Diagnosing the Adequacy of Neural Stimulation

  • J. W. Fitting
Conference paper
Part of the Update in Intensive Care and Emergency Medicine book series (UICM, volume 15)


Ventilatory failure may result from a wide range of disorders of the respiratory system, from the respiratory centers to the alveoli. In a limited number of circumstances, ventilatory failure is solely due to an insufficient neural stimulation from the respiratory centers to the respiratory muscles. Such a failing ventilatory drive occurs for instance in drug overdose, anesthesia, or primary alveolar hypoventilation. The majority of cases of ventilatory failure, however, results from disorders of the airways, the lungs, and the chest wall. Still, the question may arise as to whether the ventilatory drive is adequate to cope with these situations of increased load. This chapter will review the parameters and methods available to the clinician for assessing the adequacy of neural stimulation in ventilatory failure.


Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease Patient Respiratory Muscle Occlusion Pressure Neural Drive 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Eldridge FL (1975) Relationship between respiratory nerve and muscle activity and muscle force output. J Appi Physiol 39:567–574Google Scholar
  2. 2.
    Evanich MJ, Lopata M, Lourenco RV (1976) Phrenic nerve activity and occlusion pressure changes during CO2 rebreathing in cats. J Appi Physiol 41:536–543Google Scholar
  3. 3.
    Agostoni E, Sant’Ambrogio G, Del Portillo Carrasco H (1960) Electromyography of the diaphragm in man and transdiaphragmatic pressure. J Appi Physiol 15:1093–1097Google Scholar
  4. 4.
    Petit JM, Milic-Emili J, Delhez L (1960) Role of the diaphragm in breathing in conscious normal man: an electromyographic study. J Appi Physiol 15:1101–1106Google Scholar
  5. 5.
    Lopata M, Evanich MJ, Lourenco RV (1977) Quantification of diaphragmatic EMG response to CO2 rebreathing in humans. J Appi Physiol 43:262–270Google Scholar
  6. 6.
    Newman S, Road J, Bellemare F, Clozel JP, Lavigne CM, Grassino A (1984) Respiratory muscle length measured by sonomicrometry. J Appi Physiol 56:753–764Google Scholar
  7. 7.
    Easton PA, Fitting JW, Arnoux R, Guerraty A, Grassino AE (1989) Recovery of diaphragm function after laparotomy and chronic sonomicrometer implantation. J Appi Physiol 66:613–621Google Scholar
  8. 8.
    Bigland-Ritchie B, Woods J J (1974) Integrated EMG and oxygen uptake during dynamic contractions of human muscles. J Appi Physiol 36:475–479Google Scholar
  9. 9.
    Whitelaw WA, Derenne JP, Milic-Emili J (1975) Occlusion pressure as a measure of respiratory center output in conscious man. Respir Physiol 23:181–199PubMedCrossRefGoogle Scholar
  10. 10.
    Read DJC (1967) A clinical method for assessing the ventilatory response to carbon dioxide. Australasian Ann Med 16:20–32Google Scholar
  11. 11.
    Weil JV, Bryne-Quinn E, Sodai IE, et al. (1970) Hypoxic ventilatory drive in normal man. J Clin Invest 49:1061–1072PubMedCrossRefGoogle Scholar
  12. 12.
    Milic-Emili J, Grunstein MM (1976) Drive and timing components of ventilation. Chest 70 (Suppl): 131–133PubMedCrossRefGoogle Scholar
  13. 13.
    Newsom Davis J, Stagg D (1975) Interrelationships of the volume and time components of individual breaths in resting man. J Physiol (London) 245:481–495Google Scholar
  14. 14.
    Fitting JW, Easton PA, Grassino AE (1986) Velocity of shortening of inspiratory muscles and inspiratory flow. J Appi Physiol 60:670–677Google Scholar
  15. 15.
    Sorli J, Grassino A, Lorange G, Milic-Emili J (1978) Control of breathing in patients with chronic obstructive pulmonary disease. Clin Sei Mol Med 54:295–304Google Scholar
  16. 16.
    Holle RHO, Schoene RB, Pavlin EJ (1984) Effect of respiratory muscle weakness of P0.1 induced by partial curarization. J Appl Physiol 57:1150–1157PubMedGoogle Scholar
