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Boon AJ, Meiling JB, Luetmer MT, Klein CJ, Sorenson EJ, Harper CM, Beecher G. Paradoxical thinning of the diaphragm on ultrasound is a risk factor for requiring non-invasive ventilation in patients with neuromuscular diaphragmatic dysfunction. Muscle Nerve 2024; 70:352-359. [PMID: 38935447 DOI: 10.1002/mus.28194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 05/31/2024] [Accepted: 06/12/2024] [Indexed: 06/29/2024]
Abstract
INTRODUCTION/AIMS Point-of-care ultrasound of the diaphragm is highly sensitive and specific in the detection of neuromuscular diaphragmatic dysfunction. In some patients with neuromuscular diaphragmatic dysfunction, paradoxical thinning of the diaphragm during inspiration is observed on ultrasound; however, its frequency, electrodiagnostic associations, and prognostic significance remain uncertain. METHODS Medical records of patients presenting to two electrodiagnostic laboratories (Mayo Clinic, Rochester, Minnesota and University of Alberta, Edmonton, Alberta) from January 1, 2022 to December 31, 2022, for evaluation of suspected neuromuscular respiratory failure, were reviewed. RESULTS 214 patients were referred and 19 patients excluded due to incomplete information. Of 195 patients (384 hemidiaphragms), 104 had phrenic neuropathy, 12 had myopathy, and 79 had no evidence of neuromuscular disease affecting the diaphragm. Paradoxical thinning occurred in 31 (27%) patients with neuromuscular diaphragmatic dysfunction and was unilateral in 30, the majority (83%) having normal contralateral ultrasound. Phrenic nerve conduction studies and diaphragm electromyography results did not distinguish patients with paradoxical thinning versus without. Most patients (71%) with paradoxical thinning required non-invasive ventilation (NIV), including 16 with unilateral paradoxical thinning. Paradoxical thinning and BMI ≥30 kg/m2 were risk factors for requiring NIV in multivariable logistic regression analysis, with odds ratios of 2.887 (95% CI:1.166, 7.151) and 2.561 (95% CI: 1.186, 5.532), respectively. DISCUSSION Paradoxical thinning of the diaphragm occurs in patients with prominent neuromuscular diaphragmatic dysfunction, most commonly from phrenic neuropathy, and is a significant risk factor for requiring NIV. Unilateral paradoxical thinning is sufficient for needing NIV. BMI ≥30 kg/m2 additionally increases risk of requiring NIV in patients with neuromuscular diaphragmatic dysfunction.
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Affiliation(s)
- Andrea J Boon
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - James B Meiling
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Marianne T Luetmer
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Eric J Sorenson
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - C Michel Harper
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Grayson Beecher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Zimmermann M, Wollsching-Strobel M, Majorski DS, Kroppen D, Schwarz SB, Berger M, Windisch W, Holle JF. [Neuralgic amyotrophy: a common cause of unilateral and bilateral diaphragmatic pareses]. Pneumologie 2023; 77:814-824. [PMID: 37647918 DOI: 10.1055/a-2113-0385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
There are several causes for unilateral or bilateral diaphragmatic paresis. The most common cause is an (intraoperative) injury to the phrenic nerve.However, in up to 20% of cases, no explanation can be found despite extensive workup. Neuralgic amyotrophy (NA, also known as Parsonage-Turner syndrome) is a common underdiagnosed multifocal autoimmune-inflammatory disease that predominantly affects proximal nerve segments of the upper extremities. Classic symptoms include acute onset of severe pain in the shoulder girdle with delayed onset of paresis of the shoulder and arm muscles. In at least 7% of cases, the phrenic nerve is also affected. Based on the annual incidence of NA of 1:1000, the entity as a cause of diaphragmatic dysfunction is probably not as uncommon as previously thought. However, clinical experience shows that this diagnosis is often not considered, and diaphragmatic paresis gets wrongly classified as idiopathic.This is particularly disastrous because in the early stage of NA, medical therapy with corticosteroids is mostly not considered and the possibility that surgical repair of the diaphragm may be performed prematurely, given that the condition may resolve spontaneously many months after symptom onset.The aim of the present article is to raise awareness of the entity of NA as a cause of diaphragmatic paresis and to establish a standardized approach to diagnosis and treatment.
