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Sheers NL, O’Sullivan R, Howard ME, Berlowitz DJ. The role of lung volume recruitment therapy in neuromuscular disease: a narrative review. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1164628. [PMID: 37565183 PMCID: PMC10410160 DOI: 10.3389/fresc.2023.1164628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/16/2023] [Indexed: 08/12/2023]
Abstract
Respiratory muscle weakness results in substantial discomfort, disability, and ultimately death in many neuromuscular diseases. Respiratory system impairment manifests as shallow breathing, poor cough and associated difficulty clearing mucus, respiratory tract infections, hypoventilation, sleep-disordered breathing, and chronic ventilatory failure. Ventilatory support (i.e., non-invasive ventilation) is an established and key treatment for the latter. As survival outcomes improve for people living with many neuromuscular diseases, there is a shift towards more proactive and preventative chronic disease multidisciplinary care models that aim to manage symptoms, improve morbidity, and reduce mortality. Clinical care guidelines typically recommend therapies to improve cough effectiveness and mobilise mucus, with the aim of averting acute respiratory compromise or respiratory tract infections. Moreover, preventing recurrent infective episodes may prevent secondary parenchymal pathology and further lung function decline. Regular use of techniques that augment lung volume has similarly been recommended (volume recruitment). It has been speculated that enhancing lung inflation in people with respiratory muscle weakness when well may improve respiratory system "flexibility", mitigate restrictive chest wall disease, and slow lung volume decline. Unfortunately, clinical care guidelines are based largely on clinical rationale and consensus opinion rather than level A evidence. This narrative review outlines the physiological changes that occur in people with neuromuscular disease and how these changes impact on breathing, cough, and respiratory tract infections. The biological rationale for lung volume recruitment is provided, and the clinical trials that examine the immediate, short-term, and longer-term outcomes of lung volume recruitment in paediatric and adult neuromuscular diseases are presented and the results synthesised.
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Affiliation(s)
- Nicole L. Sheers
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
- Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Rachel O’Sullivan
- Department of Physiotherapy, Christchurch Hospital, Canterbury, New Zealand
| | - Mark E. Howard
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Turner Institute of Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - David J. Berlowitz
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
- Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Department of Physiotherapy, Austin Health, Heidelberg, VIC, Australia
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2
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Bach JR, Shih T. High-Level Spinal Cord Injury and the Failure of US Acute Rehabilitation: An Analysis and Commentary. Am J Phys Med Rehabil 2023; 102:630-635. [PMID: 36882322 DOI: 10.1097/phm.0000000000002227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
ABSTRACT Acute and long-term morbidity and mortality rates have not changed in the United States for people with high-level spinal cord injury in 40 yrs, neither has the conventional invasive respiratory management for these patients. This is despite a 2006 challenge to institutions for a paradigm shift to avoid or decannulate patients of tracheostomy tubes. Centers in Portugal, Japan, Mexico, and South Korea decannulate high-level patients to up to continuous noninvasive ventilatory support and use mechanical insufflation exsufflation, as we have done and reported since 1990, but there has been no such paradigm shift in US rehabilitation institutions. The quality of life and financial consequences of this are discussed. An example of decannulation of a relatively easy case, after failure to do so during 3 mos of acute rehabilitation, is presented to encourage institutions to begin to learn and apply noninvasive management before decannulating more severe patients with little to no ventilator free breathing ability.
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Affiliation(s)
- John R Bach
- From the Department of Physical Medicine and Rehabilitation, Rutgers University-New Jersey Medical School, Newark, New Jersey (JRB); and Rutgers University-New Jersey Medical School, Newark, New Jersey (TS)
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3
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Younger DS. Critical illness-associated weakness and related motor disorders. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:707-777. [PMID: 37562893 DOI: 10.1016/b978-0-323-98818-6.00031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Weakness of limb and respiratory muscles that occurs in the course of critical illness has become an increasingly common and serious complication of adult and pediatric intensive care unit patients and a cause of prolonged ventilatory support, morbidity, and prolonged hospitalization. Two motor disorders that occur singly or together, namely critical illness polyneuropathy and critical illness myopathy, cause weakness of limb and of breathing muscles, making it difficult to be weaned from ventilatory support, commencing rehabilitation, and extending the length of stay in the intensive care unit, with higher rates of morbidity and mortality. Recovery can take weeks or months and in severe cases, and may be incomplete or absent. Recent findings suggest an improved prognosis of critical illness myopathy compared to polyneuropathy. Prevention and treatment are therefore very important. Its management requires an integrated team approach commencing with neurologic consultation, creatine kinase (CK) measurement, detailed electrodiagnostic, respiratory and neuroimaging studies, and potentially muscle biopsy to elucidate the etiopathogenesis of the weakness in the peripheral and/or central nervous system, for which there may be a variety of causes. These tenets of care are being applied to new cases and survivors of the coronavirus-2 disease pandemic of 2019. This chapter provides an update to the understanding and approach to critical illness motor disorders.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Younger DS. Congenital myopathies. HANDBOOK OF CLINICAL NEUROLOGY 2023; 195:533-561. [PMID: 37562885 DOI: 10.1016/b978-0-323-98818-6.00027-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
The congenital myopathies are inherited muscle disorders characterized clinically by hypotonia and weakness, usually from birth, with a static or slowly progressive clinical course. Historically, the congenital myopathies have been classified according to major morphological features seen on muscle biopsy as nemaline myopathy, central core disease, centronuclear or myotubular myopathy, and congenital fiber type disproportion. However, in the past two decades, the genetic basis of these different forms of congenital myopathy has been further elucidated with the result being improved correlation with histological and genetic characteristics. However, these notions have been challenged for three reasons. First, many of the congenital myopathies can be caused by mutations in more than one gene that suggests an impact of genetic heterogeneity. Second, mutations in the same gene can cause different muscle pathologies. Third, the same genetic mutation may lead to different pathological features in members of the same family or in the same individual at different ages. This chapter provides a clinical overview of the congenital myopathies and a clinically useful guide to its genetic basis recognizing the increasing reliance of exome, subexome, and genome sequencing studies as first-line analysis in many patients.
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Affiliation(s)
- David S Younger
- Department of Clinical Medicine and Neuroscience, CUNY School of Medicine, New York, NY, United States; Department of Medicine, Section of Internal Medicine and Neurology, White Plains Hospital, White Plains, NY, United States.
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Chuang MH, Hsu JR, Hung CW, Hwang YL, Lee CC, Shen HY, Chang FK, Kuo LL, Chen SSS, Huang SJ. Factors affecting do-not-resuscitate decisions among patients with amyotrophic lateral sclerosis in Taiwan. PLoS One 2023; 18:e0282805. [PMID: 36913360 PMCID: PMC10010504 DOI: 10.1371/journal.pone.0282805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 02/22/2023] [Indexed: 03/14/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease. Usually, patients survive for approximately 2-4 years after the onset of the disease, and they often die of respiratory failure. This study examined the factors associated with signing a "do not resuscitate" (DNR) form in patients with ALS. This cross-sectional study included patients diagnosed with ALS between January 2015 and December 2019 in a Taipei City hospital. We recorded patients' age at disease onset; sex; presence of diabetes mellitus, hypertension, cancer, or depression; use of invasive positive pressure ventilator (IPPV) or non-IPPV (NIPPV); use of nasogastric tube (NG) or percutaneous endoscopic gastrostomy (PEG) tube; follow-up years; and number of hospitalizations. Data from 162 patients were recorded (99 men). Fifty-six (34.6%) signed a DNR. Multivariate logistic regression analyses revealed that the factors associated with DNR included NIPPV (OR = 6.95, 95% CI = 2.21-21.84), PEG tube feeding (OR = 2.86, 95% CI = 1.13-7.24), NG tube feeding (OR = 5.75, 95% CI = 1.77-18.65), follow-up years (OR = 1.13, 95% CI = 1.02-1.26), and number of hospital admissions (OR = 1.26, 95% CI = 1.02-1.57). The findings suggest that end-of-life decision making among patients with ALS may often be delayed. DNR decisions should be discussed with patients and their families during the early stages of disease progression. Physicians are advised to discuss DNR with patients when they can speak and to offer palliative care options.
