Diaphragm
Pacing
System
The cost of ventilator dependent
165億
140億
136億
143億
122億
人次
費用
22483人
19265人
18474人
19084人
15018人
2015
2016
2017
2018
2019
Reference:衛生福利部中央健康保險屬品質指標
The aim of Diaphragm Pacing System
Free
form
ventilator!
Central control of breathing
Ventilator associated pneumonia(VAP)
• VAP occurred in 36% of SCI
ventilated patient.1
• Increase MV weaning & ICU stays by
4.3 days
• Increase hospital LOS 4~9 days.2
• The mortality rate of VAP generally
25%-50%.3
1. Chikara Ushiku et al.(2023)
2.Chest 2002;122:2115
3. Karakuzu, Z. et al.(2018).
Early use of DPS
• Implantation at the time of high risk operations could
– Decrease tracheostomy rate
– Decrease pneumonia rate
– Decrease cost
• Central Sleep Dysfunction in critical care
– Congestive heart failure
• Diaphragm Pacing
– Reduction in atelectasis
– Improve respiratory compliance*
• 20% improvement
– Converts muscle to Type I
– Increase diaphragm strength
– Reduce barotrauma
– Improves cardiac output
Improving Ventilation
Before implantation
One Day of Pacing
Three previous pneumonias
5 Months Later
Recovered Diaphragm Control
A case with Incomplete SCI, C3
*Onders, Elmo et al , Chest 2007
Laparoscopic and Minimally Invasive Surgery
Implanting electrodes
Check diaphragm & Implanting electrodes
NeuRX DPS®
Chronic Respiratory NeuroStimulation
Settings of DPS
Evidence
Base
A Breakthrough in the Treatment
DPS applied to
SCI
(Spinal Cord Injury)
Superman : Second patient implanted
DPS(n=40)
MV(n=61)
P
VAP vent
days
24.5±15.2
days
(n=26)
33.2±23.3days 0.05
(n=36)
Mortality
3%
15%
0.04
Length of
hospital
stay
43 ± 24 days
65 ± 61 days
0.03
Kerwin, A. J., et al.(2018)
Mean time to implant 14 days
DPS group had shorter MV days if
VAP occurred
DPS decrease hospital length of
stay & mortality
Consider DPS if ventilated>14 days
Onders et
al.(2022)
DPS ≧consecutive 4 hr
DPS ≧consecutive 24 hr
• Median time from injury to treatment :28.3 months
• DPS > basal tidal volume requirements by a mean of 48.4%
Best Practices Guidelines of SCI
•Diaphragm Pacing Is an Early Reproducible Surgical Procedures to
Decease Mechanical Ventilation in Spinal Cord Injured patients .
•The American College of Surgeons Trauma
Quality Program Recommends DP as Best Practice Guidelines .
 Improve respiratory mechanics (spontaneous TV)
 Reduces weaning time and achieves independence
from the ventilator
 Decreases hospital cost and length of stay.
DPS applied to
ACHS
(Acquired Central Hypoventilation Syndrome)
• ACHS:CHS occur secondary to brainstem dysfunction from mechanical injury,
bleeding, tumor or Arnold-Chiari malformation
stroke, infection, and trauma in the medulla
• Candidates for diaphragm pacing: malfunction of the respiratory control center in
the brain stem (central alveolar hypoventilation) or interruption of the upper motor
neurons of the phrenic nerve
DiMarco, A. F. (2018). Diaphragm pacing. Clinics in Chest Medicine, 39(2), 459-471.
• Brainstem encephalitis &
cervicomedullary infarct
are candidates for DPS
• After 3 years & 12 years
implantation, still pacing
Khong, P., Lazzaro, A., & Mobbs, R. (2010). Phrenic nerve stimulation: the Australian experience. Journal
of Clinical Neuroscience, 17(2), 205-208.
 CASE1:Neuromyelitis optica(NMO) (21 y/o, Female)
-NMO with demyelinating lesions in the area postrema and cervicomedullary junction
-Severe dysphagia requiring PEG, severe central sleep apnea and chronic
hypercapnia
-Respiratory failure necessitating frequent BiPAP use
With DPS placement and immunosuppressive therapy
• Frequency of BiPAP decreased
• Improved chronic hypercapnia
 CASE2:Neuromyelitis optica(NMO)(27 y/o, male)
-NMO extensive demyelinating lesions in the lower pons, medulla, and C2-7 cervical
-Respiratory failure requiring intubation & Tr
DPS placement and immunosuppressive therapy
• Weaning from MV one month later
• Decannulated and DPS was removed 7.5 months after implant
 CASE 3: Medullary Infarct (53 y/o, male)
- Right vertebral artery occlusion → right medullary infarct
- Respiratory failure requiring intubation for 3 months
DPS placement
• Weaned from the ventilator three days later
• Continues to require DP (particularly at night) for persistent intermittent apnea
DPS applied to
CCHS
(Congenital Central Hypoventilation Syndrome)
• 32-year-old woman with CCHS & cor pulmonale due to pulmonary hypertension, Tr & ventilator
at night
• DPS improve hypoventilation, oxygenation, and pulmonary hypertension(TRGP 106→48mmHg)
Yamada, Y., et al.Pediatrics International, 64(1), e14915.
DPS applied to
ALS
(Amyotrophic lateral sclerosis)
TFDA approval
VIDD(Ventilator-induced diaphragmatic dysfunction)
• Comparison of Diaphragm
biopsy of MV>18hr VS controls
• Marked atrophy of diaphragm
myofibers.1
• Multiple recent studies have
shown that VIDD is reported in
up to 53% of mechanically
ventilated patients within 24 h of
intubation. 2
1.Levine, S., (2008. New England Journal of Medicine, 358(13), 1327-1335.
2. Peñuelas, O., (2019). Intensive care medicine experimental, 7, 1-25.
• Average tidal volume 137%
• Ease of placement, removal, functionality and safety of temporary DP , decreases diaphragm atrophy.
Conclusion
• Early DPS may be considered(>14days)
 DPS group had shorter MV days if VAP occurred
 Early DPS decrease hospital length of stay & mortality
• DPS ≧consecutive 4 hr : 92.2% ; DPS ≧consecutive 24 hr : 52.7%
• ACHS:CHS occur secondary to brainstem dysfunction from
mechanical injury, bleeding, tumor, stroke, infection, and
trauma in the medulla are candidates for DPS.
• Temporary DPS can avoid VIDD
Nobody
Chooses to go
Back to
Ventilators