Stimulus parameters for phrenic nerve pacing in infants and children

Phrenic nerve pacing has been used since 1966 to support breathing in quadriplegics and patients with central hypoventilation syndrome (CHS). Recently, using low-frequency, long-inspiratory-time (T_i) stimulation, phrenic nerve pacing has been used successfully to support breathing 24 hours per day in adults and older children. However, no similar experience exists for infants and young children. Therefore, in 27 studies in 14 infants and children we determined the effects of changing T_i and interpulse interval (the inverse of stimulus frequency) on ventilation. Diaphragmatic action potentials, airflow, tidal volume, P_ACO2 and Sa_O2 were measured during sleep. Phrenic nerve pacing proved useful in 13 of 14 patients to support breathing either during wakefulness (n = 7) or during sleep (n = 6). We found that adequate ventilation could be achieved at significantly longer interpulse intervals, 95 ± 25 (mean ± SD) ms, and shorter T_i, 580 ± 80 ms, than previously reported. At an average respiratory rate of 21 ± 8 breaths/min it was thus possible to maintain adequate ventilation despite a marked reduction in the number of phrenic nerve stimuli. Theoretically, these reductions in phrenic nerve stimulation should minimize the chance of pacing-induced diaphragmatic damage. These results suggest that 24 hour per day phrenic nerve pacing may be a realistic goal in selected infants and children.