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Affiliation(s)
- Mei-Hsing Chuang
- Division of Family Medicine, Taipei City Hospital Zhong Xiao Branch, Taipei, Taiwan
- Department of Family Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiunn-Rong Hsu
- Division of Chest Medicine, Department of Internal Medicine, Taipei City Hospital Zhong Xiao Branch, Taipei, Taiwan
| | - Chia-Wei Hung
- Division of Neurology, Department of Internal Medicine, Taipei City Hospital Zhong Xiao Branch, Taipei, Taiwan
| | - Yu Long Hwang
- Division of Neurology, Department of Internal Medicine, Taipei City Hospital Zhong Xiao Branch, Taipei, Taiwan
| | - Chih-Ching Lee
- Division of Palliative Medicine, Department of Internal Medicine, Taipei City Hospital Zhong Xiao Branch, Taipei, Taiwan
| | - Hsiu-Yi Shen
- Department of Nursing, Taipei City Hospital Zhong Xiao Branch, Taipei, Taiwan
| | - Fu-Kang Chang
- Division of Chest Medicine, Department of Internal Medicine, Taipei City Hospital Zhong Xiao Branch, Taipei, Taiwan
- * E-mail:
| | - Li-Lin Kuo
- Department of Ophthalmology, Taipei City Hospital, Taipei, Taiwan
| | - Saint Shiou-Sheng Chen
- Division of Urology, Taipei City Hospital Zhong Xiao Branch, Taipei, Taiwan
- Department of Urology, National Yang Ming Chiao Tung University, School of Medicine, Taipei, Taiwan
- Commission for General Education, College of Applied Science, National Taiwan University of Science and Technology, Taipei, Taiwan
- General Education Center, University of Taipei, Taipei, Taiwan
| | - Sheng-Jean Huang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan
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Westenberg JN, Petrof BJ, Noel F, Zielinski D, Constantin E, Oskoui M, Kaminska M. Validation of home portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders. J Clin Sleep Med 2021; 17:1579-1590. [PMID: 33739260 PMCID: PMC8656910 DOI: 10.5664/jcsm.9254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Sleep-disordered breathing (SDB) is common in patients with neuromuscular disorders (NMD), developing before chronic hypercapnia appears. Polysomnography (PSG) is the diagnostic gold standard but is often impractical and poorly accessible for individuals with NMD. We sought to determine the diagnostic accuracy, feasibility, and patient preference of home sleep apnea testing (HSAT) compared with PSG for the detection of SDB in NMD. METHODS Participants with NMD at risk for SDB aged ≥ 13 years underwent HSAT followed by overnight PSG with concomitant laboratory sleep apnea testing (same device as HSAT). Sensitivity and specificity were calculated for standard apnea-hypopnea index cutoffs for mild (≥ 5 events/h), moderate (≥ 15 events/h), and severe SDB (≥ 30 events/h) and for an oxygen desaturation index ≥ 5 events/h. Receiver operating characteristic curves were built. A questionnaire assessed patient preference. RESULTS Of 38 participants, 73% had moderate to severe SDB and 79% had technically acceptable HSAT. For an apnea-hypopnea index ≥ 15 events/h, HSAT sensitivity and specificity were 50% and 88%, respectively. For an oxygen desaturation index ≥ 5 events/h, HSAT sensitivity and specificity were 95% and 78%, respectively. The area under the receiver operating characteristic curve for an apnea-hypopnea index ≥ 15 events/h was 0.88 (95% confidence interval, 0.69-1.00) for HSAT. The HSAT underestimated the apnea-hypopnea index from PSG (bias, -10.7 ± 15.9 events/h). HSAT was preferred to PSG by 61% of participants. CONCLUSIONS HSAT is feasible, preferred by patients, and reliable for detecting SDB in most patients, although it cannot definitively rule out SDB. Therefore, HSAT is a viable diagnostic approach for SDB in NMD when PSG is not feasible, recognizing that it does not accurately distinguish between upper-airway obstruction and hypoventilation. Additional work is needed to further optimize home sleep testing in NMD. CITATION Westenberg JN, Petrof BJ, Noel F, et al. Validation of home portable monitoring for the diagnosis of sleep-disordered breathing in adolescents and adults with neuromuscular disorders. J Clin Sleep Med. 2021;17(8):1579-1590.
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Affiliation(s)
- Jean N. Westenberg
- Respiratory and Epidemiology and Clinical Research Unit, Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, Quebec, Canada
| | - Basil J. Petrof
- Respiratory Division and Sleep Laboratory, McGill University Health Centre, Montreal, Quebec, Canada
- Meakins Christie Laboratories, Translational Research in Respiratory Diseases Program, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Francine Noel
- Respiratory and Epidemiology and Clinical Research Unit, Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, Quebec, Canada
| | - David Zielinski
- Department of Pediatrics and Pediatric Sleep Laboratory, McGill University, Montreal, Quebec, Canada
| | - Evelyn Constantin
- Department of Pediatrics and Pediatric Sleep Laboratory, McGill University, Montreal, Quebec, Canada
| | - Maryam Oskoui
- Department of Pediatrics and Pediatric Sleep Laboratory, McGill University, Montreal, Quebec, Canada
- Department of Neurology and Neurosurgery, McGill University, Montreal, Quebec, Canada
| | - Marta Kaminska
- Respiratory and Epidemiology and Clinical Research Unit, Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, Quebec, Canada
- Respiratory Division and Sleep Laboratory, McGill University Health Centre, Montreal, Quebec, Canada
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Nguyen TH, Conotte S, Belayew A, Declèves AE, Legrand A, Tassin A. Hypoxia and Hypoxia-Inducible Factor Signaling in Muscular Dystrophies: Cause and Consequences. Int J Mol Sci 2021; 22:7220. [PMID: 34281273 PMCID: PMC8269128 DOI: 10.3390/ijms22137220] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 12/29/2022] Open
Abstract
Muscular dystrophies (MDs) are a group of inherited degenerative muscle disorders characterized by a progressive skeletal muscle wasting. Respiratory impairments and subsequent hypoxemia are encountered in a significant subgroup of patients in almost all MD forms. In response to hypoxic stress, compensatory mechanisms are activated especially through Hypoxia-Inducible Factor 1 α (HIF-1α). In healthy muscle, hypoxia and HIF-1α activation are known to affect oxidative stress balance and metabolism. Recent evidence has also highlighted HIF-1α as a regulator of myogenesis and satellite cell function. However, the impact of HIF-1α pathway modifications in MDs remains to be investigated. Multifactorial pathological mechanisms could lead to HIF-1α activation in patient skeletal muscles. In addition to the genetic defect per se, respiratory failure or blood vessel alterations could modify hypoxia response pathways. Here, we will discuss the current knowledge about the hypoxia response pathway alterations in MDs and address whether such changes could influence MD pathophysiology.
