Diaphragm Activation in Ventilated Patients Using a Novel Transvenous Phrenic Nerve Pacing Catheter
Diaphragm Activation in Ventilated Patients Using a Novel Transvenous Phrenic Nerve Pacing Catheter
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DOI：
10.1097/ccm.0000000000002366
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发表时间：
2017-07-01
影响因子：
8.8
通讯作者：
Hoffer, Joaquin A.
中科院分区：
文献类型：
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作者：
Reynolds, Steven;Ebner, Adrian;Hoffer, Joaquin A.
目的：超过 30% 接受正压机械通气的危重患者难以脱离呼吸机，其中许多人出现呼吸机引起的膈肌功能障碍。使用新型带电极导管进行临时经静脉膈神经起搏可以提供一种预防膈肌萎缩、强化萎缩膈肌并减轻机械通气危害的方法。我们测试了这种新方法的初始安全性、可行性和对通气的影响。设计：人类首例病例系列。设置：血管造影室。患者：24 名在选择性房间隔缺损修复手术前立即使用镇静、机械通气的患者。干预措施：通过 Seldinger 技术将带有 19 个嵌入式电极的 9.5-Fr 中心静脉导管放置到左锁骨下静脉和上腔静脉中并进行评估长达 90 分钟。确定为左右膈神经提供最佳经静脉刺激的电极组合与机械通气呼吸同步激活。测量和主要结果：一名患者因与设备无关的原因而无法进行测试。在接受完整方案的 23 名患者中，经静脉刺激在 23 次左膈捕获尝试中的 22 次 (96%) 和 23 次右膈捕获尝试中的 20 次 (87%) 激活了膈肌。在一名受试者中，先天性左侧上腔静脉妨碍了右侧捕获。所有 22 名起搏受试者在刺激辅助呼吸期间，呼吸机压力-时间-乘积均显着降低（范围，9.9-48.6%；p < 0.001）。立即或两周随访后均未出现不良事件。结论：在这个首次人体系列中，使用临时导管的膈肌起搏是安全的，并且与机械呼吸机结合有效地有助于通气。
Objectives: Over 30% of critically ill patients on positive-pressure mechanical ventilation have difficulty weaning from the ventilator, many of whom acquire ventilator-induced diaphragm dysfunction. Temporary transvenous phrenic nerve pacing using a novel electrode-bearing catheter may provide a means to prevent diaphragm atrophy, to strengthen an atrophied diaphragm, and mitigate the harms of mechanical ventilation. We tested the initial safety, feasibility, and impact on ventilation of this novel approach.Design: First-in-Humans case series.Setting: Angiogram suite.Patients: Twenty-four sedated, mechanically ventilated patients immediately prior to an elective atrial septal defect repair procedure.Interventions: A 9.5-Fr central venous catheter with 19 embedded electrodes was placed via Seldinger technique into the left subclavian vein and superior vena cava and evaluated for up to 90 minutes. The electrode combinations determined to provide best transvenous stimulation of the right and left phrenic nerves were activated in synchrony with mechanically ventilated breaths.Measurements and Main Results: One patient could not be tested for reasons unrelated to the device. In the 23 patients who underwent the full protocol, transvenous stimulation activated the diaphragm in 22 of 23 (96%) left phrenic capture attempts and 20 of 23 (87%) right phrenic capture attempts. In one subject, a congenital left-sided superior vena cava precluded right-sided capture. Significant reductions in ventilator pressure-time-product were achieved during stimulation assisted breaths in all 22 paced subjects (range, 9.9-48.6%; p < 0.001). There were no adverse events either immediately or at 2-week follow-up.Conclusions: In this First-in-Human series, diaphragm pacing with a temporary catheter was safe and effectively contributed to ventilation in conjunction with a mechanical ventilator.