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Lopes Vieira J, Miskovic A, Abel F. Interpretation of sleep studies and perioperative considerations in children with sleep-disordered breathing. BJA Educ 2023; 23:448-454. [PMID: 37876762 PMCID: PMC10591125 DOI: 10.1016/j.bjae.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 10/26/2023] Open
Affiliation(s)
| | | | - F. Abel
- Great Ormond Street Hospital, London, UK
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Racca F, Longhitano Y, Zanza C, Balzanelli MG, Draisci G, Stoia PA, Gollo E, Maio M, Grattarola C, Astuto M, Ciccarelli A, Racca G, Romenskaya T, Giordano B, Serraino A, Sansone VAM, Gregoretti C, Conti G, Piccolella F, Vaschetto R. Peri-partum respiratory management of pregnant women with neuro-muscular disorders: a prospective observational study (IT-NEUMA-Pregn study). BMC Anesthesiol 2023; 23:342. [PMID: 37833635 PMCID: PMC10571352 DOI: 10.1186/s12871-023-02307-6] [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: 06/08/2023] [Accepted: 10/09/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Pregnant women with neuromuscular diseases (NMDs) often display respiratory muscle impairment which increases the risk for pulmonary complications (PCs). The aim of this study was to identify pregnant NMDs patients with pulmonary risk factors and to apply in these women non-invasive ventilation (NIV) combined with mechanical insufflation-exsufflation (MI-E) in the peri-partum period. METHODS We conducted a multicenter observational study on women with NMDs undergoing cesarean section or spontaneous labor in a network of 7 national hospitals. In these subjects we applied a protocol for screening and preventing PCs, and we evaluated PCs rate, maternal and neonatal outcome. RESULTS Twenty-four patients out of the 94 enrolled pregnant women were at risk for PCs and were trained or retrained to use NIV and/or MI-E before delivery. After delivery, 17 patients required NIV with or without MI-E. Despite nine out of the 24 women at pulmonary risk developed postpartum PCs, none of them needed reintubation nor tracheostomy. In addition, the average birth weight and Apgar score were normal. Only one patient without pulmonary risk factors developed postpartum PCs. CONCLUSION This study showed the feasibility of applying a protocol for screening and treating pregnant NMDs women with pulmonary risk. Despite a PCs rate of 37% was observed in these patients, maternal and neonatal outcome were favorable.
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Affiliation(s)
- Fabrizio Racca
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliera SS. Antonio E Biagio E Cesare Arrigo, Alessandria, Italy
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Yaroslava Longhitano
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christian Zanza
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
- Post Graduate School of Geriatric Medicine, University of Rome "Tor Vergata", Rome, Italy.
| | | | - Gaetano Draisci
- Institute of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Paolo Augusto Stoia
- Anesthesiology and Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda Ca'Granda, Milan, Italy
| | - Evelina Gollo
- Department of Anesthesiology and Intensive Care A.O.U. Città Della Salute E Della Scienza Di Torino, Turin, Italy
| | - Mariella Maio
- Department of Anesthesiology and Intensive Care A.O.U. Città Della Salute E Della Scienza Di Torino, Turin, Italy
| | - Claudia Grattarola
- Anesthesiology and Intensive Care Unit, Istituto Giannina Gaslini, Genova, Italy
| | - Marinella Astuto
- Dipartimento Chirurgia Generale e Specialità Medico Chirurgiche, A.O.Universitaria "Policlinico-Vittorio Emanuele", Università Degli Studi Di Catania, Catania, Italy
| | - Antonello Ciccarelli
- Department of Movement, Human, and Health Sciences - Division of Health Sciences, University of Rome "Foro Italico, Rome, Italy
| | - Giulia Racca
- Division of Anesthesia and Critical Care Medicine, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Tatsiana Romenskaya
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
| | - Benedetta Giordano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | | | - Valeria Ada Maria Sansone
- The NEMO Clinical Center in Milan, Neurorehabilitation Unit, University of Milan- ERN for Neuromuscular Diseases, Milan, Italy
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
- Fondazione Istituto "G. Giglio" Cefalù, Palermo, Italy
| | - Giorgio Conti
- Institute of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabio Piccolella
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliera SS. Antonio E Biagio E Cesare Arrigo, Alessandria, Italy
| | - Rosanna Vaschetto
- Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy
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Hudec J, Prokopová T, Kosinová M, Gál R. Anesthesia and Perioperative Management for Surgical Correction of Neuromuscular Scoliosis in Children: A Narrative Review. J Clin Med 2023; 12:jcm12113651. [PMID: 37297846 DOI: 10.3390/jcm12113651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/17/2023] [Accepted: 05/20/2023] [Indexed: 06/12/2023] Open
Abstract
Scoliosis is the most frequent spinal deformity in children. It is defined as a spine deviation of more than 10° in the frontal plane. Neuromuscular scoliosis is associated with a heterogeneous spectrum of muscular or neurological symptoms. Anesthesia and surgery for neuromuscular scoliosis have a higher risk of perioperative complications than for idiopathic scoliosis. However, patients and their relatives report improved quality of life after the surgery. The challenges for the anesthetic team result from the specifics of the anesthesia, the scoliosis surgery itself, or factors associated with neuromuscular disorders. This article includes details of preanesthetic evaluation, intraoperative management, and postoperative care in the intensive care unit from an anesthetic view. In summary, adequate care for patients who have neuromuscular scoliosis requires interdisciplinary cooperation. This comprehensive review covers information about the perioperative management of neuromuscular scoliosis for all healthcare providers who take care of these patients during the perioperative period, with an emphasis on anesthesia management.
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Affiliation(s)
- Jan Hudec
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, University Hospital Brno, 601 77 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Tereza Prokopová
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, University Hospital Brno, 601 77 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
| | - Martina Kosinová
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic
- Department of Pediatric Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, University Hospital Brno, 625 00 Brno, Czech Republic
| | - Roman Gál
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Masaryk University, University Hospital Brno, 601 77 Brno, Czech Republic
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Ronco L, Khirani S, Vedrenne-Cloquet M, Barrois R, Barnerias C, Desguerre I, Bignamini E, Fauroux B. Limitations of the apnea-hypopnea index in children and young adults with neuromuscular disorders. Neuromuscul Disord 2023; 33:468-473. [PMID: 37196510 DOI: 10.1016/j.nmd.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023]
Abstract
There are no validated criteria to initiate noninvasive ventilation (NIV) in children and young adults with neuromuscular disease (NMD). In order to analyze NIV initiation criteria, we reviewed the polysomnography (PSG) criteria that led to the initiation of NIV in 61 consecutive patients with NMD, median age 4.1 (0.8-21) years, who had a PSG during their routine care. NIV was initiated on abnormal PSG data (apnea-hypopnea index (AHI) > 10 events/h and/or a transcutaneous carbon dioxide pressure > 50 mmHg and/or a pulse oximetry 〈 90%, both during at least 2% sleep time or 〉 5 consecutive minutes) in 11 (18%) patients. Six of these 11 patients had an AHI ≤ 10 events/h and would not have been ventilated if only AHI was retained. However, one of these 6 patients had isolated nocturnal hypoxemia, 3 isolated nocturnal hypercapnia and 2 abnormal respiratory events. Six (10%) patients with a normal PSG were started on NIV on clinical criteria. Our results show the limitation of the AHI when taken as the unique PSG criterion for NIV initiation in young patients with NMD and underline the need to include also abnormalities of overnight gas exchange into the NIV decision-making process.
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Affiliation(s)
- Lucia Ronco
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Pediatric Pulmonology department, Regina Margherita Children Hospital, Turin, Italy
| | - Sonia Khirani
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004 Paris, France; ASV Santé, F-92000 Gennevilliers, France
| | - Meryl Vedrenne-Cloquet
- Pediatric intensive care unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France, France
| | - Remi Barrois
- Pediatric neurology, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris; National Reference Center on Neuromuscular Diseases, France
| | - Christine Barnerias
- Pediatric neurology, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris; National Reference Center on Neuromuscular Diseases, France
| | - Isabelle Desguerre
- Pediatric neurology, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris; National Reference Center on Neuromuscular Diseases, France
| | - Elisabetta Bignamini
- Pediatric Pulmonology department, Regina Margherita Children Hospital, Turin, Italy
| | - Brigitte Fauroux
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004 Paris, France.
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Barker N, Sinha A, Jesson C, Doctor T, Narayan O, Elphick HE. Changes in UK paediatric long-term ventilation practice over 10 years. Arch Dis Child 2023; 108:218-224. [PMID: 36446480 DOI: 10.1136/archdischild-2021-323562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 11/10/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVES To provide up-to-date information on the use of long-term ventilation (LTV) in the UK paediatric population and to compare the results with data collected 10 and 20 years previously. DESIGN A single timepoint census completed by LTV centres in the UK, carried out via an online survey. SETTING AND PATIENTS All patients attending paediatric LTV services in the UK. RESULTS Data were collected from 25 LTV centres in the UK. The total study population was 2383 children and young people, representing a 2.5-fold increase in the last 10 years. The median age was 9 years (range 0-20 years). Notable changes since 2008 were an increase in the proportion of children with central hypoventilation syndrome using mask ventilation, an increase in overall numbers of children with spinal muscular atrophy (SMA) type 1, chronic lung disease of prematurity and cerebral palsy being ventilated, and a 4.2-fold increase in children using LTV for airway obstruction. The use of 24-hour ventilation, negative pressure ventilation and tracheostomy as an interface had declined. 115 children had received a disease-modifying drug. The use of ataluren and Myozyme did not influence the decision to treat with LTV, but in 35% of the children with SMA type 1 treated with nusinersin, the clinician stated that the use of this drug had or may have influenced their decision to initiate LTV. CONCLUSION The results support the need for national database for children and young people using LTV at home to inform future recommendations and assist in resource allocation planning.
