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• W2045831451 abstract "diaphragm pacing support noninvasive ventilation spinal cord injury Every year, roughly 400 Americans experience a spinal cord injury (SCI) that requires long-term invasive mechanical ventilation. Their cost of care is ≥ $100,000 (US) per year, and their life expectancy is 50% less than their counterparts who do not require invasive mechanical ventilation.1National Spinal Cord Injury Statistical Center Spinal cord injury facts and figures at a glance.J Spinal Cord Med. 2010; 33: 439-440PubMed Google ScholarBeginning in 1966, SCI has been treated with electrical stimulation of the phrenic nerves. An updated version of this original device is commonly used in the United States today (Avery Biomedical Devices, Inc). The device uses a cuff electrode placed on the phrenic nerves bilaterally through an open cervical dissection or video-assisted thoracoscopic surgery. These electrodes are attached to a radiofrequency receiver placed under the skin on the upper part of the chest (Fig 1). The stimulation signal is provided by an external transmitter, which relays the signal through an antenna.2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google Scholar An alternative strategy developed in 2004 uses an electrode deployed intramuscularly to the phrenic nerve with a needle-based system and a laparoscopic approach to the inferior aspect of the diaphragm (Synapse Biomedical Inc).3Onders RP Khansarinia S Weiser T et al.Multicenter analysis of diaphragm pacing in tetraplegics with cardiac pacemakers: positive implications for ventilator weaning in intensive care units.Surgery. 2010; 148: 893-897Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar These devices require a training period to facilitate improved diaphragmatic strength. The time required to establish an effective, paced ventilation is variable, and patients may continue to show improvement over ≥5 months.4DiMarco AF Restoration of respiratory muscle function following spinal cord injury. Review of electrical and magnetic stimulation techniques.Respir Physiol Neurobiol. 2005; 147: 273-287Crossref PubMed Scopus (69) Google ScholarIn SCI, the goal for substituting neuroelectrical support with invasive mechanical ventilation is to improve quality of life, reduce medical complications, and curtail overall costs. The acceptance of these therapies has not been universal, and worldwide use of respiratory pacers is limited. Including all possible eligible diagnoses, the number of implanted systems worldwide totals about 2,400.5Synapse Biomedical Inc Synapse biomedical fact sheet. Synapse Biomedical Inc website.http://www.synapsebiomedical.com/news/media/pdf/CompanyFactSheet-2011.pdfGoogle Scholar, 6Avery Biomedical Devices, Inc Advantages of breathing pacemakers: advantages of breathing pacemakers over positive pressure ventilation (PPV). Avery Biomedical Devices, Inc website.http://www.averybiomedical.com/breathing-pacemakers/advantages.htmlGoogle Scholar Given this reality, a clear effort to review the pros and cons of neuroelectrical respiratory support should be initiated, and the issues are summarized here.SCIs most often occur in younger people aged <60 years. Life expectancy remains high: up to 40 years.1National Spinal Cord Injury Statistical Center Spinal cord injury facts and figures at a glance.J Spinal Cord Med. 2010; 33: 439-440PubMed Google Scholar Options for long-term care of those who require invasive mechanical ventilation are limited. When developing a care plan, choosing between invasive mechanical ventilation and respiratory pacing should take into consideration many factors, including ethical, medical, and financial.Many ethical challenges exist, starting with placement after hospital discharge. Access to nursing home facilities may be a challenge, and in the best of circumstances, the quality of life is limited by little ability to participate in the community.7White AC O'Connor HH Kirby K Prolonged mechanical ventilation: review of care settings and an update on professional reimbursement.Chest. 2008; 133: 539-545Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Participation in school, employment, and usual life activities is optimized when home-based care is used. On an ethical basis, a physician's primary responsibility is to preserve autonomy, and this should drive a commitment to community-based living, allowing people with SCI to actively engage in society and to make a meaningful impact on the world.8Van de Velde D Bracke P Van Hove G Josephsson S Devisch I Vanderstraeten G The illusion and the paradox of being autonomous, experiences from persons with spinal cord injury in their transition period from hospital to home.Disabil Rehabil. 