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Affiliation(s)
- Thuy-Hang Nguyen
- Laboratory of Respiratory Physiology, Pathophysiology and Rehabilitation, Research Institute for Health Sciences and Technology, University of Mons, 7000 Mons, Belgium; (T.-H.N.); (S.C.); (A.B.); (A.L.)
| | - Stephanie Conotte
- Laboratory of Respiratory Physiology, Pathophysiology and Rehabilitation, Research Institute for Health Sciences and Technology, University of Mons, 7000 Mons, Belgium; (T.-H.N.); (S.C.); (A.B.); (A.L.)
| | - Alexandra Belayew
- Laboratory of Respiratory Physiology, Pathophysiology and Rehabilitation, Research Institute for Health Sciences and Technology, University of Mons, 7000 Mons, Belgium; (T.-H.N.); (S.C.); (A.B.); (A.L.)
| | - Anne-Emilie Declèves
- Department of Metabolic and Molecular Biochemistry, Research Institute for Health Sciences and Technology, University of Mons, 7000 Mons, Belgium;
| | - Alexandre Legrand
- Laboratory of Respiratory Physiology, Pathophysiology and Rehabilitation, Research Institute for Health Sciences and Technology, University of Mons, 7000 Mons, Belgium; (T.-H.N.); (S.C.); (A.B.); (A.L.)
| | - Alexandra Tassin
- Laboratory of Respiratory Physiology, Pathophysiology and Rehabilitation, Research Institute for Health Sciences and Technology, University of Mons, 7000 Mons, Belgium; (T.-H.N.); (S.C.); (A.B.); (A.L.)
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Dubin A. Nerve Conduction Study/Electromyography: Common Neuropathies and Considerations for Patients with Polio. Phys Med Rehabil Clin N Am 2021; 32:527-535. [PMID: 34175011 DOI: 10.1016/j.pmr.2021.02.005] [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: 10/21/2022]
Abstract
Acute poliomyelitis is now extremely rare in the United States. Worldwide there are still sporadic outbreaks, which are typically treated with acute inoculation programs. Although polio has effectively been eradicated, the full scope of the disease and its myriad manifestations both in the acute phase and in the postpolio syndrome phase, remain areas of fertile research, debate, and stimulating topics.
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Affiliation(s)
- Andrew Dubin
- Division of PM&R, Department of Orthopedics and Rehabilitation Medicine, University of Florida, 3450 Hull Road Suite 3301, POB 112727, Gainesville, FL 32611, USA.
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Park J, Kang SW, Choi WA, Lee Y, Cho HE. Response: Precise Pulmonary Function Evaluation and Management of a Patient With Freeman-Sheldon Syndrome Associated With Recurrent Pneumonia and Chronic Respiratory Insufficiency (Ann Rehabil Med 2020;44:165-70). Ann Rehabil Med 2020; 44:411-413. [PMID: 33152848 PMCID: PMC7655226 DOI: 10.5535/arm.20110.r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 06/25/2020] [Indexed: 11/05/2022] Open
Affiliation(s)
- Jihyun Park
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seong-Woong Kang
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ah Choi
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yewon Lee
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Han Eol Cho
- Department of Rehabilitation Medicine and Rehabilitation Institute of Neuromuscular Disease, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.,Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Complete Restoration of Respiratory Muscle Function in Three Subjects With Spinal Cord Injury? Am J Phys Med Rehabil 2020; 99:e90. [PMID: 31688016 DOI: 10.1097/phm.0000000000001337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Intubated ventilator-dependent patients with high-level spinal cord injury can be managed without tracheostomy tubes provided that they have sufficient cognition to cooperate and that any required surgical procedures are completed and they are medically stable. Intubation for a month or more than extubation to continuous noninvasive ventilatory support (NVS) can be safer long term than resort to tracheotomy. Noninvasive ventilation (NIV) is not conventionally being used for ventilatory support. Noninvasive interfaces include mouthpieces, nasal and oronasal interfaces, and intermittent abdominal pressure ventilators. NIV/NVS should never been used without consideration of mechanical insufflation-exsufflation for airway secretion clearance.
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Lepainteur M, Ogna A, Clair B, Dinh A, Tarragon C, Prigent H, Davido B, Barbot F, Vaugier I, Afif M, Roux AL, Rottman M, Orlikowski D, Herrmann JL, Annane D, Lawrence C. Risk factors for respiratory tract bacterial colonization in adults with neuromuscular or neurological disorders and chronic tracheostomy. Respir Med 2019; 152:32-36. [PMID: 31128607 DOI: 10.1016/j.rmed.2019.04.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 11/30/2022]
Abstract
The aim of this study was to describe the endotracheal respiratory flora in a population of adults suffering from neuromuscular or neurological disorders requiring a long-term tracheostomy and to identify risk factors for colonization. We conducted a prospective and single-center observational study among patients with chronic tracheostomy admitted for planned respiratory assessment between February 2015 and December 2016. Data were collected from patient interview and medical charts with a standardized questionnaire. A tracheal aspiration was performed for each patient. Humidifiers were analysed for bacteriological contamination. Overall 77 tracheal aspirates (TA) were obtained from patients included. Pathogenic bacteria were found in 90% of cases (69/77) with a majority of Pseudomonas aeruginosa (32/77, 41%), Staphylococcus aureus (34/77, 44%) and Serratia marcesens. (22/79, 38%) Amoxicillin + Clavulanic-acid and Cefotaxime were adapted for respectively in only 28% and 35% of the subjects due to the natural resistance of organisms. No pathogenic bacteria were isolated from humidifier samples. Risk factors significantly associated with P. aeruginosa colonization were residence in a medical-care home (p = 0.01, OR = 3.8 [1.1; 15.1]) and the presence of a cuff (p = 0.003, OR = 4.4 [1.1; 20.6]). Significant quantities of pathogenic bacteria are frequently isolated from TA of tracheostomised patients in the absence of infection. The frequent resistance of these pathogens to Amoxicillin + Clavulanic-acid precludes the use of this antibiotic in the empiric treatment of pneumonia in this population.
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Affiliation(s)
- Margaux Lepainteur
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Adam Ogna
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Bernard Clair
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Aurélien Dinh
- Maladies infectieuses, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Catherine Tarragon
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Hélène Prigent
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Benjamin Davido
- Maladies infectieuses, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Frédéric Barbot
- CIC1429 INSERM AP-HP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Isabelle Vaugier
- CIC1429 INSERM AP-HP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Muriel Afif
- Pharmacie hospitalière, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Anne-Laure Roux
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France
| | - Martin Rottman
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France
| | - David Orlikowski
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; CIC1429 INSERM AP-HP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Jean-Louis Herrmann
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France
| | - Djillali Annane
- Réanimation adultes, APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France
| | - Christine Lawrence
- Laboratoire de microbiologie et unité d'hygiène hospitalière APHP, Hôpitaux Universitaires Paris Ile de France Ouest, site R. Poincaré, 92380, Garches, France; INSERM U1173, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France.
