Diaphragmatic Twitch Research Articles

Phrenic Nerve Conduction Studies Are Enhanced by Simultaneous Visualization of the Diaphragm with Ultrasound (P01.198)

Objective: To determine if diaphragmatic ultrasound (DU) complements phrenic nerve conduction studies (PNCS) in the evaluation of phrenic neuropathy. Background PNCS are often performed to evaluate phrenic nerve function. However, PNCS can be technically difficult, and associated with false positives and negatives. Design/Methods: PNCS with simultaneous DU was performed in 10 patients (mean age: 42; range: 1-71) referred for phrenic neuropathy. The phrenic nerve was supramaximally stimulated in the neck bilaterally at end-expiration. Both the diaphragmatic compound muscle action potential (CMAP, recording electrode above xiphoid, reference electrode inferolaterally over ipsilateral costal margin) and the evoked diaphragmatic muscle twitch (visualized with percutaneous ultrasound over the lateral chest wall), were recorded. In addition, diaphragmatic movement during spontaneous respiration was visualized with DU and recorded. Correlations were sought between PNCS and DU data. Results: PNCS and DU data were concordant in 17/20 studies, documenting phrenic neuropathy in 8 patients including 2 with a very low amplitude CMAP and twitch. Of 3 discordant studies, 1 had an unevocable diaphragmatic CMAP and twitch but normal diaphragm movement with respiration (false positive), 1 had a low amplitude CMAP but normal diaphragmatic twitch and movement with respiration (false positive), and 1 had a normal CMAP but low amplitude diaphragmatic twitch and movement with respiration (false negative). Conclusions: Unlike other motor NCS, PNCS are limited by inability to visualize the evoked muscle twitch and target muscle during spontaneous movement. Addition of DU to PNCS provides this information, and enhances the diagnostic accuracy of PNCS, specifically by: 1) confirming partial phrenic neuropathy when CMAPs are low amplitude by demonstrating diminished but evocable diaphragmatic twitch and spontaneous movement, 2) reducing false positives when PNCS are technically challenging (e.g., CMAPs unevocable but diaphragmatic spontaneous movement normal), 3) reducing false negatives when CMAPs are of low-normal amplitude but diaphragmatic movement is reduced. Disclosure: Dr. Johnson has nothing to disclose. Dr. Patrick has nothing to disclose. Dr. Downs has nothing to disclose. Dr. Dogra has received personal compensation in an editorial capacity for Ultrasound Clinics. Dr. Logigian has received personal compensation for activities with Genzyme Corporation as a consultant.

Thoracoscopic patch insulation to correct phrenic nerve stimulation secondary to cardiac resynchronization therapy

Cardiac resynchronization therapy is an established therapy for heart failure, improving quality of life and prognosis. Despite advances in technique, available leads and delivery systems, trans-venous left ventricular (LV) lead positioning remains dependent on the patient's underlying venous anatomy. The left phrenic nerve courses over the surface of the pericardium laterally and may be stimulated by the LV pacing lead, causing uncomfortable diaphragmatic twitch. This paper describes a video-assisted thoracoscopic (VATS) procedure to correct phrenic nerve stimulation secondary to cardiac resynchronization therapy. Most current ways of avoiding phrenic stimulation involve either electronic reprogramming to distance the phrenic nerve from the stimulation circuit or repositioning the lead. We describe a case where the phrenic nerve was surgically insulated from the stimulating current by insinuating a patch of bovine pericardium between the epicardium and native pericardium of the heart thus completely resolving previously intolerable and incessant diaphragmatic twitch. The procedure was performed under general anaesthesia with single-lung ventilation and minimal use of neuromuscular blocking agents. Surgical patch insulation of the phrenic nerve was performed using minimally invasive VATS surgery, as a short-stay procedure, with no complications. No diaphragmatic twitch occurred post-surgery and the patient continued to gain symptomatic benefit from cardiac synchronization therapy (New York Heart Association Class III to II), enabling return to work. In cases where the trans-venous position of a LV lead is limited by troublesome phrenic nerve stimulation, thoracoscopic surgical patch insulation of the phrenic nerve could be considered to allow beneficial cardiac resynchronization therapy.

