Advertisement

Diaphragmatic energy expenditure in chronic respiratory failure

The effect of assisted ventilation with body respirators
      This paper is only available as a PDF. To read, Please Download here.

      Abstract

      Patients with chronic respiratory failure secondary to disorders which increase the work of breathing often benefit from assisted ventilation with body respirators. To test the hypothesis that body respirator therapy works by relieving the respiratory muscles of an excessive load, we recorded diaphragmatic and/or accessory inspiratory muscle electrical activity before and during assisted ventilation in 11 patients. All patients had chronic hypercapnia; seven had advanced obstructive pulmonary disease and four had severe thoracic cage restriction.
      When these patients used the tank respirator, their diaphragmatic activity fell to 9 ± SD 3 per cent of the level measured during spontaneous breathing. The reduction was highly significant in each patient (P < 0.001). Similar reductions of diaphragmatic activity occurred in the cuirass respirator. The body respirators also reduced accessory muscle activity (P < 0.02). Coincident with loss of diaphragmatic activity, the patients obtained relief from dyspnea. These results were independent of changes in arterial blood carbon dioxide tension (PaC02). Seven normal subjects were studied to further investigate the mechanism by which body respirators reduced inspiratory muscle activity. In the tank, these subjects displayed only minor reductions of diaphragmatic activity despite large decrements in end-tidal carbon dioxide pressure (PETCO2). However, when their upper airway resistance was increased, diaphragmatic activity promptly ceased in the tank.
      We conclude that capture of the ventilatory cycle by the body respirator is facilitated by loading the inspiratory muscles. We suggest that the beneficial effects of body respirator therapy for chronic respiratory failure are mediated in part through reduction of excessive inspiratory muscle contractile effort.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Curtis JK
        • Liska AP
        • Rasmussen HK
        • et al.
        IPPB therapy in chronic obstructive pulmonary disease.
        JAMA. 1968; 206: 1037
        • Emirgil C
        • Sobol BJ
        • Norman J
        • et al.
        A study of the long-term effect of therapy in chronic obstructive pulmonary disease.
        Am J Med. 1969; 47: 367
        • Cherniack RM
        • Svanhill E
        Long term use of intermittent positive-pressure breathing (IPPB) in chronic obstructive pulmonary disease.
        Am Rev Respir Dis. 1976; 113: 721
        • McClement J
        • Christianson LC
        • Hubaytar RT
        • et al.
        The body type respirator in the treatment of chronic obstructive pulmonary disease.
        Ann NY Acad Sci. 1965; 121: 746
      1. Keltz H: Personal communication.

