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Diaphragmatic pacing is a procedure that is performed to stimulate the phrenic nerve to cause diaphragm contraction. This diaphragm contraction helps in the generation of breath, provides reliable minute ventilation, and may facilitate ventilator weaning or delay the progression to noninvasive or invasive mechanical ventilation. This activity outlines the evaluation and treatment of patients with diaphragmatic dysfunction and explains the role of the interprofessional team in improving care for patients requiring this procedure. Objectives: Identify the indications of diaphragmatic pacing. Describe the technique in regards to diaphragmatic pacing. Review the potential complications of diaphragmatic pacing. Explain the importance of improving care coordination amongst the interprofessional team to enhance the delivery of care for patients with a diaphragmatic pacer. Access free multiple choice questions on this topic.

Diaphragm dysfunction is an underdiagnosed condition that causes unexplained dyspnea. The dysfunction can range from partial weakness to complete paralysis of either one hemidiaphragm or both hemidiaphragms.[1] Spinal cord injuries (SCI) and critical care polyneuropathies encompass a large number of the cases of diaphragmatic dysfunction. According to the National Spinal Cord Injury Statistics Center, the incidence of traumatic SCI in the United States was approximately 17,000 in 2016.[2] Diaphragmatic paralysis usually results from a high spinal cord injury, whereas mid-cervical lesions lead to partial weakness. SCI leads to chronic impairment and disability. Half of these patients develop tetraplegia, with 4% of these patients requiring long-term mechanical ventilation.[3] Critical illness polyneuropathy (CIP) is a common complication of critical illness affecting the motor and sensory neurons.[4] Muscle involvement causing loss of muscle mass and eventual weakness has been referred to as critical illness myopathy. The involvement of the phrenic nerve and diaphragm leads to its weakness and, at times, complete paralysis. These patients have worse outcomes with prolonged weaning, higher hospital length of stays, and dependency on mechanical ventilation.[5] Traditional approaches to management have been mainly focused on waiting for recovery through innervation while supporting the patient on mechanical ventilation. However, this is fraught with complications. In the past few years, diaphragmatic pacing (DP) has been a proven therapy to wean SCI patients from mechanical ventilation (MV).[6] A small feasibility study evaluating DP in critically ill mechanically ventilated patients demonstrated that the diaphragm could significantly help with the work of breathing when activated by a catheter-based, transvenous DP.[7] A large multi-center randomized clinical trial (RESCUE 2) is underway to compare temporary transvenous diaphragm pacing versus standard of care for weaning from mechanical ventilation.[8]

Potential complications include but are not limited to intraoperative damage to the phrenic nerve, vascular injuries, acute lung injury, pericardial and esophageal injuries, diaphragmatic perforation, viscous perforation, and peritonitis.

Diaphragm pacing is a perfect example of the need for an interprofessional team for improving outcomes in patients. This procedure not only involves clinicians across specialties, but there is also consistent involvement of ancillary services like nursing care, physical therapy, occupational therapy, and speech therapy. The rehabilitative process involves diaphragmatic conditioning after pacer implantation, which can take a long time. Education of all ancillary staff to identify clinical signs and symptoms of pacemaker malfunction and timely communication to the treating clinician is the key to the successful rehabilitation of these patients. [Level 4]