Non-Pulmonary Respiratory Failure: Plication, Nerve ...az9194.vo.msecnd.net/pdfs/120401/04.35.pdfDiaphragm Plication -Results Morbidity •Effusion, prolonged chest tube drainage,

Non-Pulmonary Respiratory Failure:

Plication, Nerve Grafting, PacingPlication, Nerve Grafting, Pacing

Rafael Andrade, MD

Division of Thoracic and Foregut Surgery

University of Minnesota

AATS/STS General Thoracic Surgery Symposium 2012



Rafael Andrade, MD

Division of Thoracic and Foregut Surgery

University of Minnesota

AATS/STS General Thoracic Surgery Symposium 2012

NO DISCLOSURES



= Diaphragm Failure

Diaphragmatic Failure

1. Peripheral = phrenic nerve injury

2. Central = spinal cord injury

Diaphragmatic Paralysis

Phrenic Nerve Injury



• Iatrogenic

• Mass effect• Mass effect

• Idiopathic



Clinical Picture

• Dyspnea, orthopnea• Dyspnea, orthopnea

• Unilateral paralysis

• Elevated hemidiaphragm on CXR



Options

• Diaphragmatic plication• Diaphragmatic plication

• Nerve graft

Diaphragm PlicationDiaphragm Plication

Diaphragm Plication

Indications

• Elevated hemidiaphragm

• Dyspnea

• (+ sniff test)

Groth. Thoracic Surg Clin 2009;19:511

Groth. Ann Thorac Surg 2010;89:S2146

Diaphragm Plication

Preop assessment

• Symptoms (validated questionnaire)

• CXR (elevated hemidiaphragm)

• Pulmonary function tests (PFT)



Diaphragm Plication

Contraindications

• Absolute:

– Neuromuscular diseases

• Relative:

– Morbid obesity

– Bilateral (?)Groth. Thoracic Surg Clin 2009;19:511


Diaphragm Plication

Approach

• Thoracotomy

• Thoracoscopy

• Laparotomy

• Laparoscopy



Diaphragm Plication - Results

Symptoms

• Significant and durable improvement (up to

10y)

• ~ 10% recurrence

Graham. Ann Thorac Surg 1990;48:248

Versteegh. Eur J Cardiothorac Surg 2007;32:449

Freeman. Ann Thorac Surg 2009;88:1112

Calvinho. Eur J Cardiothorac Surg 2009;36:883

Groth. JTCVS 2010;139:1452

SGRQ Total Score

60

80

100

Tota

l S

core

0

20

40

60

Pre 1 mo 12 mo

Tota

l S

core

Normal

23 29

Groth. JTCVS 2010;139:1452


FEV1 and FVC

• 10-20% improvement

• PFT correlate poorly with functional status





Groth. JTCVS 2010;139:1452


CXR

• Persistent tethering of diaphragm





Groth. JTCVS 2010;139:1452

Diaphragm Plication

Pre Immediate

postop1 mo 5 y


Mortality

• 0% mortality in minimally invasive series





Groth. JTCVS 2010;139:1452


Mortality


• 0-14% (3/22) mortality in recent open series





Groth. JTCVS 2010;139:1452


Mortality


• 14% (3/22) mortality in a recent open series

– 1 bilateral

– 1 neuromuscular disease




Groth. JTCVS 2010;139:1452


Morbidity

• Effusion, prolonged chest tube drainage,

atelectasis

• Hospital stay:

– 5.5 days open

– 3-4 days min inv Graham. Ann Thorac Surg 1990;48:248



Groth. JTCVS 2010;139:1452

Diaphragm Plication

Conclusions

• Good long-term solution to unilateral phrenic

paralysis (and eventration)




Groth. JTCVS 2010;139:1452

Nerve GraftingNerve Grafting

Nerve Grafting

• 1ary anastomosis

• Neurotization (e.g., spinal acc n.)

• Interposition graft

Nerve Grafting – 1ary Anastomosis

Brouillette. J Ped Surg 1986;21:63

Nerve Grafting – Neurotization

Spinal acc n.

Tubbs.Childs Nerv Syst 2008;24:1341

Phrenic

Nerve Grafting – Spinal accessory n.

