Ethical aspects of home long term ventilation in children with neuromuscular disease

Indications and practice of home invasive mechanical ventilation in children

BACKGROUND

Developments and technological advances in neonatal and pediatric intensive care units have led to a prolonged life expectancy of pediatric patients with chronic respiratory failure. Therefore, the number of hemodynamically stable pediatric patients with chronic respiratory failure who need mechanical ventilator assistance throughout the day has significantly increased.

AIMS

Numerous conditions, including parenchymal lung diseases, airway disorders, neuromotor disorders, or respiratory defects, can lead to chronic respiratory failure. For individuals who cannot tolerate non-invasive mechanical ventilation (NIMV), invasive mechanical ventilation (IMV) is the only suitable choice. Due to increasing need, mechanical ventilator technology is continuously evolving.

RESULTS

As a result of this process, home-type mechanical ventilators have been produced for patients requiring long-term IMV. Patients with chronic respiratory failure can be safely monitored at home with these ventilators.

DISCUSSION

Home follow-up of these patients has many benefits such as an increase in general quality of life and a positive contribution to their emotional and cognitive development.

CONCLUSION

In this compilation, indications for home-based IMV, features of home invasive mechanical ventilators (HMVs), patient monitoring, and the detailed advantages of using IMV at home will be elucidated.

Noninvasive respiratory assistance as aid for respiratory care in neuromuscular disorders

Chronic respiratory failure is a common complication of neuromuscular disease. The use of noninvasive ventilation and mechanically assisted cough can reduce symptoms of hypoventilation, slow lung function decline, improve sleep quality, and in some cases prolong survival in patients with neuromuscular disease. In this article, we review indications for the initiation of noninvasive ventilation and mechanically assisted cough as well as provide recommendations for settings and titration. We discuss the evidence supporting the use of noninvasive ventilation as an adjunct to rehabilitation in patients with neuromuscular disease. Lastly, we review the ethical considerations that are relevant to decisions regarding initiation and cessation of noninvasive ventilation. While noninvasive ventilation and mechanically assisted cough have become standards of care in many forms of neuromuscular disease, most current recommendations are based on expert opinion rather than much-needed data from prospective clinical trials and we emphasize topics requiring future research.

Long-term mechanical ventilation and transitions in care: A narrative review

OBJECTIVES

Individuals dependent on long-term mechanical ventilation (LTMV) for their day-to-day living are a heterogenous population who go through several transitions over their lifetime. This paper describes three transitions: 1) institution/hospital to community/home, 2) pediatric to adult care, and 3) active treatment to end-of-life for ventilator-assisted individuals (VAIs).

METHODS

A narrative review based on literature and the author's collective practical and research experience. Four online databases were searched for relevant articles. A manual search for additional articles was completed and the results are summarized.

RESULTS

Transitions from hospital to home, pediatric to adult care, and to end-of-life for VAIs are complex and challenging processes. Although there are several LTMV clinical practice guidelines highlighting key components for successful transition, there still exists gaps and inconsistencies in care. Most of the literature and experiences reported to date have been in developed countries or geographic areas with funded healthcare systems.

CONCLUSIONS

For successful transitions, the VAIs and their support network must be front-and-center. There should be a coordinated, systematic, and holistic plan (including a multi-disciplinary team), life-time follow-up, with bespoke consideration of jurisdiction and individual circumstances.

Ventilatory support at home for children: A joint position paper from the Thoracic Society of Australia and New Zealand/Australasian Sleep Association

The goal of this position paper on ventilatory support at home for children is to provide expert consensus from Australia and New Zealand on optimal care for children requiring ventilatory support at home, both non-invasive and invasive. It was compiled by members of the Thoracic Society of Australia and New Zealand (TSANZ) and the Australasian Sleep Association (ASA). This document provides recommendations to support the development of improved services for Australian and New Zealand children who require long-term ventilatory support. Issues relevant to providers of equipment and areas of research need are highlighted.

