Advanced serial analysis of the diaphragm surface EMG: insights into the effect of pressure support on the neuro-ventilatory response during the ICU stay

R S P Warnaar; A D Cornet; A Beishuizen; D W Donker; E Oppersma

doi:10.1186/s13054-025-05424-5

Advanced serial analysis of the diaphragm surface EMG: insights into the effect of pressure support on the neuro-ventilatory response during the ICU stay

R S P Warnaar^*, A D Cornet, A Beishuizen, D W Donker, E Oppersma

^*Corresponding author for this work

Intensive Care Medicine

Research output: Contribution to journal › Article › Academic › peer-review

Abstract

BACKGROUND: Ventilatory support levels in ICU patients should be tailored to both optimal gas exchange and respiratory muscle loading, as over- and underassistance may cause diaphragm dysfunction. The diaphragm's capacity to overcome mechanical load and deliver ventilatory output is reflected by the patient's neural respiratory drive (NRD), tidal volume (TV) and respiratory rate (RR). Surface electromyography of the diaphragm (sEMGdi) offers a continuous, non-invasive measure of NRD. We investigated the effect of pressure support (PS) level on the coupling of diaphragm electrical activity (sEAdi) and ventilatory output during the ICU stay.

METHODS: In clinically stable ICU patients (N = 17), four PS-levels were applied on alternate days, based on the clinical value (- 3, + 0, + 3, and + 6 cmH 2O). sEAdi time-product (ETPdi) was calculated from high-quality sEAdi waveforms, using a novel, advanced signal analysis approach. The breath-by-breath correlation between ETPdi and TV was defined as neuro-ventilatory coupling (NVC), enabling quantification of the neuro-ventilatory response.

RESULTS: On group level (13 patients, 26 PS-trials), ETPdi and RR increased with decreasing PS-levels (2.4 and 1.6 percentage point (pp)/cmH 2O), whereas TV decreased (2.5 pp/cmH 2O). Longitudinal analysis (4 patients, 14 PS-trials) showed strengthened coupling between ETPdi and TV during weaning, reflected by an increase in median NVC from 3.4% (IQR 2.9) to 26.3% (IQR 21.7) between the first and last PS-trial.

CONCLUSION: Advanced sEMGdi analysis allows for non-invasive quantification of NVC, reflecting the diaphragm's capacity to overcome mechanical load. In patients approaching liberation from MV, increasing NVC indicates the shift from near-passive to active breathing. This study demonstrates the potential of NVC to inform tailoring of ventilatory support levels.

TRIAL REGISTRATION NUMBER: Dutch Trial Register NL9654. Registered August 05, 2021.

Original language	English
Article number	258
Journal	Critical care (London, England)
Volume	29
Issue number	1
DOIs	https://doi.org/10.1186/s13054-025-05424-5
Publication status	Published - 23 Jun 2025

Keywords

Humans
Diaphragm/physiopathology
Electromyography/methods
Male
Female
Middle Aged
Intensive Care Units/organization & administration
Aged
Respiration, Artificial/methods
Tidal Volume/physiology
Positive-Pressure Respiration/methods

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@article{c3890278b61a4a84b6467737f10923cf,

title = "Advanced serial analysis of the diaphragm surface EMG: insights into the effect of pressure support on the neuro-ventilatory response during the ICU stay",

abstract = "BACKGROUND: Ventilatory support levels in ICU patients should be tailored to both optimal gas exchange and respiratory muscle loading, as over- and underassistance may cause diaphragm dysfunction. The diaphragm's capacity to overcome mechanical load and deliver ventilatory output is reflected by the patient's neural respiratory drive (NRD), tidal volume (TV) and respiratory rate (RR). Surface electromyography of the diaphragm (sEMGdi) offers a continuous, non-invasive measure of NRD. We investigated the effect of pressure support (PS) level on the coupling of diaphragm electrical activity (sEAdi) and ventilatory output during the ICU stay.METHODS: In clinically stable ICU patients (N = 17), four PS-levels were applied on alternate days, based on the clinical value (- 3, + 0, + 3, and + 6 cmH 2O). sEAdi time-product (ETPdi) was calculated from high-quality sEAdi waveforms, using a novel, advanced signal analysis approach. The breath-by-breath correlation between ETPdi and TV was defined as neuro-ventilatory coupling (NVC), enabling quantification of the neuro-ventilatory response. RESULTS: On group level (13 patients, 26 PS-trials), ETPdi and RR increased with decreasing PS-levels (2.4 and 1.6 percentage point (pp)/cmH 2O), whereas TV decreased (2.5 pp/cmH 2O). Longitudinal analysis (4 patients, 14 PS-trials) showed strengthened coupling between ETPdi and TV during weaning, reflected by an increase in median NVC from 3.4% (IQR 2.9) to 26.3% (IQR 21.7) between the first and last PS-trial. CONCLUSION: Advanced sEMGdi analysis allows for non-invasive quantification of NVC, reflecting the diaphragm's capacity to overcome mechanical load. In patients approaching liberation from MV, increasing NVC indicates the shift from near-passive to active breathing. This study demonstrates the potential of NVC to inform tailoring of ventilatory support levels.TRIAL REGISTRATION NUMBER: Dutch Trial Register NL9654. Registered August 05, 2021.",

keywords = "Humans, Diaphragm/physiopathology, Electromyography/methods, Male, Female, Middle Aged, Intensive Care Units/organization & administration, Aged, Respiration, Artificial/methods, Tidal Volume/physiology, Positive-Pressure Respiration/methods",

author = "Warnaar, {R S P} and Cornet, {A D} and A Beishuizen and Donker, {D W} and E Oppersma",

note = "{\textcopyright} 2025. The Author(s).",

year = "2025",

month = jun,

day = "23",

doi = "10.1186/s13054-025-05424-5",

language = "English",

volume = "29",

journal = "Critical care (London, England)",

issn = "1466-609X",

publisher = "Springer Science + Business Media",

number = "1",

}

TY - JOUR

T1 - Advanced serial analysis of the diaphragm surface EMG

T2 - insights into the effect of pressure support on the neuro-ventilatory response during the ICU stay

