Treatment for bilateral diaphragmatic dysfunction using phrenic nerve reconstruction and diaphragm pacemakers

Abstract

OBJECTIVES Bilateral diaphragmatic dysfunction results in severe dyspnoea, usually requiring oxygen therapy and nocturnal ventilatory support. Although treatment options are limited, phrenic nerve reconstruction (PR) offers the opportunity to restore functional activity. This study aims to evaluate combination treatment with PR and placement of a diaphragm pacemaker (DP) compared to DP placement alone in patients with bilateral diaphragmatic dysfunction. METHODS Patients with bilateral diaphragmatic dysfunction were prospectively enrolled in the following treatment algorithm: Unilateral PR was performed on the more severely impacted side with bilateral DP implantation. Motor amplitudes, ultrasound measurements of diaphragm thickness, maximal inspiratory pressure, forced expiratory volume, forced vital capacity and subjective patient-reported outcomes were obtained for retrospective analysis following completion of the prospective database. RESULTS Fourteen male patients with bilateral diaphragmatic dysfunction confirmed on chest fluoroscopy and electrodiagnostic testing were included. All 14 patients required nocturnal ventilator support, and 8/14 (57.1%) were oxygen-dependent. All patients reported subjective improvement, and all 8 oxygen-dependent patients were able to discontinue oxygen therapy following treatment. Improvements in maximal inspiratory pressure, forced vital capacity and forced expiratory volume were 68%, 47% and 53%, respectively. There was an average improvement of 180% in motor amplitude and a 50% increase in muscle thickness. Comparison of motor amplitude changes revealed significantly greater functional recovery on the PR + DP side. CONCLUSIONS PR and simultaneous implantation of a DP may restore functional activity and alleviate symptoms in patients with bilateral diaphragmatic dysfunction. PR plus diaphragm pacing appear to result in greater functional muscle recovery than pacing alone.

Postoperative Management of Lung Transplant Recipients in the Intensive Care Unit

“…Phrenic nerve reconstruction and diaphragm pacing may be considered to support functional recovery. 74…”

“…Phrenic nerve reconstruction and diaphragm pacing may be considered to support functional recovery. 74 Hyperammonemic encephalopathy is a rare but often fatal complication in lung transplantation (1 to 4%). [75][76][77] It is a medical emergency, as the delay of its management results in potential irreversible neurologic injury.…”

Dysfunction of the diaphragm

“…К относительным противопоказаниям относятся значительное ожирение и прогрессирующие нейромышечные заболевания. При двустороннем параличе пликация диафрагмы малоэффективна [32][33][34][35][36][37][38].…”

Diaphragmatic Pacing in Spinal Cord Injury

“…However, in patients with bilaterally patent phrenic nerves that remain innervated and intact with the diaphragm, pacing is an option to allow decreased dependence, or even liberation from mechanical ventilation 50 . Even in the midst of unilateral injury to the phrenic nerve, patients may still benefit from diaphragmatic stimulation when combined with techniques such as surgical phrenic nerve repair and intercostal nerve stimulation 51,52 Efficacy, defined as being able to maintain an unassisted tidal volume 15% greater than a patient's weight adjusted basal requirement, has been demonstrated in up to 98% of patients who receive pacing. 50 Up to 72% of patients receiving successful diaphragmatic pacing have been able to sustain complete weaning from the ventilator at an average of 10 days postoperatively, 53 with a range of 40-72% reported in prospective and retrospective reviews.…”