Bilateral phrenic stimulation: a simple technique to assess diaphragmatic fatigue in humans

Transdiaphragmatic pressure (Pdi) and the rate of relaxation of the diaphragm (tau) were measured at functional residual capacity (FRC) in six normal seated subjects during single-twitch stimulation of both phrenic nerves. The latter were stimulated supramaximally with needle electrodes with square-wave impulses of 0.1-ms duration at 1 Hz before and after diaphragmatic fatigue produced by resistive loaded breathing. Constancy of chest wall configuration was achieved by monitoring the diameter of the abdomen and the rib cage with a respiratory inductive plethysmograph system. During control the peak Pdi generated during the phrenic stimulation amounted to 34.4 +/- 4.2 (SE) cmH2O and represented in each subject a fixed fraction (17%) of its maximal transdiaphragmatic pressure. After diaphragmatic fatigue the peak Pdi decreased by an average of 45%, amounting to 18.1 +/- 2.7 cmH2O 5 min after the fatigue run, and tau increased from 55.2 +/- 9 ms during control to 77 +/- 8 ms 5 min after the fatigue run. The decrease in peak Pdi and the increase in tau observed after the fatigue run persisted throughout the 30 min of the recovery period studied, the peak Pdi amounting to 18.4 +/- 2.8 and 18.9 +/- 3.3 cmH2O and tau to 81.3 +/- 5.7 and 88.7 +/- 10 ms at 15 and 30 min after the end of the fatigue run, respectively. It is concluded that diaphragmatic fatigue can be detected in man by bilateral phrenic stimulation with needle electrodes without any discomfort for the subject and that the decrease in diaphragmatic strength after fatigue is long lasting.     

Influence of genioglossus tonic activity on upper airway dynamics assessed by phrenic nerve stimulation.

Upper airway (UA) dynamics can be evaluated during wakefulness by using electrical phrenic nerve stimulation (EPNS) applied at end-expiration during exclusive nasal breathing by dissociating twitch flow and phasic activation of UA muscles. This technique can be used to quantify the influence of nonphasic electromyographic (EMG) activity on UA dynamics. UA dynamics was characterized by using EPNS when increasing tonic EMG activity with CO(2) stimulation in six normal awake subjects. Instantaneous flow, esophageal and nasopharyngeal pressures, and genioglossal EMG activity were recorded during EPNS at baseline and during CO(2) ventilatory stimulation. The proportion of twitches presenting an inspiratory-flow limitation pattern decreased from 100% at baseline to 78.7 +/- 21.4% (P = 10(-4)) during CO(2) rebreathing. During CO(2) stimuli, maximal inspiratory twitch flow (VI(max)) of flow-limited twitches significantly rose, with the driving pressure at which flow limitation occurred being more negative. For the group as a whole, the increase in VI(max) and the decrease in pressure were significantly correlated with the rise in end-expiratory EMG activity. UA stability assessed by EPNS is dramatically modified during CO(2) ventilatory stimulation. Changes in tonic genioglossus EMG activity significantly contribute to the improvement in UA stability.     

Impediment in upper airway stabilizing forces assessed by phrenic nerve stimulation in sleep apnea patients

Research into respiratory diseases has reached a critical stage and the introduction of novel therapies is essential in combating these debilitating conditions. With the discovery of the peroxisome proliferator-activated receptor and its involvement in inflammatory responses of cardiovascular disease and diabetes, attention has turned to lung diseases and whether knowledge of this receptor can be applied to therapy of the human airways. In this article, we explore the prospect of peroxisome proliferator-activated receptor-γ as a marker and treatment focal point of lung diseases such as asthma, chronic obstructive pulmonary disorder, lung cancer and cystic fibrosis. It is anticipated that peroxisome proliferator-activated receptor-γ ligands will provide not only useful mechanistic pathway information but also a possible new wave of therapies for sufferers of chronic respiratory diseases.     

