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Zhong H, Zhang K, Zhou M, Xing C, An Y, Zhang Q, Guo J, Liu S, Qu Z, Feng S, Ning G. An Implantable Self-Driven Diaphragm Pacing System Based on a Microvibration Triboelectric Nanogenerator for Phrenic Nerve Stimulation. ACS APPLIED MATERIALS & INTERFACES 2024; 16:43199-43211. [PMID: 39120580 PMCID: PMC11346467 DOI: 10.1021/acsami.4c03715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 07/25/2024] [Accepted: 07/26/2024] [Indexed: 08/10/2024]
Abstract
Spinal cord injury poses considerable challenges, particularly in diaphragm paralysis. To address limitations in existing diaphragm pacing technologies, we report an implantable, self-driven diaphragm pacing system based on a microvibration triboelectric nanogenerator (MV-TENG). Leveraging the efficient MV-TENG, the system harvests micromechanical energy and converts this energy into pulses for phrenic nerve stimulation. In vitro tests confirm a stable MV-TENG output, while subcutaneous implantation of the device in rats results in a constant amplitude over 4 weeks with remarkable energy-harvesting efficacy. The system effectively induces diaphragmatic motor-evoked potentials, triggering contractions of the diaphragm. This proof-of-concept system has potential clinical applications in implantable phrenic nerve stimulation, presenting a novel strategy for advancing next-generation diaphragm pacing devices.
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Affiliation(s)
- Hao Zhong
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Ke Zhang
- College
of Electronic Information and Automation, Advanced Structural Integrity
International Joint Research Center, Tianjin
University of Science and Technology, Tianjin 300222, People’s Republic of China
| | - Mi Zhou
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Cong Xing
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Yang An
- College
of Electronic Information and Automation, Advanced Structural Integrity
International Joint Research Center, Tianjin
University of Science and Technology, Tianjin 300222, People’s Republic of China
| | - Qi Zhang
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Junrui Guo
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Song Liu
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Zhigang Qu
- College
of Electronic Information and Automation, Advanced Structural Integrity
International Joint Research Center, Tianjin
University of Science and Technology, Tianjin 300222, People’s Republic of China
| | - Shiqing Feng
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
| | - Guangzhi Ning
- Department
of Orthopedics, Tianjin Medical University
General Hospital, Tianjin 300052, People’s
Republic of China
- International
Science and Technology Cooperation Base of Spinal Cord Injury, Tianjin 300052, People’s Republic of China
- Tianjin
Key Laboratory of Spine and Spinal Cord Injury, Tianjin 300052, People’s Republic of China
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Zhu T, Jin HP, Liu SS, Zhu HJ, Wang JW. Effects of extracorporeal diaphragm pacing combined with inspiratory muscle training on respiratory function in people with stroke: a randomized controlled trial. Neurol Res 2024; 46:727-734. [PMID: 38661091 DOI: 10.1080/01616412.2024.2347133] [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: 09/17/2023] [Accepted: 04/21/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVES To evaluate the effect of external diaphragmatic pacing (EDP) combined with inspiratory muscle training on respiratory function in post-stroke patients. METHODS Patients with stroke were enrolled from the First Affiliated Hospital of Soochow University in China between 2021 and 2022. The patients were randomized into an EDP treatment group (control group) or an EDP treatment plus inspiratory muscle training group (experimental group). Each therapy was administered once a day for 6 days per week. The peak inspiratory flow (PIF), maximal inspiratory pressure (MIP), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC% ratio, and diaphragm thickness and mobility were measured and compared between the two groups after 4 weeks. RESULTS After 4 weeks of intervention, respiratory muscle function indicators including PIF (95% CI: 0.21-1.28, p = 0.008) and MIP (95% CI: 6.92-25.44, p = 0.001) significantly improved in the experimental group. Diaphragmatic thickness also significantly increased in the experimental group (p < 0.05), while diaphragmatic excursion showed no significant difference between the two groups. Additionally, FVC (95% CI: 0.14-1.14, p = 0.013) and FEV1 (95% CI: 0.20-1.06, p = 0.005) demonstrated a significant increase in the experimental group, whereas FEV1/FVC% (95% CI: -0.84 to 9.36, p = 0.099) exhibited no significant group difference. CONCLUSION EDP combined with inspiratory muscle training in individuals with stroke provides greater benefits than EDP alone in terms of respiratory function recovery, except for the parameters of diaphragmatic excursion and FEV1/FVC%.