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Bach JR. Palliative Care Becomes ‘Uninformed Euthanasia’ When Patients Are Not Offered Noninvasive Life Preserving Options. J Palliat Care 2019. [DOI: 10.1177/082585970702300308] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John R. Bach
- Center for Noninvasive Mechanical Ventilation and Pulmonary Rehabilitation, University Hospital, University of Medicine and Dentistry of New Jersey, The New Jersey Medical School, Newark, New Jersey, USA
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14
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Mechanical In-exsufflation-Expiratory Flows as Indication for Tracheostomy Tube Decannulation. Am J Phys Med Rehabil 2019; 98:e18-e20. [DOI: 10.1097/phm.0000000000000999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fiorentino G, Annunziata A, Cauteruccio R, Frega GSD, Esquinas A. Mouthpiece ventilation in Duchenne muscular dystrophy: a rescue strategy for noncompliant patients. J Bras Pneumol 2017; 42:453-456. [PMID: 28117478 PMCID: PMC5344096 DOI: 10.1590/s1806-37562016000000050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/07/2016] [Indexed: 11/30/2022] Open
Abstract
Objective: To evaluate mouthpiece ventilation (MPV) in patients with Duchenne muscular dystrophy (DMD) who are noncompliant with noninvasive ventilation (NIV). Methods: We evaluated four young patients with DMD who had previously refused to undergo NIV. Each patient was reassessed and encouraged to try MPV. Results: The four patients tolerated MPV well and were compliant with NIV at home. MPV proved to be preferable and more comfortable than NIV with any other type of interface. Two of the patients required overnight NIV and eventually agreed to use a nasal mask during the night. Conclusions: The advantages of MPV over other types of NIV include fewer speech problems, better appearance, and less impact on the patient, eliminating the risk of skin breakdown, gastric distension, conjunctivitis, and claustrophobia. The use of a mouthpiece interface should be always considered in patients with DMD who need to start NIV, in order to promote a positive approach and a rapid acceptance of NIV. Using MPV during the daytime makes patients feel safe and more likely to use NIV at night. In addition, MPV increases treatment compliance for those who refuse to use other types of interfaces.
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Affiliation(s)
- Giuseppe Fiorentino
- . Dipartimento di Fisiopatologia Respiratoria, Ospedale Monaldi di Napoli, Napoli, Italia
| | - Anna Annunziata
- . Dipartimento di Fisiopatologia Respiratoria, Ospedale Monaldi di Napoli, Napoli, Italia
| | - Rosa Cauteruccio
- . Dipartimento di Fisiopatologia Respiratoria, Ospedale Monaldi di Napoli, Napoli, Italia
| | | | - Antonio Esquinas
- . Unidad de Terapia Intensiva, Hospital General Morales Meseguer, Murcia, España
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Bach JR. Noninvasive Respiratory Management of Patients With Neuromuscular Disease. Ann Rehabil Med 2017; 41:519-538. [PMID: 28971036 PMCID: PMC5608659 DOI: 10.5535/arm.2017.41.4.519] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/19/2017] [Indexed: 12/14/2022] Open
Abstract
This review article describes definitive noninvasive respiratory management of respiratory muscle dysfunction to eliminate need to resort to tracheotomy. In 2010 clinicians from 22 centers in 18 countries reported 1,623 spinal muscular atrophy type 1 (SMA1), Duchenne muscular dystrophy (DMD), and amyotrophic lateral sclerosis users of noninvasive ventilatory support (NVS) of whom 760 required it continuously (CNVS). The CNVS sustained their lives by over 3,000 patient-years without resort to indwelling tracheostomy tubes. These centers have now extubated at least 74 consecutive ventilator unweanable patients with DMD, over 95% of CNVS-dependent patients with SMA1, and hundreds of others with advanced neuromuscular disorders (NMDs) without resort to tracheotomy. Two centers reported a 99% success rate at extubating 258 ventilator unweanable patients without resort to tracheotomy. Patients with myopathic or lower motor neuron disorders can be managed noninvasively by up to CNVS, indefinitely, despite having little or no measurable vital capacity, with the use of physical medicine respiratory muscle aids. Ventilator-dependent patients can be decannulated of their tracheostomy tubes.
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Affiliation(s)
- John R Bach
- Department of Physical Medicine and Rehabilitation for Rutgers New Jersey Medical School & Center for Ventilator Management Alternatives at University Hospital, Newark, NJ, USA
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Abstract
Morbidity and mortality have decreased in patients with neuromuscular disease due to implementation of therapies to augment cough and improve ventilation. Infants with progressive neuromuscular disease will eventually develop respiratory complications as a result of muscle weakness and their inability to compensate during periods of increased respiratory loads. The finding of nocturnal hypercapnia is often the trigger for initiating non-invasive ventilation and studies have shown that its use not only may improve sleep-disordered breathing, but also that it may have an effect on daytime function, symptoms related to hypercapnia, and partial pressure of CO2. It is important to understand the respiratory physiology of this population and to understand the benefits and limitations of assisted ventilation.
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Affiliation(s)
- Stamatia Alexiou
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Joseph Piccione
- Division of Pulmonary Medicine & Center for Pediatric Airway Disorders, Philadelphia, PA, USA
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Abstract
This review aims to explain the inevitable imbalance between respiratory load, drive, and muscular force that occurs in the natural aging of Duchenne muscular dystrophy and that predisposes these patients to sleep disordered breathing (SDB). In DMD, SDB is characterized by oxygen desaturation, apneas, hypercapnia, and hypoventilation during sleep and ultimately develops into respiratory failure during wakefulness. It can be present in all age groups. Young patients risk obstructive apneas because of weight gain, secondary to progressive physical inactivity and prolonged corticosteroid therapy; older patients hypoventilate and desaturate because of respiratory muscle weakness, in particular the diaphragm. These conditions are further exacerbated during REM sleep, the phase of maximal muscle hypotonia during which the diaphragm has to provide most of the ventilation. Evidence is given to the daytime predictors of early symptoms of SDB, important indicators for the proper time to initiate mechanical ventilation.
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Kim SM, Kang SW, Choi YC, Park YG, Won YH. Successful Extubation After Weaning Failure by Noninvasive Ventilation in Patients With Neuromuscular Disease: Case Series. Ann Rehabil Med 2017; 41:450-455. [PMID: 28758083 PMCID: PMC5532351 DOI: 10.5535/arm.2017.41.3.450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 09/27/2016] [Indexed: 11/18/2022] Open
Abstract
Objective To report successful cases of extubation from invasive mechanical ventilation at our institution using pulmonary rehabilitation consisting of noninvasive ventilation (NIV) in neuromuscular patients with experience of reintubation. Methods Patients who experienced extubation failure via the conventional weaning strategy but afterwards had extubation success via NIV were studied retrospectively. Continuous end-tidal CO2 (ETCO2) and pulse oxyhemoglobin saturation (SpO2) monitoring were performed. Extubation success was defined as a state not requiring invasive mechanical ventilation via endotracheal tube or tracheotomy during a period of at least 5 days. Results A total of 18 patients with ventilatory failure who initially experienced extubation failure were finally placed under part-time NIV after extubation. No patient had any serious or long-term adverse effect from NIV, and all patients left the hospital alive. Conclusion NIV may promote successful weaning in neuromuscular patients with experience of reintubation.
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Affiliation(s)
- Sun Mi Kim
- Department of Medicine, Graduate School of Yonsei University, Seoul, Korea
| | - Seong-Woong Kang
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Chul Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Ghil Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Yu Hui Won
- Department of Physical Medicine and Rehabilitation, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
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Bach JR. POINT: Is Noninvasive Ventilation Always the Most Appropriate Manner of Long-term Ventilation for Infants With Spinal Muscular Atrophy Type 1? Yes, Almost Always. Chest 2017; 151:962-965. [DOI: 10.1016/j.chest.2016.11.043] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 11/28/2016] [Indexed: 10/20/2022] Open
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Pinto T, Chatwin M, Banfi P, Winck JC, Nicolini A. Mouthpiece ventilation and complementary techniques in patients with neuromuscular disease: A brief clinical review and update. Chron Respir Dis 2017; 14:187-193. [PMID: 27932555 DOI: 10.1177/1479972316674411] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Noninvasive ventilatory support (NVS) is sometimes reported as suboptimal in patients with neuromuscular disease (NMD). The reasons for this include inadequate ventilator settings and/or lack of interface tolerance. NVS has been used for many years in patients with NMD disorders as a viable alternative to continuous ventilatory support via a tracheostomy tube. The mouthpiece ventilation (MPV) is a ventilatory mode that is used as daytime ventilatory support in combination with other ventilatory modalities and interfaces for nocturnal NVS. However, there is still a poor understanding of this method's benefits compared with other modalities. This review aims to highlight the indications and advantages along with the disadvantages of MPV.