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Affiliation(s)
- Nicki Barker
- Respiratory Medicine, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Aditi Sinha
- Respiratory Medicine, Royal Manchester Children's Hospital, Manchester, UK
| | - Catherine Jesson
- Respiratory Medicine, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Tahera Doctor
- Respiratory Medicine, Evelina London Children's Hospital, London, UK
| | - Omendra Narayan
- Respiratory Medicine, Royal Manchester Children's Hospital, Manchester, UK
| | - Heather E Elphick
- Respiratory Medicine, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
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6
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Gannon NP, Quanbeck ZA, Miller DJ. The influence of viral respiratory season on perioperative outcomes in patients undergoing spinal fusion for neuromuscular scoliosis. Spine Deform 2023; 11:407-414. [PMID: 36205854 DOI: 10.1007/s43390-022-00593-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 09/18/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Respiratory complications are common following neuromuscular scoliosis (NMS) spinal fusion. Concern exists regarding the safety to perform complicated procedures in winter months when viral respiratory illness is common. The purpose of this study was to compare perioperative outcomes in children with NMS undergoing spinal fusion during peak (November-March) or non-peak (April-October) viral season. METHODS The Health Care and Utilization Project (HCUP) Kids' inpatient database (KID) from 2006 to 2012 was reviewed. Children 20 years or younger who underwent spinal fusion for NMS were included. Patients were grouped by date of surgery during peak or non-peak viral season. Continuous variables were compared using t tests and categorical variables were compared using the Rao-Scott Chi-square test. Weighted logistic regression models were performed. RESULTS This study identified 5082 records, including 1711 and 3371 patients who had surgery in peak and non-peak viral seasons, respectively. Patients who had spinal fusion during peak viral season were less likely to experience respiratory failure (p = 0.0008) and did not demonstrate an increased incidence of aspiration pneumonia (p = 0.26), respiratory complication (p = 0.43), or mortality (p = 0.68). Respiratory failure was associated with younger age (p = 0.0031), the presence of a tracheostomy (p < 0.0001), and the number of chronic conditions (p < 0.0001). Higher number of chronic medical conditions (mean of 5.0) was associated with an increased risk of in-hospital mortality (p < 0.0001), aspiration pneumonia (p = 0.0009), and respiratory failure (p < 0.0001). CONCLUSION Spinal fusion for NMS during peak viral season has a lower risk of respiratory failure without an increase in mortality or other complications compared to during non-peak viral season.
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Affiliation(s)
- Nicholas P Gannon
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Zachary A Quanbeck
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Miller
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA. .,Gillette Children's Specialty Healthcare, 200 University Avenue East, St. Paul, MN, USA.
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Ruska T, Austin TM, Bruce RW, Fletcher ND. Post-operative steroids in patients with patients with severe cerebral palsy undergoing posterior spinal fusion. Spine Deform 2023; 11:415-422. [PMID: 36260207 DOI: 10.1007/s43390-022-00603-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/08/2022] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Posterior spinal fusion (PSF) represents a large physiologic challenge for children with neuromuscular scoliosis (NMS). Perioperative complications are numerous with many occurring in the post-operative period due to pain and relative immobilization. This study assessed the impact of steroids on patients undergoing PSF for NMS. METHODS A retrospective review of consecutive patients managed at a single center with PSF for NMS was reviewed. Clinical and radiographic analysis was used to evaluate baseline demographics, curve characteristics, and post-operative course. RESULTS Eighty-nine patients who underwent PSF for NMS were included. Fifty-seven of these patients did not receive post-operative steroids (NS) while 32 patients were treated with post-operative steroids (dexamethasone, WS) for a median of 3 doses (median 6.0 mg/dose every 8 h after surgery). The demographic variables of the cohorts were similar with no difference in curve magnitude, number of vertebrae fused, number of osteotomies, or EBL between groups. A 70% decrease in the median post-operative morphine equivalents was observed in the steroid cohort (0.50 mg/kg WS vs 1.65 mg/kg NS, p value < 0.001). There was an association between post-operative morphine equivalents and length of stay (Spearman's rho = 0.22, p value = 0.04). There was no difference in wound healing, infection, and pulmonary or gastrointestinal complications between groups. No difference was found in pain at discharge, 30-day ED returns, or 30-day OR returns between groups. CONCLUSIONS Post-operative dexamethasone resulted in a 70% decrease in morphine equivalent use after PSF for NMS without any increase in perioperative wound infections. LEVEL OF EVIDENCE Level 3: case-control series.
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Affiliation(s)
- Tracy Ruska
- Department of Orthopaedic Surgery, Clinical Practice Group, Children's Healthcare of Atlanta, 1400 Tullie Rd NE, Atlanta, GA, 30329, USA
| | - Thomas M Austin
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, 32610, USA
| | - Robert W Bruce
- Department of Orthopaedic Surgery, Clinical Practice Group, Children's Healthcare of Atlanta, 1400 Tullie Rd NE, Atlanta, GA, 30329, USA
| | - Nicholas D Fletcher
- Department of Orthopaedic Surgery, Clinical Practice Group, Children's Healthcare of Atlanta, 1400 Tullie Rd NE, Atlanta, GA, 30329, USA.
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8
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Long term noninvasive ventilation and continuous positive airway pressure in children with neuromuscular diseases in France. Neuromuscul Disord 2022; 32:886-892. [PMID: 36270935 DOI: 10.1016/j.nmd.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 12/31/2022]
Abstract
The aim of the study was to describe the characteristics of children with neuromuscular diseases treated with long term noninvasive ventilation or continuous positive airway pressure in France. On June 1st 2019, 387 patients (63% boys, mean age 11.2 ± 5.5 years) were treated with long term noninvasive ventilation/continuous positive airway pressure. Thirty three percent of patients had spinal muscular atrophy, 30% congenital myopathy/dystrophy, 20% Duchenne muscular dystrophy, 7% Steinert myotonic dystrophy, and 9% other neuromuscular diseases. Ninety-four percent of patients were treated with long term noninvasive ventilation and 6% with continuous positive airway pressure. Treatment was initiated electively for 85% of patients, mainly on an abnormal overnight gas exchange recording (38% of patients). Noninvasive ventilation/continuous positive airway pressure was initiated during a respiratory exacerbation in 15% of patients. Mean duration of noninvasive ventilation/continuous positive airway pressure was 3.3 ± 3.1 years. Mean objective long term noninvasive ventilation/continuous positive airway pressure use was 8.0 ± 3.1 h/24. Spinal muscular atrophy, congenital myopathy/dystrophy, and Duchenne muscular dystrophy represented 83% of children with neuromuscular diseases treated with long term noninvasive ventilation in France. Screening for nocturnal hypoventilation was satisfactory as noninvasive ventilation /continuous positive airway pressure was predominantly initiated electively.
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Cho HE, Lee JW, Choi WA, Kang SW. Clinical Implications of Routine Monitoring of Pulmonary Function and Ventilation in Patients with Duchenne Muscular Dystrophy. Yonsei Med J 2022; 63:578-584. [PMID: 35619582 PMCID: PMC9171668 DOI: 10.3349/ymj.2022.63.6.578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To investigate the effect of regular monitoring of pulmonary function and ventilatory status on the initiation of non-invasive ventilation (NIV) between patients who were routinely monitored before receiving NIV and those who were not. MATERIALS AND METHODS This retrospective cohort study included subjects with Duchenne muscular dystrophy (DMD) who first received NIV between 2010 and 2019. The subjects were assigned to either the regular-follow-up (REG) group or the non-REG group, according to their follow-up status, before initiating NIV. We compared the number of emergent cases, the results of nocturnal ventilatory monitoring, and the pulmonary function of each group at initial ventilatory support. RESULTS In total, 73 subjects were enrolled in the REG group and 47 subjects in the non-REG group. There were significantly more emergency cases due to respiratory insufficiency in the non-REG group (12/47, 25.5%) than in the REG group (3/73, 4.1%). At the time of initial ventilatory support, hypoventilatory symptoms were more common and relatively severe in the non-REG group (37/47, 78.7%) than in the REG group (18/73, 24.7%). The average age at initial ventilatory support of the non-REG group was 2.15 years older than that of the subjects in the REG group. Moreover, subjects who were not regularly monitored exhibited greater deterioration in pulmonary function compared to those who were regularly followed up. CONCLUSION Regular evaluation of pulmonary function and ventilatory status before the onset of ventilatory insufficiency is crucial to reduce the risk of patients with DMD requiring emergency care due to ventilatory insufficiency.
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Affiliation(s)
- Han Eol Cho
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Jang Woo Lee
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Won Ah Choi
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Seong-Woong Kang
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea.
