新型多功能食管电极管和双颈前膈神经磁刺激评估机械通气患者膈肌功能的应用研究
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摘要
目的监测重症监护室(ICU)机械通气患者的膈肌功能。方法纳入2013年5月至2013年11月机械通气≥72 h、病情稳定、通过撤机筛查、拟行自主呼吸试验的患者进行前瞻性研究。运用新型多功能食管电极管结合双颈前外侧膈神经磁刺激(BAMPS),监测膈神经传导时间(PNCT)、膈肌复合动作电位(CMAP)和颤触性跨膈压(TwPdi)。结果共入选14例患者,1例不能耐受磁刺激,2例无膈肌肌电信号,1例未刺激到膈神经,1例未获得有效颤触性跨膈压(PNCT、CMAP分别为7.2 ms、1.26 mV),9例取得完整检查数据的ICU机械通气患者PNCT、CMAP、TwPdi分别为(8.5±1.5)ms、(1.01±0.35)mV、(11.2±4.7)cm H2O。结论新型多功能食管电极管结合膈神经磁刺激可客观综合评估ICU患者的膈肌功能,但不是所有患者都适用。
Objective To monitor the diaphragm function of mechanical ventilated patients in the intensive care unit. Methods A prospective study was conducted on mechanical ventilation patients who had been evaluated by ventilation weaning screening test and planning to underwent spontaneous breathing trial between May 2013 and November 2013. A newly designed multi-function esophageal electrode was used to record the phrenic nerve conduction time(PNCT),diaphragm compound muscle action potential(CMAP)and twitch transdiaphragmatic pressure(TwPdi) elicited by bilateral anterolateral magnetic phrenic nerve stimulation. Results 14 patients were recruited in this study. 1 case exited because of intolerance of repetitive magnetic stimulation,2 cases had no diaphragmatic electromyographic signals nor twitch signals,1case had diaphragmatic electromyographic signal but could not be elicited by magnetic stimulation,1 case had no available TwPdi value with PNCT of 7. 2 ms and CMAP of 1. 26 mV. In the rest 9 cases,the PNCT,CMAP and TwPdi were(8. 5 ± 1. 5) ms,(1. 01 ± 0. 35) mV,(11. 2 ± 4. 7) cm H2 O,respectively.Conclusion Newly designed multi-function esophageal electrode catheter combined with bilateral anterolateral magnetic phrenic nerve stimulation can be used for non-volitional comprehensive assessment of diaphragm in critically ill patients,but not suitable for all subjects.
Objective To monitor the diaphragm function of mechanical ventilated patients in the intensive care unit. Methods A prospective study was conducted on mechanical ventilation patients who had been evaluated by ventilation weaning screening test and planning to underwent spontaneous breathing trial between May 2013 and November 2013. A newly designed multi-function esophageal electrode was used to record the phrenic nerve conduction time(PNCT),diaphragm compound muscle action potential(CMAP)and twitch transdiaphragmatic pressure(TwPdi) elicited by bilateral anterolateral magnetic phrenic nerve stimulation. Results 14 patients were recruited in this study. 1 case exited because of intolerance of repetitive magnetic stimulation,2 cases had no diaphragmatic electromyographic signals nor twitch signals,1case had diaphragmatic electromyographic signal but could not be elicited by magnetic stimulation,1 case had no available TwPdi value with PNCT of 7. 2 ms and CMAP of 1. 26 mV. In the rest 9 cases,the PNCT,CMAP and TwPdi were(8. 5 ± 1. 5) ms,(1. 01 ± 0. 35) mV,(11. 2 ± 4. 7) cm H2 O,respectively.Conclusion Newly designed multi-function esophageal electrode catheter combined with bilateral anterolateral magnetic phrenic nerve stimulation can be used for non-volitional comprehensive assessment of diaphragm in critically ill patients,but not suitable for all subjects.
引文
1 Doorduin J,van Hees HW,van der Hoeven JG,et al.Monitoring of the respiratory muscles in the critically ill.Am J Respir Crit Care Med,2013,187:20-27.