        • Nash ES
        • Briscoe WA
        • Cournand A
        The relationship between clinical and physiological findings in chronic obstructive disease of the lungs.
        Med Thoracalis. 1965; 22: 305
        • Rochester DF
        • Bettini G
        Diaphragmatic blood flow and energy expenditure in the dog. Effects of inspiratory air flow resistance and hypercapnia.
        J Clin Invest. 1976; 57: 661
        • Campbell EJM
        • Friend J
        Action of breathing exercises in pulmonary emphysema.
        Lancet. 1955; 1: 325
        • Sukumalchantra Y
        • Park SS
        • Williams Jr, MH
        The effect of intermittent positive pressure breathing in acute ventilatory failure.
        Am Rev Respir Dis. 1965; 92: 885
        • Mognoni P
        • Saibene F
        • Sant'Ambrogio G
        Contribution of the diaphragm and the other inspiratory muscles to different levels of tidal volume and static inspiratory effort in the rabbit.
        J Physiol. 1969; 202: 517
        • Delhez L
        • Petit JM
        Donnees actuelles de l'electromyographie respiratoire chez l'homme normal.
        Electromyography. 1966; 6: 101
        • Lourenco RV
        • Mueller EP
        Quantification of electrical activity in the human diaphragm.
        J Appl Physiol. 1967; 22: 598
        • Snedecor GW
        Statistical Methods.
        in: Iowa State University, Ames1956: 85
        • Wade OL
        • Gilson JC
        The effect of posture on diaphragmatic movement and vital capacity in normal subjects with a note on spirometry as an aid in determining radiological chest volumes.
        Thorax. 1951; 6: 103
        • Boyd WH
        • Basmajian JV
        Electromyography of the diaphragm in rabbits.
        Am J Physiol. 1963; 24: 943
        • Bigland B
        • Lippold OCJ
        The relation between force, velocity and integrated electrical activity in human muscles.
        J physiol. 1954; 123: 214
        • Fales JT
        • Heisey SR
        • Zierler KL
        Dependency of oxygen consumption of skeletal muscle on number of stimuli during work in the dog.
        Am J Physiol. 1960; 198: 1333
        • Bigland-Ritchie B
        • Woods JJ
        Integrated EMG and oxygen uptake during dynamic contraction of human muscles.
        J Appl Physiol. 1974; 36: 375
        • Lourenco RV
        • Cherniack NS
        • Malm JR
        • et al.
        Nervous output from the respiratory center during obstructed breathing.
        J Appl Physiol. 1966; 21: 527
        • Agostoni E
        • Sant'Ambrogio G
        • del Portillo Carrasco H
        Electromyography of the diaphragm in man and transdiaphragmatic pressure.
        J Appl Physiol. 1960; 15: 1093
        • Garcia-Ramos J
        • Arjona P
        Oxygen consumption of the breathing process.
        Am J Physiol. 1956; 184: 359
        • Harries JR
        • Tyler JM
        Mechanical assistance to respiration in emphysema.
        Am J Med. 1964; 36: 68
        • Westlake EK
        • Simpson T
        • Jaye M
        Carbon dioxide narcosis in emphysema.
        Q J Med. 1955; 94: 155
        • Gray FD
        • Field AS
        The use of mechanical assistance in treating cardiopulmonary disease.
        Am J Med Sci. 1959; 238: 146
        • Boutourline-Young HJ
        • Whittenberger JL
        The use of artificial respiration in pulmonary emphysema accompanied by high carbon dioxide levels.
        J Clin Invest. 1951; 30: 838
        • Stone DJ
        • Schwartz A
        • Newman W
        • et al.
        Precipitation by pulmonary infection of acute anoxia, cardiac failure and respiratory acidosis in chronic pulmonary disease.
        Am J Med. 1953; 14: 14
        • Lloyd BB
        • Cunningham DJC
        A quantitative approach to the regulation of human respiration.
        in: Cunningham DJC Lloyd BB The Regulation of Human Respiration. Blackwell Scientific Publications, Oxford1963: 331
        • Cherniack NS
        • Edelman NH
        • Lahiri S
        Hypoxia and hypercapnia as respiratory stimulants and depressants.
        Respir Physiol. 1970; 11: 113
        • Lee KD
        • Bishop JM
        The reflex hypoxic drive in patients with chronic bronchitis.
        Clin Sci Molec Med. 1974; 46: 347
        • Guz A
        • Noble NIM
        • Eisele JH
        • et al.
        The role of vagal inflation reflexes in man and other animals.
        in: Porter R Breathing: Hering Breuer Centenary Symposium. Churchill, London1970: 17
        • Downman CBB
        Skeletal muscle reflexes of splanchnic and intercostal nerve origin in acute spinal and decerebrate cats.
        J Neurophysiol. 1955; 18: 217
        • Remmers JE
        Extra-segmental reflexes derived from intercostal afferents: phrenic and laryngeal responses.
        J Physiol. 1973; 233: 45
        • Agostoni E
        Diaphragm activity and thoracoabdominal mechanics during positive pressure breathing.
        J Appl Physiol. 1960; 17: 215
        • Bishop B
        Abdominal muscle and diaphragm activities and cavity pressures in pressure breathing.
        J Appl Physiol. 1963; 18: 37
        • Bishop B
        Diaphragm and abdominal muscle responses to elevated airway pressures in the cat.
        J Appl Physiol. 1967; 22: 959
        • McGregor M
        • Becklake MR
        The relationship of oxygen cost of breathing to respiratory mechanical work and respiratory force.
        J Clin Invest. 1961; 49: 971
        • Cherniack RM
        The oxygen consumption and efficiency of the respiratory muscle in health and emphysema.
        J Clin Invest. 1959; 38: 494
        • Fritts Jr, HW
        • Filler J
        • Fishman AP
        • et al.
        The efficiency of ventilation during voluntary hyperpnea: studies in normal subjects and in dyspneic patients with either chronic pulmonary emphysema or obesity.
        J Clin Invest. 1959; 38: 1339
        • Richards Jr, DW
        The nature of cardiac and pulmonary dyspnea.
        Circulation. 1953; 7: 15
        • Agostini E
        Diaphragm activity during breathholding: factors related to its onset.
        J Appl Physiol. 1963; 18: 30
        • Campbell EJM
        • Freedman S
        • Clark TJH
        • et al.
        The effect of muscular paralysis induced by tubocurarine on the duration and sensation of breathholding.
        Clin Sci. 1967; 32: 425
        • Guz A
        • Nobel NIM
        • Widdicombe JB
        • et al.
        The role of vagal and glossopharyngeal afferent nerves in respiratory sensation, control of breathing and arterial pressure regulation in conscious man.
        Clin Sci. 1966; 30: 161
        • Noble NIM
        • Eisele JH
        • Frankel HL
        • et al.
        The role of the diaphragm in the sensation of holding the breath.
        Clin Sci. 1971; 41: 275
        • Garcia-Ramos J
        On the integration of respiratory movements. III. The fifth nerve afferents.
        Acta Physiol Lat Am. 1960; 10: 104
        • Fillenz M
        • Widdicombe JG
        Receptors of the lungs and airways.
        in: 4th ed. Handbook of Sensory Physiology. Springer-Verlag, New York1972: 81
        • Marks A
        • Bocles J
        • Morganti L
        A new ventilatory assistor for patients with respiratory acidosis.
        N Engl J Med. 1963; 268: 61
      2. Briscoe WA: Personal communication.

        • Hamilton EA
        • Nichols PJR
        • Tait GBW
        Late onset of respiratory insufficiency after poliomyelitis.
        Ann Physical Med. 1970; 10: 223
        • Sharp JT
        • Danon J
        • Druz WS
        • et al.
        Respiratory muscle function in patients with chronic obstructive pulmonary disease.
        Am Rev Respir Dis. 1974; 110 (part 2): 154