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Chatwin M, Sancho J, Lujan M, Andersen T, Winck JC. Waves of Precision: A Practical Guide for Reviewing New Tools to Evaluate Mechanical In-Exsufflation Efficacy in Neuromuscular Disorders. J Clin Med 2024; 13:2643. [PMID: 38731172 PMCID: PMC11084470 DOI: 10.3390/jcm13092643] [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: 03/15/2024] [Revised: 04/15/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Mechanical insufflation-exsufflation (MI-E) is essential for secretion clearance, especially in neuromuscular disorders. For the best outcomes, initiation of MI-E should be started at the correct time with regular evaluation to the response to treatment. Typically, cough peak flow has been used to evaluate cough effectiveness with and without MI-E. This review highlights the limitations of this and discussed other tools to evaluate MI-E efficacy in this rapidly developing field. Such tools include the interpretation of parameters (like pressure, flow and volumes) that derive from the MI-E device and external methods to evaluate upper airway closure. In this review we pinpoint the differences between different devices in the market and discuss new tools to better titrate MI-E and detect pathological responses of the upper airway. We discuss the importance of point of care ultrasound (POCUS), transnasal fiberoptic laryngoscopy and wave form analysis in this setting. To improve clinical practice newer generation MI-E devices should allow real-time evaluation of waveforms and standardize some of the derived parameters.
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Affiliation(s)
- Michelle Chatwin
- Neuromuscular Complex Care Centre, The National Hospital for Neurology and Neurosurgery, University College London Hospitals Foundation Trust, London WC1N 3BG, UK;
- Clinical and Academic Department of Sleep and Breathing, Royal Brompton Hospital, Part of Guys and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
| | - Jesus Sancho
- Respiratory Medicine Department, Hospital Clínico Universitario, 46010 Valencia, Spain;
- Institute of Health Research INCLIVA, 46010 Valencia, Spain
| | - Manel Lujan
- Servei de Pneumologia, Parc Taulí Hospital Universitari, Institut d’Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, 08208 Sabadell, Spain;
- Centro de Investigación Biomédica en Red (CIBERES), 28029 Madrid, Spain
| | - Tiina Andersen
- Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, 5021 Bergen, Norway;
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, 5063 Bergen, Norway
| | - Joao-Carlos Winck
- Cardiovascular R&D Centre (UniC), Faculdade de Medicina da Universidade do Porto, 4200-319 Porto, Portugal
- Pulmonology Unit, Instituto CUF, 4460-188 Porto, Portugal
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2
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Goyal JP, Kabra SK. Pediatric Pulmonology Training in India: Current Status and Future Directions. Indian J Pediatr 2023:10.1007/s12098-023-04590-0. [PMID: 37076652 PMCID: PMC10115596 DOI: 10.1007/s12098-023-04590-0] [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: 10/10/2022] [Accepted: 03/28/2023] [Indexed: 04/21/2023]
Abstract
Respiratory illnesses are common causes of morbidity and mortality in children. Postgraduates in Pediatrics spent significant time in learning to manage respiratory disorders. Improved survival of preterm neonates, improved diagnosis and survival of chronic respiratory problems, and advances in diagnosis and therapeutics have increased the need for specialists trained in managing these patients. Training programs in Pediatric Pulmonology are evolving over the past few decades. In India, super-specialty training in Pediatric Pulmonology has grown over the past few years. There is a need to modify the training structure used in industrialized countries due to differences in patient population, priorities, and limited available resources and expertise. Formal training courses have been started in a limited number of institutions. There is a large gap between the need for a trained workforce and the available specialists in the limited number of institutions. The Indian Academy of Pediatrics National Respiratory Chapter (IAPNRC) has initiated a fellowship program to bridge the gap. Comprehensive training involving academic and hands-on training may go a long way to improve the care of children with acute and chronic respiratory problems. For sustainable development of the super specialty, there is a need to work towards creating Pediatric Pulmonology service departments in various institutions that may be responsible for comprehensive training and research activities to answer common research questions.
