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Schaaf K, Mullin CM, Cunningham KW, Eaton J, Conrad SA. The ReInvigorate Study-phrenic nerve-to-diaphragm stimulation for weaning from mechanical ventilation: a protocol for a randomized pivotal clinical trial. Trials 2024; 25:519. [PMID: 39095923 PMCID: PMC11295437 DOI: 10.1186/s13063-024-08355-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND In the United States in 2017, there were an estimated 903,745 hospitalizations involving mechanical ventilation (MV). Complications from ventilation can result in longer hospital stays, increased risk of disability, and increased healthcare costs. It has been hypothesized that electrically pacing the diaphragm by phrenic nerve stimulation during mechanical ventilation may minimize or reverse diaphragm dysfunction, resulting in faster weaning. METHODS The ReInvigorate Trial is a prospective, multicenter, randomized, controlled clinical trial evaluating the safety and efficacy of Stimdia's pdSTIM System for facilitating weaning from MV. The pdSTIM system employs percutaneously placed multipolar electrodes to stimulate the cervical phrenic nerves and activate contraction of the diaphragm bilaterally. Patients who were on mechanical ventilation for at least 96 h and who failed at least one weaning attempt were considered for enrollment in the study. The primary efficacy endpoint was the time to successful liberation from mechanical ventilation (treatment vs. control). Secondary endpoints will include the rapid shallow breathing index and other physiological and system characteristics. Safety will be summarized for both primary and additional analyses. All endpoints will be evaluated at 30 days or at the time of removal of mechanical ventilation, whichever is first. DISCUSSION This pivotal study is being conducted under an investigational device exception with the U.S. Food and Drug Administration. The technology being studied could provide a first-of-kind therapy for difficult-to-wean patients on mechanical ventilation in an intensive care unit setting. TRIAL REGISTRATION Clinicaltrials.gov, NCT05998018 , registered August 2023.
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Affiliation(s)
- Katie Schaaf
- Stimdia Medical, Inc, 1355 Mendota Heights Road, Suite 300, Mendota Heights, MN, 55120, USA
| | | | | | - Jonathan Eaton
- Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA
| | - Steven A Conrad
- Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA.
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2
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Wu H, Chasteen B. Rapid review of ventilator-induced diaphragm dysfunction. Respir Med 2024; 223:107541. [PMID: 38290603 DOI: 10.1016/j.rmed.2024.107541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/01/2024]
Abstract
Ventilator-induced diaphragm dysfunction is gaining increased recognition. Evidence of diaphragm weakness can manifest within 12 h to a few days after the initiation of mechanical ventilation. Various noninvasive and invasive methods have been developed to assess diaphragm function. The implementation of diaphragm-protective ventilation strategies is crucial for preventing diaphragm injuries. Furthermore, diaphragm neurostimulation emerges as a promising and novel treatment option. In this rapid review, our objective is to discuss the current understanding of ventilator-induced diaphragm dysfunction, diagnostic approaches, and updates on strategies for prevention and management.
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Affiliation(s)
- Huimin Wu
- Pulmonary, Critical Care and Sleep Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States; Department of Adult Respiratory Care, University of Oklahoma Medical Center, Oklahoma City, OK, 73104, United States.
| | - Bobby Chasteen
- Department of Adult Respiratory Care, University of Oklahoma Medical Center, Oklahoma City, OK, 73104, United States.
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3
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Etienne H, Morris IS, Hermans G, Heunks L, Goligher EC, Jaber S, Morelot-Panzini C, Assouad J, Gonzalez-Bermejo J, Papazian L, Similowski T, Demoule A, Dres M. Diaphragm Neurostimulation Assisted Ventilation in Critically Ill Patients. Am J Respir Crit Care Med 2023; 207:1275-1282. [PMID: 36917765 PMCID: PMC10595441 DOI: 10.1164/rccm.202212-2252cp] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 03/14/2023] [Indexed: 03/15/2023] Open
Abstract
Diaphragm neurostimulation consists of placing electrodes directly on or in proximity to the phrenic nerve(s) to elicit diaphragmatic contractions. Since its initial description in the 18th century, indications have shifted from cardiopulmonary resuscitation to long-term ventilatory support. Recently, the technical development of devices for temporary diaphragm neurostimulation has opened up the possibility of a new era for the management of mechanically ventilated patients. Combining positive pressure ventilation with diaphragm neurostimulation offers a potentially promising new approach to the delivery of mechanical ventilation which may benefit multiple organ systems. Maintaining diaphragm contractions during ventilation may attenuate diaphragm atrophy and accelerate weaning from mechanical ventilation. Preventing atelectasis and preserving lung volume can reduce lung stress and strain and improve homogeneity of ventilation, potentially mitigating ventilator-induced lung injury. Furthermore, restoring the thoracoabdominal pressure gradient generated by diaphragm contractions may attenuate the drop in cardiac output induced by positive pressure ventilation. Experimental evidence suggests diaphragm neurostimulation may prevent neuroinflammation associated with mechanical ventilation. This review describes the historical development and evolving approaches to diaphragm neurostimulation during mechanical ventilation and surveys the potential mechanisms of benefit. The review proposes a research agenda and offers perspectives for the future of diaphragm neurostimulation assisted mechanical ventilation for critically ill patients.
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Affiliation(s)
- Harry Etienne
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Department of Thoracic Surgery, Tenon University Hospital, Paris, France
| | - Idunn S. Morris
- Interdepartmental Division of Critical Care Medicine and
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Greet Hermans
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospital Leuven, Leuven, Belgium
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine and
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Samir Jaber
- Intensive Care and Anesthesiology Department, Saint Eloi Hospital, Montpellier, France
| | - Capucine Morelot-Panzini
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Pneumologie
| | - Jalal Assouad
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Department of Thoracic Surgery, Tenon University Hospital, Paris, France
| | - Jésus Gonzalez-Bermejo
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Soins de Suite Réadaptation
| | - Laurent Papazian
- Service de Médecine Intensive Reanimation, Centre Hospitalier de Bastia, Bastia, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Département R3S, and
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive – Réanimation, Hopital Pitie Salpetriere, APHP, Sorbonne Universite, Paris, France; and
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive – Réanimation, Hopital Pitie Salpetriere, APHP, Sorbonne Universite, Paris, France; and
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4
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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.
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5
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Keogh C, Saavedra F, Dubo S, Aqueveque P, Ortega P, Gomez B, Germany E, Pinto D, Osorio R, Pastene F, Poulton A, Jarvis J, Andrews B, FitzGerald JJ. Non-invasive phrenic nerve stimulation to avoid ventilator-induced diaphragm dysfunction in critical care. Artif Organs 2022; 46:1988-1997. [PMID: 35377472 PMCID: PMC9790411 DOI: 10.1111/aor.14244] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/09/2022] [Accepted: 03/16/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Diaphragm muscle atrophy during mechanical ventilation begins within 24 h and progresses rapidly with significant clinical consequences. Electrical stimulation of the phrenic nerves using invasive electrodes has shown promise in maintaining diaphragm condition by inducing intermittent diaphragm muscle contraction. However, the widespread application of these methods may be limited by their risks as well as the technical and environmental requirements of placement and care. Non-invasive stimulation would offer a valuable alternative method to maintain diaphragm health while overcoming these limitations. METHODS We applied non-invasive electrical stimulation to the phrenic nerve in the neck in healthy volunteers. Respiratory pressure and flow, diaphragm electromyography and mechanomyography, and ultrasound visualization were used to assess the diaphragmatic response to stimulation. The electrode positions and stimulation parameters were systematically varied in order to investigate the influence of these parameters on the ability to induce diaphragm contraction with non-invasive stimulation. RESULTS We demonstrate that non-invasive capture of the phrenic nerve is feasible using surface electrodes without the application of pressure, and characterize the stimulation parameters required to achieve therapeutic diaphragm contractions in healthy volunteers. We show that an optimal electrode position for phrenic nerve capture can be identified and that this position does not vary as head orientation is changed. The stimulation parameters required to produce a diaphragm response at this site are characterized and we show that burst stimulation above the activation threshold reliably produces diaphragm contractions sufficient to drive an inspired volume of over 600 ml, indicating the ability to produce significant diaphragmatic work using non-invasive stimulation. CONCLUSION This opens the possibility of non-invasive systems, requiring minimal specialist skills to set up, for maintaining diaphragm function in the intensive care setting.
