Thursday, June 21, 2012

Mighty Z's Breathing Pacemaker

The parents of children who have a complicated medical diagnosis are often required to educate themselves about various medical procedures in order to make potentially life-changing decisions about whether a risk is worth the reward.  For us, one of our first risk v. reward decisions involved breathing pacers. 

When Mighty Z was born we heard about the "breathing pacemaker" (Avery Bio-medical), a device that can provide ventilatory support for patients with chronic respiratory insufficiency whose diaphragm, lungs, and phrenic nerves have residual function.  It sounded good, and without knowing the details, I really wanted Mighty Z to have one put in when she was a baby -- right up until I found out that the procedure the doctors then planned to employ to install the breathing pacer involved cutting into the phrenic nerve, and then, I changed my mind. 

Let me tell you about the phrenic nerve.  It arises from the cervical, or neck region, of the spine that supplies movement to the diaphragm.  The body contains a left and a right phrenic nerve, and they follow different paths, though they both begin in the neck.  The phrenic nerve plays a crucial role in the respiratory process in that it causes the diaphragm to contract.  Cutting into the phrenic nerve could damage the nerve, and if that happened Mighty Z could be ventilator dependent 24/7 for the rest of her life, with no chance of ever getting her trach out.  Allow someone to cut Mighty Z’s phrenic nerve?  Thanks, but no thanks.  The risk was not worth the reward.

When Mighty Z was 2, her doctor brought the subject up again.  He said that the procedure for performing the breathing pacers surgery had changed, and that now the surgeons would wrap the breathing pacers around the phrenic nerve so there would be no damage to it.  The new procedure sounded like an improvement, but I was still hesitant.  Mighty Z was doing well with her trach and her ventilator, so why rock the boat?   

I needed to know more about breathing pacers in order to make a decision about whether they made sense for Mighty Z, who was surviving without them.  I began researching the breathing pacers, and through my research I learned that a breathing pacemaker consists of surgically implanted receivers and electrodes, and an external transmitter with antennas worn directly over the implanted receivers.  The external transmitter and antennas send radiofrequency energy to the implanted receivers just under the skin, which then convert the radio waves into stimulating pulses.  These pulses are sent down the electrodes to the phrenic nerves, causing the diaphragms to contract, and it is this contraction that causes inhalation of air.  When the pulses stop, the diaphragms relax and exhalation occurs.  Repetition of this series of pulses produces a normal breathing pattern. 

While a ‘normal breathing pattern’ sounded like light at the end of the tunnel, the new and improved procedure for installing the breathing pacers still involved what seemed to me to be a long and scary tunnel.  The new procedure involved what is unquestionably major thoracic surgery.  Specifically, to install the breathing pacers, the surgeons would need to implant the electrodes an inch and a half below each nipple, and then dissect all the way up to the collar bone on either side and wrap the receivers around the phrenic nerve.  Yikes!  At that point in time, the surgeon had only performed one implant surgery on a 13-year old girl, and Mighty Z was almost 3.  Was the risk of Mighty Z undergoing major thoracic surgery (unproven in one so young) worth the potential reward of freeing Mighty Z from her trach and from her ventilator for up to 12 hours a day?  I wasn’t sure, so again I hesitated.  Some decisions are hard to make quickly (or at all), and I guess I needed a push.

I got the ‘push’ I needed from Dr. Keens (one of the leading doctors in CCHS).  Dr. Keens called me to discuss the contemplated procedure, and he, too, encouraged me to go forward with the breathing pacer surgery for Mighty Z.  With his voice added to her other doctor’s, plus all the information I learned through my research, I decided that the risk was worth the reward.

I allowed the surgery when Mighty Z was 3.  Afterwards, we had to wait six months to allow the implants to graph to Mighty Z's body before turning the external receivers on.  After the wait period passed, we did just that.  It is now 8 years later, and we have never looked back.  With the breathing pacers Mighty Z no longer needs her trach.  When Mighty Z is sick and she needs 24-hour ventilator support, she throws her external receiver in her purse and we are on our way to the doctor. 

I was scared to make the decision to allow Mighty Z to have the breathing pacer surgery at age 3, but I’m so glad I did. I had to give Mighty Z the chance to be a typical kid -- to jump in the pool, to take a bubble bath, to do all the things she couldn't do with a trach.

For Mighty Z and our family it was the best choice we ever made. Here is the TV show The Doctors talking about the breathing pacer

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  1. Shelley, my major doubt is exactly what happens when they get sick. Is it necessary only change the pacer's parameters? Did she ever need to be intubated? I really want to see Tiago free of the trach, but a guess I also need a big push. :\

  2. I am astounded by technology because it has come so far in the past 30 years. I read about CCHS a few years ago, but it wasn't until 2 years ago that my neurologist told me that I had been & still am a victim of "Ondine's Curse.:

  3. The thought of Noah getting pacers terrifies me. Should we leave well enough alone and keep the current treatment or try for something better but with a chance of 24/7 ventilation. That is so scary to me. I admire you so much for being such a strong mom and an advocate for Zoe.