Effects of transcutaneous electrical diaphragmatic stimulation in critically ill elderly patients: a randomized controlled trial

How to protect the diaphragm and the lung with diaphragm neurostimulation

PURPOSE OF REVIEW

In the current review, we aim to highlight the evolving evidence on using diaphragm neurostimulation to develop lung and diaphragm protective mechanical ventilation.

RECENT FINDINGS

Positive-pressure ventilation (PPV) causes stress and strain to the lungs which leads to ventilator-induced lung injury (VILI). In addition, PPV is frequently associated with sedatives that induce excessive diaphragm unloading which contributes to ventilator-induced diaphragmatic dysfunction (VIDD). The nonvolitional diaphragmatic contractions entrained by diaphragm neurostimulation generate negative pressure ventilation, which may be a beneficial alternative or complement to PPV. Although well established as a permanent treatment of central apnea syndromes, temporary diaphragm neurostimulation rapidly evolves to prevent and treat VILI and VIDD. Experimental and small clinical studies report comprehensive data showing that diaphragm neurostimulation has the potential to mitigate VIDD and to decrease the stress and strain applied to the lungs.

SUMMARY

Scientific interest in temporary diaphragm neurostimulation has dramatically evolved in the last few years. Despite a solid physiological rationale and promising preliminary findings confirming a beneficial effect on the diaphragm and lungs, more studies and further technological advances will be needed to establish optimal standardized settings and lead to clinical implementation and improved outcomes.

Effect of neuromuscular electrical stimulation in critically ill adults with mechanical ventilation: a systematic review and network meta-analysis

BACKGROUND

Neuromuscular electrical stimulation (NMES) is widely used as a rehabilitation methods to restore muscle mass and function in prolonged immobilization individuals. However, its effect in mechanically ventilated patients to improve clinical outcomes remains unclear.

METHODS

A comprehensive search was conducted using PubMed, Embase, Web of Science, PEDro, and the Cochrane Library from their inception until December 24th, 2023. The search targeted randomized controlled trials (RCTs) comparing NMES with physical therapy (PT) or usual ICU care (CG), for improving clinical outcomes in mechanically ventilated patients. We performed a network meta-analysis utilizing Stata version 14.0 and R 4.3.1.

RESULTS

We included 23 RCTs comprising 1312 mechanically ventilated adults. The treatments analyzed were NMES, PT, NMES combined with PT (NMES+PT), and CG. Network meta-analyses revealed that NMES or NMES+PT significantly improved extubation success rate compared to CG, with ORs of 1.85 (95% CI: 1.11, 3.08) and 5.89 (95% CI: 1.77, 19.65), respectively. Additionally, NMES exhibited a slight decrease in extubation success rate compared with NMES+PT, with OR of 0.31 (95% CI: 0.11, 0.93). Nevertheless, neither NMES nor NMES+PT showed any significant improvement in ICU length of stay (LOS), ventilation duration, or mortality when compared with PT or CG. NMES+PT emerged as the most effective strategy for all considered clinical outcomes according to the ranking probabilities. The evidence quality ranged from "low" to "very low" in this network meta-analysis.

CONCLUSIONS

NMES appears to be a straightforward and safe modality for critically ill, mechanically ventilated patients. When combined with PT, it significantly improved the extubation success rate against standard ICU care and NMES alone, and showed a better ranking over PT or NMES alone for clinical outcomes. Therefore, NMES combined with PT may be a superior rehabilitation strategy for this patient group.