AU - Warnaar, R S P

AU - Cornet, A D

AU - Beishuizen, A

AU - Donker, D W

AU - Oppersma, E

PY - 2025/6/23

Y1 - 2025/6/23

N2 - BACKGROUND: Ventilatory support levels in ICU patients should be tailored to both optimal gas exchange and respiratory muscle loading, as over- and underassistance may cause diaphragm dysfunction. The diaphragm's capacity to overcome mechanical load and deliver ventilatory output is reflected by the patient's neural respiratory drive (NRD), tidal volume (TV) and respiratory rate (RR). Surface electromyography of the diaphragm (sEMGdi) offers a continuous, non-invasive measure of NRD. We investigated the effect of pressure support (PS) level on the coupling of diaphragm electrical activity (sEAdi) and ventilatory output during the ICU stay.METHODS: In clinically stable ICU patients (N = 17), four PS-levels were applied on alternate days, based on the clinical value (- 3, + 0, + 3, and + 6 cmH 2O). sEAdi time-product (ETPdi) was calculated from high-quality sEAdi waveforms, using a novel, advanced signal analysis approach. The breath-by-breath correlation between ETPdi and TV was defined as neuro-ventilatory coupling (NVC), enabling quantification of the neuro-ventilatory response. RESULTS: On group level (13 patients, 26 PS-trials), ETPdi and RR increased with decreasing PS-levels (2.4 and 1.6 percentage point (pp)/cmH 2O), whereas TV decreased (2.5 pp/cmH 2O). Longitudinal analysis (4 patients, 14 PS-trials) showed strengthened coupling between ETPdi and TV during weaning, reflected by an increase in median NVC from 3.4% (IQR 2.9) to 26.3% (IQR 21.7) between the first and last PS-trial. CONCLUSION: Advanced sEMGdi analysis allows for non-invasive quantification of NVC, reflecting the diaphragm's capacity to overcome mechanical load. In patients approaching liberation from MV, increasing NVC indicates the shift from near-passive to active breathing. This study demonstrates the potential of NVC to inform tailoring of ventilatory support levels.TRIAL REGISTRATION NUMBER: Dutch Trial Register NL9654. Registered August 05, 2021.

AB - BACKGROUND: Ventilatory support levels in ICU patients should be tailored to both optimal gas exchange and respiratory muscle loading, as over- and underassistance may cause diaphragm dysfunction. The diaphragm's capacity to overcome mechanical load and deliver ventilatory output is reflected by the patient's neural respiratory drive (NRD), tidal volume (TV) and respiratory rate (RR). Surface electromyography of the diaphragm (sEMGdi) offers a continuous, non-invasive measure of NRD. We investigated the effect of pressure support (PS) level on the coupling of diaphragm electrical activity (sEAdi) and ventilatory output during the ICU stay.METHODS: In clinically stable ICU patients (N = 17), four PS-levels were applied on alternate days, based on the clinical value (- 3, + 0, + 3, and + 6 cmH 2O). sEAdi time-product (ETPdi) was calculated from high-quality sEAdi waveforms, using a novel, advanced signal analysis approach. The breath-by-breath correlation between ETPdi and TV was defined as neuro-ventilatory coupling (NVC), enabling quantification of the neuro-ventilatory response. RESULTS: On group level (13 patients, 26 PS-trials), ETPdi and RR increased with decreasing PS-levels (2.4 and 1.6 percentage point (pp)/cmH 2O), whereas TV decreased (2.5 pp/cmH 2O). Longitudinal analysis (4 patients, 14 PS-trials) showed strengthened coupling between ETPdi and TV during weaning, reflected by an increase in median NVC from 3.4% (IQR 2.9) to 26.3% (IQR 21.7) between the first and last PS-trial. CONCLUSION: Advanced sEMGdi analysis allows for non-invasive quantification of NVC, reflecting the diaphragm's capacity to overcome mechanical load. In patients approaching liberation from MV, increasing NVC indicates the shift from near-passive to active breathing. This study demonstrates the potential of NVC to inform tailoring of ventilatory support levels.TRIAL REGISTRATION NUMBER: Dutch Trial Register NL9654. Registered August 05, 2021.

KW - Humans

KW - Diaphragm/physiopathology

KW - Electromyography/methods

KW - Male

KW - Female

KW - Middle Aged

KW - Intensive Care Units/organization & administration

KW - Aged

KW - Respiration, Artificial/methods

KW - Tidal Volume/physiology

KW - Positive-Pressure Respiration/methods

U2 - 10.1186/s13054-025-05424-5

DO - 10.1186/s13054-025-05424-5

M3 - Article

C2 - 40551236

SN - 1466-609X

VL - 29

JO - Critical care (London, England)

JF - Critical care (London, England)

IS - 1

M1 - 258

ER -

Advanced serial analysis of the diaphragm surface EMG: insights into the effect of pressure support on the neuro-ventilatory response during the ICU stay

Abstract

Keywords

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