Effects of phrenic nerve cooling on diaphragmatic function

The effects of phrenic nerve cooling at 0 degrees C on the nerve and diaphragmatic function were evaluated in dogs. Eleven dogs, anesthetized and mechanically ventilated, were studied. Left diaphragmatic function was assessed by recording the transdiaphragmatic pressure (Pdi) generated during electrical stimulation of the left phrenic nerve at different frequencies (0.5, 30, and 100 Hz). Phrenic nerve stimulations were achieved either directly by electrodes placed around the phrenic nerve above its pericardial course or by intramuscular electrodes placed close to the phrenic nerve endings. Electrical activity of the hemidiaphragm (Edi) was recorded and phrenic nerve conduction time (PNCT) was measured during direct phrenic stimulation. A transpericardial cooling of the nerve, at 0 degrees C, on a length of 1 cm, was performed during 30 min (group A, n = 7) or 5 min (group B, n = 4). After the cooling period, phrenic and diaphragmatic functions were assessed hourly for 4 h (H1-H4). Cooling the phrenic nerve produced a complete phrenic nerve conduction block in all dogs, 100 +/- 10 s after the onset of cold exposure. Conduction recovery time was longer in group A (11 +/- 7 min) than in group B (2 +/- 0.5 min) and PNCT remained increased throughout the study in group A. Furthermore, in group A, Pdi and Edi during direct phrenic stimulation were markedly depressed from H1 to H4. No change in these parameters was noted until H3 during intramuscular stimulation, time at which a significant decrease occurred. By contrast, Pdi and Edi from direct and intramuscular stimulations remained unchanged throughout the study in group B.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of magnetic and electrical phrenic nerve stimulation in assessment of phrenic nerve conduction time

Similowski, Thomas, Selma Mehiri, Alexandre Duguet,Valérie Attali, Christian Straus, and Jean-Philippe Derenne.Comparison of magnetic and electrical phrenic nerve stimulation inassessment of phrenic nerve conduction time. J. Appl.Physiol. 82(4): 1190-1199, 1997.Cervicalmagnetic stimulation (CMS), a nonvolitional test of diaphragm function,is an easy means for measuring the latency of the diaphragm motorresponse to phrenic nerve stimulation, namely, phrenic nerve conductiontime (PNCT). In this application, CMS has some practical advantagesover electrical stimulation of the phrenic nerve in the neck (ES).Although normal ES-PNCTs have been consistently reported between7 and 8 ms, data are less homogeneous for CMS-PNCTs, with some reportssuggesting lower values. This study systematically compares ES-and CMS-PNCTs for the same subjects. Surface recordings ofdiaphragmatic electromyographic activity were obtained for sevenhealthy volunteers during ES and CMS of varying intensities. Onaverage, ES-PNCTs amounted to 6.41 ± 0.84 ms and were littleinfluenced by stimulation intensity. With CMS, PNCTs were significantlylower (average difference 1.05 ms), showing a marked increase as CMSintensity lessened. ES and CMS values became comparable for a CMSintensity 65% of the maximal possible intensity of 2.5 Tesla. Thesefindings may be the result of phrenic nerve depolarization occurringmore distally than expected with CMS, which may have clinicalimplications regarding the diagnosis and follow-up of phrenic nervelesions.

     

Diaphragm metabolism during supramaximal phrenic nerve stimulation

The metabolic changes accompanying diaphragm fatigue caused by supramaximal stimulation of the phrenic nerves are incompletely described. In particular, we wished to determine whether the occurrence of anaerobic metabolism correlated with fatigue as defined by decline in force generation. In 10 anesthetized mechanically ventilated mongrel dogs we measured arterial pressure, transdiaphragmatic pressure (Pdi), phrenic arterial flow (Qdi-Doppler flow probe), arterial and phrenic venous blood gases, and lactate levels. From these we derived indexes of diaphragm O2 consumption (VO2) and lactate production. Bilateral phrenic nerve pacing was carried out (50 Hz, duty cycle 0.4, 24 contractions/min) for two 15-min pacing periods separated by a 45-min rest period. Over each pacing period Pdi decreased from approximately 16 to approximately 10 cmH2O (P less than 0.01, no significant difference between periods). Initially, during pacing, Qdi and VO2 each increased fivefold over prepacing base line. Qdi remained elevated at this level whereas VO2 decreased over the pacing period by approximately 25%. Hence, the change in VO2 over the pacing period was due primarily to changes in O2 extraction. During the first pacing period lactate production was observed early and declined throughout the pacing period. No lactate production was observed during the second pacing period, although Pdi, VO2, and Qdi responses were the same for both pacing periods. Phrenic venous PO2 remained greater than 30 Torr throughout both pacing periods.(ABSTRACT TRUNCATED AT 250 WORDS)     