Effects of phosphodiesterase‐III inhibitors on sevoflurane‐induced impairment of rat diaphragmatic function

Volatile anesthetics are known to cause diaphragmatic dysfunction using a whole body model. The first aim of the current study was to compare the impairing effect of halothane and sevoflurane on diaphragmatic contractile functions under unfatigued and fatigued conditions. The second purpose was to determine whether phosphodiesterase-III inhibitors can attenuate sevoflurane-potentiated reduction of contractility after fatigue. Using rat-isolated muscle strips, diaphragmatic twitch characteristics and tetanic contractions were measured before and after muscle fatigue, which was induced by repetitive tetanic contraction with or without exposure to halothane (1-3 MAC) or sevoflurane (1-3 MAC). Diaphragmatic functions were further assessed with exposure to 3 MAC sevoflurane in the presence and absence of milrinone, or olprinone. Cyclic adenosine monophosphate (cAMP) concentrations in the fatigued diaphragm were also measured. Halothane (1-3 MAC) or sevoflurane (1-2 MAC) did not induce a direct inotropic effect under unfatigued and fatigued conditions. Sevoflurane at 3 MAC enhanced fatigue-induced impairment of twitch and tetanic tensions. Clinically relevant concentrations of olprinone improved the sevoflurane-induced potentiation of diaphragmatic dysfunction following fatigue, accompanied by restoration of diaphragmatic cAMP levels, although milrinone failed to do so. Our findings suggest that sevoflurane has a greater decreasing effect on diaphragmatic contractility after fatigue than halothane, and that the clinical dose of olprinone surmounts the disadvantage of sevoflurane in various conditions where diaphragmatic fatigue is predisposed.

Consequences of thyroxine treatment on diaphragm and EDL of normal and dystrophic hamsters

Previously administration of thyroxine (T4) to dystrophic hamsters improved ventilation and slowed the progression of the disease. We hypothesized that the normalization of ventilation in these animals was due to T4 improving structural and functional characteristics of the diaphragm. In the present study, contractile characteristics of the diaphragm and the extensor digitorum longus (EDL) from normal and dystrophic hamsters were evaluated after two months of T4 treatment. Compared to their placebo-treated counterparts, diaphragms and EDLs of T4-treated normal hamsters showed increased optimal muscle lengths and twitch tension, decreased contraction times and increased fatigability. T4-treatment in dystrophic hamsters showed only an increase in diaphragmatic twitch tension development. Force-frequency curves before treatment were generally higher for the normal compared to dystrophic diaphragms and EDLs. T4 administration only increased the force in normal diaphragms at the lower frequencies and in the EDLs at the higher frequencies. Although T4 serum levels were increased in both T4-treated groups, triiodothyronine (T3) was much lower in the dystrophic compared to normal hamsters, suggesting that conversion of T4 to T3 was reduced in dystrophic hamsters. We conclude that the limited functional changes in the diaphragms of T4-treated dystrophic hamsters cannot account for the marked improvement in ventilation previously reported.

Preoperative Treatment with Recombinant Human Growth Hormone Prevents Ischemia Reperfusion-Induced Diaphragmatic Dysfunction