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Affiliation(s)
- Conor Keogh
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Francisco Saavedra
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK,Electrical Engineering DepartmentUniversidad de ConcepcionConcepciónChile
| | - Sebastian Dubo
- Kinesiology DepartmentUniversidad de ConcepcionConcepciónChile
| | - Pablo Aqueveque
- Electrical Engineering DepartmentUniversidad de ConcepcionConcepciónChile
| | - Paulina Ortega
- Kinesiology DepartmentUniversidad de ConcepcionConcepciónChile
| | - Britam Gomez
- Electrical Engineering DepartmentUniversidad de ConcepcionConcepciónChile
| | - Enrique Germany
- Electrical Engineering DepartmentUniversidad de ConcepcionConcepciónChile
| | - Daniela Pinto
- Electrical Engineering DepartmentUniversidad de ConcepcionConcepciónChile
| | - Rodrigo Osorio
- Electrical Engineering DepartmentUniversidad de ConcepcionConcepciónChile
| | - Francisco Pastene
- Electrical Engineering DepartmentUniversidad de ConcepcionConcepciónChile
| | - Adrian Poulton
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
| | - Jonathan Jarvis
- School of Sport and Exercise ScienceLiverpool John Moores UniversityLiverpoolUK
| | - Brian Andrews
- Nuffield Department of Surgical SciencesUniversity of OxfordOxfordUK
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6
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Satkunendrarajah K, Karadimas SK, Fehlings MG. Spinal cord injury and degenerative cervical myelopathy. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:241-257. [PMID: 36031307 DOI: 10.1016/b978-0-323-91532-8.00006-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Spinal cord injury (SCI) often results in impaired respiratory function. Paresis or paralysis of inspiratory and expiratory muscles can lead to respiratory dysfunction depending on the level and severity of the injury, which can affect the management and care of SCI patients. Respiratory dysfunction after SCI is more severe in high cervical injuries, with vital capacity (VC) being an essential indicator of overall respiratory health. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Respiratory management includes mechanical ventilation and tracheostomy in high cervical SCI, while noninvasive ventilation is more common in patients with lower cervical and thoracic injuries. Mechanical ventilation can negatively impact the function of the diaphragm and weaning should start as soon as possible. Patients can sometimes be weaned from mechanical ventilation with assistance of electrical stimulation of the phrenic nerve or the diaphragm. Respiratory muscle training regimens may also improve patients' inspiratory function following SCI. Despite the critical advances in preventing, diagnosing, and treating respiratory complications, they continue to significantly affect persons living with SCI. Additional studies of interventions to reduce respiratory complications are likely to further decrease the morbidity and mortality associated with these injuries.
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Affiliation(s)
- Kajana Satkunendrarajah
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Neuroscience, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI, United States; Department of Physiology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Spyridon K Karadimas
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, ON, Canada; Division of Genetics and Development, Krembil Brain Institute, University Health Network, Toronto, ON, Canada.
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7
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Initial Assessment of the Percutaneous Electrical Phrenic Nerve Stimulation System in Patients on Mechanical Ventilation. Crit Care Med 2021; 48:e362-e370. [PMID: 32191413 PMCID: PMC7161723 DOI: 10.1097/ccm.0000000000004256] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Supplemental Digital Content is available in the text. Maintaining diaphragm work using electrical stimulation during mechanical ventilation has been proposed to attenuate ventilator-induced diaphragm dysfunction. This study assessed the safety and feasibility of temporary percutaneous electrical phrenic nerve stimulation on user-specified inspiratory breaths while on mechanical ventilation.
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8
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Liu Y, Abula NM, Wang Q, Tong N, Zhang X, Aisha A, Wang S. Effect of external diaphragmatic pacing therapy on patients with chronic cor pulmonale: a randomized, controlled trial. J Int Med Res 2021; 48:300060520965839. [PMID: 33208014 PMCID: PMC7683919 DOI: 10.1177/0300060520965839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objectives This study aimed to evaluate the effects of external diaphragmatic pacing (EDP) on patients with chronic cor pulmonale (CCP). Methods Fifty patients with CCP were enrolled in Kashgar Prefecture Second People’s Hospital in Xinjiang Uygur Autonomous Region of China from 2016 to 2017. The patients were randomized into a group that received anti-CCP therapy (negative control group) or a group that received additional EDP treatment (EDP group). We recorded and compared maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC, and the 6-minute walking test between the two groups on the first and tenth days of treatment. Results Ten days after treatment began, MIP, FVC, and the 6-minute walking test were significantly improved in both groups. Importantly, MIP and FVC were significantly higher in the EDP group compared with the control group on the tenth day. Conclusion In addition to treatment for CCP, these patients can obtain extra benefit by using EDP treatment.
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Affiliation(s)
- Yongchao Liu
- Department of Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Nuer Maimaiti Abula
- Emergency Department, Kashgar Prefecture Second People's Hospital, Kashgar, Xinjiang, China
| | - Qixing Wang
- Department of Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Nana Tong
- Emergency Department, Kashgar Prefecture Second People's Hospital, Kashgar, Xinjiang, China
| | - Xiangyu Zhang
- Department of Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Aisikaer Aisha
- Emergency Department, Kashgar Prefecture Second People's Hospital, Kashgar, Xinjiang, China
| | - Sheng Wang
- Department of Critical Care Medicine, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
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9
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Laghi FA, Saad M, Shaikh H. Ultrasound and non-ultrasound imaging techniques in the assessment of diaphragmatic dysfunction. BMC Pulm Med 2021; 21:85. [PMID: 33722215 PMCID: PMC7958108 DOI: 10.1186/s12890-021-01441-6] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 02/19/2021] [Indexed: 12/25/2022] Open
Abstract
Diaphragm muscle dysfunction is increasingly recognized as an important element of several diseases including neuromuscular disease, chronic obstructive pulmonary disease and diaphragm dysfunction in critically ill patients. Functional evaluation of the diaphragm is challenging. Use of volitional maneuvers to test the diaphragm can be limited by patient effort. Non-volitional tests such as those using neuromuscular stimulation are technically complex, since the muscle itself is relatively inaccessible. As such, there is a growing interest in using imaging techniques to characterize diaphragm muscle dysfunction. Selecting the appropriate imaging technique for a given clinical scenario is a critical step in the evaluation of patients suspected of having diaphragm dysfunction. In this review, we aim to present a detailed analysis of evidence for the use of ultrasound and non-ultrasound imaging techniques in the assessment of diaphragm dysfunction. We highlight the utility of the qualitative information gathered by ultrasound imaging as a means to assess integrity, excursion, thickness, and thickening of the diaphragm. In contrast, quantitative ultrasound analysis of the diaphragm is marred by inherent limitations of this technique, and we provide a detailed examination of these limitations. We evaluate non-ultrasound imaging modalities that apply static techniques (chest radiograph, computerized tomography and magnetic resonance imaging), used to assess muscle position, shape and dimension. We also evaluate non-ultrasound imaging modalities that apply dynamic imaging (fluoroscopy and dynamic magnetic resonance imaging) to assess diaphragm motion. Finally, we critically review the application of each of these techniques in the clinical setting when diaphragm dysfunction is suspected.
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Affiliation(s)
- Franco A Laghi
- Department of Internal Medicine, Sinai Hospital, 2401 W Belvedere Ave, Baltimore, MD, 21215, USA
| | - Marina Saad
- Department of Biomedical and Clinical Sciences (DIBIC), Division of Pulmonary Diseases, University of Milan, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco, V. G.B. Grassi, 74, 20157, Milan, Italy
| | - Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital (111N), 5th Avenue and Roosevelt Road, Hines, IL, 60141, USA. .,Division of Pulmonary and Critical Care Medicine, Loyola University Chicago Stritch School of Medicine, 2160 S 1st Ave, Maywood, IL, 60153, USA.
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10
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Autonomous control of ventilation through closed-loop adaptive respiratory pacing. Sci Rep 2020; 10:21903. [PMID: 33318547 PMCID: PMC7736353 DOI: 10.1038/s41598-020-78834-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 12/01/2020] [Indexed: 02/06/2023] Open
Abstract
Mechanical ventilation is the standard treatment when volitional breathing is insufficient, but drawbacks include muscle atrophy, alveolar damage, and reduced mobility. Respiratory pacing is an alternative approach using electrical stimulation-induced diaphragm contraction to ventilate the lung. Oxygenation and acid-base homeostasis are maintained by matching ventilation to metabolic needs; however, current pacing technology requires manual tuning and does not respond to dynamic user-specific metabolic demand, thus requiring re-tuning of stimulation parameters as physiological changes occur. Here, we describe respiratory pacing using a closed-loop adaptive controller that can self-adjust in real-time to meet metabolic needs. The controller uses an adaptive Pattern Generator Pattern Shaper (PG/PS) architecture that autonomously generates a desired ventilatory pattern in response to dynamic changes in arterial CO2 levels and, based on a learning algorithm, modulates stimulation intensity and respiratory cycle duration to evoke this ventilatory pattern. In vivo experiments in rats with respiratory depression and in those with a paralyzed hemidiaphragm confirmed that the controller can adapt and control ventilation to ameliorate hypoventilation and restore normocapnia regardless of the cause of respiratory dysfunction. This novel closed-loop bioelectronic controller advances the state-of-art in respiratory pacing by demonstrating the ability to automatically personalize stimulation patterns and adapt to achieve adequate ventilation.
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Abstract
PURPOSE OF REVIEW Diaphragm weakness can impact survival and increases comorbidities in ventilated patients. Mechanical ventilation is linked to diaphragm dysfunction through several mechanisms of injury, referred to as myotrauma. By monitoring diaphragm activity and titrating ventilator settings, the critical care clinician can have a direct impact on diaphragm injury. RECENT FINDINGS Both the absence of diaphragm activity and excessive inspiratory effort can result in diaphragm muscle weakness, and recent evidence demonstrates that a moderate level of diaphragm activity during mechanical ventilation improves ICU outcome. This supports the hypothesis that by avoiding ventilator overassistance and underassistance, the clinician can implement a diaphragm-protective ventilation strategy. Furthermore, eccentric diaphragm contractions and end-expiratory shortening could impact diaphragm strength as well. This review describes these potential targets for diaphragm protective ventilation. SUMMARY A ventilator strategy that results in appropriate levels of diaphragm activity has the potential to be diaphragm-protective and improve clinical outcome. Monitoring respiratory effort during mechanical ventilation is becoming increasingly important.