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Affiliation(s)
- Ting Zhu
- Department of Rehabilitation, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Hua-Ping Jin
- Department of Rehabilitation, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Sha-Sha Liu
- Department of Rehabilitation, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Hong-Jun Zhu
- Department of Rehabilitation, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Jing-Wen Wang
- Department of Rehabilitation, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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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. Closed-loop parameter optimization for patient-specific phrenic nerve stimulation. Artif Organs 2024; 48:274-284. [PMID: 37246826 DOI: 10.1111/aor.14593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/02/2023] [Accepted: 05/25/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Ventilator-induced diaphragm dysfunction occurs rapidly following the onset of mechanical ventilation and has significant clinical consequences. Phrenic nerve stimulation has shown promise in maintaining diaphragm function by inducing diaphragm contractions. Non-invasive stimulation is an attractive option as it minimizes the procedural risks associated with invasive approaches. However, this method is limited by sensitivity to electrode position and inter-individual variability in stimulation thresholds. This makes clinical application challenging due to potentially time-consuming calibration processes to achieve reliable stimulation. METHODS We applied non-invasive electrical stimulation to the phrenic nerve in the neck in healthy volunteers. A closed-loop system recorded the respiratory flow produced by stimulation and automatically adjusted the electrode position and stimulation amplitude based on the respiratory response. By iterating over electrodes, the optimal electrode was selected. A binary search method over stimulation amplitudes was then employed to determine an individualized stimulation threshold. Pulse trains above this threshold were delivered to produce diaphragm contraction. RESULTS Nine healthy volunteers were recruited. Mean threshold stimulation amplitude was 36.17 ± 14.34 mA (range 19.38-59.06 mA). The threshold amplitude for reliable nerve capture was moderately correlated with BMI (Pearson's r = 0.66, p = 0.049). Repeating threshold measurements within subjects demonstrated low intra-subject variability of 2.15 ± 1.61 mA between maximum and minimum thresholds on repeated trials. Bilateral stimulation with individually optimized parameters generated reliable diaphragm contraction, resulting in significant inhaled volumes following stimulation. CONCLUSION We demonstrate the feasibility of a system for automatic optimization of electrode position and stimulation parameters using a closed-loop system. This opens the possibility of easily deployable individualized stimulation in the intensive care setting to reduce ventilator-induced diaphragm dysfunction.
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Affiliation(s)
- Conor Keogh
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Francisco Saavedra
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- Department of Electrical Engineering, Universidad de Concepcion, Concepcion, Chile
| | - Sebastian Dubo
- Department of Physiotherapy, Universidad de Concepcion, Concepcion, Chile
| | - Pablo Aqueveque
- Department of Electrical Engineering, Universidad de Concepcion, Concepcion, Chile
| | - Paulina Ortega
- Department of Physiotherapy, Universidad de Concepcion, Concepcion, Chile
| | - Britam Gomez
- Department of Electrical Engineering, Universidad de Concepcion, Concepcion, Chile
| | - Enrique Germany
- Department of Electrical Engineering, Universidad de Concepcion, Concepcion, Chile
| | - Daniela Pinto
- Department of Electrical Engineering, Universidad de Concepcion, Concepcion, Chile
| | - Rodrigo Osorio
- Department of Electrical Engineering, Universidad de Concepcion, Concepcion, Chile
| | - Francisco Pastene
- Department of Electrical Engineering, Universidad de Concepcion, Concepcion, Chile
| | - Adrian Poulton
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Jonathan Jarvis
- School of Sports and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Brian Andrews
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - James J FitzGerald
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Panelli A, Verfuß MA, Dres M, Brochard L, Schaller SJ. Phrenic nerve stimulation to prevent diaphragmatic dysfunction and ventilator-induced lung injury. Intensive Care Med Exp 2023; 11:94. [PMID: 38109016 PMCID: PMC10728426 DOI: 10.1186/s40635-023-00577-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023] Open
Abstract
Side effects of mechanical ventilation, such as ventilator-induced diaphragmatic dysfunction (VIDD) and ventilator-induced lung injury (VILI), occur frequently in critically ill patients. Phrenic nerve stimulation (PNS) has been a valuable tool for diagnosing VIDD by assessing respiratory muscle strength in response to magnetic PNS. The detection of pathophysiologically reduced respiratory muscle strength is correlated with weaning failure, longer mechanical ventilation time, and mortality. Non-invasive electromagnetic PNS designed for diagnostic use is a reference technique that allows clinicians to measure transdiaphragm pressure as a surrogate parameter for diaphragm strength and functionality. This helps to identify diaphragm-related issues that may impact weaning readiness and respiratory support requirements, although lack of lung volume measurement poses a challenge to interpretation. In recent years, therapeutic PNS has been demonstrated as feasible and safe in lung-healthy and critically ill patients. Effects on critically ill patients' VIDD or diaphragm atrophy outcomes are the subject of ongoing research. The currently investigated application forms are diverse and vary from invasive to non-invasive and from electrical to (electro)magnetic PNS, with most data available for electrical stimulation. Increased inspiratory muscle strength and improved diaphragm activity (e.g., excursion, thickening fraction, and thickness) indicate the potential of the technique for beneficial effects on clinical outcomes as it has been successfully used in spinal cord injured patients. Concerning the potential for electrophrenic respiration, the data obtained with non-invasive electromagnetic PNS suggest that the induced diaphragmatic contractions result in airway pressure swings and tidal volumes remaining within the thresholds of lung-protective mechanical ventilation. PNS holds significant promise as a therapeutic intervention in the critical care setting, with potential applications for ameliorating VIDD and the ability for diaphragm training in a safe lung-protective spectrum, thereby possibly reducing the risk of VILI indirectly. Outcomes of such diaphragm training have not been sufficiently explored to date but offer the perspective for enhanced patient care and reducing weaning failure. Future research might focus on using PNS in combination with invasive and non-invasive assisted ventilation with automatic synchronisation and the modulation of PNS with spontaneous breathing efforts. Explorative approaches may investigate the feasibility of long-term electrophrenic ventilation as an alternative to positive pressure-based ventilation.