Diaphragm EMG measured by cervical magnetic and electrical phrenic nerve stimulation

The purpose of the study was to compareelectrical stimulation (ES) and cervical magnetic stimulation (CMS) ofthe phrenic nerves for the measurement of the diaphragm compound muscleaction potential (CMAP) and phrenic nerve conduction time. A specially designed esophageal catheter with three pairs of electrodes was used,with control of electrode positioning in 10 normal subjects. Pair A and pairB were close to the diaphragm (pairA lower than pairB); pair C waspositioned 10 cm above the diaphragm to detect the electromyogram fromextradiaphragmatic muscles. Electromyograms were also recorded fromupper and lower chest wall surface electrodes. The shape of the CMAPmeasured with CMS (CMS-CMAP) usually differed from that of the CMAPmeasured with ES (ES-CMAP). Moreover, the latency of theCMS-CMAP from pair B (5.3 ± 0.4 ms) was significantly shorter than that from pairA (7.1 ± 0.7 ms). The amplitude of the CMS-CMAP(1.00 ± 0.15 mV) was much higher than that of ES-CMAP (0.26 ± 0.15 mV) when recorded from pair C.Good-quality CMS-CMAPs could be recorded in some subjects from anelectrode positioned very low in the esophagus. The differences betweenES-CMAP and CMS-CMAP recorded either from esophageal or chest wallelectrodes make CMS unreliable for the measurement of phrenic nerveconduction time.

     

Changes in afferent and efferent phrenic activities with electrically induced diaphragmatic fatigue.

In anesthetized artificially ventilated cats, diaphragmatic fatigue was produced by direct muscle stimulation with trains of pulses for 30 min. Failure of contraction was assessed from decrease in the maximal relaxation rate of transdiaphragmatic pressure twitches. Motor activities (electromyogram and motor phrenic neurogram) were processed by fast-Fourier transform analysis, which provided the power spectrum density function (PSDF). The discharge frequency of diaphragmatic afferents was also measured. In control conditions (before fatigue), intra-arterial bolus injection of lactic acid enhanced tonically active diaphragmatic afferents, whereas it reduced the firing rate of afferent fibers activated in phase with diaphragmatic contraction or relaxation. The same sensory response pattern was observed with the development of diaphragmatic fatigue. Leftward shift in PSDFs of motor phrenic neurogram also occurred, but it preceded the failure of diaphragmatic contraction as well as the changes in the electromyogram's PSDF and afferent paths, which were closely associated with lengthening of both inspiratory and total breath durations. After section of the phrenic nerves, the motor phrenic response disappeared during the fatigue trial. This demonstrates the existence of complex reflex-induced changes in the ventilatory control during diaphragmatic fatigue. They seem to involve the participation of several types of phrenic afferents.     