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Affiliation(s)
- Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Adult Intensive Care Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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12
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Goligher EC, Dres M, Patel BK, Sahetya SK, Beitler JR, Telias I, Yoshida T, Vaporidi K, Grieco DL, Schepens T, Grasselli G, Spadaro S, Dianti J, Amato M, Bellani G, Demoule A, Fan E, Ferguson ND, Georgopoulos D, Guérin C, Khemani RG, Laghi F, Mercat A, Mojoli F, Ottenheijm CAC, Jaber S, Heunks L, Mancebo J, Mauri T, Pesenti A, Brochard L. Lung- and Diaphragm-Protective Ventilation. Am J Respir Crit Care Med 2020; 202:950-961. [PMID: 32516052 DOI: 10.1164/rccm.202003-0655cp] [Citation(s) in RCA: 151] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Mechanical ventilation can cause acute diaphragm atrophy and injury, and this is associated with poor clinical outcomes. Although the importance and impact of lung-protective ventilation is widely appreciated and well established, the concept of diaphragm-protective ventilation has recently emerged as a potential complementary therapeutic strategy. This Perspective, developed from discussions at a meeting of international experts convened by PLUG (the Pleural Pressure Working Group) of the European Society of Intensive Care Medicine, outlines a conceptual framework for an integrated lung- and diaphragm-protective approach to mechanical ventilation on the basis of growing evidence about mechanisms of injury. We propose targets for diaphragm protection based on respiratory effort and patient-ventilator synchrony. The potential for conflict between diaphragm protection and lung protection under certain conditions is discussed; we emphasize that when conflicts arise, lung protection must be prioritized over diaphragm protection. Monitoring respiratory effort is essential to concomitantly protect both the diaphragm and the lung during mechanical ventilation. To implement lung- and diaphragm-protective ventilation, new approaches to monitoring, to setting the ventilator, and to titrating sedation will be required. Adjunctive interventions, including extracorporeal life support techniques, phrenic nerve stimulation, and clinical decision-support systems, may also play an important role in selected patients in the future. Evaluating the clinical impact of this new paradigm will be challenging, owing to the complexity of the intervention. The concept of lung- and diaphragm-protective ventilation presents a new opportunity to potentially improve clinical outcomes for critically ill patients.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Martin Dres
- Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Assistance Publique-Hopitaux de Paris, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Unite Mixte de Recherche-Sorbonne 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Sante et de la Recherche Medicale, Sorbonne Université, Paris, France
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Sarina K Sahetya
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jeremy R Beitler
- Division of Pulmonary, Allergy, and Critical Care Medicine, Center for Acute Respiratory Failure, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Suita, Japan
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy.,Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy
| | - Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Savino Spadaro
- Department Morphology, Surgery and Experimental Medicine, ICU, St. Anne's Archbishop Hospital, University of Ferrara, Ferrara, Italy
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Intensive Care Unit, Department of Medicine, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Marcelo Amato
- Laboratório de Pneumologia, Laboratório de Investicação Médica 9, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Alexandre Demoule
- Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), Assistance Publique-Hopitaux de Paris, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,Unite Mixte de Recherche-Sorbonne 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Institut National de la Sante et de la Recherche Medicale, Sorbonne Université, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine.,Institute for Health Policy, Management, and Evaluation, and.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine.,Institute for Health Policy, Management, and Evaluation, and.,Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Claude Guérin
- Médecine Intensive-Réanimation, Hopital Edouard Herriot Lyon, Faculté de Médecine Lyon-Est, Université de Lyon, Institut National de la Santé et de la Recherche Médicale 955 Créteil, Lyon, France
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, University of Southern California, Los Angeles, California
| | - Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Stritch School of Medicine, Loyola University, Maywood, Illinois.,Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Hines, Illinois
| | - Alain Mercat
- Département de Médecine Intensive-Réanimation et Médecine Hyperbare, Centre Hospitalier d'Angers, Angers, France
| | - Francesco Mojoli
- Department of Anesthesia and Intensive Care, Scientific Hospitalization and Care Institute, San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | | | - Samir Jaber
- Anesthesiology and Intensive Care, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, Montpellier University Hospital Center, University of Montpellier, Joint Research Unit 9214, National Institute of Health and Medical Research U1046, National Scientific Research Center, Montpellier, France; and
| | - Leo Heunks
- Department of Intensive Care, Vrije University Location, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jordi Mancebo
- Servei de Medicina Intensiva Hospital de Sant Pau, Barcelona, Spain
| | - Tommaso Mauri
- Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Antonio Pesenti
- Dipartimento di Medicina d'Urgenza e di Terapia Intensiva e Anestesia, Fondazione Policlinico Universitario, A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico, Rome, Italy.,Department of Critical Care Medicine, Antwerp University Hospital, Antwerp, Belgium
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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13
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Sklar MC, Dres M, Fan E, Rubenfeld GD, Scales DC, Herridge MS, Rittayamai N, Harhay MO, Reid WD, Tomlinson G, Rozenberg D, McClelland W, Riegler S, Slutsky AS, Brochard L, Ferguson ND, Goligher EC. Association of Low Baseline Diaphragm Muscle Mass With Prolonged Mechanical Ventilation and Mortality Among Critically Ill Adults. JAMA Netw Open 2020; 3:e1921520. [PMID: 32074293 DOI: 10.1001/jamanetworkopen.2019.21520] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Low diaphragm muscle mass at the outset of mechanical ventilation may predispose critically ill patients to poor clinical outcomes. OBJECTIVE To determine whether lower baseline diaphragm thickness (Tdi) is associated with delayed liberation from mechanical ventilation and complications of acute respiratory failure (reintubation, tracheostomy, prolonged ventilation >14 days, or death in the hospital). DESIGN, SETTING, AND PARTICIPANTS Secondary analysis (July 2018 to June 2019) of a prospective cohort study (data collected May 2013 to January 2016). Participants were 193 critically ill adult patients receiving invasive mechanical ventilation at 3 intensive care units in Toronto, Ontario, Canada. EXPOSURES Diaphragm thickness was measured by ultrasonography within 36 hours of intubation and then daily. Patients were classified as having low or high diaphragm muscle mass according to the median baseline Tdi. MAIN OUTCOMES AND MEASURES The primary outcome was time to liberation from ventilation accounting for the competing risk of death and adjusting for age, body mass index, severity of illness, sepsis, change in Tdi during ventilation, baseline comorbidity, and study center. Secondary outcomes included in-hospital death and complications of acute respiratory failure. RESULTS A total of 193 patients were available for analysis; the mean (SD) age was 60 (15) years, 73 (38%) were female, and the median (interquartile range) Sequential Organ Failure Assessment score was 10 (8-13). Median (interquartile range) baseline Tdi was 2.3 (2.0-2.7) mm. In the primary prespecified analysis, baseline Tdi of 2.3 mm or less was associated with delayed liberation from mechanical ventilation (adjusted hazard ratio for liberation, 0.51; 95% CI, 0.36-0.74). Lower baseline Tdi was associated a higher risk of complications of acute respiratory failure (adjusted odds ratio, 1.77; 95% CI, 1.20-2.61 per 0.5-mm decrement) and prolonged weaning (adjusted odds ratio, 2.30; 95% CI, 1.42-3.74). Lower baseline Tdi was also associated with a higher risk of in-hospital death (adjusted odds ratio, 1.47; 95% CI, 1.00-2.16 per 0.5-mm decrement), particularly after discharge from the intensive care unit (adjusted odds ratio, 2.68; 95% CI, 1.35-5.32 per 0.5-mm decrement). CONCLUSIONS AND RELEVANCE In this study, low baseline diaphragm muscle mass in critically ill patients was associated with prolonged mechanical ventilation, complications of acute respiratory failure, and an increased risk of death in the hospital.