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Affiliation(s)
- Alessandro Panelli
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Michael A Verfuß
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Martin Dres
- Sorbonne Université, INSERM UMRS 1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation, Département R3S, APHP, Sorbonne Université, Hôpital Pitie Salpêtrière, Paris, France
| | - Laurent Brochard
- Unity Health Toronto, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany.
- Technical University of Munich, School of Medicine and Health, Klinikum Rechts der Isar, Department of Anesthesiology and Intensive Care Medicine, Munich, Germany.
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Panelli A, Bartels HG, Krause S, Verfuß MA, Grimm AM, Carbon NM, Grunow JJ, Stutzer D, Niederhauser T, Brochard L, Weber-Carstens S, Schaller SJ. First non-invasive magnetic phrenic nerve and diaphragm stimulation in anaesthetized patients: a proof-of-concept study. Intensive Care Med Exp 2023; 11:20. [PMID: 37081235 PMCID: PMC10118662 DOI: 10.1186/s40635-023-00506-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 03/01/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Mechanical ventilation has side effects such as ventilator-induced diaphragm dysfunction, resulting in prolonged intensive care unit length of stays. Artificially evoked diaphragmatic muscle contraction may potentially maintain diaphragmatic muscle function and thereby ameliorate or counteract ventilator-induced diaphragm dysfunction. We hypothesized that bilateral non-invasive electromagnetic phrenic nerve stimulation (NEPNS) results in adequate diaphragm contractions and consecutively in effective tidal volumes. RESULTS This single-centre proof-of-concept study was performed in five patients who were 30 [IQR 21-33] years old, 60% (n = 3) females and undergoing elective surgery with general anaesthesia. Following anaesthesia and reversal of muscle relaxation, patients received bilateral NEPNS with different magnetic field intensities (10%, 20%, 30%, 40%); the stimulation was performed bilaterally with dual coils (connected to one standard clinical magnetic stimulator), specifically designed for bilateral non-invasive electromagnetic nerve stimulation. The stimulator with a maximal output of 2400 Volt, 160 Joule, pulse length 160 µs at 100% intensity was limited to 50% intensity, i.e. each single coil had a maximal output of 0.55 Tesla and 1200 Volt. There was a linear relationship between dosage (magnetic field intensity) and effect (tidal volume, primary endpoint, p < 0.001). Mean tidal volume was 0.00, 1.81 ± 0.99, 4.55 ± 2.23 and 7.43 ± 3.06 ml/kg ideal body weight applying 10%, 20%, 30% and 40% stimulation intensity, respectively. Mean time to find an initial adequate stimulation point was 89 (range 15-441) seconds. CONCLUSIONS Bilateral non-invasive electromagnetic phrenic nerve stimulation generated a tidal volume of 3-6 ml/kg ideal body weight due to diaphragmatic contraction in lung-healthy anaesthetized patients. Further perspectives in critically ill patients should include assessment of clinical outcomes to confirm whether diaphragm contraction through non-invasive electromagnetic phrenic nerve stimulation potentially ameliorates or prevents diaphragm atrophy.
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Affiliation(s)
- Alessandro Panelli
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Hermann Georges Bartels
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Sven Krause
- Institute for Human Centered Engineering, Bern University of Applied Sciences, Biel, Switzerland
| | - Michael André Verfuß
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Aline Michèle Grimm
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Niklas Martin Carbon
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Julius J Grunow
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Diego Stutzer
- Institute for Human Centered Engineering, Bern University of Applied Sciences, Biel, Switzerland
| | - Thomas Niederhauser
- Institute for Human Centered Engineering, Bern University of Applied Sciences, Biel, Switzerland
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Stefan J Schaller
- Department of Anesthesiology and Operative Intensive Care Medicine (CVK, CCM), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität Zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.
- Department of Anesthesiology and Intensive Care, School of Medicine, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany.
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