1
|
Lionello F, Lapia F, Molena B, Padoan A, Lococo S, Arcaro G, Guarnieri G, Vianello A. The Safety of a High-Flow Nasal Cannula in Neuromuscular Disease Patients with Acute Respiratory Failure: A Retrospective Case-Series Study. J Clin Med 2023; 12:6061. [PMID: 37763001 PMCID: PMC10531616 DOI: 10.3390/jcm12186061] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/04/2023] [Accepted: 09/17/2023] [Indexed: 09/29/2023] Open
Abstract
(1) Background: Although Non-Invasive Ventilation (NIV) is effective in preventing mortality and endotracheal intubation in patients with Acute Respiratory Failure (ARF) linked to a neuromuscular disorder, its efficacy can be affected by patient intolerance. A High-Flow Nasal Cannula (HFNC) appears to have a significant advantage over NIV as far as patient tolerance is concerned. The aim of the study was to investigate HFNC's safety profile in a group of consecutive Neuromuscular Disease (NMD) patients intolerant to NIV who were admitted to an Intermediate Respiratory Care Unit (IRCU) for ARF. (2) Methods: The clinical course of nine NMD patients intolerant to NIV and switched to HFNC was reported. HFNC was provided during daytime hours and NIV during the night-time to the NIV-intolerant patients. HFNC was utilized 24 h a day in those patients who were intolerant of even nocturnal NIV. (3) Results: HFNC was simple to use and it was well tolerated by all of the patients. Three out of nine patients experienced treatment failure, consisting of the need for ETI and/or death during their IRCU stay. The remaining 6 had a favorable outcome. Treatment failure was linked to the utilization of HFNC 24 h a day. (4) Conclusion: HFNC during the daytime hours, together with nocturnal NIV, seems to be a safe therapeutic approach for NMD patients with ARF. A round-the-clock use of HFNC tends to be linked to a high likelihood of failure.
Collapse
Affiliation(s)
- Federico Lionello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (F.L.); (B.M.); (S.L.); (G.A.); (G.G.)
| | - Francesco Lapia
- Department of Internal Medicine and Medical Therapy, University of Pavia, Piazza Golgi 19, 271000 Pavia, Italy;
| | - Beatrice Molena
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (F.L.); (B.M.); (S.L.); (G.A.); (G.G.)
| | - Andrea Padoan
- Department of Medicine, University of Padova, Via Giustiniani 2, 35128 Padova, Italy;
| | - Sara Lococo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (F.L.); (B.M.); (S.L.); (G.A.); (G.G.)
| | - Giovanna Arcaro
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (F.L.); (B.M.); (S.L.); (G.A.); (G.G.)
| | - Gabriella Guarnieri
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (F.L.); (B.M.); (S.L.); (G.A.); (G.G.)
| | - Andrea Vianello
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, 35128 Padova, Italy; (F.L.); (B.M.); (S.L.); (G.A.); (G.G.)
| |
Collapse
|
2
|
Stephen CD, Schaefer PW, Appleby BS, Oakley DH. Case 5-2022: A 65-Year-Old Woman with Rapidly Progressive Weakness in the Right Arm and Recurrent Falls. N Engl J Med 2022; 386:674-687. [PMID: 35172059 DOI: 10.1056/nejmcpc2115852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Christopher D Stephen
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| | - Pamela W Schaefer
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| | - Brian S Appleby
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| | - Derek H Oakley
- From the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Massachusetts General Hospital, and the Departments of Neurology (C.D.S.), Radiology (P.W.S.), and Pathology (D.H.O.), Harvard Medical School - both in Boston; and the Department of Neurology, National Prion Disease Pathology Surveillance Center, Case Western Reserve University School of Medicine, Cleveland (B.S.A.)
