March 14, 2003
"Christopher Reeve has electrodes planted in his diaphragm to restore his ability to breathe naturally. "
Reeve Breathing on His Own
By SANDRA BLAKESLEE
Christopher Reeve, the actor who has been paralyzed and on a respirator since breaking his neck in a riding accident eight years ago, has had electrodes implanted in his diaphragm in an effort to restore his ability to breathe naturally.
The results are extremely promising, said Dr. Raymond Onders, who performed outpatient surgery on Mr. Reeve at University Hospitals of Cleveland on Feb. 28. He can breathe without the respirator for more than two hours at a stretch compared with 10 minutes before the operation, Dr. Onders said. As his diaphragm muscles regain strength over the next couple of months, Mr. Reeve may be able to wean himself permanently from the respirator.
While breathing on his own, he is regaining the ability to talk normally. And when he is breathing more normally — not through the ventilator's hole in his throat — he can smell odors for the first time since his accident.
Mr. Reeve, 50, who is expected to describe his experience at a news conference today in Cleveland, is the third person to receive the experimental treatment, called diaphragm pacing via laparoscopy, which has been approved by the Food and Drug Administration for use in 35 patients. In the treatment, tiny wires are threaded through small incisions directly into the diaphragm. Surgeons use a tubelike instrument that causes very little tissue damage, and patients go home the same day.
If the federal agency approves the operation, it is expected to cost about $10,000. It is now financed by the agency, the Department of Veterans Affairs and other donors for use in five patients. Hospital officials say $2 million to $3 million more will be needed to complete the trial.
One of Mr. Reeve's major goals has been to get off the respirator, said Dr. John McDonald, a neurologist at Washington University School of Medicine in St. Louis who designed an intensive exercise program that has enabled Mr. Reeve, once paralyzed below the neck, to wiggle his extremities, to sit up partly by himself and, with great effort using neck muscles, to breathe for short periods without a respirator.
"Once Chris can breathe naturally on his own, and everything so far says he will, his exercise program should work even better," Dr. McDonald said.
Mr. Reeve was a candidate for the treatment because the phrenic nerves that control breathing, which run from the spinal cord to the diaphragm, were not injured by his fall. But the nerves meet the spinal cord below the site of Mr. Reeve's injury, so they could no longer receive signals from the brain stem where breathing is initiated. As a result, they stopped functioning. Many years ago, doctors realized that if these nerves could be activated artificially, more natural breathing might be restored.
The new technique, for which research was also done at Case Western Reserve University in Cleveland, involves running wires from a control box worn outside the body to electrodes on the diaphragm.
When the electrodes are stimulated by current, the diaphragm contracts and air is sucked into the lungs. When the nerve is unstimulated, the diaphragm relaxes and air moves out of the lungs. About 75 percent of natural breathing is carried out by this process, with the rest under the control of other muscles.
The control box sends a signal to the electrodes on the diaphragm 12 times a minute, a normal breathing rate. Surgeons have used similar methods before, but the procedure required invasive surgery that involved opening the chest cavity.
"Chris felt it was a drastic and dangerous procedure that was not worth the risk," Dr. McDonald said. When he heard about the less invasive and far less expensive procedure developed by biomedical engineers in Cleveland, he asked to take part in the experiment.
To see if Mr. Reeve was a candidate, doctors tested his phrenic nerves to make sure they were all right.
In the operation, Dr. Onders made four dime-size holes in Mr. Reeve's abdomen and threaded a specially designed laparoscope up into his left and right diaphragm muscles. Then he used a mapping technique to find the exact area, called the motor point, where the phrenic nerve contacts the diaphragm. When this motor point is activated, the entire diaphragm contracts.
The location of the motor point is not obvious, said Dr. Anthony DeMarco, program director for the experiment at University Hospitals of Cleveland. The probe is inside the muscle but the nerve can be almost anywhere on the other side of the muscle wall, he said. By stimulating different muscle areas, the surgeon looks for the region that responds most strongly to stimulation.
Upon finding these points in Mr. Reeve, Dr. Onders implanted four electrodes in the diaphragm, two on each side, and ran connecting wires out to the chest wall. When the electrodes are stimulated with a mild current, Mr. Reeve takes a natural breath. Eventually, an external battery will automatically send electrical impulses to his diaphragm.
After resting at his home in New York for a week, Mr. Reeve returned to Cleveland on Sunday for training to restore diaphragm strength. All this week, doctors have been electrically activating his diaphragm for 10 to 15 minutes and allowing him to rest for the remainder of an hour. The muscles are slowly regenerating after years of nonuse, said Dr. Onders, who hopes that in 12 weeks Mr. Reeve will be able to wean himself completely from the respirator.
It is difficult to talk while on a respirator, but without it Mr. Reeve can talk normally, though his voice is still weak. It has not risen above a whisper, his doctors said, but it will soon come back. Able to breathe naturally, Mr. Reeve could smell scents placed under his nose — oranges, peppermint and coffee.
About 200 to 300 spinal cord patients a year might be eligible for the operation, Dr. Onders said. It could also benefit many patients who need to be on respirators for long periods but whose nerves are free of disease. Mr. Reeve was to return home today to practice breathing.