2012; 34: 491-502Crossref PubMed Scopus (11) Google Scholar The use of respiratory pacing can be an important tool in helping to achieve these fundamental goals of SCI care.Speech is the lynchpin when preserving autonomy in people with SCI. Allowing for communication with caregivers enables the patients with SCI to preserve autonomy over their body. Preserved speech facilitates the use of adaptive communication devices, including telephones, alarms, and computers. These devices also preserve autonomy by permitting a return to the workplace. Speech can be addressed during invasive mechanical ventilation, but the quality of speech is poor. The use of speaking valves can be helpful but may be contraindicated when there is a risk of tube obstruction from secretions.9Hess DR Facilitating speech in the patient with a tracheostomy.Respir Care. 2005; 50: 519-525PubMed Google Scholar The use of respiratory pacing generates more-intelligible speech,10Esclarín A Bravo P Arroyo O Mazaira J Garrido H Alcaraz MA Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury.Paraplegia. 1994; 32: 687-693Crossref PubMed Scopus (33) Google Scholar facilitating all goals of autonomy, including a return to gainful employment.4DiMarco AF Restoration of respiratory muscle function following spinal cord injury. Review of electrical and magnetic stimulation techniques.Respir Physiol Neurobiol. 2005; 147: 273-287Crossref PubMed Scopus (69) Google ScholarBecause long-term survival from SCI has become more commonplace, the source of mortality has changed from renal failure to respiratory infections with sepsis.1National Spinal Cord Injury Statistical Center Spinal cord injury facts and figures at a glance.J Spinal Cord Med. 2010; 33: 439-440PubMed Google Scholar When choosing between invasive mechanical ventilation and respiratory pacing as long-term ventilation strategies, medical concerns should be paramount. Morbidity from the pacer placement procedure is small, with no reported fatalities, and the anesthetic has been well tolerated.11Onders RP Elmo M Khansarinia S et al.Complete worldwide operative experience in laparoscopic diaphragm pacing: results and differences in spinal cord injured patients and amyotrophic lateral sclerosis patients.Surg Endosc. 2009; 23: 1433-1440Crossref PubMed Scopus (130) Google Scholar Early implantation improves weaning and the ability to successfully use the pacer around the clock.12Le Pimpec-Barthes F Gonzalez-Bermejo J Hubsch JP et al.Intrathoracic phrenic pacing: a 10-year experience in France.J Thorac Cardiovasc Surg. 2011; 142: 378-383Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar This may be because early implantation avoids diaphragm fatigue as a result of disuse atrophy and loss of type 1 (slow twitch) muscle fibers.13Ragnarsson KT Functional electrical stimulation after spinal cord injury: current use, therapeutic effects and future directions.Spinal Cord. 2008; 46: 255-274Crossref PubMed Scopus (211) Google Scholar These pacer-based contractions drive a more effective form of respiration, improving basilar ventilation, reducing atelectasis, increasing lung compliance, and decreasing the work of breathing.11Onders RP Elmo M Khansarinia S et al.Complete worldwide operative experience in laparoscopic diaphragm pacing: results and differences in spinal cord injured patients and amyotrophic lateral sclerosis patients.Surg Endosc. 2009; 23: 1433-1440Crossref PubMed Scopus (130) Google Scholar This more open lung appears to have improved not only ventilation but also airway clearance with reduction in risk of infection. Two studies compared invasive mechanical ventilation to respiratory pacing and reported that pacing appears to reduce the incidence of respiratory infections.10Esclarín A Bravo P Arroyo O Mazaira J Garrido H Alcaraz MA Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury.Paraplegia. 1994; 32: 687-693Crossref PubMed Scopus (33) Google Scholar, 14Hirschfeld S Exner G Luukkaala T Baer GA Mechanical ventilation or phrenic nerve stimulation for treatment of spinal cord injury-induced respiratory insufficiency.Spinal Cord. 2008; 46: 738-742Crossref PubMed Scopus (82) Google Scholar This reduction in infections drives a trend toward improved survival.2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google ScholarSafety is another important issue in the treatment choice for ventilatory support. Invasive mechanical ventilation is commonly associated with complications such as barotrauma, but on a long-term basis, other complications are common and can be life threatening, including disconnection, power loss, and device failure. The respiratory pacing system reduces these risks. The elimination of tubing reduces concerns of disconnection.2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google Scholar The improvement in battery life reduces concerns of power failure2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google Scholar and has been shown to improve safety during times of natural disasters with power loss (eg, hurricanes, earthquakes).15Onders RP Elmo MJ Ignagni AR Diaphragm pacing stimulation system for tetraplegia in individuals injured during childhood or adolescence.J Spinal Cord Med. 2007; 30: S25-S29Crossref