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10
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Sequera-Ramos L, Garcia-Marcinkiewicz A, Riva T, Fuchs A. Noninvasive ventilation in children: A review for the pediatric anesthesiologist. Paediatr Anaesth 2022; 32:262-272. [PMID: 34877751 DOI: 10.1111/pan.14364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 01/19/2023]
Abstract
Preserving adequate respiratory function is essential in the perioperative period. Mechanical ventilation with endotracheal intubation is widely used for this purpose. In select patients, noninvasive ventilation (NIV) may be an alternative to invasive ventilation or may complement respiratory management. NIV is used to provide ventilatory support and increase gas exchange at the alveolar level without the use of an invasive artificial airway such as an endotracheal tube or tracheostomy. NIV includes both continuous positive airway pressure (CPAP) and noninvasive positive pressure ventilation. Indications for NIV range from acute hypoxic respiratory failure in the intensive care unit or the emergency department, to chronic respiratory failure in patients with neuromuscular disease with nocturnal hypoventilation. In the perioperative setting, NIV is commonly applied as CPAP, and bilevel positive airway pressure (BPAP). There are limited data on the role of NIV in children in the perioperative setting, and there are no clear guidelines regarding optimal timing of use and pressure settings of perioperative NIV. Contraindications to the use of NIV include reduced level of consciousness, apnea, severe respiratory distress, and inability to maintain upper airway patency or airway protective reflexes. Common problems encountered during NIV involve airway leaks and asynchrony with auto-triggering. High-flow nasal oxygen (HFNO) has emerged as an alternative to NIV when trying to decrease the work of breathing and improve oxygenation in children. HFNO delivers humidified and heated oxygen at rates between 2 and 70 L/min using specific nasal cannulas, and flows are determined by the patient's weight and clinical needs. HFNO can be useful as a method for preoxygenation in infants and children by prolonging apnea time before desaturation, yet in children with decreased minute ventilation or apnea HFNO does not improve alveolar gas exchange. Clinicians experienced with these devices, such as pediatric intensivists and pulmonary medicine specialists, can be useful resources for the pediatric anesthesiologist caring for complex patients on NIV.
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Affiliation(s)
- Luis Sequera-Ramos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Annery Garcia-Marcinkiewicz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Unit for Research & Innovation in Anaesthesia, Department of Paediatric Anaesthesia, Istituto Giannina Gaslini, Genoa, Italy
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Fauroux B, Abel F, Amaddeo A, Bignamini E, Chan E, Corel L, Cutrera R, Ersu R, Installe S, Khirani S, Krivec U, Narayan O, MacLean J, Perez De Sa V, Pons-Odena M, Stehling F, Trindade Ferreira R, Verhulst S. ERS Statement on pediatric long term noninvasive respiratory support. Eur Respir J 2021; 59:13993003.01404-2021. [PMID: 34916265 DOI: 10.1183/13993003.01404-2021] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 10/03/2021] [Indexed: 11/05/2022]
Abstract
Long term noninvasive respiratory support, comprising continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV), in children is expanding worldwide, with increasing complexities of children being considered for this type of ventilator support and expanding indications such as palliative care. There have been improvements in equipment and interfaces. Despite growing experience, there are still gaps in a significant number of areas: there is a lack of validated criteria for CPAP/NIV initiation, optimal follow-up and monitoring; weaning and long term benefits have not been evaluated. Therapeutic education of the caregivers and the patient is of paramount importance, as well as continuous support and assistance, in order to achieve optimal adherence. The preservation or improvement of the quality of life of the patient and caregivers should be a concern for all children treated with long term CPAP/NIV. As NIV is a highly specialised treatment, patients are usually managed by an experienced pediatric multidisciplinary team. This Statement written by experts in the field of pediatric long term CPAP/NIV aims to emphasize on the most recent scientific input and should open up to new perspectives and research areas.
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Affiliation(s)
- Brigitte Fauroux
- AP-HP, Hôpital Necker, Pediatric noninvasive ventilation and sleep unit, Paris, France .,Université de Paris, EA 7330 VIFASOM, Paris, France
| | - François Abel
- Respiratory Department, Sleep & Long-term Ventilation Unit, Great Ormond Street Hospital for Children, London, UK
| | - Alessandro Amaddeo
- Emergency department, Institute for Maternal and Child Health IRCCS Burlo Garofolo, Trieste, Italy
| | - Elisabetta Bignamini
- Pediatric Pulmonology Unit Regina Margherita Hospital AOU Città della Salute e della Scienza Turin Italy
| | - Elaine Chan
- Respiratory Department, Sleep & Long-term Ventilation Unit, Great Ormond Street Hospital for Children, London, UK
| | - Linda Corel
- Pediatric ICU, Centre for Home Ventilation in Children, Erasmus university Hospital, Rotterdam, the Netherlands
| | - Renato Cutrera
- Pediatric Pulmonology Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Refika Ersu
- Division of Respiratory Medicine, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa Canada
| | - Sophie Installe
- Department of Pediatrics, Antwerp University Hospital, Edegem, Belgium
| | - Sonia Khirani
- AP-HP, Hôpital Necker, Pediatric noninvasive ventilation and sleep unit, Paris, France.,Université de Paris, EA 7330 VIFASOM, Paris, France.,ASV Santé, Gennevilliers, France
| | - Uros Krivec
- Department of Paediatric Pulmonology, University Children's Hospital Ljubljana, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Omendra Narayan
- Sleep and Long Term Ventilation unit, Royal Manchester Children's Hospital and University of Manchester, Manchester, UK
| | - Joanna MacLean
- Division of Respiratory Medicine, Department of Pediatrics, University of Alberta, Edmonton Canada
| | - Valeria Perez De Sa
- Department of Pediatric Anesthesia and Intensive Care, Children's Heart Center, Skåne University Hospital, Lund, Sweden
| | - Marti Pons-Odena
- Pediatric Home Ventilation Programme, University Hospital Sant Joan de Déu, Barcelona, Spain.,Respiratory and Immune dysfunction research group, Institut de Recerca Sant Joan de Déu, Esplugues de Llobregat, Spain
| | - Florian Stehling
- Pediatric Pulmonology and Sleep Medicine, Cystic Fibrosis Center, Childreńs Hospital, University of Duisburg-Essen, Essen, Germany
| | - Rosario Trindade Ferreira
- Pediatric Respiratory Unit, Department of Paediatrics, Hospital de Santa Maria, Academic Medical Centre of Lisbon, Portugal
| | - Stijn Verhulst
- Department of Pediatrics, Antwerp University Hospital, Edegem, Belgium.,Laboratory of Experimental Medicine and Pediatrics, University of Antwerp, Antwerp, Belgium
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12
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Gascón-Navarro JA, De La Torre-Aguilar MJ, Fernández-Ramos JA, Torres-Borrego J, Pérez-Navero JL. Experience in neuromuscular diseases in children and adolescents and their comorbidities in a tertiary hospital. Ital J Pediatr 2021; 47:228. [PMID: 34784950 PMCID: PMC8597309 DOI: 10.1186/s13052-021-01176-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 10/23/2021] [Indexed: 12/27/2022] Open
Abstract
Introduction Neuromuscular diseases include a large group of heterogeneous and rare pathologies that affect different components of the motor unit. It is essential to optimize resources to know the prevalence of comorbidities in the most frequent groups to establish an early multidisciplinary approach in a specialized setting. Patients and methods Retrospective descriptive study of pediatric and adolescent patients with neuromuscular diseases (NMDs). The Inclusion criteria were NMDs patients with motor neuron involvement divided into three groups, depending on the affected component of the motor unit. Group I: involvement of the motor neuron; Group II: peripheral neuropathies; Group III: myopathies. Demographic variables, association with comorbidities, need for respiratory support, and rehabilitative treatment were collected in each group. Results Ninety-six patients who met the inclusion criteria were studied. In group I, when compared to the other two groups, a higher incidence of scoliosis (68.3%, p = 0.011), deformity of the rib cage (31.3%, p = 0.0001), chronic respiratory insufficiency (62.5%, p = 0.001) and bronchial aspiration (12.5%, p = 0.03) was detected. In this group, 50%of the patients required non-invasive mechanical ventilation (p = 0.0001). The in-hospital requirement for respiratory physiotherapy was higher in group I (75%, p = 0.001). We observed a higher incidence of scoliosis in Group III compared to Group II. Conclusions Neuromuscular diseases with motor neuron involvement present more comorbidities and require an early approach after diagnosis to improve prognosis.
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Affiliation(s)
- J A Gascón-Navarro
- Department of Pediatrics. Reina Sofia University Hospital, Córdoba University, Maimónides Biomedical Research Institute of Córdoba (IMIBIC), Avd. Menéndez Pidal s/n. PC, 14004, Córdoba, Spain
| | - M J De La Torre-Aguilar
- Department of Pediatrics. Reina Sofia University Hospital, Córdoba University, Maimónides Biomedical Research Institute of Córdoba (IMIBIC), Avd. Menéndez Pidal s/n. PC, 14004, Córdoba, Spain.
| | - J A Fernández-Ramos
- Neuropediatrics Unit. Department of Pediatrics. Reina Sofia University Hospital, Córdoba University, Córdoba, Spain.,Center for Biomedical Research on Rare Diseases (CIBERER), ISCIII, Madrid, Spain
| | - J Torres-Borrego
- Pediatric Pneumology Unit, Department of Pediatrics. Reina Sofía University Hospital, Córdoba University, Córdoba, Spain
| | - J L Pérez-Navero
- Department of Pediatrics. Reina Sofia University Hospital, Córdoba University, Maimónides Biomedical Research Institute of Córdoba (IMIBIC), Avd. Menéndez Pidal s/n. PC, 14004, Córdoba, Spain.,Center for Biomedical Research on Rare Diseases (CIBERER), ISCIII, Madrid, Spain
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13
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Racca F, Longhitano Y, Wolfler A, Carfagna F, Grattarola C, Serio P, Sbaraglia F, Amigoni A, Savron F, Caramelli F, Montagnini L, Astuto M, Gallo E, Zanza C, Vaschetto R, Conti G. Perioperative management of children with neuromuscular disorders based on a common protocol: A prospective, national study in Italy. Acta Anaesthesiol Scand 2021; 65:1195-1204. [PMID: 33963537 DOI: 10.1111/aas.13844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/15/2021] [Accepted: 04/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non-invasive ventilation (NIV) associated with mechanical insufflation-exsufflation (MI-E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared perioperative protocol that consists in using NIV combined with MI-E to improve the postoperative outcome of NMD children (IT-NEUMA-Ped). METHOD We conducted a multicentre, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals. RESULTS We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs, and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 (2-14) days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher intensive care unit (ICU) admission rate and longer hospital LOS. CONCLUSION Disease severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI-E can help in preventing and resolve PPCs.
