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Rationale <p>Diaphragm neurostimulation-assisted ventilation (DNAV) can improve cardiopulmonary function during passive mechanical ventilation. However, this technique requires a reliable method to monitor and titrate diaphragmatic loading to avoid both insufficient and excessive diaphragmatic stimulation.</p> Objective <p>To establish whether the reduction in airway pressure-time product (ΔPTPaw) obtained during diaphragm neurostimulation in assist control volume-controlled mode accurately quantifies the magnitude of respiratory muscle effort elicited by neurostimulation.</p> Methods <p>This was a secondary analysis of the STIMULUS trial. Diaphragm neurostimulation was titrated across four levels targeting progressive occlusion pressures of 0, − 5, − 10, and − 15&#xa0;cm H₂O at two PEEP levels. At each level, airway, esophageal, and gastric pressures were recorded to compute transdiaphragmatic pressure-time product (PTPdi), respiratory muscles pressure-time product (PTPmus), and ΔPTPaw, defined as the difference in airway pressure-time product between non-stimulated and stimulated breaths. Linear mixed-effects models, Bland–Altman analyses, and receiver operating characteristic (ROC) curves were used to assess agreement and discriminative ability.</p> Measurements and main results <p>Twelve patients contributed 494 high-quality respiratory cycles (63% of recorded cycles). Valid Pdi data were available in nine patients. Increasing neurostimulation was associated with higher PTPdi and PTPmus and a corresponding reduction in PTPaw. ΔPTPaw was correlated with both PTPdi (R² = 0.82) and PTPmus (R² = 0.92), with good agreement observed (limits: − 4 to 44&#xa0;cm H₂O·s/min for PTPdi, and − 5 to 39&#xa0;cm H₂O·s/min for PTPmus). ΔPTPaw demonstrated excellent discrimination for inadequate (area under receiver operating characteristic curve, AUROC ≥ 0.94) and excessive (AUROC ≥ 0.86) diaphragmatic effort.</p> Conclusions <p>ΔPTPaw is a reliable, non-invasive surrogate for monitoring diaphragm loading during DNAV under assist-controlled volume-controlled mode and may guide neurostimulation titration in mechanically ventilated patients.</p>

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Monitoring diaphragmatic effort during diaphragm neurostimulation-assisted ventilation

  • 期刊论文

  • 出版模式：

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  • 发表日期：

    2025年12月23日

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  • Andrea Castellvi-Font,
  • Idunn S. Morris,
  • Francisco José Parrilla-Gómez,
  • Matías Madormo,
  • Catherine A. Bellissimo,
  • Viral Thakkar,
  • Nawzer Mehta,
  • Thiago Bassi,
  • Laurent J. Brochard,
  • Niall D. Ferguson,
  • Ewan C. Goligher

摘要

Rationale

Diaphragm neurostimulation-assisted ventilation (DNAV) can improve cardiopulmonary function during passive mechanical ventilation. However, this technique requires a reliable method to monitor and titrate diaphragmatic loading to avoid both insufficient and excessive diaphragmatic stimulation.

Objective

To establish whether the reduction in airway pressure-time product (ΔPTPaw) obtained during diaphragm neurostimulation in assist control volume-controlled mode accurately quantifies the magnitude of respiratory muscle effort elicited by neurostimulation.

Methods

This was a secondary analysis of the STIMULUS trial. Diaphragm neurostimulation was titrated across four levels targeting progressive occlusion pressures of 0, − 5, − 10, and − 15 cm H₂O at two PEEP levels. At each level, airway, esophageal, and gastric pressures were recorded to compute transdiaphragmatic pressure-time product (PTPdi), respiratory muscles pressure-time product (PTPmus), and ΔPTPaw, defined as the difference in airway pressure-time product between non-stimulated and stimulated breaths. Linear mixed-effects models, Bland–Altman analyses, and receiver operating characteristic (ROC) curves were used to assess agreement and discriminative ability.

Measurements and main results

Twelve patients contributed 494 high-quality respiratory cycles (63% of recorded cycles). Valid Pdi data were available in nine patients. Increasing neurostimulation was associated with higher PTPdi and PTPmus and a corresponding reduction in PTPaw. ΔPTPaw was correlated with both PTPdi (R² = 0.82) and PTPmus (R² = 0.92), with good agreement observed (limits: − 4 to 44 cm H₂O·s/min for PTPdi, and − 5 to 39 cm H₂O·s/min for PTPmus). ΔPTPaw demonstrated excellent discrimination for inadequate (area under receiver operating characteristic curve, AUROC ≥ 0.94) and excessive (AUROC ≥ 0.86) diaphragmatic effort.

Conclusions

ΔPTPaw is a reliable, non-invasive surrogate for monitoring diaphragm loading during DNAV under assist-controlled volume-controlled mode and may guide neurostimulation titration in mechanically ventilated patients.