Non-Pulmonary Respiratory Failure: Plication, Nerve...
Transcript of Non-Pulmonary Respiratory Failure: Plication, Nerve...
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
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
NO DISCLOSURES
Non-Pulmonary Respiratory Failure:
Plication, Nerve Grafting, PacingPlication, Nerve Grafting, Pacing
= Diaphragm Failure
Diaphragmatic Failure
1. Peripheral = phrenic nerve injury
2. Central = spinal cord injury
Diaphragmatic Paralysis
Phrenic Nerve Injury
Diaphragmatic Paralysis
Phrenic Nerve Injury
• Iatrogenic
• Mass effect• Mass effect
• Idiopathic
Diaphragmatic Paralysis
Phrenic Nerve Injury
Clinical Picture
• Dyspnea, orthopnea• Dyspnea, orthopnea
• Unilateral paralysis
• Elevated hemidiaphragm on CXR
Diaphragmatic Paralysis
Phrenic Nerve Injury
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)
Groth. Thoracic Surg Clin 2009;19:511
Groth. Ann Thorac Surg 2010;89:S2146
Diaphragm Plication
Contraindications
• Absolute:
– Neuromuscular diseases
• Relative:
– Morbid obesity
– Bilateral (?)Groth. Thoracic Surg Clin 2009;19:511
Groth. Ann Thorac Surg 2010;89:S2146
Diaphragm Plication
Approach
• Thoracotomy
• Thoracoscopy
• Laparotomy
• Laparoscopy
Groth. Thoracic Surg Clin 2009;19:511
Groth. Ann Thorac Surg 2010;89:S2146
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
Diaphragm Plication - Results
FEV1 and FVC
• 10-20% improvement
• PFT correlate poorly with functional status
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
Diaphragm Plication - Results
CXR
• Persistent tethering of diaphragm
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
Diaphragm Plication
Pre Immediate
postop1 mo 5 y
Diaphragm Plication - Results
Mortality
• 0% mortality in minimally invasive series
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
Diaphragm Plication - Results
Mortality
• 0% mortality in minimally invasive series
• 0-14% (3/22) mortality in recent open series
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
Diaphragm Plication - Results
Mortality
• 0% mortality in minimally invasive series
• 14% (3/22) mortality in a recent open series
– 1 bilateral
– 1 neuromuscular disease
Graham. Ann Thorac Surg 1990;48:248
Versteegh. Eur J Cardiothorac Surg 2007;32:449
Freeman. Ann Thorac Surg 2009;88:1112
Groth. JTCVS 2010;139:1452
Diaphragm Plication - Results
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
Versteegh. Eur J Cardiothorac Surg 2007;32:449
Freeman. Ann Thorac Surg 2009;88:1112
Groth. JTCVS 2010;139:1452
Diaphragm Plication
Conclusions
• Good long-term solution to unilateral phrenic
paralysis (and eventration)
Graham. Ann Thorac Surg 1990;48:248
Versteegh. Eur J Cardiothorac Surg 2007;32:449
Freeman. Ann Thorac Surg 2009;88:1112
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)
Kaufman. Chest 2011;140:191
NCS
EMG
Nerve Grafting
Preop evaluation
1. NCS = no conduction1. NCS = no conduction
2. EMG = intact motor unit (no atrophy)
Kaufman. Chest 2011;140:191
Nerve Grafting
Intraop evaluation
Neurolysis NCS/EMG +/- interposition
graft
Kaufman. Chest 2011;140:191
Nerve Grafting
Results
• 12 patients (4-38 mo f/u)
– 3 neurolysis alone
– 9 neurolysis + grafts
Kaufman. Chest 2011;140:191
Nerve Grafting
Results
• Approach
– 8 cervical
– 4 cervical + thoracotomy
• 165 min
Kaufman. Chest 2011;140:191
Nerve Grafting
Results: 82% (9/11) improved SF36
Kaufman. Chest 2011;140:191
Nerve Grafting
Results
• Δ FEV1 and FVC: 0% – 29%
• Sniff test: improved in 8/9
Kaufman. Chest 2011;140:191
Nerve Grafting
Conclusion
• Phrenic nerve neurolysis/graft has a high
likelihood of improvementlikelihood of improvement
Kaufman. Chest 2011;140:191
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
Laparoscopic placement
• 5/6 patients weaned off ventilator
Onders. Surg Endosc 2005;19:633
Diaphragm Pacing
Laparoscopic placement
• Multi-institutional series (n=87)
• ALS or spinal cord injury
• 50% use pacing for periods of 4-24 h (off vent)
Onders. Surg Endosc 2009;23:1433
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
Phrenic Nerve Pacing
Inclusion
• Vent dependent
• Cervical phrenic n. stimulation
EMG response
• Transcranial magnetic stimulation
no EMG responseLe Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing
Inclusion
• Vent dependent
• Cervical phrenic n. stimulation
EMG response
• Transcranial magnetic stimulation
no EMG responseLe Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing
Inclusion
• Vent dependent
• Cervical phrenic n. stimulation
EMG response
• Transcranial magnetic stimulation
no EMG responseLe Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing - Procedure
• Cervical phrenic n. stimulation
EMG responseEMG response
• Transcranial magnetic stimulation
no EMG response
Intraop testing of thresholds
Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing - Procedure
• Cervical phrenic n. stimulation
EMG response
no EMG response
Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing - Procedure
• Cervical phrenic n. stimulation
EMG response
• stimulation
no EMG response
Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing - Conditioning
Protocol
• Start stimulation 2 weeks post implant
• Daily sessions
• Session duration:
– Breath-by-breath monitoring of tidal volume
Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing - Conditioning
Protocol
• Start stimulation 2 weeks post implant
• Daily sessions
• Session duration:
– Breath-by-breath monitoring of tidal volume
Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing - Conditioning
Protocol
• Initial sessions as short as 2 min
• Reconditioning complete: 8 h without fatigue
• Session duration:
– Breath-by-breath monitoring of tidal volume
Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing
Results
• 0 deaths
• 2 atelectasis
Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing
Results
• Complete reconditioning: 18/20 (90%)
• Reconditioning duration
– < 2 months: 13
– 2-3 months: 3
– > 3 months: 2Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing
Results
• All 18 pts could tolerate continuous stimulation
• 8 elected to continue night-time vent
Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing
Results
• Tracheal suctioning: 5x/d 3x/d
• Resp infections/year: 0.7 0.1
• Improved sense of taste, smell
• Better sleep
Le Pimpec-Barthes. JTCVS 2011;142:378
Phrenic Nerve Pacing
• Very promising in carefully selected patients
• Labor-intensive
• Multi-disciplinary team
Le Pimpec-Barthes. JTCVS 2011;142:378
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
Polentes. Neurobiol Dis 2004;16:638
RL
Polentes. Neurobiol Dis 2004;16:638
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
Non-Pulmonary Respiratory Failure:
Plication, Nerve Grafting, PacingPlication, Nerve Grafting, Pacing
Conclusions
Diaphragmatic Paralysis
Phrenic Nerve Injury
1. Plication is standard of care
2. Nerve grafting:
– Promising
– Proper patient selection (young patients?)
Diaphragmatic Paralysis
Central
1. Pacing is very promising and should
be implemented more widely
2. Grafting is the ultimate goal