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Affiliation(s)
- Fabrizio Racca
- Department of Anaesthesiology and Intensive Care Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo Alessandria Italy
| | - Yaroslava Longhitano
- Department of Anaesthesiology and Intensive Care Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo Alessandria Italy
| | - Andrea Wolfler
- Department of Anaesthesiology and Intensive Care Vittore Buzzi Children's Hospital Milan Italy
| | - Fabio Carfagna
- Department of Translational Medicine University of Eastern Piedmont Amedeo Avogadro School of Medicine Novara Italy
| | - Claudia Grattarola
- Department of Anaesthesiology and Intensive Care Unit Istituto Giannina Gaslini Genova Italy
| | - Paola Serio
- Department of Paediatric Anaesthesia and Intensive Care Meyer Children Hospital Florence Italy
| | - Fabio Sbaraglia
- Department of Emergency Medicine, Anaesthesia and Intensive Care University Hospital Agostino Gemelli IRCCS Rome Italy
| | - Angela Amigoni
- Paediatric Intensive Care Unit Department of Woman's and Child's Health University Hospital of Padova Padua Italy
| | - Fabio Savron
- Department of Anaesthesia and Intensive Care Institute for Maternal and Child Health – IRCCS “Burlo Garofolo” Trieste Italy
| | - Fabio Caramelli
- Department of Anaesthesia and Intensive Care University of Bologna Hospital of Bologna Sant'Orsola‐Malpighi Polyclinic Bologna Italy
| | - Luigi Montagnini
- Department of Anaesthesiology and Intensive Care Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo Alessandria Italy
| | - Marinella Astuto
- Dipartimento Chirurgia Generale e Specialità Medico Chirurgiche A.O.Universitaria “Policlinico‐Vittorio Emanuele”Università degli Studi di Catania Catania Italy
| | - Elisa Gallo
- Department of Translational Medicine University of Eastern Piedmont Amedeo Avogadro School of Medicine Novara Italy
| | - Christian Zanza
- Department of Anaesthesiology and Intensive Care Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo Alessandria Italy
- Foundation of “Nuovo Ospedale Alba‐Bra” Department of Emergency Medicine, Anaesthesia and Critical Care Medicine Michele and Pietro Ferrero Hospital Verduno Italy
| | - Rosanna Vaschetto
- Department of Translational Medicine University of Eastern Piedmont Amedeo Avogadro School of Medicine Novara Italy
| | - Giorgio Conti
- Department of Emergency Medicine, Anaesthesia and Intensive Care University Hospital Agostino Gemelli IRCCS Rome Italy
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14
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Vandendriessche E, Proesmans M, Ortibus E, Moens P. Complication rate after scoliosis surgery in children with cerebral palsy. Acta Orthop Belg 2021. [DOI: 10.52628/87.2.08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Scoliosis is an important problem in children with cerebral palsy (CP). However, the choice for a spinal fusion has to be weighed against the risks of major surgery in this vulnerable population. Paediatricians are frequently consulted preoperatively to assess the (respiratory) risk involved, but data on this question specific for CP are rare. Therefore, we investigated the complication rate after scoliosis surgery in children with CP, compared to idiopathic scoliosis (IS), and we searched for risk factors for the most common complications. In a retrospective monocenter study we analyzed the medical records from all children with CP and IS undergoing scoliosis surgery from 2010 until 2014. Duration of hospitalization and postoperative complications were compared within a 6-month follow-up. Univariate and multivariate logistic regression models were used to identify risk factors. The study included 44 patients with CP (mean age 15y0mo) and 78 patients with IS (mean age 14y6mo). Children with CP experience a higher rate of complications : respiratory and cardiovascular, as well as wound infections and decubitus ulcers (p<0.05). Postoperative pneumonia was the most frequent complication in both patient groups (43% and 18% in CP and IS respectively), with epilepsy being a significant risk factor (OR 3.85, p= 0.037) in children with CP. Intensive care unit and total hospital stay were longer in the CP group (p<0.001). These results may add information on perioperative care and surgical decision making.
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15
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Fishman H, Hamid JS, Barrowman N, Momoli F, Maclusky I, Katz SL. Associations between polysomnography measurements and postoperative adverse respiratory events in children with neuromuscular disease. J Clin Sleep Med 2021; 17:757-765. [PMID: 33231163 DOI: 10.5664/jcsm.9026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
STUDY OBJECTIVES To determine if polysomnographic cardiorespiratory outcomes are associated with and could have the potential to predict the presence of postoperative adverse respiratory events in children with neuromuscular disease undergoing any surgical procedure. METHODS A retrospective cohort study was conducted at a tertiary pediatric institution. The study population included individuals with neuromuscular disease admitted for a surgical intervention under general anesthetic who had undergone a polysomnogram within 1 year before surgical intervention. Polysomnographic indices and postoperative adverse respiratory events were collected through chart review. Multivariable logistic regression was used to model postoperative adverse respiratory events, where PSG results were considered primary predictors. RESULTS Postoperative adverse respiratory events occurred in 25/61 (41%) of individuals and consisted mainly of desaturations requiring intervention 33 (73%), airway obstruction 15 (33%), and atelectasis (22%). Results from the unadjusted and adjusted logistic regression models indicated that saturation nadir and bulbar dysfunction individually were independent risk factors for postoperative adverse respiratory events with the highest areas under the receiver operating characteristic curve. A multivariable prediction model using these 2 risk factors provided an area under the receiver operating characteristic curve of 0.74 (95% confidence interval, 0.65-0.83). CONCLUSIONS Knowing that nocturnal oxygen saturation nadir and the presence of bulbar dysfunction are potential predictors of postoperative adverse respiratory events is useful for future counseling of families and surgical planning, in an effort to improve perioperative management and reduce adverse events.
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Affiliation(s)
- Haley Fishman
- Centre Hospitalier Universitaire Sainte-Justine, Department of Pediatrics, Division of Pediatric Respirology, Montreal, Quebec, Canada.,University of Montreal, Faculty of Medicine, Montreal, Quebec, Canada
| | - Jemila S Hamid
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada
| | - Ian Maclusky
- University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario, Department of Pediatrics, Division of Pediatric Respirology, Ottawa, Ontario, Canada
| | - Sherri Lynne Katz
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario, Department of Pediatrics, Division of Pediatric Respirology, Ottawa, Ontario, Canada
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16
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Landoni G, Likhvantsev V, Kuzovlev A, Cabrini L. Perioperative Noninvasive Ventilation After Adult or Pediatric Surgery: A Comprehensive Review. J Cardiothorac Vasc Anesth 2021; 36:785-793. [PMID: 33893015 DOI: 10.1053/j.jvca.2021.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 11/11/2022]
Abstract
Postoperative pulmonary complications and acute respiratory failure are among the leading causes of adverse postoperative outcomes. Noninvasive ventilation may safely and effectively prevent acute respiratory failure in high-risk patients after cardiothoracic surgery and after abdominal surgery. Moreover, noninvasive ventilation can be used to treat postoperative hypoxemia, particularly after abdominal surgery. Noninvasive ventilation also can be helpful to prevent or manage intraoperative acute respiratory failure during non-general anesthesia, primarily in patients with poor respiratory function. Finally, noninvasive ventilation is superior to standard preoxygenation in delaying desaturation during intubation in morbidly obese and in critically ill hypoxemic patients. The few available studies in children suggest that noninvasive ventilation could be safe and valuable in treating hypoxemic or hypercapnic acute respiratory failure after cardiac surgery; on the other hand, it could be dangerous after tracheoesophageal correction.
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Affiliation(s)
- Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Faculty of Medicine, Vita Salute San Raffaele University, Milan, Italy.
| | - Valery Likhvantsev
- Department of Anesthesiology and Intensive Care, First Moscow State Medical University, Moscow, Russia; V. Negovsky Reanimatology Research Institute, Moscow, Russia
| | - Artem Kuzovlev
- V. Negovsky Reanimatology Research Institute, Moscow, Russia
| | - Luca Cabrini
- Università degli Studi dell'Insubria, Varese, Italy; Ospedale di Circolo e Fondazione Macchi, Varese, ASST-Settelaghi, Varese, Italy
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17
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Sedra F, Shafafy R, Sadek AR, Aftab S, Montgomery A, Nadarajah R. Perioperative Optimization of Patients With Neuromuscular Disorders Undergoing Scoliosis Corrective Surgery: A Multidisciplinary Team Approach. Global Spine J 2021; 11:240-248. [PMID: 32875888 PMCID: PMC7882827 DOI: 10.1177/2192568220901692] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
STUDY DESIGN Narrative review. OBJECTIVE The high rate of complications associated with the surgical management of neuromuscular spinal deformities is well documented in the literature. This is attributed to attenuated protective physiological responses in multiple organ systems. METHODS Review and synthesis of the literature pertaining to optimization of patients with neuromuscular scoliosis undergoing surgery. Our institutional practice in the perioperative assessment and management of neuromuscular scoliosis is also described along with a clinical vignette. RESULTS Respiratory complications are the most common to occur following surgery for neuromuscular disorders. Other categories include gastrointestinal, cardiac, genitourinary, blood loss, and wound complications. A multidisciplinary approach is required for perioperative optimization of these patients and numerous strategies are described, including respiratory management. CONCLUSION Perioperative optimization for patients with neuromuscular disorders undergoing corrective surgery for spinal deformity is multifaceted and complex. It requires a multidisciplinary evidence-based approach. Preadmission of patients in advance of surgery for assessment and optimization may be required in certain instances to identify key concerns and formulate a tailored treatment plan.