Background. Respiratory complications continue to be a major cause of morbidity and mortality following major vascular surgery. The recent UK Small Aneurysm Trial cited preoperative respiratory function as the major predictor of outcome following elective aortic surgery.Aim. The aim of this study was to investigate the effect of aortic clamping and revascularization on diaphragmatic muscle function in a small animal model and to evaluate the role of preoperative treatment with recombinant human growth hormone (rhGH) in preventing diaphragmatic muscle dysfunction.Methods. Male Sprague-Dawley rats (n = 18) were randomized into one of three groups: control (n = 6) underwent laparotomy only; IR (n = 6) had a laparotomy with infrarenal cross-clamping for 30 min followed by lower torso revascularization for 2 h; IR + rhGH (n = 6) were treated with rhGH (Genotropin 0.3 IU/kg/day) for 5 days before laparotomy and aortic cross-clamping for 30 min followed by lower torso revascularization for 2 h. Diaphragmatic muscle contractile function was assessed ex vivo using electrical field stimulation in a tissue bath.Results. Two hours of IR injury resulted in a significant impairment in diaphragmatic twitch (Control, 242.01 + 38.45 g; IR, 108.55 + 7.15 g). This impairment was prevented by pretreatment with rhGH (rhGH, 319.14 + 30.71 g; P < 0.01). Tetanic function was also significantly impaired by ischemia reperfusion injury (control, 605 + 77.63 g; IR, 228.12 + 14.38 g). Again, pretreatment with rhGH prevented this deterioration (IR + rhGH, 704.39 + 45.69 g; P < 0.05) compared with controls.Conclusion. The results of this study suggest that preoperative administration of rhGH may have a role in preventing the diaphragmatic dysfunction associated with infrarenal aortic cross-clamping and revascularization.

Alteration in diaphragmatic contractility during septic peritonitis in rats: effect of polyethylene glycol-absorbed superoxide dismutase.

To assess the alterations in diaphragmatic contractility measured in vitro during experimental septic peritonitis and to evaluate the effect of polyethylene glycol-absorbed superoxide dismutase (PEG-SOD) on the alterations in contractility. Prospective, randomized, controlled animal trial. Research laboratory. A total of 321 male Wistar rats, weighing 250-300 g. Rats were treated with cecal ligation and puncture (CLP). In the first experiment, diaphragmatic contractility was measured at 4, 10, 12, and 16 hrs after CLP. In the second experiment, PEG-SOD (4,000 units/kg) was administered intraperitoneally, and then diaphragmatic contractility was measured at 10 and 16 hrs after CLP. Levels of lipid peroxides and antioxidant enzymes in the diaphragm tissue were measured at 10 and 16 hrs after CLP. In experiment 1, diaphragmatic twitch characteristics and force-frequency relationships were determined at 4, 10, 12, and 16 hrs after CLP. In experiment 2, the effects of administration of PEG-SOD on twitch characteristics and force-frequency relationships were determined at 10 and 16 hrs after CLP. The levels of diaphragmatic thiobarbituric acid reactive substances and superoxide dismutase (SOD) and glutathione peroxidase activities were measured at 10 and 16 hrs after CLP. Twitch tension and force-frequency curves were significantly lower in the CLP groups than in the sham-operated group. Administration of PEG-SOD attenuated the reduction in twitch tension and the downward shift of force-frequency curves after CLP. Diaphragmatic levels of thiobarbituric acid reactive substances increased after CLP. However, the administration of PEG-SOD prevented increases in levels of diaphragmatic thiobarbituric acid reactive substances after CLP. Diaphragmatic SOD activity, but not glutathione peroxidase activity, was increased after CLP. Intra-abdominal sepsis (CLP) induced a marked reduction in diaphragmatic contractility, but PEG-SOD attenuated this reduction. Therefore, we conclude that oxygen-derived free radicals play an important role in the alterations in diaphragmatic contractility during intra-abdominal sepsis.

Diaphragmatic dysfunction secondary to experimental lower torso ischaemia-reperfusion injury is attenuated by thermal preconditioning.

Preconditioning describes the process whereby tissue exposure to a subcritical stress confers protection from subsequent injuries. This study assessed diaphragmatic muscle function after lower torso ischaemia-reperfusion (IR) and the role of thermal preconditioning in attenuation of this injury. Sprague-Dawley rats were randomized into three groups (24 per group): a control group, an IR group that had aortic cross-clamping for 1 h followed by reperfusion, and a third group that received thermal preconditioning 18 h before IR. Diaphragmatic function was assessed at 24 h, 48 h and 7 days. IR resulted in significant diaphragmatic twitch and tetanic dysfunction compared with control muscle. Thermal preconditioning significantly attenuated this injury (P < 0.05). Mean(s.e.m.) muscle twitch and tetanic forces in the IR group were 204.9(17.2) and 282.7(19.2) g respectively at 24 h. Corresponding twitch and tetanic forces in preconditioned muscle were 270.4(25.1) and 552.0(35.2) g. This study demonstrated that systemic IR injury produced a respiratory muscle mechanical dysfunction that was attenuated by thermal preconditioning, at 24 h, 48 h and 7 days. Preconditioning may have a role in clinical practice, particularly before elective surgery.

