\ NS Department of Veterans Affairs Journal of Rehabilitation Research and Development Vol . 33 No . 2, April 1996 Pages 123-132 Electrical stimulation to restore respiration Graham Creasey, MD ; John Elefteriades, MD ; Anthony DiMarco, MD ; Pasi Talonen, PhD; Manfred Bijak, MSc ; Werner Girsch, MD ; Carole Kantor, MS MetroHealth Medical Center, Departments of Medicine and of Physical Medicine and Rehabilitation, Cleveland, OH 44109 ; Case W estern Reserve University, Cleveland, OH 44106 Y ale University School of Medicine, Department of Cardiothoracic Surgery, New Haven, CT 06520 ; Atrotech OY , Tampere, Finland SF33721; University of Vienna, Departments of Plastic Surgery and of Biomedical Engineering and Physics, Vienna, Austria A -1090 ; Tantalus, Inc ., Highland Park, NJ 08904 Abstract—Electrical stimulation has been used for over 25 years to restore breathing to patients with high quadriplegia causing respiratory paralysis and patients with central alveolar hypoventilation . Three groups have developed electrical pacing systems for long-term support of respiration in humans . These systems consist of electrodes implanted on the phrenic nerves, connected by leads to a stimulator implanted under the skin, and powered and controlled from a battery- powered transmitter outside the body . The systems differ principally in the electrode design and stimulation waveform. Approximately 1,000 people worldwide have received one of the three phrenic pacing devices, most with strongly positive results: reduced risk of tracheal problems and chronic infection, the ability to speak and smell more normally, reduced risk of accidental interruption of respiration, greater independence, and reduced costs and time for ventilatory care . For patients with partial lesions of the phrenic nerves, intercostal muscle stimulation may supplement respiration. This material is based upon work supported by the Cleveland FES Center . Dr. DiMarco's work was supported in part by NIH and FDA. Drs . Creasey and DiMarco are affiliated with the Department of Physical Medicine and Rehabilitation and the Department of Medicine, respectively, at MetroHealth Medical Center, Cleveland, OH and with Case Western Reserve University, Cleveland, OH. Dr. Elefteriades is with the Yale University School of Medicine, Department of Cardiothoracic Surgery, New Haven, CT . Dr . Talonen is with Atrotech OY, Tampere, Finland SF33721 . Mr. Bijak is with the University of Vienna, Department of Biomedical Engineering and Physics, Vienna. Austria, and Dr. Girsch is with the Department of Plastic Surgery of that University . Ms. Kantor is with Tantalus, Inc ., Highland Park, NJ. Address all correspondence and requests for reprints to: P . Hunter Peckham, PhD, Cleveland FES Center, 11000 Cedar Avenue, Suite 207, Case Western Reserve University, Cleveland, OH 44106-7211 . Key words : central alveolar hypoventilation, diaphragm pacing, FES, phrenic nerve stimulation, respiratory paralysis. INTRODUCTION Electrical stimulation of the phrenic nerve to restore respiration was first suggested in 1783 by Hufeland (1) and then demonstrated as a method of cardiopulmonary resuscitation by Ure in 1819 (2), Duchenne de Boulogne in 1872 (3), and Beard and Rockwell in 1878 (4) . In the early part of this century, transcutaneous phrenic nerve stimulation was tested in the acute treatment of apneic newborns by Israel and of polio patients by Sarnoff (5) . Based on research starting in 1959, Glenn and colleagues developed chronic phrenic nerve stimulation (6-10) . In this life-sustaining application of electrical stimulation, patients can breathe entirely by diaphragm pacing . Several groups that use Glenn's method have demonstrated its effectiveness and clinical utility for long-term ventilation in patients with high quadriplegia or central hypoventilation . Investiga- tors in Finland and Austria have developed variant electrodes and stimulation techniques in an attempt to reduce muscle fatigue and produce smoother contrac- tion . To expand the patient group who can be helped to breathe with electrical stimulation, other workers are studying intercostal muscle stimulation in patients with partial lesions of motor neurons supplying the dia- phragm. 123