A narrative review of the experience and decision-making for children on home mechanical ventilation

Technological advances in mechanical ventilation have made home care possible for children requiring long-term ventilation. However, there are ethical and logistical challenges to transitioning home. The aim of this narrative review is to identify the experiences of the children and their families and the decision-making process to embark on home mechanical ventilation. A systematic review of the literature using Medline and OVID databases was conducted. Children <18 years requiring non-invasive ventilation or tracheostomy with ventilation or continuous positive pressure ventilation were included. The initial search yielded 1351 results, 1017 after duplications were removed and 111 after abstracts were reviewed. After applying inclusion and exclusion criteria to full text analysis, 48 references were analysed. The children and families described home ventilation as facilitating better health and functional status. However, they concurrently described social isolation, stigma, financial stress and loss of independence. The decision-making process to embark on home ventilation needs more research.

The role of sleep diagnostics and non-invasive ventilation in children with spinal muscular atrophy

Spinal muscular atrophy (SMA) is a degenerative motor neurone disorder causing progressive muscular weakness. Without assisted ventilation or novel therapies, most children with SMA type 1 die before the second year of life due to respiratory failure as the respiratory muscles and bulbar function are severely affected. Active respiratory treatment (mechanically assisted cough, invasive or non-invasive ventilation) has improved survival significantly in recent decades, but often at the cost of becoming ventilator dependent. The advent of a new oligonucleotide based therapy (Nusinersen) has created new optimism for improving motor function. However, the long-term effect on respiratory function is unclear and non-invasive respiratory support will remain an important part of medical management in patients with SMA. This review summarises the existing knowledge about sleep-disordered breathing and respiratory failure in patients with SMA, especially type 1, as well as the evidence of improved outcome and survival in patients treated with non-invasive or invasive ventilation. Practical considerations and ethical concerns are delineated with discussion on how these may be affected by the advent of new therapies such as Nusinersen.

Respiratory Care Considerations for Children with Medical Complexity

Children with medical complexity (CMC) are a growing population of diagnostically heterogeneous children characterized by chronic conditions affecting multiple organ systems, the use of medical technology at home as well as intensive healthcare service utilization. Many of these children will experience either a respiratory-related complication and/or they will become established on respiratory technology at home during their care trajectory. Therefore, healthcare providers need to be familiar with the respiratory related complications commonly experienced by CMC as well as the indications, technical and safety considerations and potential complications that may arise when caring for CMC using respiratory technology at home. This review will outline the most common respiratory disease manifestations experienced by CMC, and discuss various respiratory-related treatment options that can be considered, including tracheostomy, invasive and non-invasive ventilation, as well as airway clearance techniques. The caregiver requirements associated with caring for CMC using respiratory technology at home will also be reviewed.

[Non-invasive and invasive out of hospital ventilation in chronic respiratory failure : Consensus report of the working group on ventilation and intensive care medicine of the Austrian Society of Pneumology]

The current consensus report was compiled under the patronage of the Austrian Society of Pneumology (Österreichischen Gesellschaft für Pneumologie, ÖGP) with the intention of providing practical guidelines for out-of-hospital ventilation that are in accordance with specific Austrian framework parameters and legal foundations. The guidelines are oriented toward a 2004 consensus ÖGP recommendation concerning the setup of long-term ventilated patients and the 2010 German Respiratory Society S2 guidelines on noninvasive and invasive ventilation of chronic respiratory insufficiency, adapted to national experiences and updated according to recent literature. In 11 chapters, the initiation, adjustment, and monitoring of out-of-hospital ventilation is described, as is the technical equipment and airway access. Additionally, the different indications-such as chronic obstructive pulmonary diseases, thoracic restrictive and neuromuscular diseases, obesity hypoventilation syndrome, and pediatric diseases-are discussed. Furthermore, the respiratory physiotherapy of adults and children on invasive and noninvasive long-term ventilation is addressed in detail.

Home mechanical ventilation in childhood-onset hereditary neuromuscular diseases: 13 years' experience at a single center in Korea

Introduction

Children with hereditary neuromuscular diseases (NMDs) are at a high risk of morbidity and mortality related to respiratory failure. The use of home mechanical ventilation (HMV) has saved the lives of many children with NMD but, due to a lack of studies, dependable guidelines are not available. We drew upon our experience to compare the various underlying NMDs and to evaluate HMV with regard to respiratory morbidity, the proper indications and timing for its use, and to develop a policy to improve the quality of home noninvasive ventilation (NIV).

Methods

We retrospectively analyzed the medical records of 57 children with childhood-onset hereditary NMDs in whom HMV was initiated between January 2000 and May 2013 at Seoul National University Children's Hospital. The degree of respiratory morbidity was estimated by the frequency and duration of hospitalizations caused by respiratory distress.