PubMed Scopus (57) Google Scholar The ability to smell is also fundamental during times of crisis, that is, being able to smell smoke and thus maintaining awareness of fire risk is lost when using invasive mechanical ventilation. The use of respiratory pacing restores olfactory function and the safety that comes with it.16Adler D Gonzalez-Bermejo J Duguet A et al.Diaphragm pacing restores olfaction in tetraplegia.Eur Respir J. 2009; 34: 365-370Crossref PubMed Scopus (42) Google ScholarEstimating the true financial burden of care is a challenge because differences in care models from country to country have such a large impact on these comparisons. Two published data sets address this issue, and both are European studies. One evaluated only institutionalized patients,10Esclarín A Bravo P Arroyo O Mazaira J Garrido H Alcaraz MA Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury.Paraplegia. 1994; 32: 687-693Crossref PubMed Scopus (33) Google Scholar and the other assessed both institutionalized and community-based patients.14Hirschfeld S Exner G Luukkaala T Baer GA Mechanical ventilation or phrenic nerve stimulation for treatment of spinal cord injury-induced respiratory insufficiency.Spinal Cord. 2008; 46: 738-742Crossref PubMed Scopus (82) Google Scholar Both studies showed a cost benefit for respiratory pacing despite a higher cost for the respiratory pacing device than for the mechanical ventilator. The cost savings are realized through reduction in respiratory care provider hours and admissions for respiratory infections. The US National Spinal Cord Injury Statistical Center estimates the annual cost of care for those with high SCI at $177,808.1National Spinal Cord Injury Statistical Center Spinal cord injury facts and figures at a glance.J Spinal Cord Med. 2010; 33: 439-440PubMed Google Scholar The greatest part of the cost is not due to equipment. For example, in Illinois, the annual cost to care for children who depend on technology, such as those with home-based tracheostomy and mechanical ventilation, averages $152,369. Of those costs, 50% is spent on in-home nursing and health services. The cost for inpatient readmission is an additional 25%. The cost for consumables and technology adds only 6% per year.17Illinois Department of Healthcare and Family Services Summary of private duty nursing: net liability in identified medical programs for state fiscal year 2010. Illinois Department of Healthcare and Family Services website.http://www2.illinois.gov/hfs/PublicInvolvement/ccmn/Documents/090811_ccmn_ncps.pdfGoogle ScholarGiven this model where the greatest driver of cost is the human cost, for in-home professional caregivers, reducing this factor of the equation would be most helpful. In reality, locating sufficiently trained caregivers is a limiting factor, with 61% of patients with SCI reporting episodes of unmet personal assistance monthly.18Hagglund KJ Clark MJ Mokelke EK Stout BJ The current state of personal assistance services: implications for policy and future research.NeuroRehabilitation. 2004; 19: 115-120PubMed Google Scholar Respiratory pacing may help to reduce these costs and improve access to in-home care. By eliminating invasive mechanical ventilation, there is a reduction in the level of training needed to care for the patient with SCI. Respiratory pacing may even allow for some patients to be completely decannulated safely, further reducing the complexities of home care.19Bolikal P Bach JR Goncalves M Electrophrenic pacing and decannulation for high-level spinal cord injury: a case series.J Spinal Cord Med. 2012; 35: 170-174Crossref PubMed Scopus (9) Google Scholar Regardless of the benefits gained from optimizing in-home care, in the end, any model to examine costs must deal with the reality that only about 40% of patients will be able to be weaned off therapy 100% of the time.2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google Scholar, 20Gater Jr, DR Dolbow D Tsui B Gorgey AS Functional electrical stimulation therapies after spinal cord injury.NeuroRehabilitation. 2011; 28: 231-248Crossref PubMed Scopus (53) Google Scholar Changes in common care models that encourage early pacer placement may avoid this complication, but for now, the ability to safely wean from invasive mechanical ventilation to respiratory pacing in a home environment can help to mitigate this concern.15Onders RP Elmo MJ Ignagni AR Diaphragm pacing stimulation system for tetraplegia in individuals injured during childhood or adolescence.J Spinal Cord Med. 2007; 30: S25-S29Crossref PubMed Scopus (57) Google ScholarIn summary, physicians should support the use of respiratory pacing in patients with SCI. Ethical, medical, and economic considerations support this hypothesis. To date, the application of respiratory pacing has been limited, and a commitment to more-aggressive care models should be considered. Every year, roughly 400 Americans experience a spinal cord injury (SCI) that requires long-term invasive mechanical