Diaphragmatic Pacing in Neuromuscular Respiratory Failure

Abstract

Electrical activation of the diaphragm is a technology that allows the treatment of selected forms of respiratory failure. The diaphragmatic pacing is carried out by an implanted electrode and receiver with a pocket or tabletop external transmitter. The device electrically stimulates the phrenic nerves to contract the diaphragm rhythmically. The main indication for diaphragm pacing is for ventilator-dependent subjects after high cervical cord injury and patients with central alveolar hypoventilation. The clinical requirements are stable clinical condition and intact phrenic nerves, diaphragms, and lungs. In most patients, a training period is required to provoke a gradual conditioning effect, improving endurance to diaphragmatic fatigue. A cooperative patient, supportive family and friends, and a skilled care team are paramount conditions. Diaphragmatic pacing probably does not lengthen life, but it can increase the quality of life. Tracheostomy is usually required to overcome upper airway obstruction. Poor results are related to inadequate selection of patients, complications related to implantation, system failure, inappropriate pacing schedule, inadequate follow-up, or lack of patient compliance or family support. The long-term results of diaphragm pacing demonstrate its usefulness both in adult and pediatric patients when applied in the correct circumstances.

Non-cardiac implantable electrical devices: brief review and implications for anesthesiologists

“…11 Phrenic nerve stimulator or diaphragmatic pacemaker A diaphragmatic pacemaker electrically stimulates the phrenic nerve to cause rhythmic contraction of the diaphragm. 12 , 13 Since its approval by the FDA in 1987, this device has been used to treat hundreds of patients with respiratory failure due to high cervical cord injury (C1-C2) or respiratory center dysfunction (central alveolar hypoventilation). 14 Successful implantation of the diaphragm pacemaker relies on an intact phrenic nerve and a functional diaphragm.…”

“…Hence, patients with lesions of the phrenic nerve, its nucleus, or weakness of the diaphragm are not suitable candidates. 12,13 Surgical implantation of a diaphragmatic pacemaker is usually performed laparoscopically. Four electrodes are implanted in each phrenic nerve.…”

“…The transmitter controls the frequency of breaths, tidal volume, pulse interval, pulse width, and slope of pulse. 12 Spinal cord stimulator…”

Diaphragmatic Pacing and Protocol with Locked‐in Syndrome

“…Both devices have been used successfully in maintaining respiratory independence without a ventilator in patients with spinal cord injury or multiple sclerosis and who suffer from respiratory failure [1,2]. Advantages to diaphragmatic pacing over positive pressure ventilator support include less barotrauma, improved comfort, less cumbersome transfers, improved autonomy, decreased pulmonary infections, and overall improvement in quality of life [3,4]. Several experts have published methods and suggestions for management of stimulators in these populations [1,5].…”

“…Medullary and pontine infarctions are known to cause respiratory insufficiency as well, but few published reports examine methods of respiratory management for this population [6‐8]. The few articles that address diaphragmatic or phrenic nerve pacing in this population lack both application to the rehabilitation setting and pacing protocols that minimize the time required to wean from a ventilator [3,8]. This case presentation illustrates the application and protocol used for diaphragmatic stimulation in a patient with pontine ischemia during subacute rehabilitation.…”