Yang. J Neurosurg 2011;15:190

Nerve Grafting - Interposition

Schoeller. JTCVS 2001;122:1235

Nerve Grafting - Interposition

Schoeller. JTCVS 2001;122:1235

9 monthsPreop

Nerve Grafting

• Largest series: 12 patients, unilateral

• 3 techniques• 3 techniques

– Neurolysis (adhesions)

– Neurotization

– Interposition graft

Kaufman. Chest 2011;140:191

Nerve Grafting

Preop evaluation

1. Nerve conduction study (NCS)1. Nerve conduction study (NCS)

2. Electromyography (EMG)


NCS

EMG

Nerve Grafting

Preop evaluation

1. NCS = no conduction1. NCS = no conduction

2. EMG = intact motor unit (no atrophy)


Nerve Grafting

Intraop evaluation

Neurolysis NCS/EMG +/- interposition

graft


Nerve Grafting

Results

• 12 patients (4-38 mo f/u)

– 3 neurolysis alone

– 9 neurolysis + grafts


Nerve Grafting

Results

• Approach

– 8 cervical

– 4 cervical + thoracotomy

• 165 min


Nerve Grafting

Results: 82% (9/11) improved SF36


Nerve Grafting

Results

• Δ FEV1 and FVC: 0% – 29%

• Sniff test: improved in 8/9


Nerve Grafting

Conclusion

• Phrenic nerve neurolysis/graft has a high

likelihood of improvementlikelihood of improvement


Nerve Grafting

• Promising

• Main question is patient selection

Central Diaphragm Paralysis

Central Diaphragm Paralysis

• Pacing

• Spinal cord graft

PacingPacing

Pacing

• Direct diaphragmatic pacing

• Phrenic nerve pacing

Diaphragm PacingDiaphragm Pacing

Diaphragm Pacing

Laparoscopic placement

• Requires intraop mapping (OR time 3-5h)

Onders. Surg Endosc 2005;19:633

Diaphragm Pacing


• 5/6 patients weaned off ventilator


Diaphragm Pacing


• Multi-institutional series (n=87)

• ALS or spinal cord injury

• 50% use pacing for periods of 4-24 h (off vent)


Phrenic Nerve PacingPhrenic Nerve Pacing

Phrenic Nerve Pacing

Thoracoscopic lead placement

• Multidisciplinary, multi-institutional study (France)

• 20 patients (19 post-traumatic)

Le Pimpec-Barthes. JTCVS 2011;142:378


Inclusion

• Vent dependent

• Cervical phrenic n. stimulation

EMG response

• Transcranial magnetic stimulation

no EMG responseLe Pimpec-Barthes. JTCVS 2011;142:378


Inclusion

• Vent dependent


EMG response




Inclusion

• Vent dependent


EMG response



Phrenic Nerve Pacing - Procedure


EMG responseEMG response


no EMG response

Intraop testing of thresholds




EMG response

no EMG response




EMG response

• stimulation

no EMG response


Phrenic Nerve Pacing - Conditioning

Protocol

• Start stimulation 2 weeks post implant

• Daily sessions

• Session duration:

– Breath-by-breath monitoring of tidal volume



Protocol

• Start stimulation 2 weeks post implant

• Daily sessions





Protocol

• Initial sessions as short as 2 min

• Reconditioning complete: 8 h without fatigue





Results

• 0 deaths

• 2 atelectasis



Results

• Complete reconditioning: 18/20 (90%)

• Reconditioning duration

– < 2 months: 13

– 2-3 months: 3

– > 3 months: 2Le Pimpec-Barthes. JTCVS 2011;142:378


Results

• All 18 pts could tolerate continuous stimulation

• 8 elected to continue night-time vent



Results

• Tracheal suctioning: 5x/d 3x/d

• Resp infections/year: 0.7 0.1

• Improved sense of taste, smell

• Better sleep



• Very promising in carefully selected patients

• Labor-intensive

• Multi-disciplinary team


Spinal Cord GraftingSpinal Cord Grafting

Spinal Cord Grafting

Olfactory ensheathing cellsOlfactory ensheathing cells

(OEC)

Spinal Cord OEC Grafting- Preclinical

Spinal Cord OEC Grafting- Preclinical

• LEFT C2 spinal cord injury in rats

Polentes. Neurobiol Dis 2004;16:638

RL


RL


Spinal Cord OEC Grafting- Clinical

Phase I trials = safePhase I trials = safe

Mackay-Sim.Brain. 2008 Sep;131:2376

Lima. Neurorehabil Neural Repair. 2010 Jan;24:10



Conclusions



1. Plication is standard of care

2. Nerve grafting:

– Promising

– Proper patient selection (young patients?)


Central

1. Pacing is very promising and should

be implemented more widely

2. Grafting is the ultimate goal

Documents

Non-Pulmonary Respiratory Failure: Plication, Nerve ...az9194.vo.msecnd.net/pdfs/120401/04.35.pdfDiaphragm Plication -Results Morbidity •Effusion, prolonged chest tube drainage,