ventilation. Their cost of care is ≥ $100,000 (US) per year, and their life expectancy is 50% less than their counterparts who do not require invasive mechanical ventilation.1National Spinal Cord Injury Statistical Center Spinal cord injury facts and figures at a glance.J Spinal Cord Med. 2010; 33: 439-440PubMed Google Scholar Beginning in 1966, SCI has been treated with electrical stimulation of the phrenic nerves. An updated version of this original device is commonly used in the United States today (Avery Biomedical Devices, Inc). The device uses a cuff electrode placed on the phrenic nerves bilaterally through an open cervical dissection or video-assisted thoracoscopic surgery. These electrodes are attached to a radiofrequency receiver placed under the skin on the upper part of the chest (Fig 1). The stimulation signal is provided by an external transmitter, which relays the signal through an antenna.2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google Scholar An alternative strategy developed in 2004 uses an electrode deployed intramuscularly to the phrenic nerve with a needle-based system and a laparoscopic approach to the inferior aspect of the diaphragm (Synapse Biomedical Inc).3Onders RP Khansarinia S Weiser T et al.Multicenter analysis of diaphragm pacing in tetraplegics with cardiac pacemakers: positive implications for ventilator weaning in intensive care units.Surgery. 2010; 148: 893-897Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar These devices require a training period to facilitate improved diaphragmatic strength. The time required to establish an effective, paced ventilation is variable, and patients may continue to show improvement over ≥5 months.4DiMarco AF Restoration of respiratory muscle function following spinal cord injury. Review of electrical and magnetic stimulation techniques.Respir Physiol Neurobiol. 2005; 147: 273-287Crossref PubMed Scopus (69) Google Scholar In SCI, the goal for substituting neuroelectrical support with invasive mechanical ventilation is to improve quality of life, reduce medical complications, and curtail overall costs. The acceptance of these therapies has not been universal, and worldwide use of respiratory pacers is limited. Including all possible eligible diagnoses, the number of implanted systems worldwide totals about 2,400.5Synapse Biomedical Inc Synapse biomedical fact sheet. Synapse Biomedical Inc website.http://www.synapsebiomedical.com/news/media/pdf/CompanyFactSheet-2011.pdfGoogle Scholar, 6Avery Biomedical Devices, Inc Advantages of breathing pacemakers: advantages of breathing pacemakers over positive pressure ventilation (PPV). Avery Biomedical Devices, Inc website.http://www.averybiomedical.com/breathing-pacemakers/advantages.htmlGoogle Scholar Given this reality, a clear effort to review the pros and cons of neuroelectrical respiratory support should be initiated, and the issues are summarized here. SCIs most often occur in younger people aged <60 years. Life expectancy remains high: up to 40 years.1National Spinal Cord Injury Statistical Center Spinal cord injury facts and figures at a glance.J Spinal Cord Med. 2010; 33: 439-440PubMed Google Scholar Options for long-term care of those who require invasive mechanical ventilation are limited. When developing a care plan, choosing between invasive mechanical ventilation and respiratory pacing should take into consideration many factors, including ethical, medical, and financial. Many ethical challenges exist, starting with placement after hospital discharge. Access to nursing home facilities may be a challenge, and in the best of circumstances, the quality of life is limited by little ability to participate in the community.7White AC O'Connor HH Kirby K Prolonged mechanical ventilation: review of care settings and an update on professional reimbursement.Chest. 2008; 133: 539-545Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar Participation in school, employment, and usual life activities is optimized when home-based care is used. On an ethical basis, a physician's primary responsibility is to preserve autonomy, and this should drive a commitment to community-based living, allowing people with SCI to actively engage in society and to make a meaningful impact on the world.8Van de Velde D Bracke P Van Hove G Josephsson S Devisch I Vanderstraeten G The illusion and the paradox of being autonomous, experiences from persons with spinal cord injury in their transition period from hospital to home.Disabil Rehabil. 