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Affiliation(s)
- Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Martin Dres
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- AP-HP, Service de Pneumologie, Médecine Intensive-Réanimation (Département "R3S"), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Gordon D Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Damon C Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Nuttapol Rittayamai
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Siriraj Hospital, Division of Respiratory Disease and Tuberculosis, Department of Medicine, Faculty of Medicine, Mahidol University, Bangkok, Thailand
| | - Michael O Harhay
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - W Darlene Reid
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Dmitry Rozenberg
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - William McClelland
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Stephen Riegler
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
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14
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Zhou XL, Wei XJ, Li SP, Ma HL, Zhao Y. Lung-protective ventilation worsens ventilator-induced diaphragm atrophy and weakness. Respir Res 2020; 21:16. [PMID: 31924204 PMCID: PMC6954632 DOI: 10.1186/s12931-020-1276-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023] Open
Abstract
Background Lung–protective ventilation (LPV) has been found to minimize the risk of ventilator–induced lung injury (VILI). However, whether LPV is able to diminish ventilator–induced diaphragm dysfunction (VIDD) remains unknown. This study was designed to test the hypothesis that LPV protects the diaphragm against VIDD. Methods Adult male Wistar rats received either conventional mechanical (tidal volume [VT]: 10 ml/kg, positive end–expiratory pressure [PEEP]: 2 cm H2O; CV group) or lung-protective (VT: 5 ml/kg, PEEP: 10 cm H2O; LPV group) ventilation for 12 h. Then, diaphragms and lungs were collected for biochemical and histological analyses. Transcriptome sequencing (RNA–seq) was performed to determine the differentially expressed genes in the diaphragms between groups. Results Our results suggested that LPV was associated with diminished pulmonary injuries and reduced oxidative stress compared with the effects of the CV strategy in rats. However, animals that received LPV showed increased protein degradation, decreased cross–sectional areas (CSAs) of myofibers, and reduced forces of the diaphragm compared with the same parameters in animals receiving CV (p < 0.05). In addition, the LPV group showed a higher level of oxidative stress in the diaphragm than the CV group (p < 0.05). Moreover, RNA–seq and western blots revealed that the peroxisome proliferator–activated receptor γ coactivator–1alpha (PGC–1α), a powerful reactive oxygen species (ROS) inhibitor, was significantly downregulated in the LPV group compared with its expression in the CV group (p < 0.05). Conclusions Compared with the CV strategy, the LPV strategy did not protect the diaphragm against VIDD in rats. In contrast, the LPV strategy worsened VIDD by inducing oxidative stress together with the downregulation of PGC–1α in the diaphragm. However, further studies are required to determine the roles of PGC–1α in ventilator-induced diaphragmatic oxidative stress.
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Affiliation(s)
- Xian-Long Zhou
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Xiao-Jun Wei
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Shao-Ping Li
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Hao-Li Ma
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Yan Zhao
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China.
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15
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Abstract
Pathologic processes that involve the central nervous system, phrenic nerve, neuromuscular junction, and skeletal muscle can impair diaphragm function. When these processes are of sufficient severity to cause diaphragm dysfunction, respiratory failure may be a consequence. This article reviews basic diaphragm anatomy and physiology and then discusses diagnostic and therapeutic approaches to disorders that result in unilateral or bilateral diaphragm dysfunction. This discussion provides a context in which disorders of the diaphragm and their implications on respiratory function can be better appreciated.
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Affiliation(s)
- F Dennis McCool
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA.
| | - Kamran Manzoor
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA
| | - Taro Minami
- Division of Pulmonary, Critical Care, and Sleep Medicine, The Warren Alpert Medical School of Brown University, Memorial Hospital of Rhode Island, 111 Brewster Street, Pawtucket, RI 02860, USA
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16
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Schreiber A, Bertoni M, Goligher EC. Avoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation: Diaphragm-Protective Ventilation and Early Mobilization. Crit Care Clin 2018; 34:357-381. [PMID: 29907270 DOI: 10.1016/j.ccc.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Both limb muscle weakness and respiratory muscle weakness are exceedingly common in critically ill patients. Respiratory muscle weakness prolongs ventilator dependence, predisposing to nosocomial complications and death. Limb muscle weakness persists for months after discharge from intensive care and results in poor long-term functional status and quality of life. Major mechanisms of muscle injury include critical illness polymyoneuropathy, sepsis, pharmacologic exposures, metabolic derangements, and excessive muscle loading and unloading. The diaphragm may become weak because of excessive unloading (leading to atrophy) or because of excessive loading (either concentric or eccentric) owing to insufficient ventilator assistance.
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Affiliation(s)
- Annia Schreiber
- Respiratory Intensive Care Unit and Pulmonary Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Scientific Institute of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili 1, Brescia 25123, Italy
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, 585 University Avenue, Peter Munk Building, 11th Floor Room 192, Toronto, ON M5G 2N2, Canada.
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17
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de Vries H, Jonkman A, Shi ZH, Spoelstra-de Man A, Heunks L. Assessing breathing effort in mechanical ventilation: physiology and clinical implications. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:387. [PMID: 30460261 DOI: 10.21037/atm.2018.05.53] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent studies have shown both beneficial and detrimental effects of patient breathing effort in mechanical ventilation. Quantification of breathing effort may allow the clinician to titrate ventilator support to physiological levels of respiratory muscle activity. In this review we will describe the physiological background and methodological issues of the most frequently used methods to quantify breathing effort, including esophageal pressure measurement, the work of breathing, the pressure-time-product, electromyography and ultrasound. We will also discuss the level of breathing effort that may be considered optimal during mechanical ventilation at different stages of critical illness.
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Affiliation(s)
- Heder de Vries
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Angélique Spoelstra-de Man
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam Cardiovascular Sciences, VU University Medical Centre, Amsterdam, The Netherlands
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18
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Vassilakopoulos T, Petrof BJ. A Stimulating Approach to Ventilator-induced Diaphragmatic Dysfunction. Am J Respir Crit Care Med 2017; 169:336-41. [PMID: 14739134 DOI: 10.1164/rccm.200304-489cp] [Citation(s) in RCA: 288] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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19
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Hachmann JT, Grahn PJ, Calvert JS, Drubach DI, Lee KH, Lavrov IA. Electrical Neuromodulation of the Respiratory System After Spinal Cord Injury. Mayo Clin Proc 2017; 92:1401-1414. [PMID: 28781176 DOI: 10.1016/j.mayocp.2017.04.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 03/22/2017] [Accepted: 04/03/2017] [Indexed: 12/12/2022]
Abstract
Spinal cord injury (SCI) is a complex and devastating condition characterized by disruption of descending, ascending, and intrinsic spinal circuitry resulting in chronic neurologic deficits. In addition to limb and trunk sensorimotor deficits, SCI can impair autonomic neurocircuitry such as the motor networks that support respiration and cough. High cervical SCI can cause complete respiratory paralysis, and even lower cervical or thoracic lesions commonly result in partial respiratory impairment. Although electrophrenic respiration can restore ventilator-independent breathing in select candidates, only a small subset of affected individuals can benefit from this technology at this moment. Over the past decades, spinal cord stimulation has shown promise for augmentation and recovery of neurologic function including motor control, cough, and breathing. The present review discusses the challenges and potentials of spinal cord stimulation for restoring respiratory function by overcoming some of the limitations of conventional respiratory functional electrical stimulation systems.
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Affiliation(s)
- Jan T Hachmann
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Peter J Grahn
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Jonathan S Calvert
- Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic, Rochester, MN
| | - Dina I Drubach
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Kendall H Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN; Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | - Igor A Lavrov
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN.
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20
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Nair J, Streeter KA, Turner SMF, Sunshine MD, Bolser DC, Fox EJ, Davenport PW, Fuller DD. Anatomy and physiology of phrenic afferent neurons. J Neurophysiol 2017; 118:2975-2990. [PMID: 28835527 DOI: 10.1152/jn.00484.2017] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/17/2017] [Accepted: 08/17/2017] [Indexed: 12/23/2022] Open
Abstract
Large-diameter myelinated phrenic afferents discharge in phase with diaphragm contraction, and smaller diameter fibers discharge across the respiratory cycle. In this article, we review the phrenic afferent literature and highlight areas in need of further study. We conclude that 1) activation of both myelinated and nonmyelinated phrenic sensory afferents can influence respiratory motor output on a breath-by-breath basis; 2) the relative impact of phrenic afferents substantially increases with diaphragm work and fatigue; 3) activation of phrenic afferents has a powerful impact on sympathetic motor outflow, and 4) phrenic afferents contribute to diaphragm somatosensation and the conscious perception of breathing. Much remains to be learned regarding the spinal and supraspinal distribution and synaptic contacts of myelinated and nonmyelinated phrenic afferents. Similarly, very little is known regarding the potential role of phrenic afferent neurons in triggering or modulating expression of respiratory neuroplasticity.
