Effect of phrenic nerve electrical stimulation on extubation outcomes in mechanically ventilated ICU patients: a meta-analysis_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

HAO Tian ^1,3 , CHENG Jie ² , LI Qi ⁴ ,  ZHANG Zhigang ^1,3

1. School of Nursing, Lanzhou University, Lanzhou, Gansu 730030, P. R. China;
2. Nursing Department, Changzhi People’s Hospital, Changzhi, Shanxi 046000, P. R. China;
3. Department of Critical Care Medicine, First Hospital of Lanzhou University, Lanzhou, Gansu 730000, P. R. China;
4. Department of Neurology, First Hospital of Lanzhou University, Lanzhou, Gansu 730000, P. R. China;

Corresponding author：

ZHANG Zhigang, Email: zzg3444@163.com

Keywords：

Phrenic nerve electrical stimulation; intensive care unit; mechanical ventilation; ventilator-induced diaphragmatic dysfunction; meta-analysis

DOI：

10.7507/1671-6205.202404077

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Objective To assess the effectiveness of phrenic nerve electrical stimulation (PNES) on extubation outcomes in intensive care unit (ICU) patients undergoing mechanical ventilation using a meta-analysis approach. Methods A comprehensive search was conducted on the Cochrane Library, PubMed, Web of Science, Embase, and China National Knowledge Infrastructure (CNKI) for randomized controlled trials (RCTs) published from database inception to December 2023, evaluating the effect of PNES on extubation outcomes in ICU patients receiving mechanical ventilation. The control group received standard rehabilitation measures, while the intervention group received PNES in addition to standard rehabilitation. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias. Meta-analysis was performed using RevMan5.4 software. Results Nine RCTs were included in the final analysis. The quality assessment indicated that one study was rated as Grade A and eight as Grade B, reflecting relatively high study quality. Meta-analysis results demonstrated that PNES significantly improved extubation success rates [relative risk (RR)=1.33, 95%CI 1.09 - 1.62, P=0.006], maximal inspiratory pressure (MIP) [mean difference (MD)=1.36, 95%CI 0.46 - 2.27, P=0.003], and diaphragmatic thickness fraction (DTF) (MD=7.11, 95%CI 0.53 - 13.69, P=0.03) compared with the control group. PNES also significantly reduced the duration of mechanical ventilation (MD=–2.23, 95%CI –3.07- –1.38, P<0.000 01), re-intubation rates (RR=0.35, 95%CI 0.15 - 0.85, P=0.02), and rapid shallow breathing index (RSBI) (MD=–11.57, 95%CI –18.51 - –4.62, P=0.001). Additionally, PNES shortened ICU length of stay (MD=–4.03, 95%CI –5.95 - –2.11, P<0.000 1), with all differences being statistically significant. Conclusion PNES effectively reduces the duration of mechanical ventilation and ICU length of stay, decreases re-intubation rates and RSBI, and improves extubation success, MIP, and DTF in ICU patients. Future high-quality, large-scale, multi-center RCTs are needed to further validate these findings.

Citation： HAO Tian, CHENG Jie, LI Qi, ZHANG Zhigang. Effect of phrenic nerve electrical stimulation on extubation outcomes in mechanically ventilated ICU patients: a meta-analysis. Chinese Journal of Respiratory and Critical Care Medicine, 2025, 24(1): 9-17. doi: 10.7507/1671-6205.202404077 Copy