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Affiliation(s)
- Tiago Pinto
- 1 Lung Function and Ventilation Unit, Department of Pulmonary Medicine, Porto, Portugal
| | - Michelle Chatwin
- 2 Clinical and Academic Department of Sleep and Breathing, Royal Brompton Hospital, London, UK
| | - Paolo Banfi
- 3 Don Gnocchi Foundation IRCSS, Milan, Italy
| | | | - Antonello Nicolini
- 5 Respiratory Diseases Unit and ALS Centre, Hospital of Sestri Levante, Italy
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22
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Successful tracheostomy decannulation after complete or sensory incomplete cervical spinal cord injury. Spinal Cord 2017; 55:601-605. [DOI: 10.1038/sc.2016.194] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 12/04/2016] [Accepted: 12/18/2016] [Indexed: 11/09/2022]
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Randerath W, Verbraecken J, Andreas S, Arzt M, Bloch KE, Brack T, Buyse B, De Backer W, Eckert DJ, Grote L, Hagmeyer L, Hedner J, Jennum P, La Rovere MT, Miltz C, McNicholas WT, Montserrat J, Naughton M, Pepin JL, Pevernagie D, Sanner B, Testelmans D, Tonia T, Vrijsen B, Wijkstra P, Levy P. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J 2016; 49:13993003.00959-2016. [DOI: 10.1183/13993003.00959-2016] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/25/2016] [Indexed: 02/07/2023]
Abstract
The complexity of central breathing disturbances during sleep has become increasingly obvious. They present as central sleep apnoeas (CSAs) and hypopnoeas, periodic breathing with apnoeas, or irregular breathing in patients with cardiovascular, other internal or neurological disorders, and can emerge under positive airway pressure treatment or opioid use, or at high altitude. As yet, there is insufficient knowledge on the clinical features, pathophysiological background and consecutive algorithms for stepped-care treatment. Most recently, it has been discussed intensively if CSA in heart failure is a “marker” of disease severity or a “mediator” of disease progression, and if and which type of positive airway pressure therapy is indicated. In addition, disturbances of respiratory drive or the translation of central impulses may result in hypoventilation, associated with cerebral or neuromuscular diseases, or severe diseases of lung or thorax. These statements report the results of an European Respiratory Society Task Force addressing actual diagnostic and therapeutic standards. The statements are based on a systematic review of the literature and a systematic two-step decision process. Although the Task Force does not make recommendations, it describes its current practice of treatment of CSA in heart failure and hypoventilation.
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Affiliation(s)
- J.R. Bach
- Department of Physical Medicine and Rehabilitation, University Hospital B-403, 150 Bergen Street, Newark, NJ, USA,
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25
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Dretzke J, Blissett D, Dave C, Mukherjee R, Price M, Bayliss S, Wu X, Jordan R, Jowett S, Turner AM, Moore D. The cost-effectiveness of domiciliary non-invasive ventilation in patients with end-stage chronic obstructive pulmonary disease: a systematic review and economic evaluation. Health Technol Assess 2016; 19:1-246. [PMID: 26470875 DOI: 10.3310/hta19810] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic progressive lung disease characterised by non-reversible airflow obstruction. Exacerbations are a key cause of morbidity and mortality and place a considerable burden on health-care systems. While there is evidence that patients benefit from non-invasive ventilation (NIV) in hospital during an acute exacerbation, evidence supporting home use for more stable COPD patients is limited. In the U.K., domiciliary NIV is considered on health economic grounds in patients after three hospital admissions for acute hypercapnic respiratory failure. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of domiciliary NIV by systematic review and economic evaluation. DATA SOURCES Bibliographic databases, conference proceedings and ongoing trial registries up to September 2014. METHODS Standard systematic review methods were used for identifying relevant clinical effectiveness and cost-effectiveness studies assessing NIV compared with usual care or comparing different types of NIV. Risk of bias was assessed using Cochrane guidelines and relevant economic checklists. Results for primary effectiveness outcomes (mortality, hospitalisations, exacerbations and quality of life) were presented, where possible, in forest plots. A speculative Markov decision model was developed to compare the cost-effectiveness of domiciliary NIV with usual care from a UK perspective for post-hospital and more stable populations separately. RESULTS Thirty-one controlled effectiveness studies were identified, which report a variety of outcomes. For stable patients, a modest volume of evidence found no benefit from domiciliary NIV for survival and some non-significant beneficial trends for hospitalisations and quality of life. For post-hospital patients, no benefit from NIV could be shown in terms of survival (from randomised controlled trials) and findings for hospital admissions were inconsistent and based on limited evidence. No conclusions could be drawn regarding potential benefit from different types of NIV. No cost-effectiveness studies of domiciliary NIV were identified. Economic modelling suggested that NIV may be cost-effective in a stable population at a threshold of £30,000 per quality-adjusted life-year (QALY) gained (incremental cost-effectiveness ratio £28,162), but this is associated with uncertainty. In the case of the post-hospital population, results for three separate base cases ranged from usual care dominating to NIV being cost-effective, with an incremental cost-effectiveness ratio of less than £10,000 per QALY gained. All estimates were sensitive to effectiveness estimates, length of benefit from NIV (currently unknown) and some costs. Modelling suggested that reductions in the rate of hospital admissions per patient per year of 24% and 15% in the stable and post-hospital populations, respectively, are required for NIV to be cost-effective. LIMITATIONS Evidence on key clinical outcomes remains limited, particularly quality-of-life and long-term (> 2 years) effects. Economic modelling should be viewed as speculative because of uncertainty around effect estimates, baseline risks, length of benefit of NIV and limited quality-of-life/utility data. CONCLUSIONS The cost-effectiveness of domiciliary NIV remains uncertain and the findings in this report are sensitive to emergent data. Further evidence is required to identify patients most likely to benefit from domiciliary NIV and to establish optimum time points for starting NIV and equipment settings. FUTURE WORK RECOMMENDATIONS The results from this report will need to be re-examined in the light of any new trial results, particularly in terms of reducing the uncertainty in the economic model. Any new randomised controlled trials should consider including a sham non-invasive ventilation arm and/or a higher- and lower-pressure arm. Individual participant data analyses may help to determine whether or not there are any patient characteristics or equipment settings that are predictive of a benefit of NIV and to establish optimum time points for starting (and potentially discounting) NIV. STUDY REGISTRATION This study is registered as PROSPERO CRD42012003286. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Janine Dretzke
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Deirdre Blissett
- Health Economics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Chirag Dave
- Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
| | - Rahul Mukherjee
- Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham, UK
| | - Malcolm Price
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Sue Bayliss
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Xiaoying Wu
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Rachel Jordan
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Sue Jowett
- Health Economics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Alice M Turner
- Heart of England NHS Foundation Trust, Heartlands Hospital, Birmingham, UK.,Queen Elizabeth Hospital Research Laboratories, University of Birmingham, Birmingham, UK
| | - David Moore
- Public Health, Epidemiology and Biostatistics, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
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McDonald CM, Meier T, Voit T, Schara U, Straathof CSM, D'Angelo MG, Bernert G, Cuisset JM, Finkel RS, Goemans N, Rummey C, Leinonen M, Spagnolo P, Buyse GM. Idebenone reduces respiratory complications in patients with Duchenne muscular dystrophy. Neuromuscul Disord 2016; 26:473-80. [PMID: 27238057 DOI: 10.1016/j.nmd.2016.05.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 05/10/2016] [Accepted: 05/10/2016] [Indexed: 02/02/2023]
Abstract
