Corrective effect of diaphragm pacing on the decrease in cardiac output induced by positive pressure mechanical ventilation in anesthetized sheep

Abstract

Positive pressure ventilation (PPV) is a fundamental life support measure, but it decreases cardiac output (CO). Diaphragmatic contractions produce negative intrathoracic and positive abdominal pressures, promoting splanchnic venous return. We hypothesized that: 1) diaphragm pacing alone could produce adequate ventilation without decreasing CO; 2) diaphragm pacing on top of PPV could improve CO. Of 11 anesthetized and mechanically ventilated ewes (39.6±5.9kg), 3 were discarded from analysis because of hemodynamic instability during the experiment, and 8 retained for analysis. Phrenic stimulation electrodes were inserted in the diaphragm (implanted phrenic nerve stimulation, iPS). CO was measured by the thermodilution technique (pulmonary artery catheter). CO during end-expiratory apnea served as reference. Median CO was 9.77 [6.25-11.25] lmin^-1 during end-expiratory apnea, 8.25 [5.06-9.25] lmin^-1 during "PPV" (-15%) (p<0.05), 9.19 [5.60-10.19] lmin^-1 during "PPV-iPS" (NS vs apnea) and 9.37 [6.12-10.48] lmin^-1 during "iPS" (NS vs. apnea). iPS-driven ventilation was comparable to its PPV counterpart (median 92% [74-97], NS). Diaphragm pacing alone can produce adequate ventilation without reducing CO. Superimposed onto PPV, diaphragm pacing can reduce the PPV-induced decrease in CO.

Keywords: Cardiac output; Diaphragm; Hemodynamics; Phrenic stimulation; Positive pressure ventilation.