植入式膈肌起搏器在高位颈髓损伤患者中的应用经验及文献分析  

The clinic experience of implantable diaphragm pacer in a patient with high cervical spinal cord injury and literature review

作　　者：杨明亮[1] 赵红梅 李建军[1] 杨德刚[1] 王强[2] 高连军[3] 邓卫萍 杜良杰[1] 宫慧明[1] 陈亮[1] 王玉明[1] 贾彦梅 李娟 Yang Mingliang;Zhao Hongmei;Li Jianjun;Yang Degang;Wang Qiang;Gao Lianjun;Deng Weiping;Du Liangjie;Gong Huiming;Chen Liang;Wang Yuming;Jian Yanmei;Li Juan(Department of Spinal and Neural Function Reconstruction,Capital Medical University School of Rehabilitation Medicine（China Rehabilitation Research Center）,Beijing 100068,China)

机构地区：[1]首都医科大学康复医学院中国康复研究中心脊柱脊髓神经功能重建外科,北京100068 [2]首都医科大学康复医学院中国康复研究中心麻醉科,北京100068 [3]首都医科大学康复医学院中国康复研究中心呼吸与重症医学科,北京100068 [4]中日友好医院呼吸与危重症医学科

出　　处：《中华结核和呼吸杂志》2018年第9期718-723,共6页Chinese Journal of Tuberculosis and Respiratory Diseases

基　　金：北京脑重大疾病研究院科研促进项目（2013）;中央级公益性科研院所基本科研业务费专项资金（中康2018CZ-1）

摘　　要：目的总结植入式膈肌起搏器在高位颈髓损伤患者的临床应用经验。方法患者男，14岁。2015年因脊髓炎导致颈2脊髓损伤，无自主呼吸，依赖呼吸机维持生命2年。2017年8月，在中国康复研究中心接受膈肌起搏器植入手术。以phrenic nerve和electrical stimulation和spinal cordinjury，或implantable diaphragm pacer和spinal cord injury，或breathing pacemaker system和spinal cord injury等为关键词检索PubMed，范围为所有领域，时间在1970年1月1日到2018年1月1日；以膈神经和电刺激和脊髓损伤，或膈肌起搏器和脊髓损伤，或呼吸起搏器和脊髓损伤等为关键词，在CNKI和万方数据进行中文检索。检索CNKI时间范围为1981年1月1日至2018年1月1日，万方数据时间范围为1900年1月1日至2018年1月1日。结果术前患者无自主呼吸。经皮电刺激膈神经可见右侧膈肌收缩有力，左侧未见明显收缩。术后4周测试记录右侧起搏电压阈值为0．1V，最大化效应起搏电压为0．7V；左侧给予0．7V起搏电压，未观察到明显膈肌收缩。给予双侧0．7V电压起搏，最大潮气量840ml。起搏模式为双侧起搏电压0．1～0．2V，起搏频率9次／min（卧床）或12次／min（轮椅活动模式），潮气量为（435±32）ml。适应性训练2周后，患者连续12h脱机，血气分析结果正常。手术后6周，可乘坐轮椅外出活动。与膈肌起搏器和脊髓损伤相关的英文文献共78篇，其中临床实验6篇，综述10篇。内容涉及膈肌起搏器手术前准备、膈神经功能评估方法、外科手术、并发症、手术效果及动物模型研究等。中文文献11篇，其中8篇为综述，1篇为动物研究，2篇为新闻报道。文献报道的IDP适应证为中枢性肺通气不足、睡眠呼吸暂停综合征、脑干损伤或疾病导致呼吸衰竭、C3以上脊髓损伤或疾病失去自主呼吸。结论植入式膈肌起搏器对部分有适应证的因高位颈髓损�Objective To report the use of implantable diaphragm pacer （IDP） in a patient with high cervical spinal cord injury （HCSCI）. Methods A 14-year-old male patient, who suffered from a HCSCI at C2 neurological level and had been on a ventilator for 2 years, received IDP in August 2017 at China Rehabilitation Research Center. A systematic literature review was performed on IDP in patients with HCSCI in Pubmed, CNKI, and Wanfang databases, using the keywords： phrenic nerve and electrical stimulation and spinal cord injury; IDP and spinal cord injury; breathing pacemaker system and spinal cord injury. All fields were covered from 1970/01/01 to 2018/01/01 in Pubmed, from 1981/01/01 to 2018/01/ 01 in CNKI, and from 1900/01/01to 2018/01/01 in Wanfang. Results No spontaneous breathing was observed preoperatively in the patient. The electrical response of phrenic nerves was intact on the right, but unresponsive on the left. We got started with the IDP at 4 weeks after surgery. The threshold voltage of the right hemidiaphragm pacing was 0. 1 V and at the level of 0. 7 V with an optimal effect. No significant diaphragmatic contraction was found at left side with the extent up till 0. 7 V. The maximum tidal volume was 840 ml when electrical stimulation was given at an intensity of 0. 7 V bilaterally. The bilateral stimulation voltage at 0. 1 -0. 2 V, pacing frequencies at 9 beats/rain in bed, or at 12 beats/min on wheelchair, were set to maintain the tidal volume at the level of （435 ± 32 ） ml. After 2-week adaptive training, the patient could wean from the ventilator for 12 hours and had a normal blood gas analysis. At 6 week after surgery, with the aid of IDP, the patient could get out in wheelchair for outdoor activities. By literature review, we found 78 English papers, including 6 clinical trials, 10 reviews, and 11 Chinese papers, consisting of 8 reviews, 1 study in animal, and 2 news reports. Extensive contents, such as preoperative evaluation, preoperative preparation, surgical procedures, complications,

关 键 词：呼吸功能不全 电刺激 通气机 颈髓损伤 植入式膈肌起搏器 

分 类 号：R651.2[医药卫生—外科学]