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Affiliation(s)
- Jayakrishnan Nair
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, Florida; and
| | - Kristi A Streeter
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, Florida; and
| | - Sara M F Turner
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, Florida; and
| | - Michael D Sunshine
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, Florida; and
| | - Donald C Bolser
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, Florida; and
| | - Emily J Fox
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida.,McKnight Brain Institute, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, Florida; and.,Brooks Rehabilitation, Jacksonville, Florida
| | - Paul W Davenport
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, Florida; and
| | - David D Fuller
- Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida; .,McKnight Brain Institute, University of Florida, Gainesville, Florida.,Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, Florida; and
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21
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Electric Muscle Stimulation for Weaning from Mechanical Ventilation in Elder Patients with Severe Sepsis and Acute Respiratory Failure – A Pilot Study. INT J GERONTOL 2017. [DOI: 10.1016/j.ijge.2017.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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22
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Kramer C, Zoubaa S, Kretschmer A, Jordan D, Blobner M, Fink H. Denervation versus pre‐ and postsynaptic muscle immobilization: Effects On acetylcholine‐ and muscle‐specific tyrosine kinase receptors. Muscle Nerve 2016; 55:101-108. [DOI: 10.1002/mus.25159] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 04/07/2016] [Accepted: 04/19/2016] [Indexed: 12/26/2022]
Affiliation(s)
- Christopher Kramer
- Klinik für AnaesthesiologieTechnische Universität München, Klinikum rechts der IsarIsmaninger Strasse 2281675München Germany
| | - Saida Zoubaa
- Institut für Allgemeine Pathologie und Pathologische AnatomieTechnische Universität München, Klinikum rechts der IsarMünchen Germany
| | - Alexander Kretschmer
- Klinik für AnaesthesiologieTechnische Universität München, Klinikum rechts der IsarIsmaninger Strasse 2281675München Germany
| | - Denis Jordan
- Klinik für AnaesthesiologieTechnische Universität München, Klinikum rechts der IsarIsmaninger Strasse 2281675München Germany
| | - Manfred Blobner
- Klinik für AnaesthesiologieTechnische Universität München, Klinikum rechts der IsarIsmaninger Strasse 2281675München Germany
| | - Heidrun Fink
- Klinik für AnaesthesiologieTechnische Universität München, Klinikum rechts der IsarIsmaninger Strasse 2281675München Germany
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23
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Berger D, Bloechlinger S, von Haehling S, Doehner W, Takala J, Z'Graggen WJ, Schefold JC. Dysfunction of respiratory muscles in critically ill patients on the intensive care unit. J Cachexia Sarcopenia Muscle 2016; 7:403-12. [PMID: 27030815 PMCID: PMC4788634 DOI: 10.1002/jcsm.12108] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 12/18/2015] [Accepted: 01/27/2016] [Indexed: 12/13/2022] Open
Abstract
Muscular weakness and muscle wasting may often be observed in critically ill patients on intensive care units (ICUs) and may present as failure to wean from mechanical ventilation. Importantly, mounting data demonstrate that mechanical ventilation itself may induce progressive dysfunction of the main respiratory muscle, i.e. the diaphragm. The respective condition was termed 'ventilator-induced diaphragmatic dysfunction' (VIDD) and should be distinguished from peripheral muscular weakness as observed in 'ICU-acquired weakness (ICU-AW)'. Interestingly, VIDD and ICU-AW may often be observed in critically ill patients with, e.g. severe sepsis or septic shock, and recent data demonstrate that the pathophysiology of these conditions may overlap. VIDD may mainly be characterized on a histopathological level as disuse muscular atrophy, and data demonstrate increased proteolysis and decreased protein synthesis as important underlying pathomechanisms. However, atrophy alone does not explain the observed loss of muscular force. When, e.g. isolated muscle strips are examined and force is normalized for cross-sectional fibre area, the loss is disproportionally larger than would be expected by atrophy alone. Nevertheless, although the exact molecular pathways for the induction of proteolytic systems remain incompletely understood, data now suggest that VIDD may also be triggered by mechanisms including decreased diaphragmatic blood flow or increased oxidative stress. Here we provide a concise review on the available literature on respiratory muscle weakness and VIDD in the critically ill. Potential underlying pathomechanisms will be discussed before the background of current diagnostic options. Furthermore, we will elucidate and speculate on potential novel future therapeutic avenues.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
| | - Stefan Bloechlinger
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland; Department of Clinical Cardiology, Inselspital University Hospital of Bern Bern Switzerland
| | - Stephan von Haehling
- Department of Cardiology and Center for Innovative Clinical Trials University of Göttingen Göttingen Germany
| | - Wolfram Doehner
- Center for Stroke Research Berlin Charite Universitätsmedizin Berlin Berlin Germany
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery and Dept. of Neurology, Inselspital University Hospital of Bern Bern Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
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24
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Francis CA, Hoffer JA, Reynolds S. Ultrasonographic Evaluation of Diaphragm Thickness During Mechanical Ventilation in Intensive Care Patients. Am J Crit Care 2016; 25:e1-8. [PMID: 26724302 DOI: 10.4037/ajcc2016563] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Mechanical ventilation is associated with atrophy and weakness of the diaphragm. Ultrasound is an easy noninvasive way to track changes in thickness of the diaphragm. OBJECTIVE To validate ultrasound as a means of tracking thickness of the diaphragm in patients undergoing mechanical ventilation by evaluating interobserver and interoperator reliability and to collect initial data on the relationship of mode of ventilation to changes in the diaphragm. METHODS Daily ultrasound images of the quadriceps and the right side of the diaphragm were acquired in 8 critically ill patients receiving various modes of mechanical ventilation. Thickness of the diaphragm and the quadriceps was measured, and changes with time were noted. Interoperator and interobserver reliability were measured. RESULTS Intraclass correlation coefficients between operators and between observers for thickness of the diaphragm and quadriceps were greater than 0.95, indicating excellent interoperator and interobserver reliability. Patients receiving assist-control ventilation (n = 4) showed a mean decline in diaphragm thickness of 4.7% per day. Patients receiving pressure support ventilation (n = 8) showed a mean increase in diaphragm thickness of 1.5% per day. Quadriceps thickness declined in all participants (n = 8) at a mean rate of 2.0% per day. CONCLUSIONS Use of ultrasound to measure thickness of the diaphragm in 8 intensive care patients undergoing various modes of mechanical ventilation was feasible and yielded reproducible results. Ultrasound tracking of changes in thickness of the diaphragm in this small sample indicated that the thickness decreased during assist-control mode and increased during pressure support mode.
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Affiliation(s)
- Colin Anthony Francis
- Colin Anthony Francis is a doctoral student in the Department of Experimental Medicine, University of British Columbia, Vancouver, Canada. Joaquín Andrés Hoffer is a professor in the Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada. Steven Reynolds is a critical care physician in the Department of Critical Care, Royal Columbian Hospital, Fraser Health Authority, New Westminster, BC, Canada
| | - Joaquín Andrés Hoffer
- Colin Anthony Francis is a doctoral student in the Department of Experimental Medicine, University of British Columbia, Vancouver, Canada. Joaquín Andrés Hoffer is a professor in the Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada. Steven Reynolds is a critical care physician in the Department of Critical Care, Royal Columbian Hospital, Fraser Health Authority, New Westminster, BC, Canada
| | - Steven Reynolds
- Colin Anthony Francis is a doctoral student in the Department of Experimental Medicine, University of British Columbia, Vancouver, Canada. Joaquín Andrés Hoffer is a professor in the Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada. Steven Reynolds is a critical care physician in the Department of Critical Care, Royal Columbian Hospital, Fraser Health Authority, New Westminster, BC, Canada
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Goligher EC, Fan E, Herridge MS, Murray A, Vorona S, Brace D, Rittayamai N, Lanys A, Tomlinson G, Singh JM, Bolz SS, Rubenfeld GD, Kavanagh BP, Brochard LJ, Ferguson ND. Evolution of Diaphragm Thickness during Mechanical Ventilation. Impact of Inspiratory Effort. Am J Respir Crit Care Med 2015; 192:1080-8. [DOI: 10.1164/rccm.201503-0620oc] [Citation(s) in RCA: 286] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Filho Pinto DR, Tedde ML, Avino AJG, Brandão SLB, Zanatta I, Hahn R. Video-assisted thoracoscopic implantation of a diaphragmatic pacemaker in a child with tetraplegia: indications, technique, and results. J Bras Pneumol 2015; 41:90-4. [PMID: 25750678 PMCID: PMC4350829 DOI: 10.1590/s1806-37132015000100011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 09/04/2014] [Indexed: 12/03/2022] Open
Abstract
We report the case of a child with tetraplegia after cervical trauma, who subsequently underwent diaphragmatic pacemaker implantation. We reviewed the major indications for diaphragmatic pacing and the types of devices employed. We highlight the unequivocal benefit of diaphragmatic pacing in the social and educational reintegration of individuals with tetraplegia.