Effects of dilated cardiomyopathy on the diaphragm in the Syrian hamster.

This study aimed to elucidate changes in respiratory muscles and their mechanism in cardiomyopathy. The contractile properties and histology of the diaphragm, as well as serum levels of insulin-like growth factor (IGF)-1, were examined in 10 hamsters with idiopathic dilated cardiomyopathy (CM) and 10 controls. At 28 weeks, body weight in CM was reduced compared with controls (114+/-10 versus 144+/-14 g, p<0.0001). The ratio of diaphragm to body weight was significantly higher in CM than in controls (0.228+/-0.015 versus 0.182+/-0.017, p<0.0001). In vitro, maximal diaphragmatic twitch (303+/-63 versus 455+/-119 g x cm(-2)) and tetanic tensions (1,555+/-369 versus 2,204+/-506 g x cm(-2)) were significantly lower in CM than in controls (p<0.005). The half-relaxation time was significantly shorter in CM (19+/-1 ms) than in controls (24+/-3 ms, p<0.0005). Fatiguability at 25 Hz was significantly less in CM (28%) than in controls (42%, p<0.0001). Diaphragm and gastrocnemius adenosine triphosphatase staining showed type I fibre atrophy in CM, associated with an increase in the number of type I fibres in the diaphragm. Histological examination of both muscles revealed an abnormal muscular pattern. Finally, serum levels of IGF-1 were 47% lower in the CM group than in controls (p<0.0001) and were clearly related to the changes in the contractile properties and histology of the diaphragm. In conclusion, cardiomyopathy in hamsters: 1) depressed the force-generating capacity and shortened the relaxation of the hamster diaphragm; 2) induced type I fibre atrophy in combination with a myopathic pattern; and 3) was associated with a significant reduction in serum levels of insulin-like growth factor-1, related to the diaphragmatic changes. Whether these changes are primary myopathic or secondary to heart failure remains to be elucidated.

Effects of selenium deficiency on diaphragmatic function after resistive loading.

Diaphragmatic fatigue has been associated with increased production of reactive oxygen species. Among the defenses against reactive oxygen species is the glutathione redox system. The selenium-dependent enzyme glutathione peroxidase is an important component of this system. Thus, we hypothesized that selenium deficiency would lower glutathione peroxidase activity and render the diaphragm more susceptible to a mild exertional protocol. Sprague-Dawley rats were fed a selenium-deficient or control diet for 12 weeks then divided into four experimental groups: (1) unloaded, basic diet with selenium supplementation (control); (2) unloaded, selenium-deficient diet; (3) loaded, basic diet with selenium supplementation; and (4) loaded, selenium-deficient diet. Diaphragmatic in vitro contractile properties, glutathione peroxidase activity and glutathione content were measured. During inspiratory resistive loading, the animals breathed against an inspiratory resistor at 70% of maximal airway pressure until the target pressure was not achieved for five consecutive breaths. Selenium deficiency resulted in a significant decrease in diaphragmatic glutathione peroxidase activity, without changes in total glutathione content. Neither selenium deficiency nor inspiratory resistive loading alone impaired diaphragmatic contractility. Selenium deficiency in conjunction with inspiratory resistive loading resulted in a significant decrease in diaphragmatic twitch and tetanic force, with a downward shift in the force/frequency curve. These data suggest that selenium deficiency lowers diaphragmatic glutathione peroxidase activity, and when these animals are subjected to the oxidative stress of resistive loading, there is an impairment in muscle function. We conclude that a functional glutathione peroxidase is necessary to protect the diaphragm against the effects of resistive loading.

Assessment of the voluntary activation of the diaphragm using cervical and cortical magnetic stimulation.

