Assessment of human diaphragm strength and activation using phrenic nerve stimulation

doi:10.1016/0034-5687(84)90003-3

Respiration Physiology

Volume 58, Issue 3, December 1984, Pages 263-277

Respiration Physiolo...

https://doi.org/10.1016/0034-5687(84)90003-3 Get rights and content

Abstract

The phrenic nerves were stimulated bilaterally in human subjects with supermaximal shocks and the transdiaphragmatic pressure (Pdi) twitches recorded at end-expiratory lung volume with glottis closed. Stimulus maximality was monitored by the evoked muscle potentials. The highly reproducible twitch amplitudes elicited from the relaxed diaphragm were greater with bound (48 ± 13 cm H₂O) than unbound (34.6 ± 10 cm H₂O abdomen in sitting position. With bound abdomen, the twitch amplitudes were similar in sitting and supine positions. When the same stimuli were applied during voluntary contractions the superimposed twitch amplitude declined almost linearly with the voluntary Pdi exerted, reflecting a progressively increasing activation by the CNS. From this relationship both the maximal Pdi (Pdi_max) and the relative degree of diaphragm activation (% Pdi_max) can be estimated for any type of breathing effort. Generally no twitch could be detected during maximal efforts (Pdi_max:218 ± 34 cm H₂O) indicating that all stimulated motor units were already fully activated. The Pdi_twitch/Pdi_max ratio of 0.21 ± 0.04 was similar to the twitch/tetanus ratios of isolated mammalian muscle, suggesting that bilateral stimulation can activate all phrenic motor neurons.

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This technique also can be used to separately evaluate the function of each hemidiaphragm. A Pdi twitch greater than 10 cm H2O with unilateral phrenic nerve stimulation or greater than 20 cm H2O with bilateral phrenic nerve stimulation excludes significant diaphragm weakness.31,32 However, irrespective of how the diaphragm is activated (by voluntary or nonvolitional means), it requires placement of catheters in both the lower esophagus and the stomach, thus eliciting some patient discomfort and requiring expertise that may not be available to the clinician.
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The diaphragm is a dome-shaped muscle that separates the chest from the abdomen. The diaphragm plays a vital role in the respiratory system. With each contraction of the diaphragm toward the bottom of the rib cage, the lungs expand and fill with air, expanding the thoracic cavity and decreasing intrathoracic pressure and drawing air into the lungs. When the diaphragm relaxes, the elastic recoil of the lungs predominates, which causes exhalation. The diaphragm is also important in expulsive actions such as sneezing, coughing, vomiting, and crying. Dysfunctions of the diaphragm can be classified as paralysis, weakness, or eventration. One of the common abnormal developments of the diaphragm is congenital diaphragmatic hernia (CDH), which has been reported to be as high as 1 in 2500 births. Treating CDH is a challenging issue in tissue engineering. Advances in regenerative medicine suggest innovative options for the repair of diaphragmatic defects. By combining tissue engineering and cell transplantation, scientists aim to replace damaged tissues and organs. Before reconstructing diaphragmatic defects, it is important to understand two primary factors: the mechanism of CDH and that the substitute tissue should be biologically and biomechanically similar to the part of the native diaphragm it is replacing. Once the diaphragm is repaired, the affected lungs should also function normally.
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Citation Excerpt :
Whilst chest circumference was not measured in the current study, lung volumes were indeed larger in men compared to women (data not presented), which may partially explain our observations. Subjects were resting at functional residual capacity immediately prior to each stimulation − an important consideration given that lung volumes are known to increase CMAP amplitude (Bellemare and Bigland-Ritchie, 1984). Males also had marginally longer onset latencies, likely as a consequence of phrenic nerve length.
Stimulation of the phrenic nerve via cervical magnetic stimulation (CMS) elicits a compound muscle action potential (CMAP) that allows for assessment of diaphragm activation. The reliability of CMS to evoke the CMAP recorded by chest wall surface EMG has yet to be comprehensively examined.
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All CMAP characteristics demonstrated high reproducibility within (ICCs > 0.96) and between (ICCs > 0.89) experimental sessions. No statistically significant bilateral or sex-based differences were found (p > 0.05).
CMS is a reliable and non-invasive method to evaluate phrenic nerve conduction.
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Thirteen patients with suspected asymmetric diaphragmatic weakness based on dyspnea and hemidiaphragm elevation on the chest radiograph were studied as well as three patients with maltase acid deficiency (a cause of symmetrical diaphragmatic weakness). The transdiaphragmatic pressure response to unilateral magnetic stimulation (lateral twitch transdiaphragmatic pressure [latPdiTw]) and the diaphragm compound muscle action potentials (CMAPs) elicited by transcutaneous electrical stimulation of each phrenic nerve as well as OEP were performed.
The CMAPs and latPdiTw showed unilateral or predominantly unilateral diaphragmatic weakness in nine of the 13 patients. By OEP, the affected side of the thorax and abdomen contributed < 45% of the inspiratory capacity in each of these nine patients, whereas no asymmetry was noted in the other four patients or in the three patients with maltase acid deficiency. All patients preferred OEP over CMAP or latPdiTw.
OEP detected asymmetric ventilation in all patients diagnosed with unilateral diaphragm weakness and in no patients without this diagnosis. Thus, OEP is an effective noninvasive alternative that is preferred by the patients over CMAP response and latPdiTw.
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^∗: Present address: Meakins-Christie Laboratories, McGill University, 3775 University St., Montreal, Canada H3A-2B4.

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Assessment of human diaphragm strength and activation using phrenic nerve stimulation

Abstract

Chest

Respir. Physiol.

Abdominal and thoracic pressure at different lung volumes

J. Appl. Physiol.

Detection of diaphragmatic fatigue in man by phrenic stimulation

J. Appl. Physiol.

Extent of motor unit activation during effort

J. Appl. Physiol.

Force reserve of the diaphragm in COPD patients

J. Appl. Physiol.

Motor unit firing rates during maximal voluntary contractions of three human muscles

J. Neurophysiol.

Central and peripheral fatigue in sustained maximal contractions of human quadriceps muscles

Clin. Sci. Mol. Med.

Contractile speed and EMG changes during fatigue of sustained maximal voluntary contraction

J. Neurophysiol.

Dynamic properties of mammalian skeletal muscles

Physiol. Rev.

Maximal work of one breathing cycle

J. Appl. Physiol. Rev.

On inhibition as a reflex accompaniment of the tendon jerk and other forms of active muscular response

Limitations of measurement of transdiaphragmatic pressure in detecting diaphragmatic weakness

Thorax

Action of the costal and crural parts of the diaphragm on the rib cage in dogs

J. Appl. Physiol.

Human skeletal muscle function: Description of tests and normal values

Clin. Sci. Mol. Med.

The diaphragm as a muscle: Mechanisms underlying fatigue

Am. Rev. Respir. Dis.

Adaptibility of the hamster diaphragm to exercise and/or emphysema

J. Appl. Physiol.

Mechanics of the human diaphragm during voluntary contractions: Statics

J. Appl. Physiol.