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Affiliation(s)
- J P Goyal
- Department of Pediatrics, AIIMS, Jodhpur, India
| | - S K Kabra
- Department of Pediatrics, AIIMS, New Delhi, India.
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A Review on the Anesthetic Management of Patients with Neuromuscular Diseases. Anesth Pain Med 2023. [DOI: 10.5812/aapm-132088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Context: Neuromuscular diseases (NMDs) are regarded as a clinically and genetically heterogeneous group of diseases characterized by weakening muscle strength and dystrophic changes in the muscle. Due to the nature of these diseases, it can be challenging for anesthesiologists to provide appropriate pain medications, symptom management, and other necessary techniques that are implemented to anesthetize the patient properly. Evidence Acquisition: This study was based on the available literature and the authors’ experience. The current study aimed to review the available anesthesia for patients suffering from NMDs. The search process resulted in the detection of relevant articles using valid keywords on electronic databases, including Embase, PubMed, Scopus, Web of Science, and Cochrane Library. Subsequently, 24 articles published between 2009 to 2022 were identified as eligible for this review. Results: When anesthetizing a patient with NMD, special attention should be paid to preoperative evaluation, medical-history taking, risk of difficult intubation or cardiac incidents, respiratory insufficiency, and frequent pulmonary infections. It is also necessary to keep in mind that these patients are at risk of prolonged paralysis, hyperkalemia, rigidity, malignant hyperthermia, cardiac arrest, rhabdomyolysis, or even death. Conclusions: Problems of anesthesia in patients with NMDs arise from the nature of the condition itself and the interaction of anesthetics and muscle relaxants with anticholinesterase drugs used in therapy. Each patient’s individual risk should be assessed before anesthesia. Therefore, it is important (and even necessary before major surgery) to perform a thorough preoperative examination to not only determine perioperative risk but also to ensure optimal perioperative follow-up.
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Respiratory phenotypes of neuromuscular diseases: A challenging issue for pediatricians. Pediatr Neonatol 2023; 64:109-118. [PMID: 36682912 DOI: 10.1016/j.pedneo.2022.09.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 08/25/2022] [Accepted: 09/21/2022] [Indexed: 01/05/2023] Open
Abstract
Neuromuscular disease (NMDs) encompass a heterogeneous group of genetic disorders, with respiratory problems of variable intensity and progression described at any pediatric age, from infancy to adolescence, and they are largely associated with significant lifelong morbidity and high mortality. Restriction of breathing, impaired gas exchange, decline of lung function and sleep disordered breathing progressively develop because of muscular weakness and culminate in respiratory failure. Depending on the disease progression, airways manifestations can take weeks to months or even years to evolve, thus depicting two major respiratory phenotypes, characterized by rapid or slow progression to respiratory failure. Assessing type and age at onset of airways problems and their evolution over time can support pediatricians in the diagnostic assessment of NMD. In addition, knowing the characteristics of patients' respiratory phenotype can increase the level of awareness among neonatologists, geneticists, neurologists, pulmonologists, nutritionists, and chest therapists, supporting them in the challenging task of the multidisciplinary medical care of patients. In this review we examine the issues related to the pediatric respiratory phenotypes of NMD and present a novel algorithm that can act as a guide for the diagnostic agenda and the key preventive or therapeutic interventions of airways manifestations. With prolonged survival of children with NMD, the advent of neuromuscular respiratory medicine, including accurate assessment of the respiratory phenotype, will help physicians to determine patients' prognoses and to design studies for the evaluation of new therapies.