Attenuation of phrenic motor discharge by phrenic nerve afferents

Short latency phrenic motor responses to phrenic nerve stimulation were studied in anesthetized, paralyzed cats. Electrical stimulation (0.2 ms, 0.01-10 mA, 2 Hz) of the right C5 phrenic rootlet during inspiration consistently elicited a transient reduction in the phrenic motor discharge. This attenuation occurred bilaterally with an onset latency of 8-12 ms and a duration of 8-30 ms. Section of the ipsilateral C4-C6 dorsal roots abolished the response to stimulation, thereby confirming the involvement of phrenic nerve afferent activity. Stimulation of the left C5 phrenic rootlet or the right thoracic phrenic nerve usually elicited similar inhibitory responses. The difference in onset latency of responses to cervical vs. thoracic phrenic nerve stimulation indicates activation of group III afferents with a peripheral conduction velocity of approximately 10 m/s. A much shorter latency response (5 ms) was evoked ipsilaterally by thoracic phrenic nerve stimulation. Section of either the C5 or C6 dorsal root altered the ipsilateral response so that it resembled the longer latency contralateral response. The low-stimulus threshold and short latency for the ipsilateral response to thoracic phrenic nerve stimulation suggest that it involves larger diameter fibers. Decerebration, decerebellation, and transection of the dorsal columns at C2 do not abolish the inhibitory phrenic-to-phrenic reflex.     

c-Fos expression in the central nervous system elicited by phrenic nerve stimulation.

Phrenic nerve afferents (PNa) have been shown to activate neurons in the spinal cord, brain stem, and forebrain regions. The c-Fos technique has been widely used as a method to identify neuronal regions activated by afferent stimulation. This technique was used to identify central neural areas activated by PNa. The right phrenic nerve of urethane-anesthetized rats was stimulated in the thorax. The spinal cord and brain were sectioned and stained for c-Fos expression. Labeled neurons were found in the dorsal horn laminae I and II of the C3-C5 spinal cord ipsilateral to the site of PNa stimulation. c-Fos-labeled neurons were found bilaterally in the medial subnuclei of the nucleus of the solitary tract, rostral ventral respiratory group, and ventrolateral medullary reticular formation. c-Fos-labeled neurons were found bilaterally in the paraventricular and supraoptic hypothalamic nuclei, in the paraventricular thalamic nucleus, and in the central nucleus of the amygdala. The presence of c-Fos suggests that these neurons are involved in PNa information processing and a component of the central mechanisms regulating respiratory function.     

Diaphragmatic pressures: transvenous vs. direct phrenic nerve stimulation

Diaphragmatic force, determined by stimulating the phrenic nerve while simultaneously measuring the pressures in a closed respiratory system, was assessed in five anesthetized dogs over a 5-h period to evaluate the inherent variability of this technique. Transdiaphragmatic pressure (Pdi) was measured at functional residual capacity during stimulation (120 Hz, 0.2-ms duration) of one phrenic nerve by either direct phrenic nerve stimulation (DPNS) or transvenous phrenic nerve stimulation (TPNS). An analysis of variance showed no significant (P greater than 0.50) change during the 5-h period. There was a significant correlation (r = 0.94, P less than 0.001) between Pdi obtained by TPNS and that obtained by DPNS. It is concluded that either DPNS or TPNS can be used to evaluate diaphragmatic strength over a 5-h period and that TPNS can be used in lieu of DPNS.     

Human diaphragmatic EMG: changes with lung volume and posture during supramaximal phrenic stimulation

If esophageal and chest wall recordings of diaphragmatic electromyographic activity (EMG) accurately reflect neural drive to this muscle, then compound muscle action potentials (CMAPs) produced by supramaximal stimulation of the phrenic nerve should not alter with changes in diaphragmatic position. Maximal CMAPs were therefore recorded 1) during changes in lung volume from near residual volume to near total lung capacity, 2) during isovolume maneuvers at different lung volumes, and 3) while subjects were lying, sitting, and standing. The areas of maximal CMAPs recorded with the gastroesophageal catheter increased 5.1 +/- 3.6 times (mean +/- SD) between these volumes, increased 2.4 +/- 1.3 times as the diaphragm descended during an isovolume maneuver (at functional residual capacity), and increased 4.4 +/- 2.4 times between the lying and standing positions. Because the stimuli were supramaximal, these changes in EMG reflect changes in the relationship between the esophageal electrodes and the diaphragmatic muscle fibers. Artifactual changes were also documented for surface electrodes on the chest wall. Because of these positional changes in maximal CMAPs, previous studies, which used integrated diaphragmatic EMG to document "reflex" changes in neural drive, should be reevaluated.