PHRENIC NERVE PACER Bethany Jerabek DNP ARNP Maida

PHRENIC NERVE PACER Bethany Jerabek, DNP, ARNP Maida Lynn Chen, MD Director, Sleep Disorders Program Seattle Children’s Hospital

Objectives • Describe motives for transition to a phrenic nerve pacer • Identify how to transition to a phrenic nerve pacer • Focus: Eligibility for placement *The following are only suggested guidelines. Each individual case may require a different approach.

Why do you want Pacers? • • Freedom from positive pressure ventilation? Tracheostomy decannulation? Decrease amount of equipment? Decrease daily monitoring? Decrease hospital admissions or office visits? Increase mobility? Improve quality of life?

Myth 1: Phrenic nerve pacer placement is a surgery on the lungs.

BUSTED! • Phrenic nerve pacer placement is NOT a surgery on the lungs • Thoracoscopic placement approach used to to attach electrodes on the phrenic nerves bilaterally and implant a connected receiver below abdominal skin • Lungs must be deflated, one at a time, during surgery to attach electrodes • Recovery after surgery is related to deflated lungs

CCHS Phrenic Nerve Pacer Placement Eligibility Pathway 2 Functional diaphragm and intact phrenic nerve • Demonstrates spontaneous breath on No command while awake • OR fluoroscopy/ultrasound to visualize spontaneous diaphragmatic movement Yes

Myth 2: Phrenic nerve pacer placement guarantees tracheostomy decannulation.

BUSTED! • Phrenic nerve pacer placement does NOT guarantee tracheostomy removal • Difficult to predict until the pacer is in place • Tracheostomy may not be decannulated for several months following pacer placement • Tracheostomy cannot always be removed • Full-time ventilatory support vs. night-time ventilatory support • A backup plan for acute illness or pacer failure must still be in place • Positive pressure ventilation via mask or tracheostomy • Intubation

CCHS Phrenic Nerve Pacer Placement Eligibility Pathway 3 Clearance by ENT • For potential tracheostomy decannulation No with pacer placement • For potential tonsillectomy and/or adenoidectomy with pacer placement 3 Yes No 4 Absence of pulmonary hypertension • Echo within past 12 months Yes

Myth 3: An implanted cardiac pacemaker is required before phrenic nerve pacer placement.

BUSTED! • An implanted cardiac pacemaker is NOT mandatory for phrenic nerve stimulator placement • Phenotype dependent • History with prior anesthesia is important • Discretion of the surgeon, pulmonologist, pre-anesthesia evaluation • One-time ECG not necessarily helpful • More important to have well versed and prepared anesthesiologist (pediatric specific, experienced)

CCHS Phrenic Nerve Pacer Placement Eligibility Pathway No 5 Evaluation for or implanted cardiac pacemaker Yes

Myth 4: Home nursing care will remain the same.

BUSTED! • May have reduced home nursing care • Possible loss of daytime and school nursing care • More of a challenge to get support services • All children are individualized

CCHS Phrenic Nerve Pacer Placement Eligibility Pathway 6 Will quality of life and/or health improve with phrenic nerve pacer placement? No Understanding of potential implications on home health nursing and support? Yes

Myth 5: Phrenic nerve pacers make all future medical care easier.

BUSTED! • Phrenic nerve pacers will NOT always make future medical care easier • Not well known at all health care facilities • Without trach, looks no different than anybody else to EMS • Not MRI compatible • Require frequent attention and tinkering • Biannual or annual comprehensive evaluation • Cause artifact on transthoracic cardiorespiratory monitors • Costly system • Back-up pacer transmitter • Back-up Bi. PAP • No external alarms

CCHS Phrenic Nerve Pacer Placement Eligibility Pathway No 1 Absent or mild intrinsic lung disease Absence of chest wall deformity No foreseeable need for MRI • Absence of VP shunt Medically stable condition Yes

CCHS Phrenic Nerve Pacer Placement Eligibility Pathway 9 Notifications • Pediatric Intensive Care Unit • Respiratory Therapy 8 Complete CCHS phrenic nerve pacer placement preoperative assessment checklist 7 Consultations • • • Yes General surgery Neurosurgery Anesthesiology Pulmonology Cardiology Social work Active care coordination plan if considering tracheostomy decannulation Eligible for phrenic nerve pacer placement

Myth 6: Phrenic nerve pacers are the same as diaphragm pacers.

BUSTED!

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