Diaphragm Neurostimulation Assisted Ventilation in Critically Ill Patients

Etienne, Harry; Morris, Idunn S; Hermans, Greet; Heunks, Leo; Goligher, Ewan C.; Jaber, Samir; Morélot-Panzini, Capucine; Assouad, Jalal; Gonzalez-Bermejo, Jésus; Papazian, Laurent; Similowski, Thomas; Demoule, Alexandre; Dres, Martin

doi:10.1164/rccm.202212-2252cp

Cited by 10 publications

(8 citation statements)

References 58 publications

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“…In recent years, an increasing number of studies have been published that augment MV with minimally- or non-invasive PNS 15 – 17 , 19 , 33 , 34 . The results of these studies are promising as they showed beneficial effects of PNS regarding diaphragmatic atrophy, decreasing atelectasis and MV pressures in pig model and partially in human patients 18 , 32 , 34 – 37 .…”

Section: Discussionmentioning

confidence: 99%

“…However, in recent decades, several trans- or percutaneous as well as esophageal methods of electrical or electromagnetic phrenic nerve stimulation have been established and positively evaluated in animals and humans 14 – 19 . The unifying goal was to establish a minimally invasive, temporary PNS method that provides ventilatory support to critically ill patients 17 . Despite these promising results, to date no direct comparison of the ventilatory characteristics of minimally invasive PNS with MV has been performed.…”

Section: Introductionmentioning

confidence: 99%

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Breath-by-breath comparison of a novel percutaneous phrenic nerve stimulation approach with mechanical ventilation in juvenile pigs: a pilot study

Deininger,

Ziles,

Borleis

et al. 2024

Sci Rep

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About one in three critically ill patients requires mechanical ventilation (MV). Prolonged MV, however, results in diaphragmatic weakness, which itself is associated with delayed weaning and increased mortality. Inducing active diaphragmatic contraction via electrical phrenic nerve stimulation (PNS) not only provides the potential to reduce diaphragmatic muscular atrophy but also generates physiological-like ventilation and therefore offers a promising alternative to MV. Reasons why PNS is not yet used in critical care medicine are high procedural invasiveness, insufficient evidence, and lack of side-by-side comparison to MV. This study aims to establish a minimal-invasive percutaneous, bilateral electrode placement approach for sole PNS breathing and thereby enable, for the first time, a breath-by-breath comparison to MV. Six juvenile German Landrace pigs received general anesthesia and orotracheal intubation. Following the novel ultrasound-guided, landmark-based, 4-step approach, two echogenic needles per phrenic nerve were successfully placed. Stimulation effectiveness was evaluated measuring tidal volume, diaphragmatic thickening and tomographic electrical impedance in a breath-by-breath comparison to MV. Following sufficient bilateral phrenic nerve stimulation in all pigs, PNS breaths showed a 2.2-fold increase in diaphragmatic thickening. It induced tidal volumes in the lung-protective range by negative pressure inspiration and improved dorso-caudal regional ventilation in contrast to MV. Our study demonstrated the feasibility of a novel ultrasound-guided, percutaneous phrenic nerve stimulation approach, which generated sufficient tidal volumes and showed more resemblance to physiological breathing than MV in a breath-by-breath comparison.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Breath-by-breath comparison of a novel percutaneous phrenic nerve stimulation approach with mechanical ventilation in juvenile pigs: a pilot study

Deininger,

Ziles,

Borleis

et al. 2024

Sci Rep

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“…This may help implement careful monitoring and delivering of lung and diaphragm protective ventilation at the bedside. Another possibility would be to artificially titrate the inspiratory effort in sedated patients using phrenic nerve stimulation [ 89 ]. Recent studies have reported promising technological developments that may be relevant in critically ill patients [ 90 – 92 ].…”