Results

The most common NMD was spinal muscular atrophy (SMA, n = 33). Emergent mechanical ventilation was initiated in 44% of the patients before the confirmed diagnosis, and the indicators of pre-HMV respiratory morbidity (e.g., extubation trials, hypoxia, hospitalizations, and intensive care unit stay) were greater in these patients than in others. The proportion of post-HMV hospitalizations (range, 0.00−0.52; median, 0.01) was lower than that of pre-HMV hospitalizations (0.02−1.00; 0.99) (P < 0.001). Eight patients were able to maintain home NIV. The main causes of NIV failure were air leakage and a large amount of airway secretions.

Conclusions

The application of HMV helped reduce respiratory morbidity in children with childhood-onset hereditary NMD. Patients with SMA type I can benefit from an early diagnosis and the timely application of HMV. The choice between invasive and noninvasive HMV should be based on the patient’s age and NIV trial tolerance. Systematic follow-up guidelines provided by a multidisciplinary team are needed.

[Multicentric study of medical care and practices in spinal muscular atrophy type 1 over two 10-year periods]

AIM

Questions about care practices and the role of palliative care in pediatric neurodegenerative diseases have led the Neuromuscular Committee of the French Society of Neurology to conduct a retrospective study in spinal muscular atrophy type 1, a genetic disease most often leading to death before the age of 1 year.

MATERIAL AND METHODS

A retrospective multicenter study from pediatricians included in the reference centers of pediatric neuromuscular diseases was carried out on two 10-year periods (1989-1998 and 1999-2009).

RESULTS

The 1989-1998 period included 12 centers with 106 patients, the 1999-2009 period 13 centers with 116 children. The mean age of onset of clinical signs was 2.1 months (range, 0-5.5 months), the median age at diagnosis was 4 months (range, 0-9 months) vs 3 months. The median age of death was 7.5 months (range, 0-24 months) vs 6 months. The care modalities included physiotherapy (90 %), motor support (61 % vs 26 % for the previous period), enteral nutrition by nasogastric tube (52 % vs 24 %), and 3.4 % of children had a gastrostomy (vs 1.8 %). At home, pharyngeal aspiration was used in 64 % (vs 41 %), oxygen therapy in 8 %, noninvasive ventilatory support in 7 %. The mean age at death was 8.1 months (range, 0-24 months) vs 7 months, the time from diagnosis to death was 4 months vs 3 months. Death occurred at home in 23 % vs 17 %, in a pediatric unit in 62 % vs 41 %. The use of analgesics and sedative drugs was reported in 60 % of cases: 40 % morphine (vs 18 %) and benzodiazepines in 48 % (vs 29 %). Respiratory support was limited mostly to oxygen by nasal tube (55 % vs 54 %), noninvasive ventilation in 9 % of the cases, and intubation and assisted mechanical ventilation (2 %).

DISCUSSION AND CONCLUSION

These results confirm a change in practices and the development of palliative care in children with a French consensus of practices quite different from the standard care in North-America and closer to the thinking of English medical teams. A prospective study within the 2011 national hospital clinical research program (PHRC 2011) is beginning in order to evaluate practices and the role of families and caregivers.

Home mechanical ventilation in children is feasible in developing countries

BACKGROUND

The results of many national surveys on pediatric home mechanical ventilation (HMV) in developed countries have been presented elsewhere, but data from developing countries with low national incomes are scarce.

METHODS

Twenty-nine pediatric patients, treated in the Mother and Child Institute of Serbia, who had been receiving long-term ventilatory support at home, were surveyed. The major criterion for initiating HMV was hypercapnia, diagnosed by blood gas analysis, performed in the morning, after awakening. Other criteria were either symptoms of hypoventilation during the night associated with an apnea index of >5, or apnoea-hypopnoea index of >15, or nocturnal hypoxemia, defined as an oxygen saturation rate of <90% for >5% of total sleep time.

RESULTS

The mean age at initiation of HMV was 9.3 years (range 0.5-17.8 years). Patients waited for HMV initiation either in hospital or at home; the mean period was 6.3 months (range 1-18 months). The subjects received HMV for a mean of 25.06 months (range 3-119 months). There was a significant difference in the duration of HMV for different underlying diseases (P= 0.046), and mechanical malfunction was strongly dependent on the duration of HMV (P= 0.011). Eleven patients underwent invasive HMV via a tracheostomy, and 18 others received non-invasive ventilation, via nasal and full-face masks.