In Duchenne muscular dystrophy (DMD), progressive loss of respiratory function leads to restrictive pulmonary disease and places patients at significant risk for severe respiratory complications. Of particular concern are ineffective cough, secretion retention and recurrent respiratory tract infections. In a Phase 3 randomized controlled study (DMD Long-term Idebenone Study, DELOS) in DMD patients 10-18 years of age and not taking concomitant glucocorticoid steroids, idebenone (900 mg/day) reduced significantly the loss of respiratory function over a 1-year study period. In a post-hoc analysis of DELOS we found that more patients in the placebo group compared to the idebenone group experienced bronchopulmonary adverse events (BAEs): placebo: 17 of 33 patients, 28 events; idebenone: 6 of 31 patients, 7 events. The hazard ratios (HR) calculated "by patient" (HR 0.33, p = 0.0187) and for "all BAEs" (HR 0.28, p = 0.0026) indicated a clear idebenone treatment effect. The overall duration of BAEs was 222 days (placebo) vs. 82 days (idebenone). In addition, there was also a difference in the use of systemic antibiotics utilized for the treatment of BAEs. In the placebo group, 13 patients (39.4%) reported 17 episodes of antibiotic use compared to 7 patients (22.6%) reporting 8 episodes of antibiotic use in the idebenone group. Furthermore, patients in the placebo group used systemic antibiotics for longer (105 days) compared to patients in the idebenone group (65 days). This post-hoc analysis of DELOS indicates that the protective effect of idebenone on respiratory function is associated with a reduced risk of bronchopulmonary complications and a reduced need for systemic antibiotics.
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Affiliation(s)
- Craig M McDonald
- University of California Davis Medical Center, Sacramento, CA, USA
| | | | - Thomas Voit
- Institut de Myologie, UPMC INSERM UMR 974, CNRS FRE 3617, Groupe Hospitalier de la Pitié Salpêtrière, Paris, France
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Teoh LJ, Geelhoed EA, Bayley K, Leonard H, Laing NG. Health care utilization and costs for children and adults with duchenne muscular dystrophy. Muscle Nerve 2016; 53:877-84. [PMID: 26562484 DOI: 10.1002/mus.24965] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2015] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Duchenne muscular dystrophy (DMD) is an incurable neuromuscular disorder of childhood. Healthcare, caregiving, and other resource needs of affected individuals are thought to be substantial; however, the economic burden associated with DMD has not yet been assessed specifically in Australia. METHODS Australian households with a child with DMD were asked to complete a cross-sectional survey. Data were collected on annual resource utilization including hospital and medical services, equipment, home modifications, informal care, and working days lost. RESULTS Mean healthcare costs were found to be $10,046 Australian dollars per affected individual and were markedly higher than average Australian health expenditures at each age group. The mean total cost was $46,700 (median $32,300), with healthcare costs contributing 22% of total costs. CONCLUSIONS The annual economic cost of DMD was found to be high, reflecting a significant socioeconomic burden, especially in boys who reach adulthood, where household resource use and caregiving burden is highest. Muscle Nerve 53: 877-884, 2016.
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Affiliation(s)
- Lucinda J Teoh
- School of Population Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Elizabeth A Geelhoed
- Harry Perkins Institute of Medical Research, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Klair Bayley
- Harry Perkins Institute of Medical Research, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Helen Leonard
- Telethon Kids Institute, Child Disability Research, West Perth, Western Australia, Australia
| | - Nigel G Laing
- Harry Perkins Institute of Medical Research, The University of Western Australia, Nedlands, Western Australia, Australia
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MacIntyre EJ, Asadi L, Mckim DA, Bagshaw SM. Clinical Outcomes Associated with Home Mechanical Ventilation: A Systematic Review. Can Respir J 2016; 2016:6547180. [PMID: 27445559 PMCID: PMC4904519 DOI: 10.1155/2016/6547180] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 08/23/2015] [Indexed: 11/18/2022] Open
Abstract
Background. The prevalence of patients supported with home mechanical ventilation (HMV) for chronic respiratory failure has increased. However, the clinical outcomes associated with HMV are largely unknown. Methods. We performed a systematic review of studies evaluating patients receiving HMV for indications other than obstructive lung disease, reporting at least one clinically relevant outcome including health-related quality of life (HRQL) measured by validated tools; hospitalization requirements; caregiver burden; and health service utilization. We searched MEDLINE, EMBASE, CINAHL, the Cochrane library, clinical trial registries, proceedings from selected scientific meetings, and bibliographies of retrieved citations. Results. We included 1 randomized control trial (RCT) and 25 observational studies of mixed methodological quality involving 4425 patients; neuromuscular disorders (NMD) (n = 1687); restrictive thoracic diseases (RTD) (n = 481); obesity hypoventilation syndrome (OHS) (n = 293); and others (n = 748). HRQL was generally described as good for HMV users. Mental rather than physical HRQL domains were rated higher, particularly where physical assessment was limited. Hospitalization rates and days in hospital appear to decrease with implementation of HMV. Caregiver burden associated with HMV was generally high; however, it is poorly described. Conclusion. HRQL and need for hospitalization may improve after establishment of HMV. These inferences are based on relatively few studies of marked heterogeneity and variable quality.
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Affiliation(s)
- Erika J. MacIntyre
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T6G 2B7
| | - Leyla Asadi
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T6G 2R3
| | - Doug A. Mckim
- Division of Respirology and Respiratory Rehabilitation Services, Faculty of Medicine and Dentistry, University of Ottawa, Ottawa, ON, Canada T6G 2R3
| | - Sean M. Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T6G 2B7
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada T6G 2R3
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29
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Bach JR, Herrero MV, Chiou M. Complementary therapies that do not include respiratory therapies are a very small part of the story. J Pediatr Rehabil Med 2016; 9:73-5. [PMID: 26966803 DOI: 10.3233/prm-160363] [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: 11/15/2022] Open
Affiliation(s)
- John Robert Bach
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - María Victoria Herrero
- Kinesiology and Physical Medicine University, Petrona Villegas de Cordero Hospital, Buenos Aires, San Fernando, Argentina
| | - Michael Chiou
- Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, University Hospital, Newark, NJ, USA
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30
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LoMauro A, D'Angelo MG, Aliverti A. Assessment and management of respiratory function in patients with Duchenne muscular dystrophy: current and emerging options. Ther Clin Risk Manag 2015; 11:1475-88. [PMID: 26451113 PMCID: PMC4592047 DOI: 10.2147/tcrm.s55889] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is an X-linked myopathy resulting in progressive weakness and wasting of all the striated muscles including the respiratory muscles. The consequences are loss of ambulation before teen ages, cardiac involvement and breathing difficulties, the main cause of death. A cure for DMD is not currently available. In the last decades the survival of patients with DMD has improved because the natural history of the disease can be changed thanks to a more comprehensive therapeutic approach. This comprises interventions targeted to the manifestations and complications of the disease, particularly in the respiratory care. These include: 1) pharmacological intervention, namely corticosteroids and idebenone that significantly reduce the decline of spirometric parameters; 2) rehabilitative intervention, namely lung volume recruitment techniques that help prevent atelectasis and slows the rate of decline of pulmonary function; 3) scoliosis treatment, namely steroid therapy that is used to reduce muscle inflammation/degeneration and prolong ambulation in order to delay the onset of scoliosis, being an additional contribution to the restrictive lung pattern; 4) cough assisted devices that improve airway clearance thus reducing the risk of pulmonary infections; and 5) non-invasive mechanical ventilation that is essential to treat nocturnal hypoventilation, sleep disordered breathing, and ultimately respiratory failure. Without any intervention death occurs within the first 2 decades, however, thanks to this multidisciplinary therapeutic approach life expectancy of a newborn with DMD nowadays can be significantly prolonged up to his fourth decade. This review is aimed at providing state-of-the-art methods and techniques for the assessment and management of respiratory function in DMD patients.
