36x60 poster template

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Management of Phrenic Pacemakers Kelly D.
Skinner, MSN, CRRN, ANP, GNP, Phyllis OConnor,
RN, Howard Dillon, RN, BSN, Norma Maxim, RN,
ADN VA Boston Healthcare System
LOGO
LOGO
Patient Profiles
What is a phrenic pacemaker?
Phrenic Pacemaker

• Definition
• The phrenic pacemaker is an implantable
  diaphragmatic phrenic nerve stimulator that
  provides support for patients with chronic
  ventilatory insufficiency whose diaphragm,
  lungs, and phrenic nerves have residual function
  (Aron, 2005).
• Indications
• Potential candidates for a phrenic pacemaker
  include but are not limited to those individuals
  who require chronic ventilatory support related
  to
• Central alveolar hypoventilation
• Decreased day or night ventilatory drive (i.e.,
  sleep apnea, Ondines Curse)
• Brain stem injury or disease
• Spinal cord injury or disease

• Mr. M. is a 57 year old male veteran who was
  critically injured in a motor vehicle accident in
  1984. The accident rendered him a C-2
  quadriplegic who became dependent on a mechanical
  ventilator to breathe. In 1985, Mr. M. had a
  phrenic pacemaker implanted. The phrenic
  pacemaker took the place of the mechanical
  ventilator. Mr. M. has been phrenically paced
  for almost twenty years. He attributes an
  increased quality of life benefit directly to the
  phrenic pacemaker. Mr. M. states that the
  phrenic pacemaker is 100 natural compared to
  being on a ventilator.
• Mr. L. is 42 year old male veteran who was
  rendered a C2 quadriplegic from a motor cycle
  accident. Since his respiratory muscles lost
  their ability to function, Mr. L. relied on a
  mechanical ventilator to breathe until he had a
  phrenic pacemaker placed in 1985. This was
  almost twenty years ago. Mr. L. reports that
  it really feels like I am breathing on my own
  with the phrenic pacemaker.

Internal View
External View
Mr. M.
Mr. L.
CHART or PICTURE
Phrenic Pacemaker System Components

• External radio transmitter with a 9-volt battery
  or batteries
• External antennae
• Radio receivers implanted into subcutaneous
  pockets
• Electrodes sutured to the phrenic nerves
• The external radio transmitter transmits energy
  or an electrical stimulus through the two
  antennae that are taped to the persons skin.
  The signal is then received by the radio
  receivers implanted in the subcutaneous pockets
  under the skin. The electrical pulses are then
  delivered by the platinum electrodes which are
  sutured to the phrenic nerves. The diaphragm
  muscle contracts and inhalation occurs. The
  transmitter then stops producing a stimulus,
  which causes the diaphragm to relax and
  exhalation occurs. The signals are automatically
  repeated by the transmitter. These bursts of
  pulses are applied for 1.6 seconds and repeated
  12 times per minute. As a result, a normal
  breathing pattern is produced.

Advantages Disadvantages
Avery Biomedical Devices, Inc.

• Advantages
  Potential Disadvantages
• -Improved venous return due to negative
  -Battery exhaustion
• not positive pressure
• -External components are small and silent
  -Wire breakage from the 9-volt
• 
  battery to the
  portable transmitter
• -Provides safe pacing 24 hours per day
  - Breakage of the antenna wire
• -Cost effective related to the ventilator
  - Breakage of the electrode wires
• disposables being eliminated
  
• -FDA approved and reimbursed by many -
  Temporary loss of pacing
• insurance carriers
  
• -Increased mobility and independence
  - Infection
• -Improved quality of life
  - Dehiscence

• DEPARTMENT OF VETERANS
  AFFAIRS
• VA BOSTON
  HEALTHCARE SYSTEM
  
• 
  
• NURSING SERVICE PROCEDURE NO. 118-P-02
• SUBJECT Phrenic Pacers Skin Care of the
  Individual With
• PURPOSE To outline the care of individuals with
  phrenic pacers, i.e., care of
• skin under pacer.
• DEFINITION The diaphragm pacing system is an
  implantable diaphragmatic/
• phrenic nerve stimulator that provides support
  for individuals with chronic
• ventilatory insufficiency whose phrenic nerves
  are intact.
• SPECIAL CONSIDERATIONS
• Ambu bag must be available at all times.
• Respiratory Therapy is responsible for the
  changing of the antenna with
• Nursing assistance, if required.
• Antenna must be changed every 6 months and PRN
  (cracked antenna, loosened
• connections, patient complaining of difficulty
  breathing)
• Tegaderm must be changed monthly and PRN
  (dislodged, loss of contact with
• skin)
• Transmitter do not allow to become wet, do not
  drop, protect during

ESSENTIAL STEPS IN PROCEDURE KEY POINTS 1.
Explain procedure to patient.
1. Decrease patient anxiety 2. Wash
hands.
2. Handwashing is considered

the single
most important

procedure in preventing cross-

contamination. 3.
Put on gloves.
3. Standard precautions. 4.
Following patient inspiration, gently
4. Changing one antenna at a lift
off right antenna including both
time allows the patient to layers of
Tegaderm, wash and dry
continue breathing with skin, removing any
remaining the
other pacer. adhesive. 5. Place on
layer of Tegaderm followed 5.
Antenna should be positioned by antenna
over the implanted receiver. and
repositioned until contact

provides maximum operation

efficiency
(breathing).

Antenna must lie flat. 6. Cover antenna
with second layer of Tegaderm. Apply
hypoallergenic tape if necessary. 7.
Repeat steps 3, 4, 5, and 6 for the left
antenna. 8. Ambu patient and notify
Respiratory Therapy immediately if patient
experiences respiratory distress. 9.
Document in Medical Record/ Treatment
Sheet.

NPRO 118-P-02 7/03
Helpful Hints

• If the phrenic pacemaker malfunctions, adequate
  ventilatory support must be maintained or
• the person will arrest.
• Ensure pulse oximetry and apnea monitor are
  available. Document refusal.
• A back- up ventilator is warranted. The person
  with a phrenic pacemaker can also be
• taught to perform glossopharyngeal (frog)
  breathing to provide emergency respiration.
• Turn off the phrenic pacemaker during prolonged
  manual and/or mechanical ventilation.
• Transtelephonic monitors relay data from the
  phrenic pacemaker if a problem is suspected.
• MRI and shock wave lithotripsy are
  contraindicated.
• Avoid exposure of the implanted components to
  therapeutic levels of ultrasound energy.
• Nurses should review the hospital policy and the
  phrenic pacemaker instruction manual when
• caring for a spinal cord injured individual with
  a phrenic pacemaker.