  17. 17.
    Aubier M, Murciano D, Fournier M, Milic-Emili J, Pariente R, Derenne JP (1980) Central respiratory drive in acute respiratory failure of patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 122:191–199PubMedGoogle Scholar
  18. 18.
    Bégin R, Bureau MA, Lupien L, Bernier JP, Lemieux B (1982) Pathogenesis of respiratory insufficiency in myotonic dystrophy. Am Rev Respir Dis 125:312–318PubMedGoogle Scholar
  19. 19.
    Marini J J, Smith TC, Lamb V (1986) Estimation of inspiratory muscle strength in mechanically ventilated patients: The measurement of maximal inspiratory pressure. J Crit Care 1:32–38Google Scholar
  20. 20.
    Easton PA, Fitting JW, Grassino AE (1987) Costal and crural diaphragm in early inspiration: free breathing and occlusion. J Appl Physiol 63:1622–1628PubMedGoogle Scholar
  21. 21.
    Shekleton M, Lopata M, Evanich MJ, Lourenco RV (1976) Effect of elastic loading on mouth occlusion pressure during CO2 rebreathing in man. Am Rev Respir Dis 114:341–346PubMedGoogle Scholar
  22. 22.
    Lopata M, La Fata J, Evanich M, Lourenco RV (1977) Effects of flow-resistive loading on mouth occlusion pressure during CO2 rebreathing. Am Rev Respir Dis 115:73–81PubMedGoogle Scholar
  23. 23.
    Lopata M, Evanich M J, Lourenco RV (1977) Relationship between mouth occlusion pressure and electrical activity of the diaphragm: effects of flow-resistive loading. Am Rev Respir Dis 116:449–455PubMedGoogle Scholar
  24. 24.
    Grassino AE, Derenne JP, Almirall J, Milic-Emili J, Whitelaw W (1981) Configuration of the chest wall and occlusion pressures in awake humans. J Appl Physiol 50:134–142PubMedGoogle Scholar
  25. 25.
    Marazzini L, Cavestri R, Gori D, Gatti L, Longhini E (1978) Difference between mouth and esophageal occlusion pressure during CO2 rebreathing in chronic obstructive pulmonary disease. Am Rev Respir Dis 118:1027–1033PubMedGoogle Scholar
  26. 26.
    Murciano D, Aubier M, Bussi S, Derenne JP, Pariente R, Milic-Emili J (1982) Comparison of esophageal, tracheal, and mouth occlusion pressure in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 126:837–841PubMedGoogle Scholar
  27. 27.
    Pepe PE, Marini J J (1982) Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction. Am Rev Respir Dis 126:166–170PubMedGoogle Scholar
  28. 28.
    Rossi A, Gottfried SB, Zocchi L, et al. (1985) Measurement of static compliance of the total respiratory system in patients with acute respiratory failure during mechanical ventilation: The effect of intrinsic positive end-expiratory pressure. Am Rev Respir Dis 131:672–677Google Scholar
  29. 29.
    Montgomery AB, Stager MA, Schoene RB (1985) Marked suppression of ventilation while awake following massive ingestion of atenolol. Chest 86:920–921CrossRefGoogle Scholar
  30. 30.
    Herrera M, Blasco J, Venegas J, Barba R, Dobias A, Marquez E (1985) Mouth occlusion pressure (P0.1) in acute respiratory failure. Intensive Care Med 11:134–139PubMedCrossRefGoogle Scholar
  31. 31.
    Sassoon CSH, Te TT, Mahutte CK, Light RW (1987) Airway occlusion pressure. An important indicator for successful weaning in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 135:107–113Google Scholar
  32. 32.
    Murciano D, Boczkowski J, Lecocguic Y, Milic-Emili J, Pariente R, Aubier M (1988) Tracheal occlusion pressure: A simple index to monitor respiratory muscle fatigue during acute respiratory failure in patients with chronic obstructive pulmonary disease. Ann Intern Med 108:800–805Google Scholar
  33. 33.
    Bellemare F, Grassino A (1982) Effect of pressure and timing of contraction on human diaphragm fatigue. J Appl Physiol 53:1190–1195PubMedCrossRefGoogle Scholar
  34. 34.
    Montgomery AB, Holle RHO, Neagley SR, Pierson DJ, Schoene RB (1987) Prediction of successful ventilator weaning using airway occlusion pressure and hypercapnic challenge. Chest 91:496–499PubMedCrossRefGoogle Scholar
