1
|
Zhong H, Zhang K, Zhou M, Xing C, An Y, Zhang Q, Guo J, Liu S, Qu Z, Feng S, Ning G. An Implantable Self-Driven Diaphragm Pacing System Based on a Microvibration Triboelectric Nanogenerator for Phrenic Nerve Stimulation. ACS APPLIED MATERIALS & INTERFACES 2024; 16:43199-43211. [PMID: 39120580 PMCID: PMC11346467 DOI: 10.1021/acsami.4c03715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/10/2024]
Abstract
Spinal cord injury poses considerable challenges, particularly in diaphragm paralysis. To address limitations in existing diaphragm pacing technologies, we report an implantable, self-driven diaphragm pacing system based on a microvibration triboelectric nanogenerator (MV-TENG). Leveraging the efficient MV-TENG, the system harvests micromechanical energy and converts this energy into pulses for phrenic nerve stimulation. In vitro tests confirm a stable MV-TENG output, while subcutaneous implantation of the device in rats results in a constant amplitude over 4 weeks with remarkable energy-harvesting efficacy. The system effectively induces diaphragmatic motor-evoked potentials, triggering contractions of the diaphragm. This proof-of-concept system has potential clinical applications in implantable phrenic nerve stimulation, presenting a novel strategy for advancing next-generation diaphragm pacing devices.
Collapse
Affiliation(s)
- Hao Zhong
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Ke Zhang
- College
of Electronic Information and Automation, Advanced Structural Integrity
International Joint Research Center, Tianjin
University of Science and Technology, Tianjin 300222, People’s Republic of China
| | - Mi Zhou
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Cong Xing
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Yang An
- College
of Electronic Information and Automation, Advanced Structural Integrity
International Joint Research Center, Tianjin
University of Science and Technology, Tianjin 300222, People’s Republic of China
| | - Qi Zhang
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Junrui Guo
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Song Liu
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Zhigang Qu
- College
of Electronic Information and Automation, Advanced Structural Integrity
International Joint Research Center, Tianjin
University of Science and Technology, Tianjin 300222, People’s Republic of China
| | - Shiqing Feng
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Guangzhi Ning
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| |
Collapse
|
2
|
Onders RP, Elmo M, Young B, Tinkoff G. Observational study of early diaphragm pacing in cervical spinal cord injured patients to decrease mechanical ventilation during the COVID-19 pandemic. Surgery 2023; 173:870-875. [PMID: 36266119 PMCID: PMC9448705 DOI: 10.1016/j.surg.2022.06.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/07/2022] [Accepted: 06/23/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Decreasing the burden of mechanical ventilation for spinal cord injuries was never more relevant than during the COVID-19 pandemic. Data have shown diaphragm pacing can replace mechanical ventilation, decrease wean times, improve respiratory mechanics, and decrease hospital costs for patients with spinal cord injuries. This is the largest report of diaphragm pacing during the pandemic. METHODS This is a retrospective analysis of prospective Institutional Review Board approved databases of nonrandomized interventional experience at a single institution. Subgroup analysis limited to traumatic cervical spinal cord injuries that were implanted laparoscopically with diaphragm electrodes within 30 days of injury. RESULTS For the study group of early implanted traumatic cervical spinal cord injuries, 13 subjects were identified from a database of 197 diaphragm pacing implantations from January 1, 2020, to December 31, 2022, for all indications. All subjects were male with an average age of 49.3 years (range, 17-70). Injury mechanisms included falls (6), motor vehicle accident (4), gunshot wound (2), and diving (1). Time from injury to diaphragm pacing averaged 11 days (range, 3-22). Two patients are deceased and neither weaned from mechanical ventilation. Nine of the remaining 11 patients weaned from mechanical ventilation. Four patients never had a tracheostomy and 3 additional patients had tracheostomy decannulation. Three of these high-risk pulmonary compromised patients survived COVID-19 infections utilizing diaphragm pacing. CONCLUSION Diaphragm pacing successfully weaned from mechanical ventilation 82% of patients surviving past 90 days. Forty-four percent of this group never underwent a tracheostomy. Only 22% of the weaned group required long term tracheostomies. Early diaphragm pacing for spinal cord injuries decreases mechanical ventilation usage and tracheostomy need which allows for earlier placement for rehabilitation.
