# Presentation: 323883

## Management of Phrenic Pacemakers

**Kelly D. Skinner, MSN, CRRN, ANP, GNP, Phyllis O’Connor, RN, **
**Howard Dillon, RN, BSN, & Norma Maxim, RN, ADN**** **
**VA Boston Healthcare System**

_**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, Ondine’s 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.”**

**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.**

-                          _**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 **
** ****transfer with protective bag, if available.**
**Antenna wires ~do not bend or kink, ~exercise care during transfer, ~avoid **
**  ****having the patient bend or strain repeatedly.**
_**EQUIPMENT:**_  **Tegaderm  ****              **
**                            ****Hypoallergenic tape**
**                            ****Comfort Bath or basin with warm water, wash cloth & soap**
**                            ****Towel**                                                                                            

_**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**

- CHART or
- PICTURE

**LOGO**

**LOGO**

**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 person’s 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.**

**Phrenic Pacemaker System Components**

**Phrenic Pacemaker**

**Patient Profiles**

**Advantages & Disadvantages**

**Helpful Hints**

_**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**

**              ****Mr. M.**

**              ****Mr. L.**

**    **_**Internal View**_** **

**   ****Avery Biomedical Devices, Inc.****    **

**    **_**External View**_** **

**What is a phrenic pacemaker?**