Diaphragmatic Diseases: Effect of Diaphragm Pacing on Quality of Life: The State of Art
Özet
Diaphragm pacing is a minimally invasive surgical procedure which acts to actively contract diaphragms that are atrophied due to decreased work load. The goal is to achieve active diaphragm contraction to restore efficient breathing. The current indications for diaphram pacing are high level spinal cord injuries (SCI), central hypoventilation syndromes and “select” amytrophic lateral sclerosis (ALS). Two different implantation techniques are used. The first technique is intrathoracic diaphragm pacing in which electrodes are placed around the phrenic nerves through thoracotomy and the second is intraperitoneal diaphragm pacing in which diaphragmatic electrodes are implanted through laparoscopy. Our surgical technique involves implantation of the electrodes to both diaphragms through a 4-port laparascopy. Both techniques require stimulatable diaphragms in patients with respiratory insufficiency. Preoperative selection criteria for pacing includes positive evidence of stimulatable diaphragms tested through diaphragm EMG, diaphragm ultrasound and one of the four evidence of chronic hypoventilation:forced vital capacity <50%, maximal inspiratory pressure <60 cmH2O, pCO2>45 mmHg or saturation <88% for 5 minutes during sleep. A few periopertive morbidites and no periopeative mortality has been reported. By restoring effective breathing, improvement in quality of life such as better sleep cycles, less day time spent on non-invasive mechanical ventilation, less pneumonia attacks, less hospitalisation are achieved during the follow-up of the patients. With the better understanding of the respiration dynamics in patients who undergoes pacing, timing of the implantation will be more precise especially in ALS patients. Diaphragm thickness fraction measurements by diaphragm US is a reliable tool to asses the functionality of the system. Diaphragm pacing is an effective surgical procedure to improve quality of life however randomised clinical trials are needed to state that the system prolongs survival by delaying ventilator dependence or weaning from the mechanical ventilator.
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