| |
Collapse
|
3
|
Fujii S, Horiuchi K, Oshima Y, Eguchi K, Nagai A, Iwata I, Matsushima M, Yabe I. Inflammatory Myopathy Associated with Anti-mitochondrial Antibody Presenting Only with Respiratory Failure. Intern Med 2021; 60:3801-3804. [PMID: 34092736 PMCID: PMC8710372 DOI: 10.2169/internalmedicine.7448-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A 56-year-old woman presenting with type II respiratory failure was transferred to our hospital. She did not exhibit muscle weakness or elevated serum myogenic enzymes, but needle electromyography revealed myogenic changes in the limb muscles, and her blood tests were positive for anti-mitochondrial antibodies (AMA). Muscle histopathological findings included immune-mediated necrotizing myopathy, so she was diagnosed with inflammatory myopathy associated with AMA. After treatment with corticosteroids and noninvasive positive pressure ventilation, her symptoms improved. If a diagnosis of type II respiratory failure is difficult, inflammatory myopathy associated with AMA should be considered as a differential diagnosis.
Collapse
Affiliation(s)
- Shintaro Fujii
- Department of Neurology, Hakodate Municipal Hospital, Japan
| | | | - Yuki Oshima
- Department of Neurology, Hakodate Municipal Hospital, Japan
| | - Katsuki Eguchi
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Azusa Nagai
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Ikuko Iwata
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Masaaki Matsushima
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Ichiro Yabe
- Department of Neurology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| |
Collapse
|
4
|
Bernardes Neto SCG, Torres-Castro R, Lima Í, Resqueti VR, Fregonezi GAF. Weaning from mechanical ventilation in people with neuromuscular disease: a systematic review. BMJ Open 2021; 11:e047449. [PMID: 34521661 PMCID: PMC8442075 DOI: 10.1136/bmjopen-2020-047449] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 08/16/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This systematic review aimed in assessing the effects of different weaning protocols in people with neuromuscular disease (NMD) receiving invasive mechanical ventilation, identifying which protocol is the best and how different protocols can affect weaning outcome success, duration of weaning, intensive care unit (ICU) and hospital stay and mortality. DESIGN Systematic review. DATA SOURCES Electronic databases (MEDLINE, EMBASE, Web of Science and Scopus) were searched from January 2009 to August 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials (RCTs) and non-RCT that evaluated patients with NMD (adults and children from 5 years old) in the weaning process managed with a protocol (pressure support ventilation; synchronised intermittent mandatory ventilation; continuous positive airway pressure; 'T' piece). PRIMARY OUTCOME Weaning success. SECONDARY OUTCOMES Weaning duration, ICU stay, hospital stay, ICU mortality, complications (pneumothorax, ventilation-associated pneumonia). DATA EXTRACTION AND SYNTHESIS Two review authors assessed the titles and the abstracts for inclusion and reviewed the full texts independently. RESULTS We found no studies that fulfilled the inclusion criteria. CONCLUSIONS The absence of studies about different weaning protocols for patients with NMD does not allow concluding the superiority of any specific weaning protocol for patients with NMD or determining the impact of different types of protocols on other outcomes. The result of this review encourages further studies. PROSPERO REGISTRATION NUMBER CRD42019117393.