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Affiliation(s)
- Fady Sedra
- Royal London Hospital, Barts Health NHS Trust, London, UK,Cairo University Hospitals, Cairo, Egypt,Fady Sedra, Department of Spinal Surgery, Royal London Hospital, Barts Health NHS Trust, Whitechapel Rd, Whitechapel, London E1 1FR, UK.
| | | | | | - Syed Aftab
- Royal London Hospital, Barts Health NHS Trust, London, UK
| | | | - Ramesh Nadarajah
- Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
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18
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Fauroux B, Griffon L, Amaddeo A, Stremler N, Mazenq J, Khirani S, Baravalle-Einaudi M. Respiratory management of children with spinal muscular atrophy (SMA). Arch Pediatr 2020; 27:7S29-7S34. [PMID: 33357594 DOI: 10.1016/s0929-693x(20)30274-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Spinal muscular atrophy (SMA) causes a predominantly bilateral proximal muscle weakness and atrophy. The respiratory muscles are also involved with a weakness of the intercostal muscles and a relatively spared diaphragm. This respiratory muscle weakness translates into a cough impairment, resulting in poor clearance of airway secretions and recurrent pulmonary infections, restrictive lung disease due to a poor or insufficient chest wall and lung growth, nocturnal hypoventilation and, finally, respiratory failure. Systematic and regular monitoring of respiratory muscle performance is necessary in children with SMA in order to anticipate respiratory complications, such as acute and chronic respiratory failure, and guide clinical care. This monitoring is based in clinical practice on volitional and noninvasive tests, such as vital capacity, sniff nasal inspiratory pressure, maximal static pressures, peak expiratory flow and peak cough flow because of their simplicity, availability and ease. In young children, those with poor cooperation or severe respiratory muscle weakness, other, mostly invasive, tests may be required to evaluate respiratory muscle performance. A sleep study, or at least overnight monitoring of nocturnal gas exchange is mandatory for detecting nocturnal alveolar hypoventilation. Training for patients and caregivers in cough-assisted techniques is recommended when respiratory muscle strength falls below 50% of predicted or in case of recurrent or severe respiratory infections. Noninvasive ventilation (NIV) should be initiated in case of isolated nocturnal hypoventilation and followed by a pediatric respiratory team with expertise in NIV. Multidisciplinary (neurology and respiratory) pediatric management is crucial for optimal care of children with SMA. © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.
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Affiliation(s)
- B Fauroux
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France.
| | - L Griffon
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France
| | - A Amaddeo
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France
| | - N Stremler
- Pediatric Ventilation Unit, Pediatric department, Timone-Enfants Hospital, 13385 Marseille AP-HM, Marseille, France
| | - J Mazenq
- Pediatric Ventilation Unit, Pediatric department, Timone-Enfants Hospital, 13385 Marseille AP-HM, Marseille, France
| | - S Khirani
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France; ASV Sante, Gennevilliers, France
| | - M Baravalle-Einaudi
- Pediatric Ventilation Unit, Pediatric department, Timone-Enfants Hospital, 13385 Marseille AP-HM, Marseille, France
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19
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Al-Iede MM, Al-Zayadneh E, Bridge C, Alqutawneh B, Waters K. Risk factors for postoperative pulmonary complications in children with severely compromised pulmonary function secondary to severe scoliosis. Pediatr Pulmonol 2020; 55:2782-2790. [PMID: 32729967 DOI: 10.1002/ppul.24997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES After corrective surgery for scoliosis, postoperative pulmonary complications lead to increases in morbidity, length of hospital stay (LOS) and mortality. This study aimed to identify associations with such respiratory complications, and to assess the utility of noninvasive ventilation (NIV) in children with severe scoliosis METHODS: This retrospective cohort study included all children aged ≤17 years who underwent spinal surgery for scoliosis between January 2009 and January 2012 at a quaternary pediatric hospital. Data were collated regarding polysomnography (PSG) and NIV use, before and after corrective surgery. Factors associated with severely compromised pulmonary function (SCPF) were established and correlations with the occurrence of postoperative pulmonary complications and LOS were identified. RESULTS Altogether, 133 children had corrective surgery for scoliosis, aged 12.7 (range: 2-17) years at operation. Scoliosis causes were identified as: idiopathic (39.8%), neuromuscular disease (32.2%), syndrome (15.7%), and congenital (12%). Correlates with SCPF (forced vital capacity [FVC] <40% predicted, n = 10) included markers of sleep hypoventilation, including serum bicarbonate ≥29 mmol/L, morning pCO2 > 50mm Hg (P = .003), and overnight, episodic CO2 retention of >7 mm Hg. Using these parameters an additional eight children with SCPF were identified making a total of 18 out of 133 (13.5%) of the patients. Postoperative pulmonary complications were seen in 24 children (18%) and their occurrence correlated with higher Cobb angle (>90°), lower pulmonary function (FVC), higher serum bicarbonate and underlying neuromuscular disease. Amongst the 18 children with SCPF, regular use of NIV preoperatively was associated with reduced rate of postoperative pulmonary complications (P = .02) and reduced LOS by 6.4 days (P = .01). CONCLUSION Nocturnal hypoventilation on PSG identifies children with SCPF. Use of NIV in children with SCPF was linked to fewer postoperative pulmonary complications and reduced duration of hospital stay.
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Affiliation(s)
| | - Enas Al-Zayadneh
- Department of Pediatrics, The University of Jordan, Amman, Jordan
| | - Corinne Bridge
- Department of Orthopaedics, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Basim Alqutawneh
- Radiology Department, Blacktown-Mount Druitt Hospital, Sydney, Australia
| | - Karen Waters
- Discipline of Paediatrics & Child Health, University of Sydney, New South Wales, Australia.,Sleep Department, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
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20
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Chen TH, Liang WC, Chen IC, Liu YC, Hsu JH, Jong YJ. Combined noninvasive ventilation and mechanical insufflator-exsufflator for acute respiratory failure in patients with neuromuscular disease: effectiveness and outcome predictors. Ther Adv Respir Dis 2020; 13:1753466619875928. [PMID: 31544581 PMCID: PMC6759712 DOI: 10.1177/1753466619875928] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: To determine the effectiveness of combined noninvasive ventilation (NIV) and mechanical insufflator-exsufflator (MI-E) for acute respiratory failure (ARF) in patients with neuromuscular disease (NMD), and outcome predictors. Methods: A prospectively observational study of patients with ARF was conducted in a pediatric intensive care unit (PICU). All received combined NIV/MI-E during PICU stays between 2007 and 2017. Pertinent clinical variables of heart rate (HR), respiratory rate (RR), pH, PaCO2, and PaO2/FiO2 ratio were collected at baseline and at 2 h, 4-8 h, and 12-24 h after initiating use of NIV/MI-E. Treatment success was defined as avoiding intubation. Results: A total of 62 ARF episodes in 56 patients with NMD (median age, 13 years) were enrolled. The most frequent underlying NMD was spinal muscular atrophy (32/62, 52%). ARF was primarily due to pneumonia (65%). The treatment success rate was 86%. PICU stay and hospitalization were shorter in the success group (9.4 ± 6.1 vs. 21.9 ± 13.9 days and 16.3 ± 7.8 vs. 33.6 ± 17.9 days, respectively; both p < 0.05). HR, RR, pH, and PaCO2 showed a progressive improvement, particularly after 4 h following successful NIV/MI-E treatment. RR decrease at 4 h, and pH increase and PaCO2 decrease at 4-8 h might predict success of NIV/MI-E treatment. The multivariate analysis identified PaCO2 at 4-8 h of 58.0 mmHg as an outcome predictor of NIV/MI-E treatment. Conclusions: Applying combined NIV/MI-E in the acute care setting is an efficient means of averting intubation in NMD patients with ARF. Clinical features within 8 h of the institution may predict treatment outcome. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Tai-Heng Chen
- Division of Pediatric Emergency, Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung.,PhD Program in Translational Medicine, Graduate Institute of Clinical Medicine, Kaohsiung Medical University and Academia Sinica.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Wen-Chen Liang
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung.,Departments of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - I-Chen Chen
- Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung.,Departments of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Yi-Ching Liu
- Departments of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung
| | - Jong-Hau Hsu
- Department of Pediatrics, Kaohsiung Medical University Hospital, #100, Tz-You 1st Road, Kaohsiung, 80708.,Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung
| | - Yuh-Jyh Jong
- Department of Pediatrics, Kaohsiung Medical University Hospital, No. 100, Tzyou 1st Road, Kaohsiung 80708.,Departments Laboratory Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung.,Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung.,Department of Biological Science and Technology, Institute of Molecular Medicine and Bioengineering, College of Biological Science and Technology, National Chiao Tung University, Hsinchu
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21
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Chen TH, Hsu JH. Noninvasive Ventilation and Mechanical Insufflator-Exsufflator for Acute Respiratory Failure in Children With Neuromuscular Disorders. Front Pediatr 2020; 8:593282. [PMID: 33194926 PMCID: PMC7661489 DOI: 10.3389/fped.2020.593282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 10/12/2020] [Indexed: 02/04/2023] Open
Abstract
Children with neuromuscular disorder (NMD) usually have pulmonary involvement characterized by weakened respiratory muscles, insufficient coughing, and inability to clear airway secretions. When suffering from community-acquired pneumonia, these patients are more likely to develop acute respiratory failure (ARF). Therefore, recurrent pneumonias leading to acute on chronic respiratory failure accounts for a common cause of mortality in children with NMD. For many years, noninvasive ventilation (NIV) has been regarded as a life-prolonging tool and has been used as the preferred intervention for treating chronic hypoventilation in patients with advanced NMD. However, an increasing number of studies have proposed the utility of NIV as first-line management for acute on chronic respiratory failure in NMD patients. The benefits of NIV support in acute settings include avoiding invasive mechanical ventilation, shorter intensive care unit or hospital stays, facilitation of extubation, and improved overall survival. As the difficulty in clearing respiratory secretions is considered a significant risk factor attributing to NIV failure, combined coughing assistance of mechanical insufflator-exsufflator (MI-E) with NIV has been recommended the treatment of acute neuromuscular respiratory failure. Several recent studies have demonstrated the feasibility and effectiveness of combined NIV and MI-E in treating ARF of children with NMD in acute care settings. However, to date, only one randomized controlled study has investigated the efficacy of NIV in childhood ARF, but subjects with underlying NMD were excluded. It reflects the need for more studies to elaborate evidence-based practice, especially the combined NIV and MI-E use in children with acute neuromuscular respiratory failure. In this article, we will review the feasibility, effectiveness, predictors of outcome, and perspectives of novel applications of combined NIV and MI-E in the treatment of ARF in NMD children.