CONCLUSION

HMV is feasible in developing countries. Valuable reimbursement policies as well as an organized and functional network are essential for its implementation, as a standard of care in leading national pediatric hospitals.

Outcome of long-term mechanical ventilation support in children

BACKGROUND

Improved technology and care in recent years have significantly improved the prognosis and quality of life for patients on long-term mechanical ventilation. This study examined the status of children on long-term mechanical ventilation (MV) support in Taiwan.

METHODS

The medical records of patients between January 1998 and December 2006 were retrospectively reviewed, and the clinical factors were systematically reviewed.

RESULTS

One hundred and thirty-nine (139) patients aged 3 months to 18 years, with 53 (38.1%) girls and 86 (61.9%) boys, were enrolled. The common underlying disorders included neurologic/neuromuscular diseases (n=100, 71.9%) and airway/lung dysfunction (n=19, 13.7%). After instituting MV, the children returned to the medical center mainly for infection (n=157, 47.7%) and elective surgery or procedures (n=46, 13.9%). After long-term follow-up, 37 (26.6%) died, 81 (58.3%) were transferred to respiratory care wards in local hospitals, and 21 (15.1%) received home care support.

CONCLUSIONS

There are now more children on long-term MV support in Taiwan and most are in respiratory care wards in local hospitals. The shift in underlying diagnoses from pulmonary disease to neurogenic respiratory insufficiency affects hospitalization. The main cause of respiratory insufficiency is neurologic insult.

Ethical challenges in the care of children and families affected by life-limiting neuromuscular diseases

OBJECTIVE

We sought to understand how neuromuscular clinicians respond to the ethical challenges that arise in caring for children with life-limiting neuromuscular diseases.

METHODS

We conducted a national survey of interdisciplinary professionals who care for children with Duchenne Muscular Dystrophy and Spinal Muscular Atrophy Type-1 to document their knowledge, attitudes, beliefs and reported practices with regard to prominent ethical challenges, and their suggestions for ethics interventions that would assist them in improving clinical practice.

RESULTS

157 participants completed paper or electronic surveys for an overall participation rate of 24%. A significant minority of respondents were either unaware of or chose not to adopt relevant ethical guidelines, and reported experiencing crises of conscience in the care of their patients. In response to 8 ethical dilemmas, there was variability in how often respondents encountered them, their comfort in addressing them, and their reported practices, including only 24% who have requested ethics consultation.

CONCLUSION

Training of interdisciplinary clinicians is needed to improve their adoption of relevant ethical guidelines, cultivate greater awareness of diverse attitudes regarding the ethical permissibility of different treatment options and the utility of ethics consultation, and foster greater confidence and competence in responding to ethical challenges that arise in pediatric neuromuscular practice.

Ethical challenges in home mechanical ventilation: a secondary analysis

The aim of this study was to explore the ethical challenges in home mechanical ventilation based on a secondary analysis of qualitative empirical data. The data included perceptions of healthcare professionals in hospitals and community health services and family members of children and adults using home mechanical ventilation. The findings show that a number of ethical challenges, or dilemmas, arise at all levels in the course of treatment: deciding who should be offered home mechanical ventilation, respect for patient and family wishes, quality of life, dignity and equal access to home mechanical ventilation. Other challenges were the impacts home mechanical ventilation had on the patient, the family, the healthcare services and the allocation of resources. A better and broader understanding of these issues is crucial in order to improve the quality of care for both patient and family and assist healthcare professionals involved in home mechanical ventilation to make decisions for the good of the patient and his or her family.

Risk factors for morbidity and mortality in pediatric home mechanical ventilation

BACKGROUND

Home mechanical ventilation (HMV) is increasingly used in children with chronic respiratory insufficiency, but data on incidence and type of adverse events are limited.

SETTING

Pediatric HMV program at a tertiary university hospital.

METHODS

The authors retrospectively analyzed the type and incidence of severe emergencies in a mixed pediatric HMV program.

RESULTS

In all, 295 patient-years of HMV in 54 patients could be analyzed. A total of 26 patients had neuromuscular disease. In 16 patients, mechanical ventilation was initiated at <1 year of age. A total of 45 children were ventilated via tracheostomy and 9 by nasal mask. This study identified 68 severe emergencies (0.2 per patient-year) leading to 4 deaths. Respiratory causes were found in 48 cases (including 15 tracheostomy-related and 3 ventilator failures). Only age, but not underlying diagnosis or mode of ventilation, correlated with incidence of emergencies.