2012; 34: 491-502Crossref PubMed Scopus (11) Google Scholar The use of respiratory pacing can be an important tool in helping to achieve these fundamental goals of SCI care. Speech is the lynchpin when preserving autonomy in people with SCI. Allowing for communication with caregivers enables the patients with SCI to preserve autonomy over their body. Preserved speech facilitates the use of adaptive communication devices, including telephones, alarms, and computers. These devices also preserve autonomy by permitting a return to the workplace. Speech can be addressed during invasive mechanical ventilation, but the quality of speech is poor. The use of speaking valves can be helpful but may be contraindicated when there is a risk of tube obstruction from secretions.9Hess DR Facilitating speech in the patient with a tracheostomy.Respir Care. 2005; 50: 519-525PubMed Google Scholar The use of respiratory pacing generates more-intelligible speech,10Esclarín A Bravo P Arroyo O Mazaira J Garrido H Alcaraz MA Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury.Paraplegia. 1994; 32: 687-693Crossref PubMed Scopus (33) Google Scholar facilitating all goals of autonomy, including a return to gainful employment.4DiMarco AF Restoration of respiratory muscle function following spinal cord injury. Review of electrical and magnetic stimulation techniques.Respir Physiol Neurobiol. 2005; 147: 273-287Crossref PubMed Scopus (69) Google Scholar Because long-term survival from SCI has become more commonplace, the source of mortality has changed from renal failure to respiratory infections with sepsis.1National Spinal Cord Injury Statistical Center Spinal cord injury facts and figures at a glance.J Spinal Cord Med. 2010; 33: 439-440PubMed Google Scholar When choosing between invasive mechanical ventilation and respiratory pacing as long-term ventilation strategies, medical concerns should be paramount. Morbidity from the pacer placement procedure is small, with no reported fatalities, and the anesthetic has been well tolerated.11Onders RP Elmo M Khansarinia S et al.Complete worldwide operative experience in laparoscopic diaphragm pacing: results and differences in spinal cord injured patients and amyotrophic lateral sclerosis patients.Surg Endosc. 2009; 23: 1433-1440Crossref PubMed Scopus (130) Google Scholar Early implantation improves weaning and the ability to successfully use the pacer around the clock.12Le Pimpec-Barthes F Gonzalez-Bermejo J Hubsch JP et al.Intrathoracic phrenic pacing: a 10-year experience in France.J Thorac Cardiovasc Surg. 2011; 142: 378-383Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar This may be because early implantation avoids diaphragm fatigue as a result of disuse atrophy and loss of type 1 (slow twitch) muscle fibers.13Ragnarsson KT Functional electrical stimulation after spinal cord injury: current use, therapeutic effects and future directions.Spinal Cord. 2008; 46: 255-274Crossref PubMed Scopus (211) Google Scholar These pacer-based contractions drive a more effective form of respiration, improving basilar ventilation, reducing atelectasis, increasing lung compliance, and decreasing the work of breathing.11Onders RP Elmo M Khansarinia S et al.Complete worldwide operative experience in laparoscopic diaphragm pacing: results and differences in spinal cord injured patients and amyotrophic lateral sclerosis patients.Surg Endosc. 2009; 23: 1433-1440Crossref PubMed Scopus (130) Google Scholar This more open lung appears to have improved not only ventilation but also airway clearance with reduction in risk of infection. Two studies compared invasive mechanical ventilation to respiratory pacing and reported that pacing appears to reduce the incidence of respiratory infections.10Esclarín A Bravo P Arroyo O Mazaira J Garrido H Alcaraz MA Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury.Paraplegia. 1994; 32: 687-693Crossref PubMed Scopus (33) Google Scholar, 14Hirschfeld S Exner G Luukkaala T Baer GA Mechanical ventilation or phrenic nerve stimulation for treatment of spinal cord injury-induced respiratory insufficiency.Spinal Cord. 2008; 46: 738-742Crossref PubMed Scopus (82) Google Scholar This reduction in infections drives a trend toward improved survival.2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google Scholar Safety is another important issue in the treatment choice for ventilatory support. Invasive mechanical ventilation is commonly associated with complications such as barotrauma, but on a long-term basis, other complications are common and can be life threatening, including disconnection, power loss, and device failure. The respiratory pacing system reduces these risks. The elimination of tubing reduces concerns of disconnection.2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google Scholar The improvement in battery life reduces concerns of power failure2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google Scholar and has been shown to improve safety during times of natural disasters with power loss (eg, hurricanes, earthquakes).15Onders RP Elmo MJ Ignagni AR Diaphragm pacing stimulation system for tetraplegia in individuals injured during childhood or adolescence.J Spinal Cord Med. 2007; 30: S25-S29Crossref PubMed Scopus (57) Google Scholar The ability to smell is also fundamental during times of crisis, that is, being able to smell smoke and thus maintaining awareness of fire risk is lost when using invasive mechanical ventilation. The use of respiratory pacing restores olfactory function and the safety that comes with it.16Adler D Gonzalez-Bermejo J Duguet A et al.Diaphragm pacing restores olfaction in tetraplegia.Eur Respir J. 2009; 34: 365-370Crossref PubMed Scopus (42) Google Scholar Estimating the true financial burden of care is a challenge because differences in care models from country to country have such a large impact on these comparisons. Two published data sets address this issue, and both are European studies. One evaluated only institutionalized patients,10Esclarín A Bravo P Arroyo O Mazaira J Garrido H Alcaraz MA Tracheostomy ventilation versus diaphragmatic pacemaker ventilation in high spinal cord injury.Paraplegia. 