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Affiliation(s)
- Darcy Ribeiro Filho Pinto
- Caxias do Sul University Foundation, Caxias do Sul General Hospital, Department of Thoracic Surgery, Caxias do Sul, Brazil. Department of Thoracic Surgery, Caxias do Sul General Hospital, Caxias do Sul University Foundation, Caxias do Sul, Brazil
| | - Miguel Lia Tedde
- University of São Paulo, School of Medicine, Hospital das Clínicas, São Paulo, Brazil. Department of Thoracic Surgery, Heart Institute, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Alexandre José Gonçalves Avino
- Caxias do Sul University Foundation, Caxias do Sul General Hospital, Department of Thoracic Surgery, Caxias do Sul, Brazil. Department of Thoracic Surgery, Caxias do Sul General Hospital, Caxias do Sul University Foundation, Caxias do Sul, Brazil
| | - Suzan Lúcia Brancher Brandão
- Caxias do Sul University Foundation, Caxias do Sul General Hospital, Department of Thoracic Surgery, Caxias do Sul, Brazil. Department of Thoracic Surgery, Caxias do Sul General Hospital, Caxias do Sul University Foundation, Caxias do Sul, Brazil
| | - Iuri Zanatta
- Caxias do Sul University Foundation, Caxias do Sul General Hospital, Caxias do Sul, Brazil. Caxias do Sul General Hospital, Caxias do Sul University Foundation, Caxias do Sul, Brazil
| | - Rafael Hahn
- Caxias do Sul University Foundation, Caxias do Sul General Hospital, Caxias do Sul, Brazil. Caxias do Sul General Hospital, Caxias do Sul University Foundation, Caxias do Sul, Brazil
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DiMarco AF, Kowalski KE, Hromyak DR, Geertman RT. Long-term follow-up of spinal cord stimulation to restore cough in subjects with spinal cord injury. J Spinal Cord Med 2014; 37:380-8. [PMID: 24090524 PMCID: PMC4116721 DOI: 10.1179/2045772313y.0000000152] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVE To determine the long-term effects of the cough stimulation system. DESIGN Nonrandomized clinical trial of subjects using the study device well beyond the period of close follow-up. SETTING Use of the study device in the home setting. PARTICIPANTS Subjects (N = 10) implanted with the device for a minimum of 2 years (mean 4.6 ± 0.6 years). INTERVENTIONS Application of daily stimulation. OUTCOME MEASURES Airway pressure generation and other clinical assessments including ease in raising secretions, life quality, caregiver support, and incidence of respiratory tract infections were measured at 1 year and mean 4.6 years after implantation. RESULTS Each subject continued to use the device on a regular basis. During SCS, mean maximum airway pressures were 103.1 ± 20.4 and 107.7 ± 23.0 cm H₂O at the 1-year and mean 4.6-year follow-up points, respectively (P < 0.05 compared with pre-implant and not significantly different (NS) compared with 1-year follow-up). Benchmarks related to ease in raising secretions and improvements in life quality related to respiratory care were maintained at the mean 4.6 year follow-up. The need for trained caregivers to provide other means of secretion management remained significantly below the pre-implant values (P < 0.05). The incidence of acute respiratory tract infections remained low at 0.2 ± 0.1 events/year, which is significantly below the pre-implant value of 1.4 ± 0.3 events/year (P < 0.05). CONCLUSION Subjects continued to use the system on a long-term basis beyond the period of close follow-up and to continued derive significant clinical benefits.
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Affiliation(s)
- Anthony F. DiMarco
- Correspondence to: Anthony F. DiMarco, Department of Physical Medicine and Rehabilitation, Case Western Reserve University, MetroHealth Campus, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
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Laghi F, Shaikh H. Preventing ventilator-induced diaphragmatic dysfunction with phrenic nerve stimulation. Crit Care Med 2014; 42:492-4. [PMID: 24434468 DOI: 10.1097/ccm.0000000000000003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Edward Hines, Jr. Veterans Affairs Hospital, Hines, IL; and, Division of Pulmonary and Critical Care, Department of Medicine, Loyola University, Maywood, IL Pulmonary and Critical Care Section, Edward Hines, Jr. Veterans Affairs Hospital, Hines, IL
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Effect of intermittent phrenic nerve stimulation during cardiothoracic surgery on mitochondrial respiration in the human diaphragm. Crit Care Med 2014; 42:e152-6. [PMID: 24126442 DOI: 10.1097/ccm.0b013e3182a63fdf] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Recent studies have shown that brief periods of mechanical ventilation in animals and humans can lead to ventilator-induced diaphragmatic dysfunction, which includes muscle atrophy, reduced force development, and impaired mitochondrial function. Studies in animal models have shown that short periods of increased diaphragm activity during mechanical ventilation support can attenuate ventilator-induced diaphragmatic dysfunction but corresponding human data are lacking. The purpose of this study was to examine the effect of intermittent diaphragm contractions during cardiothoracic surgery, including controlled mechanical ventilation, on mitochondrial respiration in the human diaphragm. DESIGN Within subjects repeated measures study. SETTING Operating room in an academic health center. PATIENTS Five subjects undergoing elective cardiothoracic surgery. INTERVENTIONS In patients (age 65.6 ± 6.3 yr) undergoing cardiothoracic surgery, one phrenic nerve was stimulated hourly (30 pulses/min, 1.5 msec duration, 17.0 ± 4.4 mA) during the surgery. Subjects received 3.4 ± 0.6 stimulation bouts during surgery. Thirty minutes following the last stimulation bout, samples of diaphragm muscle were obtained from the anterolateral costal regions of the stimulated and inactive hemidiaphragms. MEASUREMENTS AND MAIN RESULTS Mitochondrial respiration was measured in permeabilized muscle fibers with high-resolution respirometry. State III mitochondrial respiration rates (pmol O2/s/mg wet weight) were 15.05 ± 3.92 and 11.42 ± 2.66 for the stimulated and unstimulated samples, respectively (p < 0.05). State IV mitochondrial respiration rates were 3.59 ± 1.25 and 2.11 ± 0.97 in the stimulated samples and controls samples, respectively (p < 0.05). CONCLUSION These are the first data examining the effect of intermittent contractions on mitochondrial respiration rates in the human diaphragm following surgery/mechanical ventilation. Our results indicate that very brief periods (duty cycle ~1.7%) of activity can improve mitochondrial function in the human diaphragm following surgery/mechanical ventilation.
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Galeiras Vázquez R, Rascado Sedes P, Mourelo Fariña M, Montoto Marqués A, Ferreiro Velasco ME. Respiratory management in the patient with spinal cord injury. BIOMED RESEARCH INTERNATIONAL 2013; 2013:168757. [PMID: 24089664 PMCID: PMC3781830 DOI: 10.1155/2013/168757] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 07/11/2013] [Accepted: 07/30/2013] [Indexed: 12/19/2022]
Abstract
Spinal cord injuries (SCIs) often lead to impairment of the respiratory system and, consequently, restrictive respiratory changes. Paresis or paralysis of the respiratory muscles can lead to respiratory insufficiency, which is dependent on the level and completeness of the injury. Respiratory complications include hypoventilation, a reduction in surfactant production, mucus plugging, atelectasis, and pneumonia. Vital capacity (VC) is an indicator of overall pulmonary function; patients with severely impaired VC may require assisted ventilation. It is best to proceed with intubation under controlled circumstances rather than waiting until the condition becomes an emergency. Mechanical ventilation can adversely affect the structure and function of the diaphragm. Early tracheostomy following short orotracheal intubation is probably beneficial in selected patients. Weaning should start as soon as possible, and the best modality is progressive ventilator-free breathing (PVFB). Appropriate candidates can sometimes be freed from mechanical ventilation by electrical stimulation. Respiratory muscle training regimens may improve patients' inspiratory function following a SCI.
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Affiliation(s)
- Rita Galeiras Vázquez
- Critical Care Unit, Complexo Hospitalario Universitario A Coruña, CP. 15006, A Coruña, Spain
| | - Pedro Rascado Sedes
- Critical Care Unit, Complexo Hospitalario Universitario de Santiago de Compostela, CP. 15702, Santiago de Compostela, Spain
| | - Mónica Mourelo Fariña
- Critical Care Unit, Complexo Hospitalario Universitario A Coruña, CP. 15006, A Coruña, Spain
| | - Antonio Montoto Marqués
- Spinal Cord Injury Unit, Complexo Hospitalario Universitario A Coruña, CP. 15006, A Coruña, Spain
- Department of Medicine, University of A Coruña, CP. 15006, A Coruña, Spain
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Santos LAD, Borgi JR, Daister JLN, Pazzianotto-Forti EM. Efeitos da estimulação diafragmática elétrica transcutânea na função pulmonar em idosos. REVISTA BRASILEIRA DE GERIATRIA E GERONTOLOGIA 2013. [DOI: 10.1590/s1809-98232013000300008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUÇÃO: O envelhecimento promove mudanças em diversos sistemas orgânicos, inclusive no respiratório, evidenciando alterações nos centros reguladores da ventilação, nos quimiorreceptores, na densidade óssea da caixa torácica, além de diminuição da força dos músculos inspiratórios. OBJETIVO: Avaliar o efeito de um programa de treinamento específico da musculatura respiratória por meio da estimulação diafragmática elétrica transcutânea (EDET) sobre a função pulmonar de idosos. MÉTODO: 21 idosos foram divididos em dois grupos: controle (GC), composto por sete indivíduos com idade de 69,86±3,48 anos, e grupo EDET (EDET), composto por 14 voluntários com idade de 71,36±4,73 anos, submetidos ao treinamento com EDET durante duas semanas. Avaliaram-se os volumes e capacidades pulmonares, como volume corrente (VC), volume minuto (VM), capacidade inspiratória (CI) e capacidade vital (CV) por meio da ventilometria e a força da musculatura respiratória antes da primeira e após a décima sessão, por meio da avaliação das pressões respiratórias máximas. Utilizaram-se os testes de Wilcoxon e Mann-Whitney para as devidas comparações estatísticas, sendo adotado um nível de significância de 5%. RESULTADOS: O grupo EDET apresentou incremento na pressão inspiratória máxima (PImáx), na pressão expiratória máxima (PEmáx) e no volume corrente (VC) após o treinamento. CONCLUSÃO: O treinamento muscular mediante utilização da EDET promoveu melhora da força muscular respiratória e do volume corrente. Registro de ensaio clínico: RBR-5dmpkr.
