Ventilator-Assisted Living©

Spring 1999, Vol. 13, No. 1

ISSN 1066-534X

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Read selected articles from this issue ...

Computers – A Curse, A Blessing, A Necessity
Steve McPherson and Lew Boles

Living with Invasive Ventilation
Dan Garrison, Missouri

Supreme Court Rules in Favor of Teen Ventilator User

Camps for Ventilator-Assisted Children

Phrenic Nerve Pacing

Let's Hear It for Free Speech!
Sharon Davids, RRT

Potpourri: Ventilator Cart; Breathe Easy: Respiratory Care for Children with Muscular Dystrophy (booklet); Guide to the Evaluation and Management of Neuro-muscular Disease (book)

Phrenic Nerve Pacing

Phrenic nerve or diaphragmatic pacing is a way to augment diaphragm activity in the work of breathing. Small electrodes are sutured to the phrenic nerves connected by leads to receivers implanted subcutaneously. Radio signals from an external transmitter and antenna activate the receivers, and the stimulating pulses delivered to the phrenic nerve cause the diaphragm to contract, producing inhalation.

All systems must be surgically implanted, but the operation has been streamlined and generally, implants for adults are now in the neck area rather than the chest. A tracheostomy is usually required due to the possibility of upper airway obstruction; often the tracheostomy can later be closed. Several individuals with phrenic pacers also frog breathe.

Candidates for phrenic nerve pacing must have the phrenic nerve intact, as well as normal lung function and normal chest wall compliance. The two groups who benefit most from diaphragmatic pacing are people with high spinal cord injuries (SCI) and children with congenital central hypoventilation syndrome (CCHS).

However, in active children with CCHS, the electrodes can be displaced or fray with movement. Phrenic nerve pacing has not been shown to be effective in people with chest wall deformities, such as post-polio syndrome, but it has been used in a small number of people with COPD.

Two phrenic nerve pacing systems are available (only one – Avery/Dobelle – has been completely approved for use in the United States by the FDA). They are the Mark IV Breathing Pacemaker System from Avery/Dobelle, and Med-Implant, manufactured in Austria and used only in Germany and Austria.

The Avery/Dobelle system, either with unipolar or bipolar electrodes, has been used most widely since its development in the 1960s by Glenn and co-workers (1,000 implants since 1968). The MedImplant is also quadripolar with the advantage of low frequency stimulation, thus lessening diaphragmatic fatigue.

Phrenic nerve pacers improve respiratory physiology because air is drawn into the lungs naturally by diaphragmatic contractions, rather than air forced into the lungs under pressure from a mechanical ventilator. The systems are costly (approximately $40,000-50,000), but they are covered by Medicare and many private insurers. When balanced against the longterm costs of ventilator equipment, supplies, and care, phrenic pacing systems may be less expensive.


Atrostim® Phrenic Nerve Stimulator V2.0
(available only outside USA)
Atrotech OY
Tampere, Finland

Atrostim® Phrenic Nerve Stimulator V1.0
(available in USA as IDE)
Lifestream Medical Corporation

Mark IV Breathing Pacemaker
Avery Laboratories, Inc. (formerly The Dobelle Institute in 1999),

MedImplant Biotechnisches Labor
Laudongasse 10, A-1080 Vienna, Austria


Chervin RD, Guilleminault C. (1994). Diaphragm pacing review and reassessment. Sleep, 17 (2), 176-187.

Creasey G, Elefteriades J, DiMarco A, Talonen P, Bijak M, Girsch W, Kantor C. (1996). Electrical stimulation to restore respiration. Journal of Rehabilitation Research and Development, 33 (2), 123-132.

Moxham J, Shneerson J. (1993). Diaphragmatic pacing. American Review of Respiratory Disease, 148, 533-536.

Weese-Mayer DE, Silvestri JM, Kenny AS, Ilbawi MI, Hauptman SA, Lipton JW, Talonen PP, Garcia HG, Watt JW, Exner G, Baer GA, Elefteriades JA, Peruzzi WT, Alex CG, Harlid R, Vincken W, Davis GM, Decramer M, Kuenzle C, Saeterhaug A, Schober JG. (1996). Diaphragm pacing with a quadripolar phrenic nerve electrode: an international study. PACE, 19, 1311-1319.

Thanks to the FES Information Center, Cleveland, Ohio, for providing information
(800-666-2353 or

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