Collapse
Affiliation(s)
- Saint Clair Gomes Bernardes Neto
- PneumoCardioVascular Lab/HUOL, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares and Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, Brazil
| | - Rodrigo Torres-Castro
- Department of Physical Therapy, Faculty of Medicine, University of Chile, Santiago, Chile
- International Physiotherapy Research Network (PhysioEvidence), Natal, Brazil
| | - Íllia Lima
- FACISA - Faculdade de Ciências de Saúde do Trairi, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Vanessa R Resqueti
- International Physiotherapy Research Network (PhysioEvidence), Natal, Brazil
- PneumoCardioVascular Lab/HUOL, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares and Departamento de Fisioterapia, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Guilherme A F Fregonezi
- International Physiotherapy Research Network (PhysioEvidence), Natal, Brazil
- 1PneumoCardioVascular Lab/HUOL, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares and Departamento de Fisioterapia Universidade Federal do Rio Grande do Norte, Federal University of Rio Grande do Norte, Natal, Brazil
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Respiratory Involvement in Patients with Neuromuscular Diseases: A Narrative Review. Pulm Med 2019; 2019:2734054. [PMID: 31949952 PMCID: PMC6944960 DOI: 10.1155/2019/2734054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 04/08/2019] [Accepted: 11/20/2019] [Indexed: 12/11/2022] Open
Abstract
Respiratory muscle weakness is a major cause of morbidity and mortality in patients with neuromuscular diseases (NMDs). Respiratory involvement in NMDs can manifest broadly, ranging from milder insufficiency that may affect only sleep initially to severe insufficiency that can be life threatening. Patients with neuromuscular diseases exhibit very often sleep-disordered breathing, which is frequently overlooked until symptoms become more severe leading to irreversible respiratory failure necessitating noninvasive ventilation (NIV) or even tracheostomy. Close monitoring of respiratory function and sleep evaluation is currently the standard of care. Early recognition of sleep disturbances and initiation of NIV can improve the quality of life and prolong survival. This review discusses the respiratory impairment during sleep in patients with NMDs, the diagnostic tools available for early recognition of sleep-disordered breathing and the therapeutic options available for overall respiratory management of patients with NMDs.
Collapse
|
7
|
Bernardes Neto SCG, Torres R, Lima Í, Resqueti VR, Fregonezi GAF. Weaning from mechanical ventilation in people with neuromuscular disease: protocol for a systematic review. BMJ Open 2019; 9:e029890. [PMID: 31690604 PMCID: PMC6858241 DOI: 10.1136/bmjopen-2019-029890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Neuromuscular diseases (NMD) are characterised by progressive muscular impairment. The muscle weakness is directly related to respiratory muscles weakness, causing reduction in vital capacity, especially when associated with mechanical ventilation (MV). Conventional MV weaning in NMD is generally difficult. Weaning process can be conducted in protocols such as: 'T' piece or Pressure Support Ventilaton. Weaning failure is frequent because of muscle weakness. Protocol aim is to assess the effects of different weaning protocols in NMD patients receiving invasive MV in weaning success rate, duration of weaning, intensive care unit (ICU) stay, hospital stay and ICU mortality. METHODS AND ANALYSIS A search will be carried in the Cochrane Neuromuscular Specialised Register, MEDLINE, EMBASE, Web of Science, Scopus, United States National Institutes of Health Clinical Trials Registry, ClinicalTrials.gov and WHO International Clinical Trial Registry Protal, of randomised controlled trials (RCTs) and quasi-RCTs. Inclusion criteria of individuals are adults (above 16 years old) and children (from 5 to 16 years old), with clinical diagnosis of NMD (muscular dystrophy, amyotrophic lateral sclerosis, congenital myasthenia, myasthenia gravis, congenital myopathy, spinal muscular atrophy, Guillian Barré Syndrome, severe inherited neuropathies, metabolic myopathies, inflammatory myopathies, mitochondrial diseases) of any gender. All patients ventilated for at least 48 hours due to respiratory failure and clinically considered ready for weaning. Other respiratory or cardiovascular diagnosis associated will not be included. Intervention assessed will be weaning from MV using a protocol with 30 min to 2 hours of spontaneous breathing trial at the end point. All comparisons of different protocols will be considered. ETHICS AND DISSEMINATION Formal ethical approval is not required as primary data will not be collected, since it will be a systematic review. All studies included should have ethical committee approval. The results will be disseminated through a peer-reviewed publication and in conferences and congresses or symposia. PROSPERO REGISTRATION NUMBER CRD42019117393.