2 Mead J,Loring SH.Analysis of volume displacement and length changes of the diaphragm during breathing.J Appl Physiol Respir Environ Exerc Physiol,1982,53:750-755.
3 Man WD,Moxham J,Polkey MI.Magnetic stimulation for the measurement of respiratory and skeletal muscle function.Eur Respir J,2004,24:846-860.
4 NHLBI Workshop summary.Respiratory muscle fatigue.Report of the Respiratory Muscle Fatigue Workshop Group.Am Rev Respir Dis,1990,142:474-480.
5 Mador MJ,Khan S,Kufel TJ.Bilateral anterolateral magnetic stimulation of the phrenic nerves can detect diaphragmatic fatigue.Chest,2002,121:452-458.
6 ATS/ERS Statement on respiratory muscle testing.Am J Respir Crit Care Med,2002,166:518-624.
7 郑则广.两种测量膈神经传导时间和动作电位幅度方法的比较.中国呼吸与危重监护杂志,2002,1:36-39.
8 郑则广.电刺激和磁波刺激法评价膈肌功能的比较.中国呼吸与危重监护杂志,2004,3:117-119.
9 Luo YM,Moxham J,Polkey MI.Diaphragm electromyography using an oesophageal catheter:current concepts.Clin Sci(London,England:1979),2008,115:233-244.
10 Watson AC,Hughes PD,Louise Harris M,et al.Measurement of twitch transdiaphragmatic,esophageal,and endotracheal tube pressure with bilateral anterolateral magnetic phrenic nerve stimulation in patients in the intensive care unit.Crit Care Med,2001,29:1325-1331.
11 Hermans G,Agten A,Testelmans D,et al.Increased duration of mechanical ventilation is associated with decreased diaphragmatic force:a prospective observational study.Crit Care,2010,14:R127.
12 Cattapan SE,Laghi F,Tobin MJ.Can diaphragmatic contractility be assessed by airway twitch pressure in mechanically ventilated patients?Thorax,2003,58:58-62.
13 Demoule A,Jung B,Prodanovic H,et al.Diaphragm dysfunction on admission to the intensive care unit.Prevalence,risk factors,and prognostic impact-a prospective study.Am J Respir Crit Care Med,2013,188:213-219.
14 Luo YM,Li RF,Jolley C,et al.Neural respiratory drive in patients with COPD during exercise tests.Respiration,2011,81:294-301.
15 中华医学会重症医学分会.机械通气临床应用指南(2006).中国危重病急救医学,2007,19:65-72
16 罗远明,陈荣昌,钟南山.磁刺激诱发的膈肌复合动作电位的多导食道电极记录及其在重症监护室患者中的应用.中华结核和呼吸杂志,2005,28:505-508.
17 Wragg S,Hamnegard C,Road J,et al.Potentiation of diaphragmatic twitch after voluntary contraction in normal subjects.Thorax,1994,49:1234-1237.
18 Luo YM,Lyall RA,Harris ML,et al.Effect of lung volume on the oesophageal diaphragm EMG assessed by magnetic phrenic nerve stimulation.Euro Respir J,2000,15:1033-1038.
19 Man WDC,Luo YM,Mustfa N,et al.Postprandial effects on twitch transdiaphragmatic pressure.Euro Respir J,2002,20:577-580.
20 Mier A,Brophy C,Moxham J,et al.Influence of lung volume and rib cage configuration on transdiaphragmatic pressure during phrenic nerve stimulation in man.Respir Physiol,1990,80:193-202.
21 Chen R,Collins S,Remtulla H,et al.Phrenic nerve conduction study in normal subjects.Muscle Nerve,1995,18:330-335.
22 Luo YM,Hart N,Mustfa N,et al.Reproducibility of twitch and sniff transdiaphragmatic pressures.Respir Physiol Neurobiol,2002,132:301-306.
23 Luo YM,Lyall RA,Lou Harris M,et al.Quantification of the esophageal diaphragm electromyogram with magnetic phrenic nerve stimulation.Am J Respir Crit Care Med,1999,160:1629-1634.
