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.	豆藝璇, 黃懷, 何蓮, 等. 不同閾值負荷下吸氣肌訓練對重癥患者肺功能的影響. 中國呼吸與危重監護雜志, 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.	楊富, 方芳, 陳蘭, 等. ICU早期康復的研究進展. 護理學雜志, 2017, 32(10): 100-103.
8.	計可欣, 程潔, 鄭卿勇, 等. ICU患者早期活動方案的研究進展. 中國康復醫學雜志, 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.	盧嬌, 梁國鵬, 王波, 等. 重癥加強治療病房有創機械通氣患者早期肺康復研究進展. 中國呼吸與危重監護雜志, 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.	申麗旻, 何聰, 任珊, 等. 體外膈肌起搏對慢性阻塞性肺疾病機械通氣患者的治療效果評價. 河北醫藥, 2019, 41(19): 2898-2901. DOI: 10.3969 /j.issn.1002-7386.2019.19.004.
16.	王曉紅. 體外膈肌起搏對呼吸機相關膈肌功能障礙的有效性研究. 青島; 青島大學, 2018.
17.	詹德利, 劉偉清, 勞永光, 等. 膈肌刺激對ICU呼吸機依賴重癥腦損傷患者的膈肌功能和呼吸效率的影響. 海軍醫學雜志, 2021, 42(1): 96-98. DOI: 10.3969 /j.issn.1009-0754.2021.01.027.
18.	周玥, 陳曉艷, 蘇星, 等. 體外膈神經電刺激對神經危重癥患者呼吸機撤機的影響. 交通醫學, 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. 膈肌超聲及引導下的電刺激對老年人群肺功能的評價與干預研究[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, 王傳飛, 劉玲玲. 體外膈神經電刺激對腦卒中后肢體功能障礙患者膈肌功能、呼吸肌肌力、肺通氣功能和軀干穩定性的影響價值研究. 內科, 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.	林傳煥, 劉毅君, 谷欣. 氣道閉合壓、最大吸氣壓和呼吸淺快指數對慢阻肺患者撤機的預測價值. 臨床肺科雜志, 2016, 21(12): 2240-2243. DOI: 10.3969 /j.issn.1009-6663.2016.12.030.
28.	吳政庚, 李曉斌, 朱建輝, 等. 淺快呼吸指數預測ICU中COPD患者撤機的臨床價值. 中國醫藥導報, 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. 膈肌功能障礙的超聲檢測進展. 中國實用醫藥, 2023, 18(10): 177-180.
35.	劉芳欣, 陳昭杰, 王洲, 等. 剪切波彈性成像聯合膈肌增厚率及淺快呼吸指數預測機械通氣患者撤機結果的臨床研究. 中國呼吸與危重監護雜志, 2023, 22(1): 38-43.
36.	朱孟雷, 劉虹, 韓繼斌, 等. 膈肌超聲對重癥機械通氣患者脫機結果的預測價值. 中華危重癥醫學雜志(電子版), 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. 豆藝璇, 黃懷, 何蓮, 等. 不同閾值負荷下吸氣肌訓練對重癥患者肺功能的影響. 中國呼吸與危重監護雜志, 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. 楊富, 方芳, 陳蘭, 等. ICU早期康復的研究進展. 護理學雜志, 2017, 32(10): 100-103.
8. 計可欣, 程潔, 鄭卿勇, 等. ICU患者早期活動方案的研究進展. 中國康復醫學雜志, 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. 盧嬌, 梁國鵬, 王波, 等. 重癥加強治療病房有創機械通氣患者早期肺康復研究進展. 中國呼吸與危重監護雜志, 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. 申麗旻, 何聰, 任珊, 等. 體外膈肌起搏對慢性阻塞性肺疾病機械通氣患者的治療效果評價. 河北醫藥, 2019, 41(19): 2898-2901. DOI: 10.3969 /j.issn.1002-7386.2019.19.004.
16. 王曉紅. 體外膈肌起搏對呼吸機相關膈肌功能障礙的有效性研究. 青島; 青島大學, 2018.
17. 詹德利, 劉偉清, 勞永光, 等. 膈肌刺激對ICU呼吸機依賴重癥腦損傷患者的膈肌功能和呼吸效率的影響. 海軍醫學雜志, 2021, 42(1): 96-98. DOI: 10.3969 /j.issn.1009-0754.2021.01.027.
18. 周玥, 陳曉艷, 蘇星, 等. 體外膈神經電刺激對神經危重癥患者呼吸機撤機的影響. 交通醫學, 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. 膈肌超聲及引導下的電刺激對老年人群肺功能的評價與干預研究[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, 王傳飛, 劉玲玲. 體外膈神經電刺激對腦卒中后肢體功能障礙患者膈肌功能、呼吸肌肌力、肺通氣功能和軀干穩定性的影響價值研究. 內科, 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. 林傳煥, 劉毅君, 谷欣. 氣道閉合壓、最大吸氣壓和呼吸淺快指數對慢阻肺患者撤機的預測價值. 臨床肺科雜志, 2016, 21(12): 2240-2243. DOI: 10.3969 /j.issn.1009-6663.2016.12.030.
28. 吳政庚, 李曉斌, 朱建輝, 等. 淺快呼吸指數預測ICU中COPD患者撤機的臨床價值. 中國醫藥導報, 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. 膈肌功能障礙的超聲檢測進展. 中國實用醫藥, 2023, 18(10): 177-180.
35. 劉芳欣, 陳昭杰, 王洲, 等. 剪切波彈性成像聯合膈肌增厚率及淺快呼吸指數預測機械通氣患者撤機結果的臨床研究. 中國呼吸與危重監護雜志, 2023, 22(1): 38-43.
36. 朱孟雷, 劉虹, 韓繼斌, 等. 膈肌超聲對重癥機械通氣患者脫機結果的預測價值. 中華危重癥醫學雜志(電子版), 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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