Monitoring Neural Output

Transcription

1 Monitoring Neural Output Christer Sinderby Department of Critical Care & Keenan Research Center for Biomedical Science of St. Michael's Hospital Interdepartmental division of Critical Care Medicine, University of Toronto, Canada Disclosure: Dr. Sinderby has made inventions related to neural control of mechanical ventilation that are patented. The license for these patents belongs to Maquet Critical Care. Use of this technology provides financial benefit to Dr. Sinderby through royalties. Dr Sinderby owns 50% of Neurovent Research Inc (NVR). NVR is a research and development company that builds the equipment and catheters for research studies. NVR has a consulting agreement with Maquet Critical Care.

2 Conflict of interest Disclosure: Dr. Sinderby has made inventions related to neural control of mechanical ventilation that are patented. The license for these patents belongs to Maquet Critical Care. Commercial use of this technology provides financial benefit to Dr. Sinderby through royalties. Dr Sinderby owns 50% of Neurovent Research Inc (NVR). NVR is a research and development company that builds the equipment and catheters for research studies. NVR has a consulting agreement with Maquet Critical Care.

3 Straight lines, periodic pattern, is seldom found in biological and physiological systems. Rather variability is weighty.

4 Phrenic Nerve Golden Standard to measure Neural respiratory drive

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6 Quantification of phrenic nerve activity (PNA). Hakan S. Orer et al. J Appl Physiol 2006;101: Sinderby Unpublished observations

7 Trans-esophageal measurements of Diaphragm EMG (EMGdi) later Diaphragm Electrical Activity (EAdi) PETIT JM, MILIC-EMILI G, DELHEZ L. New technic for the study of functions of the diaphragmatic muscle by means of electromyography in man. Boll Soc Ital Biol Sper Dec 31;35:

8 Valid EAdi method using electrode array Standardization document by the ATS and ERS In: ATS/ERS Statement on Respiratory Muscle Testing. Aldrich, T., Sinderby, C., McKenzie, D, Estenne, M., and Gandevia, S. Am. J. Respir. Crit. Care Med. 166: , 2002 Sinderby & Beck, Neurally Adjusted Ventilatory Assist in Principles and Practice of Mechanical Ventilation, Third Edition Editor: Tobin MJ, McGraw-Hill Medical 2013

9 Measure Neural Respiratory Drive EAdi Amplitude Temporo-spatial summation of motor unit action potentials firing rate and recruitment

10 What Affects Neural Drive Sinderby & Beck, Neurally Adjusted Ventilatory Assist in Principles and Practice of Mechanical Ventilation, Third Edition Editor: Tobin MJ, McGraw-Hill Medical 2013

11 Effect of age Sinderby & Beck, Neurally Adjusted Ventilatory Assist in Principles and Practice of Mechanical Ventilation, Third Edition Editor: Tobin MJ, McGraw-Hill Medical 2013

12 Type 1 Apnea

13 EAdi in the Adult: Health and Disease Sinderby & Beck, Neurally Adjusted Ventilatory Assist in Principles and Practice of Mechanical Ventilation, Third Edition Editor: Tobin MJ, McGraw-Hill Medical 2013

14 Unloading, HB reflex,uncoupling, PVBC Assisted breaths Non-Assisted breaths 12 ARF

15 Sedation Monitor!

16 Monitoring Patient-Ventilator Interaction

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18 Is a fixed level of assist enough? Same patient 40 minutes apart St-Michael s Hospital, Campoccia et al, 2006

19 Keep the diaphragm going? Or at least monitor if it is! Courtesy of Dr E Goligher

20 We are getting closer to count respiratory rate accurately!

21 Weaning readiness

22 Monitoring day-to-day Spahija et al, Sacre Coeur Hospital, Montreal

23 SBT

24 Normal Edi values

25 Normal EAdi peak values Intubated, Non-Invasive, No assist

26 Frequency domain

27 EAdi Time vs Frequency Domain

28 EAdi power spectrum show fatigue Effect of pressure and timing of contraction on human diaphragm fatigue. Bellemare F, Grassino A. J Appl Physiol Respir Environ Exerc Physiol Nov;53(5):

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30 If I had another hour Neural Respiratory Monitoring Neuromuscular disorders Cheyne Stoke Delirium Uncontrolled drive Speaking, swallowing, vomiting

31 Questions?

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33 Bedside measurements of neural respiratory drive

34 Respiratory pattern

35 100 ms Occlusion Pressure (P0.1)

36 100 ms Occlusion Pressure (P0.1) Weakness!!! Dynamic hyperinflation Weakness Beck et al J Appl Physiol 85, , 1998 Courtesy Dr E Goligher

37 Esophageal & Transdiahragmatic Pressures Is Neural Drive linked to Pes and Pdi?

38 Weakness!!! Dynamic hyperinflation Weakness Beck et al J Appl Physiol 85, , 1998 Courtesy Dr E Goligher

39 Esophageal & Transdiaphragmatic Pressures Proportional assist abolish Pes and Pdi but not Edi! Sinderby & Beck, Neurally Adjusted Ventilatory Assist in Principles and Practice of Mechanical Ventilation, Third Edition Editor: Tobin MJ, McGraw-Hill Medical 2013

40 Surface EMG

41 Surface EMG Not for everyone Cross-talk Inspiratory/Expiratory/Postural muscles Electrode-to-muscle distance filtering

42 Needle EMG of the diaphragm Relatively standardized Specific to few motor units Not for long term monitoring of neural respiratory drive In: ATS/ERS Statement on Respiratory Muscle Testing. Aldrich, T., Sinderby, C., McKenzie, D, Estenne, M., and Gandevia, S. Am. J. Respir. Crit. Care Med. 166: , 2002