Diaphragm Neurostimulation Assisted Ventilation in Critically Ill Patients

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.

Keywords: diaphragm pacing; phrenic nerve stimulation; ventilation-induced diaphragm dysfunction; ventilator associated brain injury; ventilator induced lung injury.

Figure 1.

Principle of diaphragm neurostimulation assisted ventilation.

Figure 2.

Permanent and temporary approaches of diaphragm neurostimulation (Original illustration, by Pierre Bourcier).

Figure 3.

Development of diaphragm neurostimulation techniques over time.

Figure 4.

Established and plausible physiological effects of diaphragm neurostimulation assisted ventilation compared with positive pressure ventilation (Original illustration, by Pierre Bourcier).