurostimulation by both electrodes 15 days and 30 days after initial implantation. We also assessed safe removal of the electrodes at 15 days and 30 days after implementation.Results: In 3 of 4 animals, electrodes were successfully implanted in both right and left phrenic nerves. On day 1, median ventilation-minute induced by neurostimulation was not significantly different from baseline ventilation-minute [4.9 L•min -1 (4.4-5.5) vs. 4.4 L•min -1 (4.3-5.2); P=0.4] after 15 minutes. Neurostimulation was still possible 15 days and 30 days after implementation in all left side phrenic nerves. On the right side, stimulation was possible at all times in 1 animal but not in the remaining 3 animals for at least one time point, possibly due to lead displacement. Analysis of pathology after percutaneous electrode removal showed integrity of the distal portion of all phrenic nerves.Conclusions: Efficient temporary neurostimulation through the distal portion of the phrenic nerve was possible at baseline. The main complication was the displacement of electrodes on the right phrenic nerve on two occasions, which was due to the anatomy of the ovine model. It compromised diaphragm pacing on day 15 and day 30. The electrodes could be safely removed percutaneously without damage to the phrenic nerves.

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Section: Discussionmentioning

confidence: 99%

Phrenic nerve stimulation in an ovine model with temporary removable pacing leads

Etienne¹,

Dres²,

Piquet³

et al. 2022

J Thorac Dis

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“…The diaphragm is responsible for pleural and transpulmonary pressure generation and its contraction also serves to counteract the upward pressure from abdominal contents onto the lungs, reducing pressure on dependent, dorsal alveoli ( 13 , 14 ). Maintaining diaphragm contractions by facilitating spontaneous breathing while mechanically ventilated is an effective way to sustain dependent alveolar recruitment, thereby improving alveolar compliance and homogeneity, and reducing driving pressure and mechanical power ( 15 , 16 ).…”

Section: Introductionmentioning

confidence: 99%

Negative-pressure-assisted ventilation lowers driving pressure and mechanical power in an ARDS model

Rohrs

Bassi

Nicholas

et al. 2022

Journal of Applied Physiology

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Increased lung heterogeneity from regional alveolar collapse drives ventilator-induced lung injury in ARDS patients. New methods of preventing this injury require study. Our study objective was to determine whether the combination of temporary transvenous diaphragm neurostimulation with standard-of-care volume-control mode ventilation changes lung mechanics, reducing ventilator-induced lung injury risk in a preclinical ARDS model. Moderate ARDS was induced using oleic acid administered into the pulmonary artery in pigs, which were ventilated for 12 hours post-injury using volume-control mode at 8 ml/kg, PEEP 5 cmH2O, with respiratory rate and FiO2 set to achieve normal arterial blood gases. Two groups received TTDN, either every second breath (MV+TTDN50%, n=6) or every breath (MV+TTDN100%, n=6). A third group received volume-control ventilation only (MV, n=6). At study-end, PaO2/FiO2 was highest and alveolar-arterial oxygen gradient was lowest for MV+TTDN100% (p<0.05). MV+TTDN100% had the smallest end-expiratory lung volume loss and lowest extravascular lung water at study-end (p<0.05). Static lung compliance was highest and transpulmonary driving pressure was lowest at baseline, post-injury, and study-end in MV+TTDN100% (p<0.05). The total exposure to transpulmonary driving pressure, mechanical power and mechanical work was the lowest in MV+TTDN100% (p<0.05). Lung injury score and total inflammatory cytokine concentration in lung tissue were the lowest in MV+TTDN100% (p<0.05). Volume-control ventilation plus transvenous diaphragm neurostimulation on every breath improved PaO2/FiO2, A-a gradient and alveolar homogeneity, as well as reduced driving pressure, mechanical power, and mechanical work, and resulted in lower lung injury scores and tissue cytokine concentrations in a preclinical ARDS model.

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Can Cardiopulmonary Rehabilitation Facilitate Weaning of Extracorporeal Membrane Oxygenation (CaRe-ECMO)? Study Protocol for a Prospective Multidisciplinary Randomized Controlled Trial

Zheng

Sun

Mei

et al. 2022

Front. Cardiovasc. Med.

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Background: Mortality of patients suffering from critical illness has been dramatically improved with advanced technological development of extracorporeal membrane oxygenation (ECMO) therapy. However, the majority of ECMO-supported patients failed to wean from ECMO therapy. As one of several options, cardiopulmonary rehabilitation serves as effective intervention in the improvement of cardiovascular and respiratory function in various major critical illness. Nonetheless, its role in facilitating ECMO weaning has not yet been explored. The purpose of this study is to investigate the effectiveness of cardiopulmonary rehabilitation on rate of ready for ECMO weaning in ECMO-supported patients (CaRe-ECMO).Methods: The CaRe-ECMO trial is a randomized controlled, parallel group, clinical trial. This trial will be performed in a minimum number of 366 ECMO-supported eligible patients. Patients will be randomly assigned to either: (1) the CaRe-ECMO group, which will be treated with usual care including pharmacotherapy, non-pharmacotherapy, and specific nursing for ECMO therapy and the CaRe-ECMO program; or (2) the control group, which will receive usual care only. The CaRe-ECMO program consists of protocolized positioning, passive range of motion (PROM) training, neuromuscular electrical stimulation (NMES), surface electrical phrenic nerve stimulation (SEPNS), and pulmonary rehabilitation. The primary outcome of the CaRe-ECMO trial is the rate of ready for ECMO weaning at CaRe-ECMO day 7 (refers to 7 days after the CaRe-ECMO program initiation). Secondary outcomes include rate of ECMO and mechanical ventilation weaning, total length in day of ready for ECMO weaning, ECMO weaning and mechanical ventilation, all-cause mortality, rate of major post-ECMO complications, ECMO unit length of stay (LOS) and hospital LOS, total cost for hospitalization, cerebral performance category (CPC), activities of daily living (ADL), and health-related quality of life (HRQoL).Discussion: The CaRe-ECMO is designed to answer the question “whether cardiopulmonary rehabilitation can facilitate weaning of ECMO (CaRe-ECMO).” Should the implementation of the CaRe-ECMO program result in superior primary and secondary outcomes as compared to the controls, specifically the add-on effects of cardiopulmonary rehabilitation to the routine ECMO practice for facilitating successful weaning, the CaRe-ECMO trial will offer an innovative treatment option for ECMO-supported patients and meaningfully impact on the standard care in ECMO therapy.Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT05035797.

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Diaphragm function in acute respiratory failure and the potential role of phrenic nerve stimulation

Cited by 3 publications

References 58 publications

Phrenic nerve stimulation in an ovine model with temporary removable pacing leads

Phrenic nerve stimulation in an ovine model with temporary removable pacing leads

Negative-pressure-assisted ventilation lowers driving pressure and mechanical power in an ARDS model

Can Cardiopulmonary Rehabilitation Facilitate Weaning of Extracorporeal Membrane Oxygenation (CaRe-ECMO)? Study Protocol for a Prospective Multidisciplinary Randomized Controlled Trial

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