1.	Jaber S, Petrof BJ, Jung B, et al. Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med, 2011, 183(3): 364-371.
2.	Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med, 2008, 358(13): 1327-1335.
3.	Zhang J, Feng J, Jia J, et al. Research progress on the pathogenesis and treatment of ventilator-induced diaphragm dysfunction. Heliyon, 2023, 9(11): e22317.
4.	豆艺璇, 黄怀, 何莲, 等. 不同阈值负荷下吸气肌训练对重症患者肺功能的影响. 中国呼吸与危重监护杂志, 2023, 22(10): 702-709.
5.	Miranda AR, Martinez BP, Maldaner da Silva VZ, et al. Early mobilization: why, what for and how?. Med Intensiva, 2017, 41(7): 429-436.
6.	Supinski GS, Morris PE, Dhar S, et al. Diaphragm dysfunction in critical illness. Chest, 2018, 153(4): 1040-1051.
7.	杨富, 方芳, 陈兰, 等. ICU早期康复的研究进展. 护理学杂志, 2017, 32(10): 100-103.
8.	计可欣, 程洁, 郑卿勇, 等. ICU患者早期活动方案的研究进展. 中国康复医学杂志, 2023, 38(12): 1784-1791.
9.	José A, Dal Corso S. Inpatient rehabilitation improves functional capacity, peripheral muscle strength and quality of life in patients with community-acquired pneumonia: a randomised trial. J Physiother, 2016, 62(2): 96-102.
10.	卢娇, 梁国鹏, 王波, 等. 重症加强治疗病房有创机械通气患者早期肺康复研究进展. 中国呼吸与危重监护杂志, 2021, 20(11): 831-836.
11.	Kaufmann EM, Krause S, Geisshuesler L, et al. Feasibility of transesophageal phrenic nerve stimulation. Biomed Eng Online, 2023, 22(1): 5.
12.	O'Rourke J, Soták M, Curley GF, et al. Initial assessment of the percutaneous electrical phrenic nerve stimulation system in patients on mechanical ventilation. Crit Care Med, 2020, 48(5): E362-E370.
13.	Bao Q, Chen L, Chen X, et al. The effects of external diaphragmatic pacing on diaphragm function and weaning outcomes of critically ill patients with mechanical ventilation: a prospective randomized study. Ann Transl Med, 2022, 10(20): 1100.
14.	Medrinal C, Machefert M, Lamia B, et al. Transcutaneous electrical diaphragmatic stimulation in mechanically ventilated patients: a randomised study. Crit Care, 2023, 27(1): 338.
15.	申丽旻, 何聪, 任珊, 等. 体外膈肌起搏对慢性阻塞性肺疾病机械通气患者的治疗效果评价. 河北医药, 2019, 41(19): 2898-2901. DOI: 10.3969 /j.issn.1002-7386.2019.19.004.
16.	王晓红. 体外膈肌起搏对呼吸机相关膈肌功能障碍的有效性研究. 青岛; 青岛大学, 2018.
17.	詹德利, 刘伟清, 劳永光, 等. 膈肌刺激对ICU呼吸机依赖重症脑损伤患者的膈肌功能和呼吸效率的影响. 海军医学杂志, 2021, 42(1): 96-98. DOI: 10.3969 /j.issn.1009-0754.2021.01.027.
18.	周玥, 陈晓艳, 苏星, 等. 体外膈神经电刺激对神经危重症患者呼吸机撤机的影响. 交通医学, 2022, 36(4): 425-426,429.
19.	Hsin YF, Chen SH, Yu TJ, et al. Effects of transcutaneous electrical diaphragmatic stimulation on respiratory function in patients with prolonged mechanical ventilation. Ann Thorac Med, 2022, 17(1): 14-20.
20.	Dres M, de Abreu MG, Merdji H, et al. Randomized clinical study of temporary transvenous phrenic nerve stimulation in difficult-to-wean patients. Am J Respir Crit Care Med, 2022, 205(10): 1169-1178.
21.	Olímpio Júnior H, Camilo GB, Marques JA, et al. Effects of transcutaneous electrical diaphragmatic stimulation in critically ill elderly patients: a randomized controlled trial. Physiother Theory Pract, 2024, 40(12): 2754-2763.
22.	范玉婷. 膈肌超声及引导下的电刺激对老年人群肺功能的评价与干预研究[D], 2022.
23.	Vassilakopoulos T, Zakynthinos S, Roussos C. Respiratory muscles and weaning failure. Eur Respir J, 1996, 9(11): 2383-2400.
24.	邵素霞, 王传飞, 刘玲玲. 体外膈神经电刺激对脑卒中后肢体功能障碍患者膈肌功能、呼吸肌肌力、肺通气功能和躯干稳定性的影响价值研究. 内科, 2023, 18(1): 45-48. DOI: 10.16121 /j.cnki.cn45-1347 /r.2023.01.10.
25.	Aldrich TK, Sinderby C, McKenzie DK, et al. Electrophysiologic techniques for the assessment of respiratory muscle function. Am J Respir Crit Care Med, 2002, 166(4): 548-558.
26.	Schoser B, Fong E, Geberhiwot T, et al. Maximum inspiratory pressure as a clinically meaningful trial endpoint for neuromuscular diseases: a comprehensive review of the literature. Orphanet J Rare Dis, 2017, 12(1): 52.
27.	林传焕, 刘毅君, 谷欣. 气道闭合压、最大吸气压和呼吸浅快指数对慢阻肺患者撤机的预测价值. 临床肺科杂志, 2016, 21(12): 2240-2243. DOI: 10.3969 /j.issn.1009-6663.2016.12.030.
28.	吴政庚, 李晓斌, 朱建辉, 等. 浅快呼吸指数预测ICU中COPD患者撤机的临床价值. 中国医药导报, 2012, 9(30): 157-158,161.
29.	Jia D, Wang H, Wang Q, et al. Rapid shallow breathing index predicting extubation outcomes: A systematic review and meta-analysis. Intensive Crit Care Nurs, 2024, 80: 103551.
30.	Kuo PH, Wu HD, Lu BY, et al. Predictive value of rapid shallow breathing index measured at initiation and termination of a 2-hour spontaneous breathing trial for weaning outcome in ICU patients. J Formos Med Assoc, 2006, 105(5): 390-398.
31.	Segal LN, Oei E, Oppenheimer BW, et al. Evolution of pattern of breathing during a spontaneous breathing trial predicts successful extubation. Intensive Care Med, 2009, 36(3): 487-495.
32.	Ferrari G, De Filippi G, Elia F, et al. Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. Crit Ultrasound J, 2014, 6(1): 8.
33.	Vieira Santana P, Zumpano Cardenas L, Pereira de Albuquerque AL, et al. Diaphragmatic ultrasound: a review of its methodological aspects and clinical uses. J Bras Pneumol, 2020, 46(6): e20200064-e20200064.
34.	唐智生. 膈肌功能障碍的超声检测进展. 中国实用医药, 2023, 18(10): 177-180.
35.	刘芳欣, 陈昭杰, 王洲, 等. 剪切波弹性成像联合膈肌增厚率及浅快呼吸指数预测机械通气患者撤机结果的临床研究. 中国呼吸与危重监护杂志, 2023, 22(1): 38-43.
36.	朱孟雷, 刘虹, 韩继斌, 等. 膈肌超声对重症机械通气患者脱机结果的预测价值. 中华危重症医学杂志(电子版), 2021, 14(5): 425-429. DOI: 10. 3877/ cma.j.issn. 1674-6880. 2021. 05. 015.