Collapse
Affiliation(s)
- Raymond P Onders
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH.
| | - MaryJo Elmo
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Brian Young
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Glen Tinkoff
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| |
Collapse
|
3
|
Giberson CE, Cheshier SH, Poree LR, Saulino MF. Diaphragm Pacing: A Safety, Appropriateness, Financial Neutrality, and Efficacy Analysis of Treating Chronic Respiratory Insufficiency. Neuromodulation 2023; 26:490-497. [PMID: 36609087 DOI: 10.1016/j.neurom.2022.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 10/19/2022] [Accepted: 10/31/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study aimed to evaluate the safety and applicability of treating chronic respiratory insufficiency with diaphragm pacing relative to mechanical ventilation. MATERIALS AND METHODS A literature review and analysis were conducted using the safety, appropriateness, financial neutrality, and efficacy principles. RESULTS Although mechanical ventilation is clearly indicated in acute respiratory failure, diaphragm pacing improves life expectancy, increases quality of life, and reduces complications in patients with chronic respiratory insufficiency. CONCLUSION Diaphragm pacing should be given more consideration in appropriately selected patients with chronic respiratory insufficiency.
Collapse
|
4
|
Onders RP, Khansarinia S, Ingvarsson PE, Road J, Yee J, Dunkin B, Ignagni AR. Diaphragm Pacing in Spinal Cord Injury Can Significantly Decrease Mechanical Ventilation in Multicenter Prospective Evaluation. Artif Organs 2022; 46:1980-1987. [PMID: 35226374 DOI: 10.1111/aor.14221] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/18/2022] [Accepted: 02/16/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cervical spinal cord injury (SCI) can lead to dependence on mechanical ventilation (MV) with significant morbidity and mortality. The diaphragm pacing system (DPS) was developed as an alternative to MV. METHODS We conducted a prospective single arm study of DPS in MV dependent patients with high SCI and intact phrenic nerves. Following device acclimation, pacing effectiveness to provide ventilation was evaluated. The primary endpoint was the number who could use DPS to breathe for four continuous hours without MV. Secondary endpoints included the number of patients that could use DPS 24 hours/day free of MV and the ability of DPS to maintain clinically acceptable tidal volume (Vt). In addition, we conducted a meta-analysis that included the prospective study along with data from four recently published studies to evaluate DPS hourly use. RESULTS Fifty-three patients were implanted in the prospective study. Most were male (77.4%) with a median time from injury to treatment of 28.3 (IQR 12.1, 83.3) months. Four- and 24-hour use occurred in 96.2% (95%CI - 87.0%, 99.5%) and 58.5% (95% CI - 44.1%, 74.9%), respectively. Four and 24-hour results in the meta-analysis cohort (n=196) exhibited similar results 92.2% (95% CI - 82.6%,96.7%) and 52.7% (95% CI - 36.2%,68.6%) using DPS for four and 24 hours, respectively. DPS use significantly exceeded the calculated basal tidal volume requirements by a mean of 48.4% (95% CI - 37.0, 59.9%; p<0.001). CONCLUSIONS This study demonstrates that in most ventilator-dependent patients, diaphragm pacing can effectively supplement or completely replace the need for MV and support basal metabolic requirements.
Collapse
Affiliation(s)
- Raymond P Onders
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Saeid Khansarinia
- Departments of Rehabilitation and Thoracic Surgery, Piedmont Hospital, Atlanta, GA, USA
| | - Páll E Ingvarsson
- Department of Medical Rehabilitation, Landspítali - The University Hospital of Iceland, Reykjavík, Iceland
| | - Jeremy Road
- Division of Respiratory Medicine, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - John Yee
- Division of Respiratory Medicine, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Brian Dunkin
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | | |
Collapse
|
5
|
Wijkstra PJ, van der Aa H, Hofker HS, Curto F, Giacomini M, Stagni G, Dura Agullo MA, Curià Casanoves FX, Benito-Penalva J, Martinez-Barenys C, Vidal J. Diaphragm Pacing in Patients with Spinal Cord Injury: A European Experience. Respiration 2021; 101:18-24. [PMID: 34274930 DOI: 10.1159/000517401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/30/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Patients with high spinal cord injury (SCI) are unable to breathe on their own and require mechanical ventilation (MV). The long-term use of MV is associated with increased morbidity and mortality. In patients with intact phrenic nerve function, patients can be partially or completely removed from MV by directly stimulating the diaphragm motor points with a diaphragm pacing system (DPS). OBJECTIVES We describe our multicenter European experience using DPS in SCI patients who required MV. METHODS We conducted a retrospective study of patients who were evaluated for the implantation of DPS. Patients evaluated for DPS who met the prospectively defined criteria of being at least 1 year of age, and having cervical injury resulting in a complete or partial dependency on MV were included. Patients who received DPS implants were followed for up to 1 year for device usage and safety. RESULTS Across 3 centers, 47 patients with high SCI were evaluated for DPS, and 34 were implanted. Twenty-one patients had 12 months of follow-up data with a median DPS use of 15 h/day (interquartile range 4, 24). Eight patients (38.1%) achieved complete MV weaning using DPS 24 h/day. Two DPS-related complications were surgical device revision and a wire eruption. No other major complications were associated with DPS use. CONCLUSIONS Diaphragm pacing represents an attractive alternative stand-alone treatment or adjunctive therapy compared to MV in patients with high SCI. After a period of acclimation, the patients were able to reduce the daily use of MV, and many could be completely removed from MV.