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Jarosz R, Littlepage MM, Creasey G, McKenna SL. Functional electrical stimulation in spinal cord injury respiratory care. Top Spinal Cord Inj Rehabil 2013; 18:315-21. [PMID: 23459661 DOI: 10.1310/sci1804-315] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The management of chronic respiratory insufficiency and/or long-term inability to breathe independently has traditionally been via positive-pressure ventilation through a mechanical ventilator. Although life-sustaining, it is associated with limitations of function, lack of independence, decreased quality of life, sleep disturbance, and increased risk for infections. In addition, its mechanical and electronic complexity requires full understanding of the possible malfunctions by patients and caregivers. Ventilator-associated pneumonia, tracheal injury, and equipment malfunction account for common complications of prolonged ventilation, and respiratory infections are the most common cause of death in spinal cord-injured patients. The development of functional electric stimulation (FES) as an alternative to mechanical ventilation has been motivated by a goal to improve the quality of life of affected individuals. In this article, we will review the physiology, types, characteristics, risks and benefits, surgical techniques, and complications of the 2 commercially available FES strategies - phrenic nerve pacing (PNP) and diaphragm motor point pacing (DMPP).
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Affiliation(s)
- Renata Jarosz
- Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University , Stanford , California
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Mechanical ventilation, diaphragm weakness and weaning: a rehabilitation perspective. Respir Physiol Neurobiol 2013; 189:377-83. [PMID: 23692928 DOI: 10.1016/j.resp.2013.05.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 11/24/2022]
Abstract
Most patients are easily liberated from mechanical ventilation (MV) following resolution of respiratory failure and a successful trial of spontaneous breathing, but about 25% of patients experience difficult weaning. MV use leads to cellular changes and weakness, which has been linked to weaning difficulties and has been labeled ventilator induced diaphragm dysfunction (VIDD). Aggravating factors in human studies with prolonged weaning include malnutrition, chronic electrolyte abnormalities, hyperglycemia, excessive resistive and elastic loads, corticosteroids, muscle relaxant exposure, sepsis and compromised cardiac function. Numerous animal studies have investigated the effects of MV on diaphragm function. Virtually all these studies have concluded that MV use rapidly leads to VIDD and have identified cellular and molecular mechanisms of VIDD. Molecular and functional studies on the effects of MV on the human diaphragm have largely confirmed the animal results and identified potential treatment strategies. Only recently potential VIDD treatments have been tested in humans, including pharmacologic interventions and diaphragm "training". A limited number of human studies have found that specific diaphragm training can increase respiratory muscle strength in FTW patients and facilitate weaning, but larger, multicenter trials are needed.
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Oliveira ADSB, Costa LB, Assis TDO, Mota DLD, França EÉTD, Araújo Filho JCD, Rosas STP, Medeiros PLD. Effects of controlled and pressure support mechanical ventilation on rat diaphragm muscle. Acta Cir Bras 2013; 27:109-16. [PMID: 22378364 DOI: 10.1590/s0102-86502012000200003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 12/20/2011] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The objective of this study was to analyze the effects of Pressure Controlled Ventilation mode (PCV-C) and PSV mode in diaphragm muscle of rats. METHODS Wistar rats (n=18) were randomly assigned to the control group or to receive 6 hours of PCV and PSV. After this period, animals were euthanized and their diaphragms were excised, frozen in liquid nitrogen and stored in at -80º C for further histomorphometric analysis. RESULTS Results showed a 15% decrease in cross-sectional area of muscle fibers on the PCV-C group when compared to the control group (p<0.001) and by 10% when compared to the PSV group (p<0.05). Minor diameter was decreased in PCV-C group by 9% when compared with the control group (p<0.001) and by 6% when compared to the PSV group (p<0.05). When myonuclear area was analyzed, a 16% decrease was observed in the PCV-C group when compared to the PSV group (p<0.05). No significant difference between the groups was observed in myonuclear perimeter (p>0.05). CONCLUSION Short-term controlled mechanical ventilation seems to lead to muscular atrophy in diaphragm fibers. The PSV mode may attenuate the effects of VIDD.
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Hall AB, Northern D. Effect of abdominal binders on pulmonary mechanics with implications for the military surgical population. JOURNAL OF SURGICAL EDUCATION 2012; 69:34-36. [PMID: 22208829 DOI: 10.1016/j.jsurg.2011.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Revised: 05/31/2011] [Accepted: 06/07/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE After percutaneous endoscopic gastrostomy (PEG) tube placement, many surgeons will place an abdominal binder to protect the tube. Analysis of the literature shows mixed data as to the safety of abdominal binders with respect to pulmonary function. In this study, pulmonary function tests (PFTs) were used to assess changes in pulmonary status with and without an abdominal binder in volunteer active-duty personnel. DESIGN Patient's forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), forced expiratory flow (FEF), peak expiratory flow (PEF) maximal inspiratory (P(i) max) and expiratory pressures (P(e) max), total lung capacity (TLC), vital capacity (VC), functional reserve capacity (FRC), expiratory reserve volume (ERV), and residual volume (RV) were measured with and without an elastic abdominal binder in prone, 30 degree and 60 degree positions in 5 male and 5 female active-duty personnel. SETTING 81st Medical Group Clinical Research Laboratory at Keesler AFB, MS. PARTICIPANTS Five male and five female active-duty personnel of multiple ethnicities weighing between 125 and 240 lb. RESULTS There were multiple statistically significant differences in the effect on lung function in the combined data between males and females, including maximum inspiratory pressure (Pi Max) at 60 degree head-of-bed elevation and RV and TLC in the supine position (p < 0.05). There was no statistically significant effect on expiratory pressures at any head-of-bed position. CONCLUSIONS In otherwise healthy active-duty members, abdominal binder placement has a small but statistically significant effect on some lung function but not on parameters that would impede airway protection. For the purpose of protecting wounds, specifically PEG tubes, we conclude that abdominal binders cause no significant safety risk.
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Affiliation(s)
- Andrew B Hall
- 81st Medical Group, Keesler AFB, Mississippi 39534, USA.
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Adler D, Gottfried SB, Bautin N, Mirkovic T, Schmidt M, Raux M, Pavlovic D, Similowski T, Demoule A. Repetitive magnetic stimulation of the phrenic nerves for diaphragm conditioning: a normative study of feasibility and optimal settings. Appl Physiol Nutr Metab 2011; 36:1001-8. [PMID: 22014178 DOI: 10.1139/h11-095] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Electrical stimulation can enhance muscle function. We applied repetitive cervical magnetic phrenic stimulation (rCMS) to induce diaphragm contractions in 7 healthy subjects (800 ms trains; transdiaphragmatic pressure (Pdi) measurements; tolerance ratings). Each rCMS train produced a sustained diaphragm contraction. Sixty-five percent of the maximal available output at 15 Hz proved the best compromise between Pdi and discomfort with nonfatiguing contractions. rCMS appears feasible and should be investigated for diaphragm conditioning in appropriate clinical populations.
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Affiliation(s)
- Dan Adler
- Service de Pneumologie et Réanimation et Centre de Neurostimulation Respiratoire, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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Levine S, Budak MT, Dierov J, Singhal S. Inactivity-induced diaphragm dysfunction and mitochondria-targeted antioxidants: new concepts in critical care medicine. Crit Care Med 2011; 39:1844-5. [PMID: 21685759 PMCID: PMC10998542 DOI: 10.1097/ccm.0b013e31821e85ca] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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McCool D, Ayas N, Brown R. Mechanical ventilation and disuse atrophy of the diaphragm. N Engl J Med 2008; 359:89; author reply 91-2. [PMID: 18596279 DOI: 10.1056/nejmc080912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Hutchinson D, Weinik M, Betz R. Utility of Electrophysiological Studies in Assessing Peripheral Sensory and Motor Nerve Involvement in the Upper Limb After Traumatic Tetraplegia. Top Spinal Cord Inj Rehabil 2008. [DOI: 10.1310/sci1304-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Vassilakopoulos T. Ventilator-induced diaphragm dysfunction: the clinical relevance of animal models. Intensive Care Med 2007; 34:7-16. [DOI: 10.1007/s00134-007-0866-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Accepted: 08/28/2007] [Indexed: 11/25/2022]
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Onders R, McGee MF, Marks J, Chak A, Schilz R, Rosen MJ, Ignagni A, Faulx A, Elmo MJ, Schomisch S, Ponsky J. Diaphragm pacing with natural orifice transluminal endoscopic surgery: potential for difficult-to-wean intensive care unit patients. Surg Endosc 2006; 21:475-9. [PMID: 17177078 DOI: 10.1007/s00464-006-9125-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2006] [Revised: 08/28/2006] [Accepted: 10/16/2006] [Indexed: 12/12/2022]
Abstract
BACKGROUND Up to 50% of the patients in the intensive care unit (ICU) require mechanical ventilation, with 20% requiring the use of a ventilator for more than 7 days. More than 40% of this time is spent weaning the patient from mechanical ventilation. Failure to wean from mechanical ventilation can in part be attributable to rapid onset of diaphragm atrophy, barotrauma, posterior lobe atelectasis, and impaired hemodynamics, which are normally improved by maintaining a more natural negative chest pressure. The authors have previously shown that laparoscopic implantation of a diaphragm pacing system benefits selected patients. They now propose that an acute ventilator assist with interventional neurostimulation of the diaphragm in the ICU is feasible and could facilitate the weaning of ICU patients from mechanical ventilation. Natural orifice transluminal endoscopic surgery (NOTES) has the potential to expand the benefits of the diaphragm pacing system to this acute patient population by allowing it to be performed at the bedside similarly to insertion of the common gastrostomy tube. This study evaluates the feasibility of this approach in a porcine model. METHODS Pigs were anesthetized, and peritoneal access with the flexible endoscope was obtained using a guidewire, needle knife cautery, and balloon dilation. The diaphragm was mapped using a novel endoscopic electrostimulation catheter to locate the motor point (where stimulation provides complete contraction of the diaphragm). An intramuscular electrode then was placed at the motor point with a percutaneous needle. The gastrotomy was managed with a gastrostomy tube. RESULTS Four pigs were studied, and the endoscopic mapping instrument was able to map the diaphragm to identify the motor point. In one animal, a percutaneous electrode was placed into the motor point under transgastric endoscopic visualization, and the diaphragm could be paced in conjunction with mechanical ventilation. CONCLUSIONS These animal studies demonstrate the feasibility of transgastric mapping of the diaphragm and implantation of a percutaneous electrode for therapeutic diaphragmatic stimulation.
