Treatment for bilateral diaphragmatic dysfunction using phrenic nerve reconstruction and diaphragm pacemakers

Matthew R Kaufman, Thomas Bauer, Raymond P Onders, David P Brown, Eric I Chang, Kristie Rossi, Andrew I Elkwood, Ethan Paulin, Reza Jarrahy, Matthew R Kaufman, Thomas Bauer, Raymond P Onders, David P Brown, Eric I Chang, Kristie Rossi, Andrew I Elkwood, Ethan Paulin, Reza Jarrahy

Abstract

Objectives: Bilateral diaphragmatic dysfunction results in severe dyspnoea, usually requiring oxygen therapy and nocturnal ventilatory support. Although treatment options are limited, phrenic nerve reconstruction (PR) offers the opportunity to restore functional activity. This study aims to evaluate combination treatment with PR and placement of a diaphragm pacemaker (DP) compared to DP placement alone in patients with bilateral diaphragmatic dysfunction.

Methods: Patients with bilateral diaphragmatic dysfunction were prospectively enrolled in the following treatment algorithm: Unilateral PR was performed on the more severely impacted side with bilateral DP implantation. Motor amplitudes, ultrasound measurements of diaphragm thickness, maximal inspiratory pressure, forced expiratory volume, forced vital capacity and subjective patient-reported outcomes were obtained for retrospective analysis following completion of the prospective database.

Results: Fourteen male patients with bilateral diaphragmatic dysfunction confirmed on chest fluoroscopy and electrodiagnostic testing were included. All 14 patients required nocturnal ventilator support, and 8/14 (57.1%) were oxygen-dependent. All patients reported subjective improvement, and all 8 oxygen-dependent patients were able to discontinue oxygen therapy following treatment. Improvements in maximal inspiratory pressure, forced vital capacity and forced expiratory volume were 68%, 47% and 53%, respectively. There was an average improvement of 180% in motor amplitude and a 50% increase in muscle thickness. Comparison of motor amplitude changes revealed significantly greater functional recovery on the PR + DP side.

Conclusions: PR and simultaneous implantation of a DP may restore functional activity and alleviate symptoms in patients with bilateral diaphragmatic dysfunction. PR plus diaphragm pacing appear to result in greater functional muscle recovery than pacing alone.

Keywords: Diaphragm pacemaker; Diaphragm paralysis; Peripheral nerve surgery; Phrenic nerve; Phrenic nerve injury; Phrenic nerve reconstruction.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Figures

Figure 1:
Figure 1:
Preoperative and postoperative MIP values. A 68% improvement is noted postoperatively (41–69 cm H2O, P < 0.05). The reference value range is indicated in the grey shaded area (82.8 cm H2O ± 26.6). MIP: maximal inspiratory pressure; Post-Op: postoperative; Pre-Op: preoperative.
Figure 2:
Figure 2:
Results of preoperative and postoperative diaphragm EMG. MA was observed to improve by 180% postoperatively (0.05–0.14 mV, P < 0.05). The reference value range is indicated for comparison (0.56 mV ± 0.54). EMG: electromyography; MA: motor amplitude; Post-Op: postoperative; Pre-Op: preoperative.
Figure 3:
Figure 3:
Preoperative and postoperative US measurements of resting diaphragm thickness. A 50% increase in diaphragm thickness is observed postoperatively (0.12–0.18 cm, P < 0.05). Reference value and range are included for comparison (0.20 cm ± 0.04). Post-Op: postoperative; Pre-Op: preoperative; US: ultrasound.
Figure 4:
Figure 4:
Pulmonary function test results. Postoperatively, the percentage predicted values for FVC increased from 51% to 75% (P < 0.05) and FEV increased from 51% to 78% (P < 0.05). The reference value range is indicated in the grey shaded area (80–120%). FEV: forced expiratory volume; FVC: forced vital capacity; Post-Op: postoperative; Pre-Op: preoperative.
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