Collapse
Affiliation(s)
- Peter J Wijkstra
- Department of Pulmonary Diseases and Home Mechanical Ventilation, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hans van der Aa
- Department of Pulmonary Diseases and Home Mechanical Ventilation, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - H Sijbrand Hofker
- Department of Abdominal Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Francesco Curto
- Neurocritical Care Unit, ASST Grande Ospedale Metropolitan Niguarda, Milan, Italy
| | - Matteo Giacomini
- Neurocritical Care Unit, ASST Grande Ospedale Metropolitan Niguarda, Milan, Italy
| | - Giuliana Stagni
- Neurocritical Care Unit, ASST Grande Ospedale Metropolitan Niguarda, Milan, Italy
| | | | - Francesc Xavier Curià Casanoves
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain
| | - Jesús Benito-Penalva
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain
| | - Carlos Martinez-Barenys
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain.,Thoracic Surgery Department, University Hospital Germans Trias I Pujol, Barcelona, Spain
| | - Joan Vidal
- Fundación Institut Guttmann, Institut Universitari de Neurorehabilitació adscrit a la UAB, Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain.,Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol, Barcelona, Spain
| |
Collapse
|
6
|
Diaphragm pacing improves respiratory mechanics in acute cervical spinal cord injury. J Trauma Acute Care Surg 2021; 89:423-428. [PMID: 32467474 DOI: 10.1097/ta.0000000000002809] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cervical spinal cord injury (CSCI) is devastating with ventilator-associated pneumonia being a main driver of morbidity and mortality. Laparoscopic diaphragm pacing implantation (DPS) has been used for earlier liberation from mechanical ventilation. We hypothesized that DPS would improve respiratory mechanics and facilitate liberation. METHODS We performed a retrospective review of acute CSCI patients between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity score matching based on age, Injury Severity Score, ventilator days, hospital length of stay, and need for tracheostomy. Patients with complete respiratory mechanics data were analyzed and compared. Those who did not have DPS (NO DPS) had spontaneous tidal volume (Vt) recorded at time of intensive care unit admission, at day 7, and at day 14, and patients who had DPS had spontaneous Vt recorded before and after DPS. Time to ventilator liberation and changes in size of spontaneous Vt for patients while on the ventilator were analyzed. Bivariate and multivariate logistic and linear regression statistics were performed using STATA v10. RESULTS Between July 2011 and May 2017, 37 patients that had DPS were matched to 34 who did not (NO DPS). Following DPS, there was a statistically significant increase in spontaneous Vt compared with NO DPS (+88 mL vs. -13 mL; 95% confidence interval, 46-131 mL vs. -78 to 51 mL, respectively; p = 0.004). Median time to liberation after DPS was significantly shorter (10 days vs. 29 days; 95% CI, 6.5-13.6 days vs. 23.1-35.3 days; p < 0.001). Liberation prior to hospital discharge was not different between the two groups. The DPS placement was found to be associated with a statistically significant decrease in days to liberation and an increase in spontaneous Vt in multivariate linear regression models. CONCLUSION The DPS implantation in acute CSCI patients produces significant improvements in spontaneous Vt and reduces time to liberation from mechanical ventilation. Prospective comparative studies are needed to define the clinical benefits and potential cost savings of DPS implantation. LEVEL OF EVIDENCE Therapeutic IV.