The twitch occlusion technique is a promising tool for use in accessing central drive to the diaphragm and determining maximal transdiaphragmatic pressure (Pdi) from submaximal efforts. It clinical use is limited by difficulties inherent to bilateral electrical stimulation (BES) of the phrenic nerves. This study was designed to revisit the technique using cervical magnetic stimulation (CMS). In addition, the effects of a voluntary contraction on diaphragm response to magnetic stimulation of the cortex (CxMS) were studied. Seven volunteers aged 23-33 yrs were studied. Pdi was determined at relaxed functional residual capacity (FRC) in response to BES (Pdi,P-ES) and CMS (Pdi,p-CMS), and the effects of an increasing voluntary contraction (Pdi, vol) were assessed, The same procedure was applied to CxMS. Pdi,p-CMS at relaxed FRC was 27.5 +/- 2.2 cmH2O (mean+/-SEM), about 20% higher than Pdi,p-ES, and reported previously. Pd,p-CMS linearly decreased with Pdi, vol, and six out of seven subjects were capable of producing voluntary contractions sufficient to extinguish the twitch. More complex patterns were observed with CxMS. Cervical magnetic stimulation provides diaphragmatic twitch occlusion data very similar to bilateral electrical phrenic stimulation. Magnetic stimulation, be it cervical or cortical, could probably be helpful for the assessment of central and peripheral mechanisms of diaphragmatic dysfunction in the clinical setting.

Potentiation of diaphragmatic twitch after voluntary contraction in normal subjects.

Skeletal muscle twitch responses may be transiently increased by previous contractions, a phenomenon termed twitch potentiation. The aim of this study was to examine the extent and time course of diaphragmatic twitch potentiation and its relationship to both the magnitude and duration of the preceding voluntary diaphragmatic contraction. Twitch transdiaphragmatic pressure (PDI) was measured in six normal subjects, before and after voluntary diaphragm contractions of 100%, 75%, 50%, and 25% of maximum PDI (PDImax) sustained for five and 10 seconds. Twitch PDI was significantly increased after 100%, 75%, and 50% contractions. Following maximal contractions sustained for 10 seconds the mean increase in twitch PDI was 52%. Following 50% contractions sustained for five seconds the mean increase in twitch height was 28%. In all runs twitch PDI returned to rested levels within 20 minutes. Twitch potentiation can be substantial, even following submaximal contractions, and must be taken into account when twitch pressure is used to assess diaphragm contractility.

Cervical magnetic stimulation: a new painless method for bilateral phrenic nerve stimulation in conscious humans.

Assessing diaphragmatic contractility is a common goal in various situations. This assessment is mainly based on static or dynamic maximal voluntary maneuvers and twitch transdiaphragmatic pressures (Pdi) obtained by stimulation of the phrenic nerves (PS). PS eliminates the central components of diaphragmatic activation, but the available techniques of PS remain subject to some limitations. Transcutaneous PS is painful, and needle PS is potentially dangerous. Time-varying magnetic fields can stimulate nervous structures without pain and without adverse effects. In six subjects, we have studied cervical magnetic stimulation (CMS) as a method of PS. We have compared the stimulated Pdi (Pdistim) with the maximal Pdi obtained during static combined expulsive-Mueller maneuver (Pdimax) and with the Pdi generated during a sniff test (Pdisniff). CMS produced twitch Pdi averaging 33.4 +/- 9.7 cmH2O. Pdistim/Pdimax and Pdistim/Pdisniff were 24 +/- 6 and 41 +/- 14%, respectively. These values are comparable to those obtained in other studies with transcutaneous PS. They were highly reproducible in all the subjects. Electromyographic data provided evidence of bilateral maximal stimulation. CMS is a nonspecific method and may stimulate various nervous structures. However, diaphragmatic contraction was elicited by stimulation of the phrenic trunk, since the phrenicodiaphragmatic latencies (less than 7 ms) were in the range of values reported with direct stimulation of the trunk. Cocontraction of neck muscles, including the sternomastoid, was present, but its influence in the CMS-induced Pdi seems minimal. We conclude that magnetic stimulation is an easy, well-tolerated, reproducible safe, and valuable method to assess phrenic conduction and diaphragmatic twitch response.