CONCLUSIONS

Pediatric HMV including all age and diagnostic groups shows a low incidence of emergencies.

UK physicians’ attitudes and practices in long-term non-invasive ventilation of Duchenne Muscular Dystrophy

Previous studies have shown that long-term non-invasive ventilation (NIV) is not always routinely offered by all physicians in Duchenne Muscular Dystrophy (DMD), despite evidence that this treatment improves quality of life and survival. This study examined UK physicians' practices related to respiratory follow-up and DMD ventilation. A mailed questionnaire was used. Thirty-eight of the 59 (64%) UK physicians identified via the Muscular Dystrophy Campaign (MDC) responded. Eighty-one per cent of respondents felt ethically obliged to discuss NIV with families while 13% believed that NIV results in poor quality of life. Forty-seven per cent of physicians discuss in-depth the use of NIV when the patient is in respiratory failure. Eighty-four ventilated DMD patients in the respondents' practice use NIV (via Bi-Pap Nasal mask). Nearly 66% of physicians do not consider the public cost to be an impediment to offering NIV, despite significant problems with resources' allocation in their area. While the majority of UK physicians have comparable attitudes and practices regarding NIV, the questionnaire highlighted that not all specialists were aware of the existence of consensus guidelines regarding respiratory monitoring. In addition, different practices of disclosure of life-prolonging ventilation options were used by different physicians. Seventy-one per cent of physicians wished for national consensus guidelines for different DMD age groups.

Long-term non-invasive positive airway pressure ventilation in infants

AIM

To evaluate the clinical application of long-term non-invasive ventilation (NIV) in infants with life-threatening ventilatory failure with regard to: diagnosis, age at initiation, indication for and duration of treatment, clinical outcome and mortality and adverse effects.

PATIENTS AND METHODS

The medical records of 18 infants treated in a home setting during a 7-year period were reviewed. The criteria for ventilatory support were: (a) transcutaneous partial pressures of carbon dioxide (TcPCO(2)) >6.5 kPa and oxygen (TcPO(2)) < 8.5 kPa and (b) decreased cough ability and/or recurrent chest infections.

RESULTS

The median age at initiation was 4 months (range 1-12). NIV was initiated because of hypoventilation in 12 infants and because of reduced cough ability and/or recurrent infections in six infants. Tracheotomy was eventually needed in two infants. The median duration of treatment was 24 months (range 1-84). NIV produced significant improvements, with median TcPCO(2) falling from 9.9 to 6.1 kPa, and median TcPO(2) rising from 9.8 to 11.1 kPa.

CONCLUSION

NIV can be successfully and safely used in infants with prolonged life-threatening ventilatory failure, potentially avoiding intubation and tracheotomy.

Modern management of spinal muscular atrophy

Spinal muscular atrophy is an incurable disease with a frequency of 8 per 100,000 live births. The disease gene, survival motor neuron 1 (SMN1), was identified with a disease modifying gene, SMN2. There is a high mortality rate in infancy and severe morbidity in childhood. Management depends on treating or preventing complications of weakness and maintaining quality of life. Weakness may affect several organ systems: respiratory, due to restrictive lung disease; gastrointestinal, in terms of dysphagia and constipation; and orthopedic, with progressive deformities. This review focuses on management of restrictive lung disease, the most common and most serious complication. Three areas of recent development are noninvasive ventilation using new technology, new awareness of the importance of identifying sleep-disordered breathing, and a new multidisciplinary approach to standard of care. Noninvasive ventilation and improved airway clearance are helpful for preoperative and postoperative management. Standard of care requires a multidisciplinary approach.