  35. 35.
    Pourriat JL, Lamberto C, Hoang PH, Fournier JL, Vasseur B (1986) Diaphragmatic fatigue and breathing pattern during weaning from mechanical ventilation in COPD patients. Chest 90:703–707PubMedCrossRefGoogle Scholar
  36. 36.
    Agostoni E, Campbell EJM, Freedman S (1970) Energetics. In: Campbell EJM, Agostoni E, Newsom Davis J (eds) The respiratory muscles. London, Lloyd-Luke, pp 115–137Google Scholar
  37. 37.
    Field S, Kelly SM, Macklem PT (1982) The oxygen cost of breathing in patients with cardiorespiratory disease. Am Rev Respir Dis 126:9–13PubMedGoogle Scholar
  38. 38.
    Kemper M, Weissman C, Askanazi J, Hyman AI, Kinney JM (1987) Metabolic and respiratory changes during weaning from mechanical ventilation. Chest 92:979–983PubMedCrossRefGoogle Scholar
  39. 39.
    Viale JP, Annat GJ, Bouffard YM, Delafosse BX, Bertrand OM, Motin JP (1988) Oxygen cost of breathing in postoperative patients. Pressure support ventilation vs continuous positive airway pressure. Chest 93:506–509Google Scholar
  40. 40.
    Hubmayr RD, Loosbrock LM, Gillespie DJ, Rodarte JR (1988) Oxygen uptake during weaning from mechanical ventilation. Chest 94:1148–1155PubMedCrossRefGoogle Scholar
  41. 41.
    McDonald NJ, Lavelle P, Gallacher WN, Harpin RP (1988) Use of the oxygen cost of breathing as an index of weaning ability from mechanical ventilation. Intensive Care Med 14:50–54PubMedCrossRefGoogle Scholar
  42. 42.
    Lewis WD, Chwals W, Benotti PN, et al. (1988) Bedside assessment of the work of breathing. Crit Care Med 16:117–122PubMedCrossRefGoogle Scholar
  43. 43.
    Shikora SA, Bistrian BR, Borlase BC, Blackburn GL, Stone MD, Benotti PN (1990) Work of breathing: Reliable predictor of weaning and extubation. Crit Care Med 18:157–162Google Scholar
  44. 44.
    Otis AB (1954) The work of breathing. Physiol Rev 34:449–458PubMedGoogle Scholar
  45. 45.
    Kennedy SK, Weintraub RM, Skillman J J (1977) Cardiorespiratory and sympatho-adrenal responses during weaning from controlled ventilation. Surgery 82:233–240PubMedGoogle Scholar
  46. 46.
    Grassino AE, Whitelaw WA, Milic-Emili J (1976) Influence of lung volume and electrode position on electromyography of the diaphragm. J Appl Physiol 40:971–975PubMedGoogle Scholar
  47. 47.
    Fitting JW, Bradley TD, Easton PA, Lincoln MJ, Goldman MD, Grassino A (1988) Dissociation between diaphragmatic and rib cage muscle fatigue. J Appl Physiol 64:959–965PubMedGoogle Scholar
  48. 48.
    Lourenco RV, Cherniack NS, Malm JR, Fishman AP (1966) Nervous output from the respiratory center during obstructed breathing. J Appl Physiol 21:527–533PubMedGoogle Scholar
  49. 49.
    Lopata M, Evanich MJ, Lourenco RV (1976) The electromyogram of the diaphragm in the investigation of human regulation of ventilation. Chest 70 (Suppl): 162–165PubMedCrossRefGoogle Scholar
  50. 50.
    Evanich MJ, Lopata M, Lourenco RV (1976) Analytical methods for the study of electrical activity in respiratory nerves and muscles. Chest 70 (Suppl): 158–162PubMedCrossRefGoogle Scholar
  51. 51.
    Lopata M, Zubillaga G, Evanich MJ, Lourenco RV (1978) Diaphragmatic EMG response to isocapnic hypoxia and hyperoxic hypercapnia in humans. J Lab Clin Med 91:698–709PubMedGoogle Scholar
  52. 52.
    Grassino A, Goldman M, Mead J (1974) Influence of chest wall configuration on the static and dynamic characteristics of the contracting diaphragm. In: Pengelly LD, Rebuck AS, Campbell EJM (eds) Loaded breathing. Don Mills, Ontario, Longman Canada, pp 64–72Google Scholar
  53. 53.
    Aubier M, Trippenbach T, Roussos C (1981) Respiratory muscle fatigue during cardiogenic shock. J Appl Physiol 51:499–508PubMedGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 1991

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  • J. W. Fitting

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