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Affiliation(s)
- R Onders
- Department of Surgery, Case Advanced Surgical Endoscopic Team (CASE-T), Case Western Reserve University, Cleveland, OH 44106-5047, USA.
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Vassilakopoulos T, Zakynthinos S, Roussos C. Bench-to-bedside review: weaning failure--should we rest the respiratory muscles with controlled mechanical ventilation? Crit Care 2006; 10:204. [PMID: 16356210 PMCID: PMC1550863 DOI: 10.1186/cc3917] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The use of controlled mechanical ventilation (CMV) in patients who experience weaning failure after a spontaneous breathing trial or after extubation is a strategy based on the premise that respiratory muscle fatigue (requiring rest to recover) is the cause of weaning failure. Recent evidence, however, does not support the existence of low frequency fatigue (the type of fatigue that is long-lasting) in patients who fail to wean despite the excessive respiratory muscle load. This is because physicians have adopted criteria for the definition of spontaneous breathing trial failure and thus termination of unassisted breathing, which lead them to put patients back on the ventilator before the development of low frequency respiratory muscle fatigue. Thus, no reason exists to completely unload the respiratory muscles with CMV for low frequency fatigue reversal if weaning is terminated based on widely accepted predefined criteria. This is important, since experimental evidence suggests that CMV can induce dysfunction of the diaphragm, resulting in decreased diaphragmatic force generating capacity, which has been called ventilator-induced diaphragmatic dysfunction (VIDD). The mechanisms of VIDD are not fully elucidated, but include muscle atrophy, oxidative stress and structural injury. Partial modes of ventilatory support should be used whenever possible, since these modes attenuate the deleterious effects of mechanical ventilation on respiratory muscles. When CMV is used, concurrent administration of antioxidants (which decrease oxidative stress and thus attenuate VIDD) seems justified, since antioxidants may be beneficial (and are certainly not harmful) in critical care patients.
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Affiliation(s)
- Theodoros Vassilakopoulos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Spyros Zakynthinos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Charis Roussos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
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DiMarco AF, Takaoka Y, Kowalski KE. Combined intercostal and diaphragm pacing to provide artificial ventilation in patients with tetraplegia. Arch Phys Med Rehabil 2005; 86:1200-7. [PMID: 15954060 DOI: 10.1016/j.apmr.2004.11.027] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the usefulness of combined intercostal and diaphragm pacing to maintain independence from mechanical ventilation. DESIGN A prospective trial. SETTING Clinical research center at a large tertiary hospital. PARTICIPANTS Four ventilator-dependent subjects with spinal cord injury with only unilateral phrenic nerve function. INTERVENTION During an initial surgical procedure, a multipolar epidural disk electrode was positioned on the ventral surface of the upper-thoracic spinal cord via a hemilaminectomy to activate the inspiratory intercostal muscles. A phrenic nerve electrode was implanted unilaterally via the thoracic approach. MAIN OUTCOME MEASURES Inspired volume production and duration that subjects could be comfortably maintained when off mechanical ventilatory support. RESULTS Initial maximum inspired volumes from combined intercostal and diaphragm stimulation ranged between .23 and .93L and significantly increased over the course of reconditioning period to between 0.55 and 1.31L; subjects could be maintained off mechanical ventilation between 16 and 24 hours a day. CONCLUSIONS Combined intercostal and unilateral diaphragm pacing may be a useful therapeutic modality capable of maintaining long-term ventilatory support in patients with only unilateral phrenic nerve function.
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Affiliation(s)
- Anthony F DiMarco
- Departments of Physiology and Biophysics, Case Western Reserve University, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
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Sassoon CSH, Zhu E, Caiozzo VJ. Assist–Control Mechanical Ventilation Attenuates Ventilator-induced Diaphragmatic Dysfunction. Am J Respir Crit Care Med 2004; 170:626-32. [PMID: 15201132 DOI: 10.1164/rccm.200401-042oc] [Citation(s) in RCA: 186] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Controlled mechanical ventilation induced a profound diaphragm muscle dysfunction and atrophy. The effects of diaphragmatic contractions with assisted mechanical ventilation on diaphragmatic isometric, isotonic contractile properties, or the expression of muscle atrophy factor-box (MAF-box), the gene responsible for muscle atrophy, are unknown. We hypothesize that assisted mechanical ventilation will preserve diaphragmatic force and prevent overexpression of MAF-box. Studying sedated rabbits randomized equally into control animals, those with 3 days of assisted ventilation, and those with controlled ventilation, we assessed in vitro diaphragmatic isometric and isotonic contractile function. The concentrations of contractile proteins, myosin heavy chain isoform, and MAF-box mRNA were measured. Tetanic force decreased by 14% with assisted ventilation and 48% with controlled ventilation. Maximum shortening velocity tended to increase with controlled compared with assisted ventilation and control. Peak power output decreased 20% with assisted ventilation and 41% with controlled ventilation. Contractile proteins were unchanged with either modes of ventilation; myosin heavy chain 2X mRNA tended to increase and that of 2A to decrease with controlled ventilation. MAF-box gene was overexpressed with controlled ventilation. We conclude that preserving diaphragmatic contractions during mechanical ventilation attenuates the force loss induced by complete inactivity and maintains MAF-box gene expression in control.
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Affiliation(s)
- Catherine S H Sassoon
- Departmen of Medicine, VA Long Beach Healthcare System, Long Beach, California 90822, USA.
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Pride N, Rodarte J. Imagerie de la fonction des muscles respiratoires. Rev Mal Respir 2004. [DOI: 10.1016/s0761-8425(04)71400-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
The act of breathing depends on coordinated activity of the respiratory muscles to generate subatmospheric pressure. This action is compromised by disease states affecting anatomical sites ranging from the cerebral cortex to the alveolar sac. Weakness of the respiratory muscles can dominate the clinical manifestations in the later stages of several primary neurologic and neuromuscular disorders in a manner unique to each disease state. Structural abnormalities of the thoracic cage, such as scoliosis or flail chest, interfere with the action of the respiratory muscles-again in a manner unique to each disease state. The hyperinflation that accompanies diseases of the airways interferes with the ability of the respiratory muscles to generate subatmospheric pressure and it increases the load on the respiratory muscles. Impaired respiratory muscle function is the most severe consequence of several newly described syndromes affecting critically ill patients. Research on the respiratory muscles embraces techniques of molecular biology, integrative physiology, and controlled clinical trials. A detailed understanding of disease states affecting the respiratory muscles is necessary for every physician who practices pulmonary medicine or critical care medicine.
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Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Edward Hines, Jr. VA Hospital, 111 N. 5th Avenue and Roosevelt Road, Hines, IL 60141, USA.
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Pavlovic D, Wendt M. Diaphragm pacing during prolonged mechanical ventilation of the lungs could prevent from respiratory muscle fatigue. Med Hypotheses 2003; 60:398-403. [PMID: 12581619 DOI: 10.1016/s0306-9877(02)00413-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
UNLABELLED Respiratory muscle fatigue after prolonged mechanical ventilation of the lungs is a common occurrence. This is probably due to disuse atrophy. The standard technique used to overcome this problem is to gradually wean the patient from the respirator over the course of several days or weeks. HYPOTHESIS based on experience with the rehabilitation of skeletal muscles during long-term immobilisation of the extremities following trauma or surgery and on experience with diaphragm pacing in quadriplegics, intermittent electrical or magenetic stimulation of the diaphragm while the lungs are still being mechanically ventilated may be beneficial. The result of such stimulation would be to preserve the dysfunctioning diaphragm from atrophy. CONSEQUENCES dependence on the respirator, length of intubation time, risk of complications and length of stay in the ICU would be considerably reduced.
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Polkey MI, Moxham J. Clinical aspects of respiratory muscle dysfunction in the critically ill. Chest 2001; 119:926-39. [PMID: 11243977 DOI: 10.1378/chest.119.3.926] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Affiliation(s)
- M I Polkey
- Respiratory Muscle Laboratory, Royal Brompton Hospital, National Heart & Lung Institute, London, UK.
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