Collapse
|
7
|
Li HX, Cui J, Fan JS, Tong JZ. An observation of the clinical efficacy of combining Riluzole with mannitol and hyperbaric oxygen in treating acute spinal cord injury. Pak J Med Sci 2021; 37:320-324. [PMID: 33679906 PMCID: PMC7931319 DOI: 10.12669/pjms.37.2.3418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective: To examine the clinical efficacy of combining Riluzole with mannitol and hyperbaric oxygen therapy in treating thoracolumbar vertebral fracture-induced acute spinal cord injury (ASCI). Methods: From June 2015 to May 2018, 80 patients with thoracolumbar fractures and ASCI who were treated at Baoding First Central Hospital were selected. All patients underwent posterior laminectomy and screw fixation, and they were randomly divided into two groups using a random number table method. The control group received conventional postoperative treatment, while the experimental group was treated with riluzole combined with mannitol and hyperbaric oxygen on the basis of conventional treatment. The recovery of nerve function which included motor function and sensory function, and the changes of serum IL-6, CRP, BDNF, BFGF and other factors before treatment and four weeks after treatment of the two groups of patients were observed and evaluated. Results: After treatment, the motor function scores and sensory function scores of the two groups of patients were improved compared with those before treatment (p<0.05). Compared with the control group, the experimental group improved significantly, and the difference was statistically significant (p<0.05). The levels of IL-6, BDNF and NFGF in the experimental group were significantly lower than those in the control group (p<0.05). Conclusions: For patients with thoracolumbar fractures and ASCI undergoing laminar decompression and fixation, the comprehensive treatment plan of riluzole combined with mannitol and hyperbaric oxygen has certain advantages. Compared with the conventional therapy, it may significantly improve the movement and sensory functions of patients, relieve the inflammatory response of spinal cord, and promote recovery from the injury.
Collapse
Affiliation(s)
- Huan-Xia Li
- Huan-xia Li, Department of Neurosurgery, West Part, Baoding First Central Hospital, Baoding, 071000, Hebei, P.R. China
| | - Jing Cui
- Jing Cui, Department of Neurosurgery, West Part, Baoding First Central Hospital, Baoding, 071000, Hebei, P.R. China
| | - Jing-Shi Fan
- Jing-shi Fan, Department of Neurosurgery, West Part, Baoding First Central Hospital, Baoding, 071000, Hebei, P.R. China
| | - Jian-Zhou Tong
- Jian-zhou Tong, Department of Neurosurgery, West Part, Baoding First Central Hospital, Baoding, 071000, Hebei, P.R. China
| |
Collapse
|
8
|
Kerwin AJ, Diaz Zuniga Y, Yorkgitis BK, Mull J, Hsu AT, Madbak FG, Ebler DJ, Skarupa DJ, Shiber J, Crandall ML. Diaphragm pacing decreases hospital charges for patients with acute cervical spinal cord injury. Trauma Surg Acute Care Open 2020; 5:e000528. [PMID: 33381653 PMCID: PMC7754627 DOI: 10.1136/tsaco-2020-000528] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/02/2020] [Accepted: 10/04/2020] [Indexed: 11/30/2022] Open
Abstract
Background Cervical spinal cord injury (CSCI) is devastating and costly. Previous research has demonstrated that diaphragm pacing (DPS) is safe and improves respiratory mechanics. This may decrease hospital stays, vent days, and costs. We hypothesized DPS implantation would facilitate liberation from ventilation and would impact hospital charges. Methods We performed a retrospective review of patients with acute CSCI between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity matching based on age, injury severity score, ventilator days, hospital length of stay, and need for tracheostomy. We then adjusted total hospital charges by year using US Bureau of Labor Statistics annual adjusted Medical Care Prices. Bivariate and multivariate linear regression statistics were performed using STATA V.15. Results Between July 2011 and May 2017, all patients with acute CSCI were evaluated for DPS implantation. 40 patients who had laparoscopic DPS implantation (DPS) were matched to 61 who did not (NO DPS). Following DPS implantation, there was a statistically significant increase in spontaneous Vt compared with NO DPS (+88 mL vs −13 mL; 95% CI 46 to 131 vs −78 to 51 mL, respectively; p=0.004). Median time to liberation after DPS was significantly shorter (10 vs 29 days; 95% CI 6.5 to 13.6 vs 23.1 to 35.3 days; p<0.001). Adjusted hospital charges were significantly lower for DPS on multivariate linear regression models controlling for year of injury, sex, race, injury severity, and age (p=0.003). Discussion DPS implantation in patients with acute CSCI produces significant improvements in spontaneous Vt and reduces time to liberation, which translated into reduced hospital charges on a risk-adjusted, inflation-adjusted model. DPS implantation for patients with acute CSCI should be considered. Level of evidence Level III.
