Clinical Utility of Measuring Inspiratory Neural Drive During Cardiopulmonary Exercise Testing (CPET)

Abstract

Cardiopulmonary exercise testing (CPET) has traditionally included ventilatory and metabolic measurements alongside electrocardiographic characterization; however, research increasingly acknowledges the utility of also measuring inspiratory neural drive (IND) through its surrogate measure of diaphragmatic electromyography (EMGdi). While true IND also encompasses the activation of non-diaphragmatic respiratory muscles, the current review focuses on diaphragmatic measurements, providing information about additional inspiratory muscle groups for context where appropriate. Evaluation of IND provides mechanistic insight into the origins of dyspnea and exercise limitation across pathologies; yields valuable information reflecting the integration of diverse mechanical, chemical, locomotor, and metabolic afferent signals; and can help assess the efficacy of therapeutic interventions. Further, IND measurement during the physiologic stress of exercise is uniquely poised to reveal the underpinnings of physiologic limitations masked during resting and unloaded breathing, with important information provided not only at peak exercise, but throughout exercise protocols. As our understanding of IND presentation across varying conditions continues to grow and methods for its measurement become more accessible, the translation of these principles into clinical settings is a logical next step in facilitating appropriate and nuanced management tailored to each individual's unique physiology. This review provides an overview of the current state of understanding of IND measurement during CPET: its origins, known patterns of behavior and links with dyspnea in health and major respiratory diseases, and the possibility of expanding this approach to applications beyond exercise.

Effect of sequential high-flow nasal cannula oxygen therapy and non-invasive positive-pressure ventilation in patients with difficult weaning from mechanical ventilation after extubation on respiratory mechanics

“…In recent years, more and more studies have recognized the utility of measuring neural respiratory drive by EMGdi substitution (19)(20)(21)(22)(23)(24). High neural respiratory drive may lead to lung or diaphragm injury in patients under mechanical ventilation.…”

Evaluating dyspnoea in chronic obstructive pulmonary disease

“…However, accurate measurement of IND is presently limited to the laboratory by means of invasive testing [13,32]. The development of portable and non-invasive recording of EMGdi/EMGdi, max by transcutaneous diaphragmatic EMG, in the form of a wearable device, can potentially provide an objective surrogate measurement of dyspnoea intensity throughout the day, relating it to the patient's situational changes and activities in their daily lives.…”

Semi-automated Detection of the Timing of Respiratory Muscle Activity: Validation and First Application

“…In humans, the respiratory centers’ output cannot be directly measured ( Vaporidi et al, 2020 ). The respiratory drive to the respiratory muscles measured via electromyography (EMG) is used as its surrogate ( Domnik et al, 2020 ). Respiratory muscle EMG allows the identification of whether a muscle is active and provides a relative indication of the amplitude of the muscle electrical activity [e.g., the root mean square (RMS) of the EMG signal].…”