Collapse
Affiliation(s)
- Saint Clair Gomes Bernardes Neto
- RENORBIO - Biotechnology, Universidade Federal do Rio Grande do Norte, Natal, Brazil
- PneumocardioVascular LAB, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH) & Laboratório de Inovação Tecnológica em Reabilitação. Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | | | - Íllia Lima
- Faculdade de Ciências da Saúde do Trairi - FACISA, Universidade Federal do Rio Grande do Norte, Santa Cruz, RN, Brazil
| | - Vanessa R Resqueti
- PneumocardioVascular LAB, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH) & Laboratório de Inovação Tecnológica em Reabilitação. Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Guilherme A F Fregonezi
- RENORBIO - Biotechnology, Universidade Federal do Rio Grande do Norte, Natal, Brazil
- PneumocardioVascular LAB, Hospital Universitário Onofre Lopes, Empresa Brasileira de Serviços Hospitalares (EBSERH) & Laboratório de Inovação Tecnológica em Reabilitação. Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| |
Collapse
|
8
|
Silva IS, Pedrosa R, Azevedo IG, Forbes A, Fregonezi GAF, Dourado Junior MET, Lima SRH, Ferreira GMH. Respiratory muscle training in children and adults with neuromuscular disease. Cochrane Database Syst Rev 2019; 9:CD011711. [PMID: 31487757 PMCID: PMC6953358 DOI: 10.1002/14651858.cd011711.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Neuromuscular diseases (NMDs) are a heterogeneous group of diseases affecting the anterior horn cell of spinal cord, neuromuscular junction, peripheral nerves and muscles. NMDs cause physical disability usually due to progressive loss of strength in limb muscles, and some NMDs also cause respiratory muscle weakness. Respiratory muscle training (RMT) might be expected to improve respiratory muscle weakness; however, the effects of RMT are still uncertain. This systematic review will synthesize the available trial evidence on the effectiveness and safety of RMT in people with NMD, to inform clinical practice. OBJECTIVES To assess the effects of respiratory muscle training (RMT) for neuromuscular disease (NMD) in adults and children, in comparison to sham training, no training, standard treatment, breathing exercises, or other intensities or types of RMT. SEARCH METHODS On 19 November 2018, we searched the Cochrane Neuromuscular Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. On 23 December 2018, we searched the US National Institutes for Health Clinical Trials Registry (ClinicalTrials.gov), the World Health Organization International Clinical Trials Registry Platform, and reference lists of the included studies. SELECTION CRITERIA We included randomized controlled trials (RCTs) and quasi-RCTs, including cross-over trials, of RMT in adults and children with a diagnosis of NMD of any degree of severity, who were living in the community, and who did not need mechanical ventilation. We compared trials of RMT (inspiratory muscle training (IMT) or expiratory muscle training (EMT), or both), with sham training, no training, standard treatment, different intensities of RMT, different types of RMT, or breathing exercises. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodological procedures. MAIN RESULTS We included 11 studies involving 250 randomized participants with NMDs: three trials (N = 88) in people with amyotrophic lateral sclerosis (ALS; motor neuron disease), six trials (N = 112) in Duchenne muscular dystrophy (DMD), one trial (N = 23) in people with Becker muscular dystrophy (BMD) or limb-girdle muscular dystrophy, and one trial (N = 27) in people with myasthenia gravis.Nine of the trials were at high risk of bias in at least one domain and many reported insufficient information for accurate assessment of the risk of