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Affiliation(s)
- Maximilian Zimmermann
- Pneumologie, Kliniken der Stadt Köln gGmbH, Köln, Deutschland
- Lehrstuhl für Pneumologie, Universität Witten/Herdecke Fakultät für Gesundheit, Köln, Deutschland
| | - Maximilian Wollsching-Strobel
- Pneumologie, Kliniken der Stadt Köln gGmbH, Köln, Deutschland
- Humanmedizin, Universität Witten/Herdecke Fakultät für Gesundheit, Witten, Deutschland
| | | | - Doreen Kroppen
- Pneumologie, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Köln, Deutschland
| | - Sarah Bettina Schwarz
- Pneumologie, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Köln, Deutschland
| | - Melanie Berger
- Pneumologie, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Köln, Deutschland
| | - Wolfram Windisch
- Pneumologie, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Köln, Deutschland
| | - Johannes Fabian Holle
- Neurologie, Kliniken der Stadt Köln gGmbH, Köln, Deutschland
- Lehrstuhl für Pneumologie, Universität Witten/Herdecke Fakultät für Gesundheit, Köln, Deutschland
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Racca F, Vianello A, Mongini T, Ruggeri P, Versaci A, Vita GL, Vita G. Practical approach to respiratory emergencies in neurological diseases. Neurol Sci 2020; 41:497-508. [PMID: 31792719 PMCID: PMC7224095 DOI: 10.1007/s10072-019-04163-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 11/15/2019] [Indexed: 02/06/2023]
Abstract
Many neurological diseases may cause acute respiratory failure (ARF) due to involvement of bulbar respiratory center, spinal cord, motoneurons, peripheral nerves, neuromuscular junction, or skeletal muscles. In this context, respiratory emergencies are often a challenge at home, in a neurology ward, or even in an intensive care unit, influencing morbidity and mortality. More commonly, patients develop primarily ventilatory impairment causing hypercapnia. Moreover, inadequate bulbar and expiratory muscle function may cause retained secretions, frequently complicated by pneumonia, atelectasis, and, ultimately, hypoxemic ARF. On the basis of the clinical onset, two main categories of ARF can be identified: (i) acute exacerbation of chronic respiratory failure, which is common in slowly progressive neurological diseases, such as movement disorders and most neuromuscular diseases, and (ii) sudden-onset respiratory failure which may develop in rapidly progressive neurological disorders including stroke, convulsive status epilepticus, traumatic brain injury, spinal cord injury, phrenic neuropathy, myasthenia gravis, and Guillain-Barré syndrome. A tailored assistance may include manual and mechanical cough assistance, noninvasive ventilation, endotracheal intubation, invasive mechanical ventilation, or tracheotomy. This review provides practical recommendations for prevention, recognition, management, and treatment of respiratory emergencies in neurological diseases, mostly in teenagers and adults, according to type and severity of baseline disease.
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Affiliation(s)
- Fabrizio Racca
- Department of Anaesthesia and Intensive Care, Sant'Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, University of Padua, Padua, Italy
| | - Tiziana Mongini
- Neuromuscular Center, Department of Neurosciences, University of Turin, Turin, Italy
| | - Paolo Ruggeri
- Unit of Pneumology, Department BIOMORF, University of Messina, Messina, Italy
| | - Antonio Versaci
- Intensive Care Unit, AOU Policlinico "G. Martino", Messina, Italy
| | - Gian Luca Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy
| | - Giuseppe Vita
- Nemo Sud Clinical Centre for Neuromuscular Disorders, Messina, Italy.
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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van Alfen N, Doorduin J, van Rosmalen MHJ, van Eijk JJJ, Heijdra Y, Boon AJ, Gaytant MA, van den Biggelaar RJM, Sprooten RTM, Wijkstra PJ, Groothuis JT. Phrenic neuropathy and diaphragm dysfunction in neuralgic amyotrophy. Neurology 2018; 91:e843-e849. [PMID: 30054437 DOI: 10.1212/wnl.0000000000006076] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 05/25/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe the clinical phenotype and recovery of diaphragm dysfunction caused by neuralgic amyotrophy in a large cohort of patients, to improve accurate awareness of this entity, and to encourage adoption of a standardized approach for diagnosis and treatment. METHODS This observational cohort study recruited adult patients with neuralgic amyotrophy and symptoms of idiopathic phrenic neuropathy from the database of the Dutch expert center for neuralgic amyotrophy and the Dutch centers for home mechanical ventilation. Demographic and clinical information on diagnosis, symptoms, and recovery was obtained from chart review. We attempted to contact all patients for a follow-up interview. RESULTS Phrenic neuropathy occurs in 7.6% of patients with neuralgic amyotrophy. Unilateral diaphragmatic dysfunction and bilateral diaphragmatic dysfunction are frequently symptomatic, causing exertional dyspnea, orthopnea, disturbed sleep, and excessive fatigue. Diagnostic practices varied widely and were often not optimally targeted. The majority of patients experienced at least moderate recovery within 2 years. CONCLUSION We recommend screening every patient with neuralgic amyotrophy for diaphragm dysfunction by asking about orthopnea and by performing upright and supine vital capacity screening and diaphragm ultrasound in cases of suspected phrenic neuropathy to optimize diagnosis and care.
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Affiliation(s)
- Nens van Alfen
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands.
| | - Jonne Doorduin
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
| | - Marieke H J van Rosmalen
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
| | - Jeroen J J van Eijk
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
| | - Yvonne Heijdra
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
| | - Andrea J Boon
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
| | - Michael A Gaytant
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
| | - Ries J M van den Biggelaar
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
| | - Roy T M Sprooten
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
| | - Peter J Wijkstra
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
| | - Jan T Groothuis
- From the Department of Neurology (N.v.A., J.D., M.H.J.v.R., J.J.J.v.E.) and Department of Rehabilitation (J.T.G.), Donders Institute for Brain, Cognition and Behaviour, and Department of Pulmonary Diseases (Y.H.), Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen; Department of Neurology (J.J.v.E.), Jeroen Bosch Hospital, Den Bosch; Radboud University Medical Center, Nijmegen, the Netherlands; Department of Physical Medicine and Rehabilitation (A.J.B.), Mayo Clinic and Foundation, Rochester, MN; Department of Pulmonary Diseases (M.A.G.), Center for Home Mechanical Ventilation, University Medical Center Utrecht; Department of Pulmonary Diseases (R.J.M.v.d.B.), Center for Home Mechanical Ventilation, Erasmus Medical Center, Rotterdam; Department of Pulmonary Diseases (R.T.M.S.), Center for Home Mechanical Ventilation, Maastricht University Medical Center; and Department of Pulmonary Diseases (P.J.W.), Center for Home Mechanical Ventilation, University Medical Center Groningen, the Netherlands
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