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Affiliation(s)
- Tai-Heng Chen
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Emergency, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Biological Sciences, University of Southern California, Los Angeles, CA, United States
| | - Jong-Hau Hsu
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Pediatrics, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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Fauroux B, Khirani S, Griffon L, Teng T, Lanzeray A, Amaddeo A. Non-invasive Ventilation in Children With Neuromuscular Disease. Front Pediatr 2020; 8:482. [PMID: 33330262 PMCID: PMC7717941 DOI: 10.3389/fped.2020.00482] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 07/09/2020] [Indexed: 11/17/2022] Open
Abstract
The respiratory muscles are rarely spared in children with neuromuscular diseases (NMD) which puts them at risk of alveolar hypoventilation. The role of non-invasive ventilation (NIV) is then to assist or "replace" the weakened respiratory muscles in order to correct alveolar hypoventilation by maintaining a sufficient tidal volume and minute ventilation. As breathing is physiologically less efficient during sleep, NIV will be initially used at night but, with the progression of respiratory muscle weakness, NIV can be extended during daytime, preferentially by means of a mouthpiece in order to allow speech and eating. Although children with NMD represent the largest group of children requiring long term NIV, there is a lack of validated criteria to start NIV. There is an agreement to start long term NIV in case of isolated nocturnal hypoventilation, before the appearance of daytime hypercapnia, and/or in case of acute respiratory failure requiring any type of ventilatory support. NIV is associated with a correction in night- and daytime gas exchange, an increase in sleep efficiency and an increase in survival. NIV and/or intermittent positive pressure breathing (IPPB) have been shown to prevent thoracic deformities and consequent thoracic and lung hypoplasia in young children with NMD. NIV should be performed with a life support ventilator appropriate for the child's weight, with adequate alarms, and an integrated (±additional) battery. Humidification is recommended to improve respiratory comfort and prevent drying of bronchial secretions. A nasal interface (or nasal canula) is the preferred interface, a nasobuccal interface can be used with caution in case of mouth breathing. The efficacy of NIV should be assessed on the correction of alveolar ventilation. Patient ventilator synchrony and the absence of leaks can be assessed on a sleep study with NIV or on the analysis of the ventilator's in-built software. The ventilator settings and the interface should be adapted to the child's growth and progression of respiratory muscle weakness. NIV should be associated with an efficient clearance of bronchial secretions by a specific program on the ventilator, IPPB, or mechanical insufflation-exsufflation. Finally, these children should be managed by an expert pediatric multi-disciplinary team.
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Affiliation(s)
- Brigitte Fauroux
- Pediatric Non-invasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants Malades, Paris, France.,Université de Paris, VIFASOM, Paris, France
| | - Sonia Khirani
- Pediatric Non-invasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants Malades, Paris, France.,Université de Paris, VIFASOM, Paris, France.,ASV Sante, Gennevilliers, France
| | - Lucie Griffon
- Pediatric Non-invasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants Malades, Paris, France.,Université de Paris, VIFASOM, Paris, France
| | - Theo Teng
- Pediatric Non-invasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
| | - Agathe Lanzeray
- Pediatric Non-invasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
| | - Alessandro Amaddeo
- Pediatric Non-invasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker-Enfants Malades, Paris, France.,Université de Paris, VIFASOM, Paris, France
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Cognetti D, Keeny HM, Samdani AF, Pahys JM, Hanson DS, Blanke K, Hwang SW. Neuromuscular scoliosis complication rates from 2004 to 2015: a report from the Scoliosis Research Society Morbidity and Mortality database. Neurosurg Focus 2018; 43:E10. [PMID: 28965448 DOI: 10.3171/2017.7.focus17384] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Postoperative complications are one of the most significant concerns in surgeries of the spine, especially in higher-risk cases such as neuromuscular scoliosis. Neuromuscular scoliosis is a classification of multiple diseases affecting the neuromotor system or musculature of patients leading to severe degrees of spinal deformation, disability, and comorbidity, all likely contributing to higher rates of postoperative complications. The objective of this study was to evaluate deformity correction of patients with neuromuscular scoliosis over a 12-year period (2004-2015) by looking at changes in postsurgical complications and management. METHODS The authors queried the Scoliosis Research Society (SRS) Morbidity and Mortality (M&M) database for neuromuscular scoliosis cases from 2004 to 2015. The SRS M&M database is an international database with thousands of self-reported cases by fellowship-trained surgeons. The database has previously been validated, but reorganization in 2008 created less-robust data sets from 2008 to 2011. Consequently, the majority of analysis in this report was performed using cohorts that bookend the 12-year period (2004-2007 and 2012-2015). Of the 312 individual fields recorded per patient, demographic analysis was completed for age, sex, diagnosis, and preoperative curvature. Analysis of complications included infection, bleeding, mortality, respiratory, neurological deficit, and management practices. RESULTS From 2004 to 2015, a total of 29,019 cases of neuromuscular scoliosis were reported with 1385 complications, equating to a 6.3% complication rate when excluding the less-robust data from 2008 to 2011. This study shows a 3.5-fold decrease in overall complication rates from 2004 to 2015. A closer look at complications shows a significant decrease in wound infections (superficial and deep), respiratory complications, and implant-associated complications. The overall complication rate decreased by approximately 10% from 2004-2007 to 2012-2015. CONCLUSIONS This study demonstrates a substantial decrease in complication rates from 2004 to 2015 for patients with neuromuscular scoliosis undergoing spine surgery. Decreases in specific complications, such as surgical site infection, allow us to gauge our progress while observing how trends in management affect outcomes. Further study is needed to validate this report, but these results are encouraging, helping to reinforce efforts toward continual improvement in patient care.
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Affiliation(s)
| | | | - Amer F Samdani
- Shriners Hospitals for Children-Philadelphia, Pennsylvania
| | - Joshua M Pahys
- Shriners Hospitals for Children-Philadelphia, Pennsylvania
| | | | - Kathy Blanke
- Scoliosis Research Society, Milwaukee, Wisconsin
| | - Steven W Hwang
- Shriners Hospitals for Children-Philadelphia, Pennsylvania
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Mary P, Servais L, Vialle R. Neuromuscular diseases: Diagnosis and management. Orthop Traumatol Surg Res 2018; 104:S89-S95. [PMID: 29196274 DOI: 10.1016/j.otsr.2017.04.019] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 03/24/2017] [Accepted: 04/04/2017] [Indexed: 02/02/2023]
Abstract
Neuromuscular diseases (NMDs) affect the peripheral nervous system, which includes the motor neurons and sensory neurons; the muscle itself; or the neuromuscular junction. Thus, the term NMDs encompasses a vast array of different syndromes. Some of these syndromes are of direct relevance to paediatric orthopaedic surgeons, either because the presenting manifestation is a functional sign (e.g., toe-walking) or deformity (e.g., pes cavus or scoliosis) suggesting a need for orthopaedic attention or because orthopaedic abnormalities requiring treatment develop during the course of a known NMD. The main NMDs relevant to the orthopaedic surgeon are infantile spinal muscular atrophy (a motor neuron disease), peripheral neuropathies (chiefly, Charcot-Marie-Tooth disease), congenital muscular dystrophies, progressive muscular dystrophies, and Steinert myotonic dystrophy (or myotonic dystrophy type 1). Muscle weakness is a symptom shared by all these conditions. The paediatric orthopaedic surgeon must be familiar, not only with the musculoskeletal system, but also with many other domains (particularly respiratory and cardiac function and nutrition) that may interfere with the treatment and require preoperative management. Good knowledge of the natural history of each NMD is essential to ensure optimal timing of the therapeutic interventions, which must be performed under the best possible conditions in these usually frail patients. Timing is particularly crucial for the treatment of spinal deformities due to paraspinal muscle hypotonia during growth: depending on the disease and natural history, the treatment may involve non-operative methods or growing rods, followed by spinal fusion. A multidisciplinary approach is always required. Finally, the survival gains achieved in recent years increasingly require attention to preparing for adult life, to orthopaedic problems requiring treatment before the patient leaves the paediatric environment, and to the transition towards the adult healthcare system.