bias. Populations, interventions, control interventions, and outcome measures were often different, which largely ruled out meta-analysis. All included studies assessed lung capacity, our primary outcome, but four did not provide data for analysis (1 in people with ALS and three cross-over studies in DMD). None provided long-term data (over a year) and only one trial, in ALS, provided information on adverse events. Unscheduled hospitalisations for chest infection or acute exacerbation of chronic respiratory failure were not reported and physical function and quality of life were reported in one (ALS) trial.Amyotrophic lateral sclerosis (ALS)Three trials compared RMT versus sham training in ALS. Short-term (8 weeks) effects of RMT on lung capacity in ALS showed no clear difference in the change of the per cent predicted forced vital capacity (FVC%) between EMT and sham EMT groups (mean difference (MD) 0.70, 95% confidence interval (CI) -8.48 to 9.88; N = 46; low-certainty evidence). The mean difference (MD) in FVC% after four months' treatment was 10.86% in favour of IMT (95% CI -4.25 to 25.97; 1 trial, N = 24; low-certainty evidence), which is larger than the minimal clinically important difference (MCID, as estimated in people with idiopathic pulmonary fibrosis). There was no clear difference between IMT and sham IMT groups, measured on the Amyotrophic Lateral Sclerosis Functional Rating Scale (ALFRS; range of possible scores 0 = best to 40 = worst) (MD 0.85, 95% CI -2.16 to 3.85; 1 trial, N = 24; low-certainty evidence) or quality of life, measured on the EuroQol-5D (0 = worst to 100 = best) (MD 0.77, 95% CI -17.09 to 18.62; 1 trial, N = 24; low-certainty evidence) over the medium term (4 months). One trial report stated that the IMT protocol had no adverse effect (very low-certainty evidence).Duchenne muscular dystrophy (DMD)Two DMD trials compared RMT versus sham training in young males with DMD. In one study, the mean post-intervention (6-week) total lung capacity (TLC) favoured RMT (MD 0.45 L, 95% CI -0.24 to 1.14; 1 trial, N = 16; low-certainty evidence). In the other trial there was no clear difference in post-intervention (18 days) FVC between RMT and sham RMT (MD 0.16 L, 95% CI -0.31 to 0.63; 1 trial, N = 20; low-certainty evidence). One RCT and three cross-over trials compared a form of RMT with no training in males with DMD; the cross-over trials did not provide suitable data. Post-intervention (6-month) values showed no clear difference between the RMT and no training groups in per cent predicted vital capacity (VC%) (MD 3.50, 95% CI -14.35 to 21.35; 1 trial, N = 30; low-certainty evidence).Becker or limb-girdle muscular dystrophyOne RCT (N = 21) compared 12 weeks of IMT with breathing exercises in people with Becker or limb-girdle muscular dystrophy. The evidence was of very low certainty and conclusions could not be drawn.Myasthenia gravisIn myasthenia gravis, there may be no clear difference between RMT and breathing exercises on measures of lung capacity, in the short term (TLC MD -0.20 L, 95% CI -1.07 to 0.67; 1 trial, N = 27; low-certainty evidence). Effects of RMT on quality of life are uncertain (1 trial; N = 27).Some trials reported effects of RMT on inspiratory and/or expiratory muscle strength; this evidence was also of low or very low certainty. AUTHORS' CONCLUSIONS RMT may improve lung capacity and respiratory muscle strength in some NMDs. In ALS there may not be any clinically meaningful effect of RMT on physical functioning or quality of life and it is uncertain whether it causes adverse effects. Due to clinical heterogeneity between the trials and the small number of participants included in the analysis, together with the risk of bias, these results must be interpreted very cautiously.