1994; 32: 687-693Crossref PubMed Scopus (33) Google Scholar and the other assessed both institutionalized and community-based patients.14Hirschfeld S Exner G Luukkaala T Baer GA Mechanical ventilation or phrenic nerve stimulation for treatment of spinal cord injury-induced respiratory insufficiency.Spinal Cord. 2008; 46: 738-742Crossref PubMed Scopus (82) Google Scholar Both studies showed a cost benefit for respiratory pacing despite a higher cost for the respiratory pacing device than for the mechanical ventilator. The cost savings are realized through reduction in respiratory care provider hours and admissions for respiratory infections. The US National Spinal Cord Injury Statistical Center estimates the annual cost of care for those with high SCI at $177,808.1National Spinal Cord Injury Statistical Center Spinal cord injury facts and figures at a glance.J Spinal Cord Med. 2010; 33: 439-440PubMed Google Scholar The greatest part of the cost is not due to equipment. For example, in Illinois, the annual cost to care for children who depend on technology, such as those with home-based tracheostomy and mechanical ventilation, averages $152,369. Of those costs, 50% is spent on in-home nursing and health services. The cost for inpatient readmission is an additional 25%. The cost for consumables and technology adds only 6% per year.17Illinois Department of Healthcare and Family Services Summary of private duty nursing: net liability in identified medical programs for state fiscal year 2010. Illinois Department of Healthcare and Family Services website.http://www2.illinois.gov/hfs/PublicInvolvement/ccmn/Documents/090811_ccmn_ncps.pdfGoogle Scholar Given this model where the greatest driver of cost is the human cost, for in-home professional caregivers, reducing this factor of the equation would be most helpful. In reality, locating sufficiently trained caregivers is a limiting factor, with 61% of patients with SCI reporting episodes of unmet personal assistance monthly.18Hagglund KJ Clark MJ Mokelke EK Stout BJ The current state of personal assistance services: implications for policy and future research.NeuroRehabilitation. 2004; 19: 115-120PubMed Google Scholar Respiratory pacing may help to reduce these costs and improve access to in-home care. By eliminating invasive mechanical ventilation, there is a reduction in the level of training needed to care for the patient with SCI. Respiratory pacing may even allow for some patients to be completely decannulated safely, further reducing the complexities of home care.19Bolikal P Bach JR Goncalves M Electrophrenic pacing and decannulation for high-level spinal cord injury: a case series.J Spinal Cord Med. 2012; 35: 170-174Crossref PubMed Scopus (9) Google Scholar Regardless of the benefits gained from optimizing in-home care, in the end, any model to examine costs must deal with the reality that only about 40% of patients will be able to be weaned off therapy 100% of the time.2DiMarco AF Phrenic nerve stimulation in patients with spinal cord injury.Respir Physiol Neurobiol. 2009; 169: 200-209Crossref PubMed Scopus (74) Google Scholar, 20Gater Jr, DR Dolbow D Tsui B Gorgey AS Functional electrical stimulation therapies after spinal cord injury.NeuroRehabilitation. 2011; 28: 231-248Crossref PubMed Scopus (53) Google Scholar Changes in common care models that encourage early pacer placement may avoid this complication, but for now, the ability to safely wean from invasive mechanical ventilation to respiratory pacing in a home environment can help to mitigate this concern.15Onders RP Elmo MJ Ignagni AR Diaphragm pacing stimulation system for tetraplegia in individuals injured during childhood or adolescence.J Spinal Cord Med. 2007; 30: S25-S29Crossref PubMed Scopus (57) Google Scholar In summary, physicians should support the use of respiratory pacing in patients with SCI. Ethical, medical, and economic considerations support this hypothesis. To date, the application of respiratory pacing has been limited, and a commitment to more-aggressive care models should be considered." @default.
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• W2045831451 title "Point: Should Phrenic Nerve Stimulation Be the Treatment of Choice for Spinal Cord Injury? Yes" @default.
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