Collapse
Affiliation(s)
- Andrew J Kerwin
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Yohan Diaz Zuniga
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Brian K Yorkgitis
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Jennifer Mull
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Albert T Hsu
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Firas G Madbak
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - David J Ebler
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - David J Skarupa
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Joseph Shiber
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| | - Marie L Crandall
- Surgery, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida, USA
| |
Collapse
|
9
|
Onders RP, Elmo M, Stepien C, Katirji B. Spinal cord injury level and Phrenic Nerve Conduction Studies do not predict diaphragm pacing success or failure- all patients should undergo diagnostic laparoscopy. Am J Surg 2020; 221:585-588. [PMID: 33243416 DOI: 10.1016/j.amjsurg.2020.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 11/10/2020] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Diaphragm Pacing(DP) demonstrates benefits over mechanical ventilation(MV) for spinal cord injured(SCI) patients. The hypothesis of this report is that phrenic nerve conduction study(PNCS) results cannot differentiate success or failure in selection of patients for DP. Direct surgical evaluation of the diaphragm should be performed. METHODS Observational report of prospective databases of patients undergoing laparoscopic evaluation of their diaphragms to assess for ability to stimulate to cause contraction for ventilation. RESULTS In 50 SCI patients who could not be weaned from MV, PNCS results showed latencies in stimulated patients (n = 44) and non-stimulated(n = 6) overlapped (7.8 ± 2.5 ms vs 9.4 ± 2.8 ms) and the null hypothesis cannot be rejected (p-value>0.05). Amplitudes overlapped (0.4 ± 0.2 mV vs 0.2 ± 0.2 mV) and the null hypotheses cannot be rejected (P-value >0.05). In 125 non SCI patients with diaphragm paralysis, there were 78(62.4%) with false negative PNCS. CONCLUSION PNCS are inadequate pre-operative studies. Direct laparoscopic evaluation should be offered for all SCI patients to receive the benefit of DP.
Collapse
Affiliation(s)
- Raymond P Onders
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.
| | - MaryJo Elmo
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Cindy Stepien
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Bashar Katirji
- Neurology Department, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| |
Collapse
|
10
|
Edmiston TL, Elrick MJ, Kovler ML, Jelin EB, Onders RP, Sadowsky CL. Early use of an implantable diaphragm pacing stimulator for a child with severe acute flaccid myelitis-a case report. Spinal Cord Ser Cases 2019; 5:67. [PMID: 31632725 PMCID: PMC6786381 DOI: 10.1038/s41394-019-0207-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction Acute Flaccid Myelitis (AFM) is a recently recognized, polio-like illness of children that can be functionally devastating. Severe cases can lead to ventilatory failure. Incomplete phrenic nerve injuries in other populations has been shown to respond to diaphragmatic stimulation. We therefore proposed an early assessment for incomplete denervation by laparoscopic direct stimulation of the diaphragm and placement of a diaphragmatic pacing system to enhance diaphragm function. Case presentation A 3 year-old girl presented with AFM with clinically and electrodiagnostically severe involvement of all four limbs and muscles of respiration. Direct stimulation of the diaphragm demonstrated contraction and a diaphragmatic stimulator was placed at 3 weeks post presentation. The patient was immediately able to tolerate short bouts of reduced ventilation settings. Electromyography via the pacing wires demonstrated intact motor units consistent with partial denervation/reinnervation in the left hemidiaphragm, and no motor units in the right hemidiaphragm. At three months, she tolerated 6 h of pacing on pressure support setting. At 5 months she demonstrated larger tidal volumes with active pacing than without. Discussion In our experience, AFM patients who require chronic ventilator support are rarely able to be weaned. Despite clinical and surface electrodiagnostic evidence of complete phrenic nerve involvement, the patient's diaphragm responded to direct stimulation. The patient preferred pacing over non-pacing times and showed improved ventilatory ability with pacing as opposed to without, though remains ventilator-dependent. These findings support augmentation of diaphragm function and possible enhanced recovery of spontaneous function.
Collapse
Affiliation(s)
- Travis L. Edmiston
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Mathew J. Elrick
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Mark L. Kovler
- Department of Pediatric Surgery, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Eric B. Jelin
- Department of Pediatric Surgery, Johns Hopkins School of Medicine, Baltimore, MD USA
| | - Raymond P. Onders
- Department of General Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH USA
| | - Cristina L. Sadowsky
- International Center for Spinal Cord Injury, Kennedy Krieger Institute, Baltimore, MD USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD USA
| |
Collapse
|