Influence of Immersion in Water on Muscle Function and Breathing Pattern in Patients With Severe Diaphragm Weakness

doi:10.1378/chest.125.6.2069

Chest

Volume 125, Issue 6, June 2004, Pages 2069-2074

https://doi.org/10.1378/chest.125.6.2069 Get rights and content

Study objective

Dyspnea is a common symptom in patients with diaphragm weakness or paralysis. In particular, dyspnea may be aggravated by immersion. We hypothesized that immersion to the neck in water would decrease vital capacity and consequently increase the demand/capacity ratio of the respiratory muscles.

Design

Case series study.

Subjects

Seven patients with profound diaphragm weakness or paralysis proven by phrenic nerve stimulation, and seven normal control subjects.

Intervention and measurements

We measured land-based and water-based spirometry, breathing pattern, and mouth occlusion pressures.

Results

We found that the patients could preserve minute ventilation despite a fall in vital capacity from a mean of 2.3 to 1.3 L, but this required an increased respiratory rate (RR) [21.4 to 26.7 breaths/min, p = 0.018]. We used mouth occlusion pressure 100 ms after the start of inspiration (P_0.1) as an estimation of the drive to breath; P_0.1 increased from 1.4 to 3.9 cm H₂O (p = 0.018) without significant change in tidal volume.

Conclusions

Relative to control subjects, patients with diaphragm weakness have augmented drive to breathe in order to attempt to defend gas exchange. This conclusion is implied by the presevered minute ventilation with immersion, the augmented RR, and elevated P_0.1 relative to maximum static inspiratory pressure.

Section snippets

Patients

Seven consecutive patients referred to the Krankenhaus Kloster Grafschaft for consideration of noninvasive ventilatory support were recruited for this study. The protocol was approved by our ethical review committee, and all subjects gave written informed consent to participate. Patients with bulbar paralysis and consequent weakness of the facial muscles were excluded. Clinical diagnoses are shown in Table 1. Identical procedures were applied to seven healthy members of the local community of

Anthropometric Data, Lung and Muscle Function

Diagnosis, spirometric, and clinical data are shown in Table 1. Respiratory muscle strength data of the patients are shown in Table 2. All patients had severe bilateral diaphragm weakness (patients 1, 3, 4, and 6) or paresis (patients 2, 5, and 7), as judged by phrenic nerve stimulation and, in all but one patient (patient 2), expiratory muscle weakness. The control subjects were assumed to be free of neurologic and respiratory disease. Their mean Pimax was 60.3 cm H₂O, compared with 37 cm H₂O

DISCUSSION

Although dyspnea in water is recognized as a symptom suggestive of diaphragm paralysis or weakness, no previous study has systematically investigated the underlying mechanisms. Moreover, in only one of the few cases so far described in the literature was diaphragm paralysis confirmed by phrenic nerve stimulation.² Our data show that there was a substantial reduction in VC without significant reduction in tidal volume. Nevertheless, the patient's complaint of dyspnea was consistent with the

ACKNOWLEDGMENT

The authors thank Sven Wallstein and Patrick Appelhans for technical assistance with land-based and water-based measurements.

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Chest

Clinical InvestigationsPulmonary FunctionInfluence of Immersion in Water on Muscle Function and Breathing Pattern in Patients With Severe Diaphragm Weakness

Study objective

Design

Subjects

Intervention and measurements

Results

Conclusions

Section snippets

Patients

Anthropometric Data, Lung and Muscle Function

DISCUSSION

ACKNOWLEDGMENT

Respir Physiol

Out of depth, out of breath

BMJ

Idiopathic diaphragmatic weakness

BMJ

Dyspnea on immersion: mechanisms in patients with bilateral diaphragm paralysis

Am Rev Respir Dis

Lung volumes and forced ventilatory flows: Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal; Official Statement of the European Respiratory Society

Eur Respir J Suppl

The ventilatory capacity in healthy subjects: an analysis of causal factors with special reference to the respiratory forces

Scand J Clin Lab Invest

Maximal respiratory pressures: normal values and relationships to age and sex

Am Rev Respir Dis

A simple method for assessing the validity of the esophageal balloon technique

Am Rev Respir Dis

Cervical magnetic stimulation: a new painless method for bilateral phrenic nerve stimulation in conscious humans

J Appl Physiol

Clinical Investigations
Pulmonary Function
Influence of Immersion in Water on Muscle Function and Breathing Pattern in Patients With Severe Diaphragm Weakness