1. Jaber S, Petrof BJ, Jung B, et al. Rapidly progressive diaphragmatic weakness and injury during mechanical ventilation in humans. Am J Respir Crit Care Med, 2011, 183(3): 364-371.
2. Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med, 2008, 358(13): 1327-1335.
3. Zhang J, Feng J, Jia J, et al. Research progress on the pathogenesis and treatment of ventilator-induced diaphragm dysfunction. Heliyon, 2023, 9(11): e22317.
4. 豆艺璇, 黄怀, 何莲, 等. 不同阈值负荷下吸气肌训练对重症患者肺功能的影响. 中国呼吸与危重监护杂志, 2023, 22(10): 702-709.
5. Miranda AR, Martinez BP, Maldaner da Silva VZ, et al. Early mobilization: why, what for and how?. Med Intensiva, 2017, 41(7): 429-436.
6. Supinski GS, Morris PE, Dhar S, et al. Diaphragm dysfunction in critical illness. Chest, 2018, 153(4): 1040-1051.
7. 杨富, 方芳, 陈兰, 等. ICU早期康复的研究进展. 护理学杂志, 2017, 32(10): 100-103.
8. 计可欣, 程洁, 郑卿勇, 等. ICU患者早期活动方案的研究进展. 中国康复医学杂志, 2023, 38(12): 1784-1791.
9. José A, Dal Corso S. Inpatient rehabilitation improves functional capacity, peripheral muscle strength and quality of life in patients with community-acquired pneumonia: a randomised trial. J Physiother, 2016, 62(2): 96-102.
10. 卢娇, 梁国鹏, 王波, 等. 重症加强治疗病房有创机械通气患者早期肺康复研究进展. 中国呼吸与危重监护杂志, 2021, 20(11): 831-836.
11. Kaufmann EM, Krause S, Geisshuesler L, et al. Feasibility of transesophageal phrenic nerve stimulation. Biomed Eng Online, 2023, 22(1): 5.
12. O'Rourke J, Soták M, Curley GF, et al. Initial assessment of the percutaneous electrical phrenic nerve stimulation system in patients on mechanical ventilation. Crit Care Med, 2020, 48(5): E362-E370.
13. Bao Q, Chen L, Chen X, et al. The effects of external diaphragmatic pacing on diaphragm function and weaning outcomes of critically ill patients with mechanical ventilation: a prospective randomized study. Ann Transl Med, 2022, 10(20): 1100.
14. Medrinal C, Machefert M, Lamia B, et al. Transcutaneous electrical diaphragmatic stimulation in mechanically ventilated patients: a randomised study. Crit Care, 2023, 27(1): 338.
15. 申丽旻, 何聪, 任珊, 等. 体外膈肌起搏对慢性阻塞性肺疾病机械通气患者的治疗效果评价. 河北医药, 2019, 41(19): 2898-2901. DOI: 10.3969 /j.issn.1002-7386.2019.19.004.
16. 王晓红. 体外膈肌起搏对呼吸机相关膈肌功能障碍的有效性研究. 青岛; 青岛大学, 2018.
17. 詹德利, 刘伟清, 劳永光, 等. 膈肌刺激对ICU呼吸机依赖重症脑损伤患者的膈肌功能和呼吸效率的影响. 海军医学杂志, 2021, 42(1): 96-98. DOI: 10.3969 /j.issn.1009-0754.2021.01.027.
18. 周玥, 陈晓艳, 苏星, 等. 体外膈神经电刺激对神经危重症患者呼吸机撤机的影响. 交通医学, 2022, 36(4): 425-426,429.
19. Hsin YF, Chen SH, Yu TJ, et al. Effects of transcutaneous electrical diaphragmatic stimulation on respiratory function in patients with prolonged mechanical ventilation. Ann Thorac Med, 2022, 17(1): 14-20.
20. Dres M, de Abreu MG, Merdji H, et al. Randomized clinical study of temporary transvenous phrenic nerve stimulation in difficult-to-wean patients. Am J Respir Crit Care Med, 2022, 205(10): 1169-1178.