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Affiliation(s)
- P Mary
- Service d'orthopédie et de chirurgie réparatrice de l'enfant, département hospitalo-universitaire maladies musculosquelettiques et innovations thérapeutiques (MAMUTH), hôpital d'enfants Armand-Trousseau, 26, avenue du Dr-A.-Netter, 75571 Paris cedex 12, France.
| | - L Servais
- Service d'orthopédie et de chirurgie réparatrice de l'enfant, département hospitalo-universitaire maladies musculosquelettiques et innovations thérapeutiques (MAMUTH), hôpital d'enfants Armand-Trousseau, 26, avenue du Dr-A.-Netter, 75571 Paris cedex 12, France
| | - R Vialle
- Service d'orthopédie et de chirurgie réparatrice de l'enfant, département hospitalo-universitaire maladies musculosquelettiques et innovations thérapeutiques (MAMUTH), hôpital d'enfants Armand-Trousseau, 26, avenue du Dr-A.-Netter, 75571 Paris cedex 12, France
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25
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Diagnosis and management of spinal muscular atrophy: Part 2: Pulmonary and acute care; medications, supplements and immunizations; other organ systems; and ethics. Neuromuscul Disord 2017; 28:197-207. [PMID: 29305137 DOI: 10.1016/j.nmd.2017.11.004] [Citation(s) in RCA: 335] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 11/06/2017] [Accepted: 11/13/2017] [Indexed: 01/12/2023]
Abstract
This is the second half of a two-part document updating the standard of care recommendations for spinal muscular atrophy published in 2007. This part includes updated recommendations on pulmonary management and acute care issues, and topics that have emerged in the last few years such as other organ involvement in the severe forms of spinal muscular atrophy and the role of medications. Ethical issues and the choice of palliative versus supportive care are also addressed. These recommendations are becoming increasingly relevant given recent clinical trials and the prospect that commercially available therapies will likely change the survival and natural history of this disease.
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26
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Berry JG, Glotzbecker M, Rodean J, Leahy I, Hall M, Ferrari L. Comorbidities and Complications of Spinal Fusion for Scoliosis. Pediatrics 2017; 139:peds.2016-2574. [PMID: 28153850 PMCID: PMC5330399 DOI: 10.1542/peds.2016-2574] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES General pediatricians and hospitalists are increasingly summoned to optimize the comorbid conditions of children with medical complexity (CMC) undergoing major surgery. We assessed the relationship between specific chronic conditions of CMC and hospital resource use with spinal fusion for scoliosis, an operation with high cost and morbidity. METHODS Retrospective analysis of 7252 children age ≥5 years with an underlying complex chronic condition undergoing spinal fusion between January 1, 2010 through December 31, 2014 in 41 children's hospitals. Hospital length of stay (LOS), cost, and 30-day readmission rate were compared across comorbid conditions by using linear and logistic regression accounting for demographic characteristics and clustering of patients by hospital. RESULTS Fifty-nine percent of children had ≥4 comorbid conditions. As the number of chronic conditions increased from 1-3 to ≥10, median LOS increased 60% (5 [interquartile range (IQR), 4-7] to 8 [IQR, 5-13] days); median hospital cost increased 53% ($52 319 [IQR, $37 937-71 513] to $80 429 [IQR, $58 602-$111 965]); and readmission rates increased 293% (5.4% to 15.8%) (P < .001 for all). In multivariable analysis, conditions strongly associated with LOS and cost were chronic respiratory insufficiency (LOS: +2.1 days; cost: +$12 070; and bladder dysfunction (LOS: +0.8 days; cost: +$4014) (P < .001 for all). Readmission likelihood was highest with bladder dysfunction (odds ratio, 1.5; 95% confidence interval, 1.1-2.0) and epilepsy (odds ratio, 1.2; 95% confidence interval, 1.0-1.5). CONCLUSIONS Chronic respiratory insufficiency, bladder dysfunction, and epilepsy had significant associations with hospital resource use for CMC undergoing spinal fusion. Pediatricians, patients, and families may find it useful to consider these conditions when striving to benefit the children's perioperative health and outcomes.
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Affiliation(s)
- Jay G. Berry
- Complex Care Service, Division of General Pediatrics, Department of Medicine
| | | | | | - Izabela Leahy
- Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Matt Hall
- Children’s Hospital Association, Overland Park, Kansas
| | - Lynne Ferrari
- Department of Anesthesiology, Perioperative, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts; and
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Ogna A, Prigent H, Falaize L, Leroux K, Santos D, Vaugier I, Orlikowski D, Lofaso F. Bench evaluation of commercially available and newly developed interfaces for mouthpiece ventilation. CLINICAL RESPIRATORY JOURNAL 2017; 12:890-894. [DOI: 10.1111/crj.12601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 11/15/2016] [Accepted: 12/01/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Adam Ogna
- Hôpital Raymond Poincaré, Service de Réanimation médicale et unité de ventilation à domicile; AP-HP; Garches 92380 France
| | - Helene Prigent
- Hôpital Raymond Poincaré, Service de Physiologie-Explorations Fonctionnelles; AP-HP; Garches 92380 France
| | - Line Falaize
- Hôpital Raymond Poincaré, Service de Physiologie-Explorations Fonctionnelles; AP-HP; Garches 92380 France
- AP-HP, Hôpital Raymond Poincaré, INSERM CIC 14.29; Garches 92380 France
| | | | - Dante Santos
- Hôpital Raymond Poincaré, Service de Physiologie-Explorations Fonctionnelles; AP-HP; Garches 92380 France
| | - Isabelle Vaugier
- AP-HP, Hôpital Raymond Poincaré, INSERM CIC 14.29; Garches 92380 France
| | - David Orlikowski
- Hôpital Raymond Poincaré, Service de Réanimation médicale et unité de ventilation à domicile; AP-HP; Garches 92380 France
- AP-HP, Hôpital Raymond Poincaré, INSERM CIC 14.29; Garches 92380 France
| | - Frederic Lofaso
- Hôpital Raymond Poincaré, Service de Physiologie-Explorations Fonctionnelles; AP-HP; Garches 92380 France
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Becerra-Bolaños Á, Ojeda-Betancor N, Valencia L, Rodríguez-Pérez A. Dispositivos de insuflación-exsuflación en el fracaso respiratorio postoperatorio: informe de caso. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2016.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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29
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Insufflation–exsufflation devices in post-operative respiratory failure: Case report. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2016.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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30
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Cloake T, Gardner A. The management of scoliosis in children with cerebral palsy: a review. JOURNAL OF SPINE SURGERY 2016; 2:299-309. [PMID: 28097247 DOI: 10.21037/jss.2016.09.05] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Children who suffer with cerebral palsy (CP) have a significant chance of developing scoliosis during their early years and adolescence. The behavior of this scoliosis is closely associated with the severity of the CP disability and unlike idiopathic scoliosis, it continues to progress beyond skeletal maturity. Conservative measures may slow the progression of the curve, however, surgery remains the only definitive management option. Advances in surgical technique over the last 50 years have provided methods to effectively treat the deformity while also reducing complication rates. The increased risk of surgical complications with these complex patients make decisions about treatment challenging, however with careful pre-operative optimization and post-operative care, surgery can offer a significant improvement in quality of life. This review discusses the development of scoliosis in CP patient, evaluates conservative and surgical treatment options and assesses post-operative outcome.
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Abstract
BACKGROUND Patients with neuromuscular scoliosis (NMS) can pose treatment challenges related to medical comorbidities and altered spinopelvic anatomy. We reviewed the recent literature regarding evaluation and management of NMS patients and explored areas where further research is needed. METHODS We searched the PubMed database for all papers related to the treatment of NMS published from January 1, 2011 through July 31, 2014, yielding 70 papers. RESULTS A total of 39 papers contributed compelling new findings. Steroid treatment has been most promising in patients with Duchenne muscular dystrophy, leading to a significantly lower death rate, better pulmonary function, and longer independent ambulation. Growing rods in early-onset NMS were shown to result in significant improvements in major Cobb angles and pelvic obliquity, with low complication rates in patients with spinal muscular atrophy but high infection rates in those with cerebral palsy. Early reports of magnetic growing rods in NMS patients are favorable. Intraoperative neural monitoring is variable in this patient population; however, use of transcranial motor-evoked potentials in NMS patients seems to be safe. Blood loss is the highest in NMS patients when compared with all other diagnostic categories. However, tranexamic acid seems to significantly lower intraoperative blood loss. In a multicenter study, patients diagnosed with NMS had the highest surgical-site infection rate at 13.1%. Best-practice guidelines have been created regarding prevention of infection in NMS patients. Preoperative nutritional optimization and postoperative nutritional supplementation seem to help with lowering the infection rate in these patients. CONCLUSIONS There have been major advances in the management of NMS patients, but many challenges remain. Further multicenter studies and randomized clinical trials are needed, particularly in the areas of infection prophylaxis, nutritional optimization, improvement in intraoperative neural monitoring, and prevention of proximal junctional kyphosis. LEVEL OF EVIDENCE Level 4-literature review.