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Affiliation(s)
- Antonella LoMauro
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | | | - Andrea Aliverti
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
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31
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Gregoretti C, Pisani L, Cortegiani A, Ranieri VM. Noninvasive Ventilation in Critically Ill Patients. Crit Care Clin 2015; 31:435-57. [DOI: 10.1016/j.ccc.2015.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Jeong JH, Yoo WG. Effects of air stacking on pulmonary function and peak cough flow in patients with cervical spinal cord injury. J Phys Ther Sci 2015; 27:1951-2. [PMID: 26180355 PMCID: PMC4500018 DOI: 10.1589/jpts.27.1951] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/09/2015] [Indexed: 12/13/2022] Open
Abstract
[Purpose] This study evaluated the effects of air stacking on pulmonary function and peak
cough flow in patients with cervical spinal cord injury. [Subjects] Twenty-six patients
were included in the study and were randomized into experimental (n = 14) and control (n =
12) groups. [Methods] Both groups performed therapeutic exercises: the control group
performed incentive spirometry, while the experimental group performed 20 repetitions of
air stacking exercise twice a day. The training for both groups continued for 5 days a
week for 6 weeks. [Results] Forced vital capacity and peak cough flow increased
significantly in the experimental group compared to the controls. All within-group
variables in the experimental group differed significantly at 6 weeks compared to
baseline, while in the control group only Forced vital capacity differed significantly at
6 weeks compared to baseline. [Conclusion] Air stacking exercise significantly improved
pulmonary function and peak cough flow in patients with a cervical spinal cord injury.
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Affiliation(s)
- Jong-Hwa Jeong
- Department of Physical Therapy, The Graduate School, Inje University, Republic of Korea
| | - Won-Gyu Yoo
- Department of Physical Therapy, College of Biomedical Science and Engineering, Inje University, Republic of Korea
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Cost and Physician Effort Analysis of Invasive vs. Noninvasive Respiratory Management of Duchenne Muscular Dystrophy. Am J Phys Med Rehabil 2015; 94:474-82. [DOI: 10.1097/phm.0000000000000228] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kaminska M, Browman F, Trojan DA, Genge A, Benedetti A, Petrof BJ. Feasibility of Lung Volume Recruitment in Early Neuromuscular Weakness: A Comparison Between Amyotrophic Lateral Sclerosis, Myotonic Dystrophy, and Postpolio Syndrome. PM R 2015; 7:677-684. [PMID: 25845857 DOI: 10.1016/j.pmrj.2015.04.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/30/2015] [Accepted: 04/01/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Lung volume recruitment (LVR) is a cough assistance technique used in persons with neuromuscular disorders (NMDs), most typically in those requiring noninvasive ventilation (NIV). Whether it may be useful in persons with NMDs who have milder respiratory impairment is unknown. OBJECTIVE To assess the feasibility, impact on quality of life (QOL), and preliminary physiological effects of daily LVR in different categories of persons with NMDs who have an early stage of respiratory impairment. DESIGN Feasibility study. SETTING Academic tertiary care center. PARTICIPANTS Outpatients diagnosed with amyotrophic lateral sclerosis (n = 8), postpolio syndrome (n = 10), and myotonic dystrophy (n = 6) who had restrictive respiratory defects but were not yet using NIV. METHODS Participants were asked to perform LVR up to 4 times daily and log their LVR use in a diary. Physiological measurements and questionnaires were completed at baseline and after 3 months. MAIN OUTCOME MEASUREMENTS Compliance with LVR use was assessed, along with QOL and willingness to continue the treatment. Physiological measurements included forced vital capacity (FVC), lung insufflation capacity (LIC), and the LIC minus FVC difference. RESULTS Of the 24 recruited subjects, 7 with amyotrophic lateral sclerosis, 7 with postpolio syndrome, and 5 with myotonic dystrophy completed the study (n = 19). At baseline, mean values for FVC and spontaneous peak cough flow were 59.9% predicted and 373.1 L/min, respectively. For subjects completing the study, 74% were willing to continue long-term LVR use, and QOL scores were not adversely affected by LVR in any NMD subgroup. The LIC-FVC difference increased from baseline to follow-up by a mean of 0.243 L (P = .006) in all subjects (n = 19), suggesting a possible improvement in respiratory system mechanics. CONCLUSIONS In patients with NMDs who have early restrictive respiratory defects but do not yet require NIV, regular use of LVR is feasible with no negative impact on QOL over a 3-month period and may have physiological benefits. Further work is needed to determine whether early institution of LVR can improve respiratory system mechanics and help delay ventilatory failure in persons with NMDs.