Section: Managementmentioning

confidence: 99%

Critical illness-associated limb and diaphragmatic weakness

Le Stang,

Latronico,

Dres

et al. 2024

Current Opinion in Critical Care

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Purpose of review In the current review, we aim to highlight the evolving evidence on the diagnosis, prevention and treatment of critical illness weakness (CIW) and critical illness associated diaphragmatic weakness (CIDW). Recent findings In the ICU, several risk factors can lead to CIW and CIDW. Recent evidence suggests that they have different pathophysiological mechanisms and impact on outcomes, although they share common risk factors and may overlap in several patients. Their diagnosis is challenging, because CIW diagnosis is primarily clinical and, therefore, difficult to obtain in the ICU population, and CIDW diagnosis is complex and not easily performed at the bedside. All of these issues lead to underdiagnosis of CIW and CIDW, which significantly increases the risk of complications and the impact on both short and long term outcomes. Moreover, recent studies have explored promising diagnostic techniques that are may be easily implemented in daily clinical practice. In addition, this review summarizes the latest research aimed at improving how to prevent and treat CIW and CIDW. Summary This review aims to clarify some uncertain aspects and provide helpful information on developing monitoring techniques and therapeutic interventions for managing CIW and CIDW.

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“…Neurostimulation of the diaphragm, recently reviewed by Etienne et al, has a long scientific background [ 43 ]. Historically, electrical activation of the phrenic nerve inducing diaphragmatic contractions dates back to pivotal studies, with Christoph Hufeland’s 1873 human application during asphyxia in new-borns being the earliest.…”

Section: Pns For Preventive and Therapeutical Purposesmentioning

confidence: 99%

Phrenic nerve stimulation to prevent diaphragmatic dysfunction and ventilator-induced lung injury

Panelli,

Verfuß,

Dres

et al. 2023

ICMx

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Side effects of mechanical ventilation, such as ventilator-induced diaphragmatic dysfunction (VIDD) and ventilator-induced lung injury (VILI), occur frequently in critically ill patients. Phrenic nerve stimulation (PNS) has been a valuable tool for diagnosing VIDD by assessing respiratory muscle strength in response to magnetic PNS. The detection of pathophysiologically reduced respiratory muscle strength is correlated with weaning failure, longer mechanical ventilation time, and mortality. Non-invasive electromagnetic PNS designed for diagnostic use is a reference technique that allows clinicians to measure transdiaphragm pressure as a surrogate parameter for diaphragm strength and functionality. This helps to identify diaphragm-related issues that may impact weaning readiness and respiratory support requirements, although lack of lung volume measurement poses a challenge to interpretation. In recent years, therapeutic PNS has been demonstrated as feasible and safe in lung-healthy and critically ill patients. Effects on critically ill patients’ VIDD or diaphragm atrophy outcomes are the subject of ongoing research. The currently investigated application forms are diverse and vary from invasive to non-invasive and from electrical to (electro)magnetic PNS, with most data available for electrical stimulation. Increased inspiratory muscle strength and improved diaphragm activity (e.g., excursion, thickening fraction, and thickness) indicate the potential of the technique for beneficial effects on clinical outcomes as it has been successfully used in spinal cord injured patients. Concerning the potential for electrophrenic respiration, the data obtained with non-invasive electromagnetic PNS suggest that the induced diaphragmatic contractions result in airway pressure swings and tidal volumes remaining within the thresholds of lung-protective mechanical ventilation. PNS holds significant promise as a therapeutic intervention in the critical care setting, with potential applications for ameliorating VIDD and the ability for diaphragm training in a safe lung-protective spectrum, thereby possibly reducing the risk of VILI indirectly. Outcomes of such diaphragm training have not been sufficiently explored to date but offer the perspective for enhanced patient care and reducing weaning failure. Future research might focus on using PNS in combination with invasive and non-invasive assisted ventilation with automatic synchronisation and the modulation of PNS with spontaneous breathing efforts. Explorative approaches may investigate the feasibility of long-term electrophrenic ventilation as an alternative to positive pressure-based ventilation.

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Diaphragm Neurostimulation Assisted Ventilation in Critically Ill Patients

Cited by 10 publications

References 58 publications

Breath-by-breath comparison of a novel percutaneous phrenic nerve stimulation approach with mechanical ventilation in juvenile pigs: a pilot study

Breath-by-breath comparison of a novel percutaneous phrenic nerve stimulation approach with mechanical ventilation in juvenile pigs: a pilot study

Critical illness-associated limb and diaphragmatic weakness

Phrenic nerve stimulation to prevent diaphragmatic dysfunction and ventilator-induced lung injury

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