Collapse
Affiliation(s)
- Ivanizia S Silva
- Federal University of Rio Grande do NorteDepartment of Physical TherapyAvenida Senador Salgado Filho 3000, Lagoa NovaBairro Lagoa NovaNatalRio Grande do NorteBrazil59072‐970
| | - Rafaela Pedrosa
- Federal University of ParaibaDepartment of Physical TherapyJoão PessoaParaibaBrazil
| | - Ingrid G Azevedo
- Ana Bezerra University HospitalPhysical TherapyAvenida Senador Salgado Filho, 3000Bairro Lagoa NovaNatalRio Grande do NorteBrazil59078‐970
- Federal University of Rio Grande do NortePhD Program in Physical TherapyAvenida Senador Salgado Filho, 3000Bairro Lagoa NovaNatalRio Grande do NorteBrazil59078‐970
| | - Anne‐Marie Forbes
- University of TasmaniaCreative Arts & Health ‐ School of Creative Arts & MediaPrivate Bag 63HobartTASAustralia7001
| | - Guilherme AF Fregonezi
- Federal University of Rio Grande do NorteDepartment of Physical TherapyAvenida Senador Salgado Filho 3000, Lagoa NovaBairro Lagoa NovaNatalRio Grande do NorteBrazil59072‐970
- Onofre Lopes University Hospital, Brazilian Company of Hospital Services (EBSERH)PneumoCardioVascular LabNatalRio Grande do NorteBrazil59078‐970
| | - Mário ET Dourado Junior
- Federal University of Rio Grande do NorteIntegrated MedicineAv. Nilo Peçanha, 620PetrópolisNatalRio Grande do NorteBrazil59012‐300
| | - Suzianne RH Lima
- Federal University of Rio Grande do NorteIntegrated MedicineAv. Nilo Peçanha, 620PetrópolisNatalRio Grande do NorteBrazil59012‐300
| | - Gardenia MH Ferreira
- Federal University of Rio Grande do NortePhD Program in Physical TherapyAvenida Senador Salgado Filho, 3000Bairro Lagoa NovaNatalRio Grande do NorteBrazil59078‐970
| | | |
Collapse
|
9
|
Abstract
Neurologists are often called to evaluate patients with both defined and undiagnosed neuromuscular disorders when respiratory failure develops to determine if there is a neuromuscular cause. Being able to confidently diagnose neuromuscular respiratory failure and intervene appropriately is imperative, as early intervention and determination of the cause have survival implications. Outcomes are poor when the cause of neuromuscular weakness and resultant respiratory failure cannot be identified. This review discusses the clinical recognition of primary neuromuscular respiratory failure, its pathophysiology, diagnostic evaluation, and management, focusing on management of respiratory failure in the setting of Guillain-Barré syndrome and myasthenic crisis.
Collapse
Affiliation(s)
- Sara Hocker
- Department of Neurology, Division of Critical Care Neurology, College of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| |
Collapse
|
10
|
Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med 2017; 53:843-853. [PMID: 28916122 DOI: 10.1016/j.jemermed.2017.06.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 06/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) is an uncommon autoimmune disorder affecting the neuromuscular junction and manifesting as muscle weakness. A multitude of stressors can exacerbate MG. When symptoms are exacerbated, muscle weakness can be severe enough to result in respiratory failure, a condition known as myasthenic crisis (MC). OBJECTIVE This review discusses risk factors, diagnosis, management, and iatrogenic avoidance of MC. DISCUSSION MC can affect any age, ethnicity, or sex and can be precipitated with any stressor, infection being the most common. MC is a clinical diagnosis defined by respiratory failure caused by exacerbation of MG. Muscle weakness can involve any voluntary muscle. MC can be differentiated from other neuromuscular junction diseases by the presence of normal reflexes, normal sensation, lack of autonomic symptoms, lack of fasciculations, and worsening weakness with repetitive motion. Treatment should target the inciting event and airway support. All acetylcholinesterase inhibitors should be avoided in crisis, including edrophonium testing and corticosteroids initially. Respiratory support can begin with noninvasive positive-pressure ventilation, as this has been successful even in patients with bulbar weakness. If intubation is necessary, consider avoiding paralytics or use a reduced dose of nondepolarizing agents. CONCLUSIONS MC should be in the differential of any patient with muscular weakness and respiratory compromise. Emergency department management of MC should focus on ruling out infection and respiratory support. Strong consideration should be given to beginning with noninvasive positive-pressure ventilation for ventilatory support. Corticosteroids, depolarizing paralytics, and acetylcholinesterase inhibitors should be avoided in patients with MC in the emergency department.