2 Mead J,Loring SH.Analysis of volume displacement and length changes of the diaphragm during breathing.J Appl Physiol Respir Environ Exerc Physiol,1982,53:750-755.
3 Man WD,Moxham J,Polkey MI.Magnetic stimulation for the measurement of respiratory and skeletal muscle function.Eur Respir J,2004,24:846-860.
4 NHLBI Workshop summary.Respiratory muscle fatigue.Report of the Respiratory Muscle Fatigue Workshop Group.Am Rev Respir Dis,1990,142:474-480.
5 Mador MJ,Khan S,Kufel TJ.Bilateral anterolateral magnetic stimulation of the phrenic nerves can detect diaphragmatic fatigue.Chest,2002,121:452-458.
6 ATS/ERS Statement on respiratory muscle testing.Am J Respir Crit Care Med,2002,166:518-624.
7 郑则广.两种测量膈神经传导时间和动作电位幅度方法的比较.中国呼吸与危重监护杂志,2002,1:36-39.
8 郑则广.电刺激和磁波刺激法评价膈肌功能的比较.中国呼吸与危重监护杂志,2004,3:117-119.
9 Luo YM,Moxham J,Polkey MI.Diaphragm electromyography using an oesophageal catheter:current concepts.Clin Sci(London,England:1979),2008,115:233-244.
10 Watson AC,Hughes PD,Louise Harris M,et al.Measurement of twitch transdiaphragmatic,esophageal,and endotracheal tube pressure with bilateral anterolateral magnetic phrenic nerve stimulation in patients in the intensive care unit.Crit Care Med,2001,29:1325-1331.
11 Hermans G,Agten A,Testelmans D,et al.Increased duration of mechanical ventilation is associated with decreased diaphragmatic force:a prospective observational study.Crit Care,2010,14:R127.
12 Cattapan SE,Laghi F,Tobin MJ.Can diaphragmatic contractility be assessed by airway twitch pressure in mechanically ventilated patients?Thorax,2003,58:58-62.
13 Demoule A,Jung B,Prodanovic H,et al.Diaphragm dysfunction on admission to the intensive care unit.Prevalence,risk factors,and prognostic impact-a prospective study.Am J Respir Crit Care Med,2013,188:213-219.
14 Luo YM,Li RF,Jolley C,et al.Neural respiratory drive in patients with COPD during exercise tests.Respiration,2011,81:294-301.
15 中华医学会重症医学分会.机械通气临床应用指南(2006).中国危重病急救医学,2007,19:65-72
16 罗远明,陈荣昌,钟南山.磁刺激诱发的膈肌复合动作电位的多导食道电极记录及其在重症监护室患者中的应用.中华结核和呼吸杂志,2005,28:505-508.
17 Wragg S,Hamnegard C,Road J,et al.Potentiation of diaphragmatic twitch after voluntary contraction in normal subjects.Thorax,1994,49:1234-1237.
18 Luo YM,Lyall RA,Harris ML,et al.Effect of lung volume on the oesophageal diaphragm EMG assessed by magnetic phrenic nerve stimulation.Euro Respir J,2000,15:1033-1038.
19 Man WDC,Luo YM,Mustfa N,et al.Postprandial effects on twitch transdiaphragmatic pressure.Euro Respir J,2002,20:577-580.
20 Mier A,Brophy C,Moxham J,et al.Influence of lung volume and rib cage configuration on transdiaphragmatic pressure during phrenic nerve stimulation in man.Respir Physiol,1990,80:193-202.
21 Chen R,Collins S,Remtulla H,et al.Phrenic nerve conduction study in normal subjects.Muscle Nerve,1995,18:330-335.
22 Luo YM,Hart N,Mustfa N,et al.Reproducibility of twitch and sniff transdiaphragmatic pressures.Respir Physiol Neurobiol,2002,132:301-306.
23 Luo YM,Lyall RA,Lou Harris M,et al.Quantification of the esophageal diaphragm electromyogram with magnetic phrenic nerve stimulation.Am J Respir Crit Care Med,1999,160:1629-1634.