Consensus statement for standard of care in spinal muscular atrophy

Spinal muscular atrophy is a neurodegenerative disease that requires multidisciplinary medical care. Recent progress in the understanding of molecular pathogenesis of spinal muscular atrophy and advances in medical technology have not been matched by similar developments in the care for spinal muscular atrophy patients. Variations in medical practice coupled with differences in family resources and values have resulted in variable clinical outcomes that are likely to compromise valid measure of treatment effects during clinical trials. The International Standard of Care Committee for Spinal Muscular Atrophy was formed in 2005, with a goal of establishing practice guidelines for clinical care of these patients. The 12 core committee members worked with more than 60 spinal muscular atrophy experts in the field through conference calls, e-mail communications, a Delphi survey, and 2 in-person meetings to achieve consensus on 5 care areas: diagnostic/new interventions, pulmonary, gastrointestinal/nutrition, orthopedics/rehabilitation, and palliative care. Consensus was achieved on several topics related to common medical problems in spinal muscular atrophy, diagnostic strategies, recommendations for assessment and monitoring, and therapeutic interventions in each care area. A consensus statement was drafted to address the 5 care areas according to 3 functional levels of the patients: nonsitter, sitter, and walker. The committee also identified several medical practices lacking consensus and warranting further investigation. It is the authors' intention that this document be used as a guideline, not as a practice standard for their care. A practice standard for spinal muscular atrophy is urgently needed to help with the multidisciplinary care of these patients.

Spinal muscular atrophy type 1: is long-term mechanical ventilation ethical?

We present a baby with spinal muscular atrophy type 1, an inherited disorder causing progressive weakness, leading to complete paralysis of respiratory, facial and limb muscles. Without intervention, death occurs in infancy due to respiratory failure. Mechanical ventilatory support can prolong life, but the child's quality of life is highly debatable. We discuss the appropriateness of initiating and continuing intensive care for this child and others in a similar position.

Health and quality of life of ventilator-dependent children

AIM

This paper reports a qualitative study with ventilator-dependent children and their parents, describing their experiences and meanings concerning the children's health and quality of life.

BACKGROUND

Recent medical advances have enabled children to survive premature birth, congenital anomalies, critical illness and accidents with long-term use of mechanical ventilation to support breathing. In economically developed countries, the number of ventilator-dependent children is increasing and many require nurse-led home healthcare services. Debate has been polarized as to whether life on a ventilator is in the best interests of all children. The perspectives of ventilator-dependent children are largely absent in the literature.

METHODS

Principles derived from Heideggerian phenomenology were used to describe how children and their parents interpreted and rationalized the quality of the child's 'ventilator-dependent' life and their health. The study had two phases with data collection commencing in 1998 and completed in 2004.

RESULTS

The participants were 35 ventilator-dependent children, and 50 mothers and 17 fathers of 53 children. Emergent themes revealed some common features across this heterogeneous group. Ventilation made the children feel better and if they had sufficient breath, they experienced better quality of life. It was not possible to delineate the magnitude of health gain or benefit, especially amongst preverbal children and those with profound sensory impairments. Quality of life equated to quality of life experiences, but some children experienced negative social impacts and low self-esteem. Home healthcare services were not designed to bring about the desired social outcomes that children identified. Parent's accounts showed subtle more negative differences.

CONCLUSION

The acceptance of children's dependence on machines to live has brought about the need for nursing, medical, social and biological boundaries to be redefined, especially around children's meanings of their health, what they understand to be good quality of life, and what they need to achieve it. Flexible, high quality child-focused homecare is likely to improve children's outcomes.

Respiratory failure in infants due to spinal muscular atrophy with respiratory distress type 1

BACKGROUND

Spinal muscular atrophy with respiratory distress type 1 (SMARD1) is a rare autosomal recessive neuromuscular disease of unknown prevalence characterized by degeneration of anterior horn alpha-motoneurons and manifesting in the first 6months of life as life-threatening irreversible diaphragmatic paralysis associated with progressive symmetrical muscular weakness (distal lower limbs mainly involved), muscle atrophy, and peripheral sensory neuropathy.

SETTING

Pediatric intensive care unit of tertiary care hospital.

PATIENTS

We present two new cases of SMARD1 and report two new mutations in the gene IGHMBP2 which encodes immunoglobulin mu-binding protein 2 on chromosome 11q13.

CONCLUSIONS

SMARD1 is a poor-prognosis disease that should be considered when acute respiratory insufficiency, of suspected neuromuscular or unclear cause, develops during the first 6months of life. Diaphragmatic paralysis, manifesting as dyspnea and paradoxical respiration, is the most prominent presenting sign and diaphragmatic motility should be investigated early by fluoroscopy or ultrasound. Electromyography and nerve conduction studies revealing peripheral motor and sensory neuropathy then suggest the diagnosis which should be confirmed by genetic analysis.