Efficacy of combined inspiratory intercostal and expiratory muscle pacing to maintain artificial ventilation

Many patients with ventilator-dependent quadriplegia have coincident phrenic nerve injury and therefore cannot be offered phrenic nerve pacing. The purpose of this study was to assess the utility of combined inspiratory intercostal and expiratory muscle pacing to provide complete ventilatory support. Studies were performed in 15 anesthetized dogs. An electrode was positioned on the epidural surface of the upper thoracic spinal cord to activate the inspiratory intercostal muscles; a separate electrode was positioned on the epidural surface of the lower thoracic spinal cord to activate the expiratory muscles. In an attempt to replicate the effects of inspiratory intercostal pacing alone in humans, stimulus parameters during upper thoracic spinal cord stimulation were adjusted to provide suboptimal levels of ventilation (end-tidal PCO₂ of 55 to 60 mm Hg). Expiratory muscle activation was triggered electrically by the inspiratory signal with a 4.2-s delay resulting in alternate inspiratory and expiratory muscle pacing at a combined rate of 14 breaths/min. Combined pacing was maintained for an arbitrary period of 3 h. Initial intercostal muscle pacing alone resulted in an end-tidal PCO₂ of 57.1 ± 1.1 mm Hg. After the addition of expiratory muscle pacing, end-tidal PCO₂ fell to 36.3 ± 1.2 mm Hg. Tidal volume during both inspiratory and expiratory muscle pacing and end-tidal PCO₂ remained stable throughout the study period. Our results suggest that combined alternate inspiratory and expiratory muscle pacing may be a viable alternative method of artificial ventilation in ventilator-dependent quadriplegic patients.