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Audag N, Dubus JC, Combret Y. [Respiratory physiotherapy in pediatric practice]. Rev Mal Respir 2022; 39:547-560. [PMID: 35738979 DOI: 10.1016/j.rmr.2022.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/03/2022] [Indexed: 01/11/2023]
Abstract
Congestion of the upper (URT) and lower respiratory tracts (LRT) is a common symptom in several acute and chronic respiratory diseases that occur in childhood. To eliminate these secretions, airway clearance techniques (ACT) directed to the URT and LRT are frequently prescribed. The rationale for the application of these techniques is the same as in adults, but they need to be adapted to be transposed to children. The physiotherapist will be able to choose among a wide range of techniques, of which the most adequate will depend not only on the age of the child and the indication, but also on the basis of his preferences or habits, as well as those of the child. Upper airway clearance, including nasal irrigation, is now recommended for acute and chronic rhinosinusitis in children. It is also one of the symptomatic treatments recommended for infants with acute bronchiolitis. For LRT clearance, several indications, such as cystic fibrosis, primary ciliary dyskinesia and neuromuscular disease, are now widely advocated. Conversely, other indications, such as for infants with acute viral bronchiolitis, are highly controversial. Thoughtful application of these techniques is lacking in robust and precise tools to objectively assess the presence of bronchial congestion, and to treat it accordingly. Similarly, no precise and reliable evaluation of the effectiveness of these ACTs is available to date. This review is designed to explore the ACTs used by physiotherapists, to provide an overview of their current indications, and to consider complementary approaches.
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Affiliation(s)
- N Audag
- Institut de recherche expérimentale et clinique, pôle de pneumologie, ORL & dermatologie, groupe recherche en kinésithérapie respiratoire, université Catholique de Louvain, Bruxelles, Belgique; Secteur de kinésithérapie et ergothérapie, cliniques universitaires Saint-Luc, avenue Hippocrate 10, Bruxelles 1200, Belgique.
| | - J-C Dubus
- Service de médecine infantile et pneumologie pédiatrique, CHU Timone-Enfants, Marseille, France; Aix-Marseille université, IRD, AP-HM, MEPHI, IHU Méditerranée-infection, Marseille, France
| | - Y Combret
- Secteur de kinésithérapie, Groupe Hospitalier du Havre, 76600 Le Havre, France
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Lavie M, Rochman M, Sagi L, Yerushalmy Feler A, Ovadia D, Cahal M, Be'er M, Sadot E, Fattal-Valevski A, Amirav I. Nonrespiratory complications of nusinersen-treated spinal muscular atrophy type 1 patients. Pediatr Pulmonol 2022; 57:686-694. [PMID: 34921596 DOI: 10.1002/ppul.25795] [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: 09/02/2021] [Revised: 11/23/2021] [Accepted: 12/16/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Emergence of new treatments for spinal muscular atrophy type 1 (SMA1) has led to dramatic improvements in respiratory failure and survival. However, these "treated" patients sustain major problems in other organ systems, which may directly or indirectly affect their respiratory function. We observed three main nonrespiratory manifestations in these patients comprised of facial deformities, feeding problems, and spinal deformities. OBJECTIVE To investigate these three main sequelae in nusinersen-treated SMA1 patients. METHODS Data on nusinersen-treated SMA1 patients were prospectively collected throughout a 3-year period, with special focus upon nonrespiratory features of the disease. RESULTS Twenty nusinersen-treated SMA1 patients were included (eight males, median age 13.5 months, interquartile range: 4-56.2 months), among whom 17 survived after 3 years of follow-up. At follow-up, 15 (88%) patients were diagnosed with facial weakness, hypoplasia, or deformity. All but one patient (94%) were fed invasively by percutaneous endoscopic gastrostomy or nasogastric tube feeding. Four patients (25%) had maintained oral feeding in parallel to gastrostomy feeding and had clinical and radiologic evidence of aspirations. Fifteen (88%) patients were diagnosed with scoliosis, of whom seven had undergone or were scheduled to undergo corrective surgery. CONCLUSIONS Nusinersen-treated SMA1 patients may sustain facial deformities, feeding problems, and severe scoliosis, all of which affect their respiratory system. Strict surveillance of these complications is essential to avoid further respiratory morbidity.