Collapse
Affiliation(s)
- Jamie Roper
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - M Emily Fleming
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
11
|
Porteous GH, Hanson NA, Sueda LAA, Hoaglan CD, Dahl AB, Ohlson BB, Schmidt BE, Wang CC, Fagley RE. Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications. Anesth Analg 2016; 122:1450-73. [PMID: 27088999 DOI: 10.1213/ane.0000000000001196] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Vaccine-preventable diseases (VPDs) such as measles and pertussis are becoming more common in the United States. This disturbing trend is driven by several factors, including the antivaccination movement, waning efficacy of certain vaccines, pathogen adaptation, and travel of individuals to and from areas where disease is endemic. The anesthesia-related manifestations of many VPDs involve airway complications, cardiovascular and respiratory compromise, and unusual neurologic and neuromuscular symptoms. In this article, we will review the presentation and management of 9 VPDs most relevant to anesthesiologists, intensivists, and other hospital-based clinicians: measles, mumps, rubella, pertussis, diphtheria, influenza, meningococcal disease, varicella, and poliomyelitis. Because many of the pathogens causing these diseases are spread by respiratory droplets and aerosols, appropriate transmission precautions, personal protective equipment, and immunizations necessary to protect clinicians and prevent nosocomial outbreaks are described.
Collapse
Affiliation(s)
- Grete H Porteous
- From the *Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington; and †Department of Infectious Diseases, Virginia Mason Medical Center, Seattle, Washington
| | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Pedrosa R, Silva IS, Azevedo IG, Forbes AM, Fregonezi GAF, Dourado Junior MET, Lima SRH, Guerra RO, Ferreira GMH. Respiratory muscle training in children and adults with neuromuscular disease. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [DOI: 10.1002/14651858.cd011711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Rafaela Pedrosa
- Federal University of Rio Grande do Norte; PhD Program in Physical Therapy; Avenida Senador Salgado Filho, 3000 Lagoa Nova Natal Rio Grande do Norte Brazil 59072-970
| | - Ivanizia S Silva
- Federal University of Rio Grande do Norte; PhD Program in Physical Therapy; Avenida Senador Salgado Filho, 3000 Lagoa Nova Natal Rio Grande do Norte Brazil 59072-970
| | - Ingrid G Azevedo
- Federal University of Rio Grande do Norte; Physical Therapy; Avenida Senador Salgado Filho, 3000 Bairro Lagoa Nova Natal Rio Grande do Norte Brazil 59078-970
| | - Anne-Marie Forbes
- Conservatorium of Music; Senior Lecturer in Musicology; University of Tasmania Private Bag 63 Hobart TAS Australia 7001
| | - Guilherme AF Fregonezi
- Federal University of Rio Grande do Norte; PhD Program in Physical Therapy, Phd Program in Biotechnology; Avenida Senador Salgado Filho, 3000 Bairro Lagoa Nova Natal Rio Grande do Norte Brazil 59078-970
| | - Mário ET Dourado Junior
- Federal University of Rio Grande do Norte; Integrated Medicine; Av. Nilo Peçanha, 620 Petrópolis Natal Rio Grande do Norte Brazil 59012-300
| | - Suzianne RH Lima
- Federal University of Rio Grande do Norte; Integrated Medicine; Av. Nilo Peçanha, 620 Petrópolis Natal Rio Grande do Norte Brazil 59012-300
| | - Ricardo O Guerra
- Federal University of Rio Grande do Norte; PhD Program in Physical Therapy; Avenida Senador Salgado Filho, 3000 Lagoa Nova Natal Rio Grande do Norte Brazil 59072-970
| | - Gardenia MH Ferreira
- Federal University of Rio Grande do Norte; PhD Program in Physical Therapy; Avenida Senador Salgado Filho, 3000 Lagoa Nova Natal Rio Grande do Norte Brazil 59072-970
| |
Collapse
|
13
|
|