21. Olímpio Júnior H, Camilo GB, Marques JA, et al. Effects of transcutaneous electrical diaphragmatic stimulation in critically ill elderly patients: a randomized controlled trial. Physiother Theory Pract, 2024, 40(12): 2754-2763.
22. 范玉婷. 膈肌超声及引导下的电刺激对老年人群肺功能的评价与干预研究[D], 2022.
23. Vassilakopoulos T, Zakynthinos S, Roussos C. Respiratory muscles and weaning failure. Eur Respir J, 1996, 9(11): 2383-2400.
24. 邵素霞, 王传飞, 刘玲玲. 体外膈神经电刺激对脑卒中后肢体功能障碍患者膈肌功能、呼吸肌肌力、肺通气功能和躯干稳定性的影响价值研究. 内科, 2023, 18(1): 45-48. DOI: 10.16121 /j.cnki.cn45-1347 /r.2023.01.10.
25. Aldrich TK, Sinderby C, McKenzie DK, et al. Electrophysiologic techniques for the assessment of respiratory muscle function. Am J Respir Crit Care Med, 2002, 166(4): 548-558.
26. Schoser B, Fong E, Geberhiwot T, et al. Maximum inspiratory pressure as a clinically meaningful trial endpoint for neuromuscular diseases: a comprehensive review of the literature. Orphanet J Rare Dis, 2017, 12(1): 52.
27. 林传焕, 刘毅君, 谷欣. 气道闭合压、最大吸气压和呼吸浅快指数对慢阻肺患者撤机的预测价值. 临床肺科杂志, 2016, 21(12): 2240-2243. DOI: 10.3969 /j.issn.1009-6663.2016.12.030.
28. 吴政庚, 李晓斌, 朱建辉, 等. 浅快呼吸指数预测ICU中COPD患者撤机的临床价值. 中国医药导报, 2012, 9(30): 157-158,161.
29. Jia D, Wang H, Wang Q, et al. Rapid shallow breathing index predicting extubation outcomes: A systematic review and meta-analysis. Intensive Crit Care Nurs, 2024, 80: 103551.
30. Kuo PH, Wu HD, Lu BY, et al. Predictive value of rapid shallow breathing index measured at initiation and termination of a 2-hour spontaneous breathing trial for weaning outcome in ICU patients. J Formos Med Assoc, 2006, 105(5): 390-398.
31. Segal LN, Oei E, Oppenheimer BW, et al. Evolution of pattern of breathing during a spontaneous breathing trial predicts successful extubation. Intensive Care Med, 2009, 36(3): 487-495.
32. Ferrari G, De Filippi G, Elia F, et al. Diaphragm ultrasound as a new index of discontinuation from mechanical ventilation. Crit Ultrasound J, 2014, 6(1): 8.
33. Vieira Santana P, Zumpano Cardenas L, Pereira de Albuquerque AL, et al. Diaphragmatic ultrasound: a review of its methodological aspects and clinical uses. J Bras Pneumol, 2020, 46(6): e20200064-e20200064.
34. 唐智生. 膈肌功能障碍的超声检测进展. 中国实用医药, 2023, 18(10): 177-180.
35. 刘芳欣, 陈昭杰, 王洲, 等. 剪切波弹性成像联合膈肌增厚率及浅快呼吸指数预测机械通气患者撤机结果的临床研究. 中国呼吸与危重监护杂志, 2023, 22(1): 38-43.
36. 朱孟雷, 刘虹, 韩继斌, 等. 膈肌超声对重症机械通气患者脱机结果的预测价值. 中华危重症医学杂志(电子版), 2021, 14(5): 425-429. DOI: 10. 3877/ cma.j.issn. 1674-6880. 2021. 05. 015.

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Effect of phrenic nerve electrical stimulation on extubation outcomes in mechanically ventilated ICU patients: a meta-analysis

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