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Amaddeo A, Moreau J, Frapin A, Khirani S, Felix O, Fernandez-Bolanos M, Ramirez A, Fauroux B. Long term continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) in children: Initiation criteria in real life. Pediatr Pulmonol 2016; 51:968-74. [PMID: 27111113 DOI: 10.1002/ppul.23416] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Long term noninvasive continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) are increasingly used in children but limited information is available on the criteria and conditions leading to the initiation of these treatments. The aim of the study is to describe the objective overnight respiratory parameters and clinical situations that led to the initiation of CPAP/NIV in a pediatric NIV unit. MATERIAL AND METHODS Retrospective analysis of the data of all the children discharged on home CPAP/NIV over a 1 year period. RESULTS Seventy-six patients were started on CPAP (n = 64) or NIV (n = 12). CPAP/NIV was initiated because of CPAP/NIV weaning failure (Acute group) in 15 patients. None of these patients had an overnight gas exchange or sleep study before CPAP/NIV initiation. In 18 patients, CPAP/NIV was initiated on abnormal nocturnal gas exchange alone (Subacute group). These patients had a median of three of the following five overnight gas exchange abnormalities: minimal pulse oximetry (SpO2 ) <90%, maximal transcutaneous carbon dioxide (PtcCO2 ) >50 mmHg, time spent with SpO2 <90% or PtcCO2 >50 mmHg ≥2% of recording time, oxygen desaturation index >1.4/hr. In the last 43 patients, CPAP/NIV was initiated after an abnormal sleep study (Chronic group) on a mean of four of the aforementioned criteria and an apnea-hypopnea index >10/hr. CONCLUSION In clinical practice, CPAP/NIV was initiated in an acute, subacute and chronic setting with most patients having an association of several abnormal gas exchange or sleep study parameters. Future studies should evaluate the effectiveness and benefits of CPAP/NIV according to the clinical situation and initiation criteria. Pediatr Pulmonol. 2016; 51:968-974. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- A Amaddeo
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris 75015, France.,Paris Descartes University, Paris, France.,Inserm U955 Team 13, 94000, Creteil, France
| | - J Moreau
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris 75015, France.,Department of Physiology, University of Montpellier I, Montpellier, France
| | - A Frapin
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris 75015, France
| | - S Khirani
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris 75015, France.,ASV Santé, Gennevilliers, France
| | - O Felix
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris 75015, France.,Department of Pediatric, CHU de Rouen, Rouen, France
| | - M Fernandez-Bolanos
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris 75015, France
| | - A Ramirez
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris 75015, France.,ADEP ASSISTANCE, Suresnes, France
| | - B Fauroux
- Pediatric Noninvasive Ventilation and Sleep Unit, AP-HP, Hôpital Necker Enfants-Malades, Paris 75015, France.,Paris Descartes University, Paris, France.,Inserm U955 Team 13, 94000, Creteil, France
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Abstract
Non-invasive ventilation (NIV) is a well recognised and increasingly prevalent intervention in the paediatric critical care setting. In the acute setting NIV is used to provide respiratory support in a flexible manner that avoids a requirement for endotracheal intubation or tracheostomy, with the aim of avoiding the complications of invasive ventilation. This article will explore the physiological benefits, complications and epidemiology of the different modes of NIV including continuous positive airway pressure (CPAP), non-invasive positive pressure ventilation (NIPPV) and high-flow nasal cannula oxygen (HFNC). The currently available equipment and patient interfaces will be described, and the practical aspects of using NIV clinically will be explored. The current evidence for use of NIV in different clinical settings will be discussed, drawing on adult and neonatal as well as paediatric literature.
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Rumalla K, Yarbrough CK, Pugely AJ, Koester L, Dorward IG. Spinal fusion for pediatric neuromuscular scoliosis: national trends, complications, and in-hospital outcomes. J Neurosurg Spine 2016; 25:500-508. [PMID: 27203810 DOI: 10.3171/2016.2.spine151377] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to determine if the recent changes in technology, surgical techniques, and surgical literature have influenced practice trends in spinal fusion surgery for pediatric neuromuscular scoliosis (NMS). In this study the authors analyzed recent trends in the surgical management of NMS and investigated the effect of various patient and surgical factors on in-hospital complications, outcomes, and costs, using the Nationwide Inpatient Sample (NIS) database. METHODS The NIS was queried from 2002 to 2011 using International Classification of Diseases, Ninth Edition, Clinical Modification codes to identify pediatric cases (age < 18 years) of spinal fusion for NMS. Several patient, surgical, and short-term outcome factors were included in the analyses. Trend analyses of these factors were conducted. Both univariate and multivariable analyses were used to determine the effect of the various patient and surgical factors on short-term outcomes. RESULTS Between 2002 and 2011, a total of 2154 NMS fusion cases were identified, and the volume of spinal fusion procedures increased 93% from 148 in 2002 to 286 in 2011 (p < 0.0001). The mean patient age was 12.8 ± 3.10 years, and 45.6% of the study population was female. The overall complication rate was 40.1% and the respiratory complication rate was 28.2%. From 2002 to 2011, upward trends (p < 0.0001) were demonstrated in Medicaid insurance status (36.5% to 52.8%), presence of ≥ 1 comorbidity (40.2% to 52.1%), and blood transfusions (25.2% to 57.3%). Utilization of posterior-only fusions (PSFs) increased from 66.2% to 90.2% (p < 0.0001) while combined anterior release/fusions and PSF (AR/PSF) decreased from 33.8% to 9.8% (< 0.0001). Intraoperative neurophysiological monitoring (IONM) underwent increasing utilization from 2009 to 2011 (15.5% to 20.3%, p < 0.0001). The use/harvest of autograft underwent a significant upward trend between 2002 and 2011 (31.3% to 59.8%, p < 0.0001). In univariate analysis, IONM use was associated with decreased complications (40.7% to 33.1%, p = 0.049) and length of stay (LOS; 9.21 to 6.70 days, p <0.0001). Inflation-adjusted mean hospital costs increased nearly 75% from 2002 to 2011 ($36,805 to $65,244, p < 0.0001). In the multivariable analysis, nonwhite race, highest quartile of median household income, greater preexisting comorbidity, long-segment fusions, and use of blood transfusions were found to increase the likelihood of complication occurrence (all p < 0.05). In further multivariable analysis, independent predictors of prolonged LOS included older age, increased preexisting comorbidity, the AR/PSF approach, and long-segment fusions (all p < 0.05). Lastly, the likelihood of increased hospital costs (at or above the 90th percentile for LOS, 14 days) was increased by older age, female sex, Medicaid insurance status, highest quartile of median household income, AR/PSF approach, long-segment fusion, and blood transfusion (all p < 0.05). In multivariable analysis, the use of autograft was associated with a lower likelihood of complication occurrence and prolonged LOS (both p < 0.05). CONCLUSIONS Increasing use of IONM and posterior-only approaches may combat the high complication rates in NMS. The trends of increasing comorbidities, blood transfusions, and total costs in spinal fusion surgery for pediatric NMS may indicate an increasingly aggressive approach to these cases.
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Affiliation(s)
- Kavelin Rumalla
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Chester K Yarbrough
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Andrew J Pugely
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Linda Koester
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ian G Dorward
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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Noah TL, Yilmaz O, Nicolai T, Birnkrant D, Praud JP. Pediatric Pulmonology year in review 2014: Part 1. Pediatr Pulmonol 2015; 50:621-9. [PMID: 25891206 DOI: 10.1002/ppul.23202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/29/2015] [Indexed: 11/08/2022]
Abstract
Our discipline and our journal cover an extremely broad range of research and scholarly topics related to children's respiratory disorders. To better meet the needs of our readership for updated perspectives on the rapidly expanding knowledge in our field, we here summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages.
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Affiliation(s)
- Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ozge Yilmaz
- Pediatric Allergy and Pulmonology, Celal Bayar University Department of Pediatrics, Manisa, Turkey
| | | | - David Birnkrant
- MetroHealth Medical Center Department of Pediatrics, Cleveland, Ohio
| | - Jean-Paul Praud
- University Sherbrooke Pediatrics, Sherbrooke, Quebec, Canada
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Fauroux B, Quijano-Roy S, Desguerre I, Khirani S. The value of respiratory muscle testing in children with neuromuscular disease. Chest 2015; 147:552-559. [PMID: 25644908 DOI: 10.1378/chest.14-0819] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Routine lung function and respiratory muscle testing are recommended in children with neuromuscular disease (NMD), but these tests are based on noninvasive volitional maneuvers, such as the measurement of lung volumes and maximal static pressures, that young children may not always be able to perform. The realization of simple natural maneuvers such as a sniff or a cough, and the measurement of esophageal and gastric pressures during spontaneous breathing can add valuable information about the strength and endurance of the respiratory muscles in young children. Monitoring respiratory muscles in children with NMD may improve understanding of the natural history of NMD and the evaluation of disease severity. It may assist and guide clinical management and it may help the identification and selection of optimal end points, as well as the most informative parameters and patients for clinical trials.
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Affiliation(s)
- Brigitte Fauroux
- Pediatric Noninvasive Ventilation and Sleep Unit, Necker University Hospital, AP-HP, Paris; Research Unit Inserm U955 Equipe 13, Créteil.
| | - Susana Quijano-Roy
- Pediatric Department Centre de Référence Maladies Neuromusculaires (GNMH), Raymond Poincaré Hospital, AP-HP, Garches, Université Versailles UVSQ Inserm, UMRS_974, Paris
| | - Isabelle Desguerre
- Paris Descartes University Paris; Pediatric Neurology Department Centre de Référence Maladies Neuromusculaires (GNMH), Necker University Hospital, AP-HP, Paris
| | - Sonia Khirani
- ASV Santé Gennevilliers, France; Pediatric Noninvasive Ventilation and Sleep Unit, Necker University Hospital, AP-HP, Paris; Paris Descartes University Paris
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203rd ENMC international workshop: Respiratory pathophysiology in congenital muscle disorders: Implications for pro-active care and clinical research 13–15 December, 2013, Naarden, The Netherlands. Neuromuscul Disord 2015; 25:353-8. [DOI: 10.1016/j.nmd.2014.11.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 11/04/2014] [Indexed: 01/09/2023]
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