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Liberati C, Byrne BJ, Fuller DD, Croft C, Pitts T, Ehrbar J, Leon-Astudillo C, Smith BK. Diaphragm pacing and independent breathing in individuals with severe Pompe disease. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1184031. [PMID: 37583873 PMCID: PMC10423945 DOI: 10.3389/fresc.2023.1184031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/20/2023] [Indexed: 08/17/2023]
Abstract
Introduction Pompe disease is an inherited disease characterized by a deficit in acid-α-glucosidase (GAA), an enzyme which degrades lysosomal glycogen. The phrenic-diaphragm motor system is affected preferentially, and respiratory failure often occurs despite GAA enzyme replacement therapy. We hypothesized that the continued use of diaphragm pacing (DP) might improve ventilator-dependent subjects' respiratory outcomes and increase ventilator-free time tolerance. Methods Six patients (3 pediatric) underwent clinical DP implantation and started diaphragm conditioning, which involved progressively longer periods of daily, low intensity stimulation. Longitudinal respiratory breathing pattern, diaphragm electromyography, and pulmonary function tests were completed when possible, to assess feasibility of use, as well as diaphragm and ventilatory responses to conditioning. Results All subjects were eventually able to undergo full-time conditioning via DP and increase their maximal tolerated time off-ventilator, when compared to pre-implant function. Over time, 3 of 6 subjects also demonstrated increased or stable minute ventilation throughout the day, without positive-pressure ventilation assistance. Discussion Respiratory insufficiency is one of the main causes of death in patients with Pompe disease. Our results indicate that DP in Pompe disease was feasible, led to few adverse events and stabilized breathing for up to 7 years.
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Affiliation(s)
- Cristina Liberati
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States
| | - Barry J. Byrne
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
| | - David D. Fuller
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States
- Breathing Research and Therapeutics (BREATHE) Center, University of Florida, Gainesville, FL, United States
| | - Chasen Croft
- Department of Surgery, University of Florida, Gainesville, FL, United States
| | - Teresa Pitts
- Department of Speech, Language and Hearing Sciences, University of Missouri, Columbia, MO, United States
- Dalton Cardiovascular Center Investigator, University of Missouri, Columbia, MO, United States
| | - Jessica Ehrbar
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States
| | | | - Barbara K. Smith
- Department of Pediatrics, University of Florida, Gainesville, FL, United States
- Department of Physical Therapy, University of Florida, Gainesville, FL, United States
- Breathing Research and Therapeutics (BREATHE) Center, University of Florida, Gainesville, FL, United States
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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.
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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
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Bao Q, Chen L, Chen X, Li T, Xie C, Zou Z, Huang C, Zhi Y, He Z. The effects of external diaphragmatic pacing on diaphragm function and weaning outcomes of critically ill patients with mechanical ventilation: a prospective randomized study. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1100. [PMID: 36388825 PMCID: PMC9652530 DOI: 10.21037/atm-22-4145] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 10/08/2022] [Indexed: 12/30/2023]
Abstract
BACKGROUND Diaphragmatic pacing can improve diaphragm function, which is beneficial for the prognosis of patients treated with prolonged mechanical ventilation (MV). While most previous studies have focused on the role of implanted diaphragm pacing (IDP), our study is the first to examine the effects of external diaphragmatic pacing (EDP) in mechanically ventilated patients. Specifically, the effect of EDP on diaphragm function, the success rate of weaning, the duration of MV (DMV), and the intensive care unit (ICU) length of stay (ILOS) were assessed. METHODS From September 2019 to December 2020, a total of 51 mechanically ventilated patients in the ICU of the Sun Yat-sen Memorial Hospital, Sun Yat-sen University were enrolled and randomly divided into an EDP group of 27 patients and a control group of 24 patients. The control group received routine treatment, and the EDP group received EDP treatment in addition to routine treatment. The diaphragm excursion (DE), diaphragm thickening fraction (DTF), DMV, ILOS, and average survival time were recorded to evaluate efficacy. RESULTS Patients treated with EDP had increased DE [exp(B) =1.86, 95% CI: 1.39 to 2.50, P<0.001] and DTF [exp(B) =1.35, 95% CI: 1.05 to 1.76, P=0.022], shortened weaning time (P=0.026) and prolonged average survival time (P<0.001) compared to patients who did not receive EDP therapy. Especially in cases with difficult weaning, the improvement of DE and DTF in the EDP treatment group was more obvious than that in the control group (P=0.013 and P=0.032). Moreover, the DTF upon attempted spontaneous breathing trial (SBT) was negatively correlated with the fraction of inspired oxygen (FiO2) [r=-0.54; 95% confidence interval (CI): -0.77 to -0.19; P=0.004], the arterial partial pressure of oxygen (PaO2) (r=-0.58; 95% CI: -0.79 to -0.25; P=0.001), the PaO2/FiO2 ratio (r=-0.52; 95% CI: -0.75 to -0.16; P=0.006), and the serum lactate concentration (Lac) (r=-0.39; 95% CI: -0.68 to 0.003; P=0.046). CONCLUSIONS EDP treatment can effectively reduce the DMV and prolong the average survival time of mechanically ventilated patients. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR1900024096.
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Affiliation(s)
- Qiang Bao
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Liang Chen
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaotong Chen
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ting Li
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Caihong Xie
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zijun Zou
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chunrong Huang
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yaowei Zhi
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhijie He
- Department of Intensive Care Unit, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Cavka K, Fuller DD, Tonuzi G, Fox EJ. Diaphragm Pacing and a Model for Respiratory Rehabilitation After Spinal Cord Injury. J Neurol Phys Ther 2021; 45:235-242. [PMID: 34049339 PMCID: PMC8711094 DOI: 10.1097/npt.0000000000000360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Cervical spinal cord injury (CSCI) can cause severe respiratory impairment. Although mechanical ventilation (MV) is a lifesaving standard of care for these patients, it is associated with diaphragm atrophy and dysfunction. Diaphragm pacing (DP) is a strategy now used acutely to promote MV weaning and to combat the associated negative effects. Initial reports indicate that DP also may promote neuromuscular plasticity and lead to improvements in spontaneous diaphragm activation and respiratory function. These outcomes suggest the need for reevaluation of respiratory rehabilitation for patients with CSCI using DP and consideration of new rehabilitation models for these patients and their unique care needs. SUMMARY OF KEY POINTS This article discusses the rationale for consideration of DP as a rehabilitative strategy, particularly when used in combination with established respiratory interventions. In addition, a model of respiratory rehabilitation and recovery (RRR) is presented, providing a framework for rehabilitation and consideration of DP as an adjuvant rehabilitation approach. The model promotes goals such as respiratory recovery and independence, and lifelong respiratory health, via interdisciplinary care, respiratory training, quantitative measurement, and use of adjuvant strategies such as DP. Application of the model is demonstrated through a description of an inpatient rehabilitation program that applies model components to patients with CSCI who require DP. RECOMMENDATIONS FOR CLINICAL PRACTICE As DP use increases for patients with acute CSCI, so does the need and opportunity to advance rehabilitation approaches for these patients. This perspective article is a critical step in addressing this need and motivating the advancement of rehabilitation strategies for CSCI patients. (See Video Abstract, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A348).
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Affiliation(s)
- Kathryn Cavka
- Brooks Rehabilitation, Jacksonville, Florida (K.C., G.T., E.J.F.); and Department of Physical Therapy, University of Florida, Gainesville (D.D.F., E.J.F.)
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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.
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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
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