Titre : | Identifying the role of diaphragm pacing stimulation (DPS) in amyotrophic lateral sclerosis/motor neuron disease : results fromover 50 consecutive implants |
contenu dans : | |
Auteurs : | Collectif ; Elmo MJ ; Katirji B |
Type de document : | Article |
Année de publication : | 2009 |
Pages : | p. 27 |
Langues: | Anglais |
Résumé : | Background : Respiratory failure is a major cause of mortality in amyotrophic lateral sclerosis/motor neuron disease patients. Mechanical ventilation with attendant limitations is the only current therapeutic option for patients developing respiratory compromise. Diaphragm pacing stimulation (DPS) is being utilized to assist in ventilation in patients with ALS/MND and this reports the experience at the worlds largest implant site. Aim : Review of results from the initial site implanting DPS in ALS patients. Methods : From2005 to 2008, patients were evaluated prospectively and then underwent diaphragm motor point mapping with percutaneous intra-muscular electrode implantation. Diaphragm conditioning ensued. Results : 51 patients were implanted with DPS with a predicted Forced Vital Capacity (FVC) at implantation ranging from 20% predicted to 88% predicted. Only one significant peri-operative adverse events occurred in a patient with an FVC below 20% and extreme malnutrition requiring both a feeding tube and DPS. Feeding tubes were safely implanted simultaneously with DPS with a 12 month survival of 83% compared to reported historical 30 day mortality rate for gastrostomy alone of up to 40%. DPS patients with FVC below 50% at implantation have a mean survival of 16 months compared to the historical one year mortality rate of 100%. Additional findings include : DPS increases diaphragm muscle thickness as measured by ultrasound; DPS improved diaphragm movement under fluoroscopy; DPS maintains the respiratory sub-score of ALSFRS-r; DPS can convert fast twitch glycolytic (Type IIb) to functional slow twitch oxidative muscle (Type I) fibers; DPS improves posterior lobe lung ventilation; DPS increases lung compliance leading to decreased work of breathing; and patients have started utilizing DPS to improve night time ventilation. It was found that ALS patients develop instability of respiratory control and even acquired central hypoventilation. Over 50% of patients utilized DPS during sleep. DPS was used to overcome hypoventilation and hypercarbia. Conclusion : Diaphragm pacing can be safely implanted in ALS patients positively affecting diaphragm physiology to improve both peri-operative and long term survival. DPS overcomes upper motor neuron involvement and the instability of respiratory control. |