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Affiliation(s)
- Moran Lavie
- Pediatric Pulmonology Unit, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mika Rochman
- Pediatric Pulmonology Unit, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liora Sagi
- Pediatric Neurology Institute, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Yerushalmy Feler
- Pediatric Gastroenterology Unit, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dror Ovadia
- Pediatric Orthopedic Department, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Cahal
- Pediatric Pulmonology Unit, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moria Be'er
- Pediatric Pulmonology Unit, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efraim Sadot
- Pediatric Pulmonology Unit, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Intensive Care Unit, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviva Fattal-Valevski
- Pediatric Neurology Institute, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel Amirav
- Pediatric Pulmonology Unit, Tel-Aviv Sourasky Medical Center, Dana-Dwek Children's Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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7
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Rosen CL. Sleep-Disordered Breathing (SDB) in Pediatric Populations. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Podgórska-Bednarz J, Perenc L, Drużbicki M, Guzik A. Nutritional Disorders in a Group of Children and Adolescents with Syndromes or Diseases Involving Neurodysfunction. Nutrients 2021; 13:nu13061786. [PMID: 34073813 PMCID: PMC8225066 DOI: 10.3390/nu13061786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/13/2021] [Accepted: 05/19/2021] [Indexed: 02/07/2023] Open
Abstract
A study of the literature shows the lack of data on a comprehensive analysis of eating disorders in children with neurodysfunction, which constitute a clinical subgroup with an increased risk of abnormalities in this area. Therefore, the aim of this study was to determine the relationship between the coexistence of nutritional disorders and diseases or syndromes associated with neurodysfunction based on data collected during hospitalization at a rehabilitation center for children and adolescents. A retrospective analysis was carried out in a group of 327 children and adolescents aged 4–18 years. The study group covered various types of diseases or syndromes involving damage to the central nervous system. A retrospective analysis of baseline data (age, sex, main and additional diagnosis and Body Mass Index—BMI) was performed. Two assessment criteria of nutritional status were taken into account (z-score BMI and other previously published normative values). In the study group, malnutrition was found more frequently (18.0% of the respondents) than obesity (11.3% of the subjects). Hypothyroidism coexisting with malnutrition was identified in the study group (N% = 43.8%, p = 0.011) and malnutrition with tetraplegia in the subgroup of spastic cerebral palsy (N% = 34.2 %, p = 0.029).
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Affiliation(s)
- Justyna Podgórska-Bednarz
- Institute of Health Sciences, Medical College of Rzeszów University, Warzywna 1A, 35-310 Rzeszów, Poland; (L.P.); (M.D.); (A.G.)
- Centre for Innovative Research in Medical and Natural Sciences, University of Rzeszow, Warzywna 1a, 35-310 Rzeszow, Poland
- Correspondence:
| | - Lidia Perenc
- Institute of Health Sciences, Medical College of Rzeszów University, Warzywna 1A, 35-310 Rzeszów, Poland; (L.P.); (M.D.); (A.G.)
- Centre for Innovative Research in Medical and Natural Sciences, University of Rzeszow, Warzywna 1a, 35-310 Rzeszow, Poland
| | - Mariusz Drużbicki
- Institute of Health Sciences, Medical College of Rzeszów University, Warzywna 1A, 35-310 Rzeszów, Poland; (L.P.); (M.D.); (A.G.)
- Centre for Innovative Research in Medical and Natural Sciences, University of Rzeszow, Warzywna 1a, 35-310 Rzeszow, Poland
| | - Agnieszka Guzik
- Institute of Health Sciences, Medical College of Rzeszów University, Warzywna 1A, 35-310 Rzeszów, Poland; (L.P.); (M.D.); (A.G.)
- Centre for Innovative Research in Medical and Natural Sciences, University of Rzeszow, Warzywna 1a, 35-310 Rzeszow, Poland
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