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Affiliation(s)
- Marta Kaminska
- Respiratory Division, McGill University Health Centre, 1001 Decarie Blvd, D05.2504 Montreal, Quebec, Canada H4A 3J1
- Respiratory Epidemiology and Clinical Research Unit, McGill University, Montreal, Quebec, Canada
| | - Franceen Browman
- Department of Respiratory Therapy, Montreal Chest Institute, McGill University Health Centre, Montreal, Quebec, Canada
| | - Daria A Trojan
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Angela Genge
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrea Benedetti
- Respiratory Epidemiology and Clinical Research Unit, McGill University, Montreal, Quebec, Canada
- Departments of Medicine and Epidemiology, Biostatistics & Occupational Health, McGill University Health Centre, Montreal, Quebec, Canada
| | - Basil J Petrof
- Respiratory Division, McGill University Health Centre, Montreal, Quebec, Canada
- Meakins-Christie Laboratories, McGill University and Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
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Annane D, Orlikowski D, Chevret S. Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders. Cochrane Database Syst Rev 2014; 2014:CD001941. [PMID: 25503955 PMCID: PMC7068159 DOI: 10.1002/14651858.cd001941.pub3] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic alveolar hypoventilation is a common complication of many neuromuscular and chest wall disorders. Long-term nocturnal mechanical ventilation is commonly used to treat it. This is a 2014 update of a review first published in 2000 and previously updated in 2007. OBJECTIVES To examine the effects on mortality of nocturnal mechanical ventilation in people with neuromuscular or chest wall disorders. Subsidiary endpoints were to examine the effects of respiratory assistance on improvement of chronic hypoventilation, sleep quality, hospital admissions and quality of life. SEARCH METHODS We searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE on 10 June 2014. We contacted authors of identified trials and other experts in the field. SELECTION CRITERIA We searched for quasi-randomised or randomised controlled trials of participants of all ages with neuromuscular or chest wall disorder-related stable chronic hypoventilation of all degrees of severity, receiving any type and any mode of long-term nocturnal mechanical ventilation. The primary outcome measure was one-year mortality and secondary outcomes were unplanned hospital admission, short-term and long-term reversal of hypoventilation-related clinical symptoms and daytime hypercapnia, improvement of lung function and sleep breathing disorders. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to select studies, extract data and assess the risk of bias in included studies. MAIN RESULTS The 10 eligible trials included a total of 173 participants. Roughly half of the trials were at low risk of selection, attrition or reporting bias, and almost all were at high risk of performance and detection bias. Four trials reported mortality data in the long term. The pooled risk ratio (RR) of dying was 0.62 (95% confidence interval (CI) 0.42 to 0.91, P value = 0.01) in favour of nocturnal mechanical ventilation compared to spontaneous breathing. There was considerable and significant heterogeneity between the trials, possibly related to differences between the study populations. Information on unplanned hospitalisation was available from two studies. The corresponding pooled RR was 0.25 (95% CI 0.08 to 0.82, P value = 0.02) in favour of nocturnal mechanical ventilation. For most of the outcome measures there was no significant long-term difference between nocturnal mechanical ventilation and no ventilation. Most of the secondary outcomes were not assessed in the eligible trials. Three out of the 10 trials, accounting for 39 participants, two with a cross-over design and one with two parallel groups, compared volume- and pressure-cycled non-invasive mechanical ventilation in the short term. From the only trial (16 participants) on parallel groups, there was no difference in mortality (one death in each arm) between volume- and pressure-cycled mechanical ventilation. Data from the two cross-over trials suggested that compared with pressure-cycled ventilation, volume-cycled ventilation was associated with less sleep time spent with an arterial oxygen saturation below 90% (mean difference (MD) 6.83 minutes, 95% CI 4.68 to 8.98, P value = 0.00001) and a lower apnoea-hypopnoea (per sleep hour) index (MD -0.65, 95% CI -0.84 to -0.46, P value = 0.00001). We found no study that compared invasive and non-invasive mechanical ventilation or intermittent positive pressure versus negative pressure ventilation. AUTHORS' CONCLUSIONS Current evidence about the therapeutic benefit of mechanical ventilation is of very low quality, but is consistent, suggesting alleviation of the symptoms of chronic hypoventilation in the short term. In four small studies, survival was prolonged and unplanned hospitalisation was reduced, mainly in participants with motor neuron diseases. With the exception of motor neuron disease and Duchenne muscular dystrophy, for which the natural history supports the survival benefit of mechanical ventilation against no ventilation, further larger randomised trials should assess the long-term benefit of different types and modes of nocturnal mechanical ventilation on quality of life, morbidity and mortality, and its cost-benefit ratio in neuromuscular and chest wall diseases.
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Affiliation(s)
- Djillali Annane
- Critical Care Department, Hôpital Raymond Poincaré, Assistance Publique - Hôpitaux de Paris, 104. Boulevard Raymond Poincaré, Garches, Ile de France, 92380, France.
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Rodrigues MR, Carvalho CRF, Santaella DF, Lorenzi-Filho G, Marie SKN. Effects of yoga breathing exercises on pulmonary function in patients with Duchenne muscular dystrophy: an exploratory analysis. J Bras Pneumol 2014; 40:128-33. [PMID: 24831396 PMCID: PMC4083644 DOI: 10.1590/s1806-37132014000200005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 02/18/2014] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE: Duchenne muscular dystrophy (DMD) is the most common form of muscular dystrophy
in children, and children with DMD die prematurely because of respiratory failure.
We sought to determine the efficacy and safety of yoga breathing exercises, as
well as the effects of those exercises on respiratory function, in such children.
METHODS: This was a prospective open-label study of patients with a confirmed diagnosis of
DMD, recruited from among those followed at the neurology outpatient clinic of a
university hospital in the city of São Paulo, Brazil. Participants were taught how
to perform hatha yoga breathing exercises and were instructed to perform the
exercises three times a day for 10 months. RESULTS: Of the 76 patients who entered the study, 35 dropped out and 15 were unable to
perform the breathing exercises, 26 having therefore completed the study (mean
age, 9.5 ± 2.3 years; body mass index, 18.2 ± 3.8 kg/m2). The yoga
breathing exercises resulted in a significant increase in FVC (% of predicted:
82.3 ± 18.6% at baseline vs. 90.3 ± 22.5% at 10 months later; p = 0.02) and
FEV1 (% of predicted: 83.8 ± 16.6% at baseline vs. 90.1 ± 17.4% at
10 months later; p = 0.04). CONCLUSIONS: Yoga breathing exercises can improve pulmonary function in patients with DMD.
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Powering the immune system: mitochondria in immune function and deficiency. J Immunol Res 2014; 2014:164309. [PMID: 25309931 PMCID: PMC4189529 DOI: 10.1155/2014/164309] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/20/2014] [Accepted: 08/25/2014] [Indexed: 01/15/2023] Open
Abstract
Mitochondria are critical subcellular organelles that are required for several metabolic processes, including oxidative phosphorylation, as well as signaling and tissue-specific processes. Current understanding of the role of mitochondria in both the innate and adaptive immune systems is expanding. Concurrently, immunodeficiencies arising from perturbation of mitochondrial elements are increasingly recognized. Recent observations of immune dysfunction and increased incidence of infection in patients with primary mitochondrial disorders further support an important role for mitochondria in the proper function of the immune system. Here we review current findings.
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Bhattacharjee R, Gozal D. Sleep Hypoventilation Syndromes and Noninvasive Ventilation in Children. Sleep Med Clin 2014. [DOI: 10.1016/j.jsmc.2014.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Open circuit mouthpiece ventilation: Concise clinical review. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:211-8. [PMID: 24841239 DOI: 10.1016/j.rppneu.2014.03.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/16/2014] [Accepted: 03/24/2014] [Indexed: 11/22/2022] Open
Abstract
In 2013 new "mouthpiece ventilation" modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece. Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via "mask" interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22mm angled mouthpieces and straw-type mouthpieces are the most commonly used. NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates "air-stacking" to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.
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Walker MA, Slate N, Alejos A, Volpi S, Iyengar RS, Sweetser D, Sims KB, Walter JE. Predisposition to infection and SIRS in mitochondrial disorders: 8 years' experience in an academic center. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:465-468, 468.e1. [PMID: 25017538 DOI: 10.1016/j.jaip.2014.02.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Revised: 01/13/2014] [Accepted: 02/07/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Melissa A Walker
- Department of Neurology, Massachusetts General Hospital, Boston, Mass
| | - Nancy Slate
- Department of Molecular Biology, Massachusetts General Hospital, Boston, Mass
| | - Alexandra Alejos
- Division of Allergy and Immunology, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - Stefano Volpi
- Department of Pediatrics, Università degli Studi di Genova, Genova, Italy
| | - Rajashri S Iyengar
- Division of Allergy and Immunology, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Mass
| | - David Sweetser
- Department of Genetics, Massachusetts General Hospital, Boston, Mass
| | - Katherine B Sims
- Department of Neurology, Massachusetts General Hospital, Boston, Mass
| | - Jolan E Walter
- Division of Allergy and Immunology, Department of Pediatrics, Massachusetts General Hospital for Children, Boston, Mass.
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Anderson JL, Hasney KM, Beaumont NE. Systematic review of techniques to enhance peak cough flow and maintain vital capacity in neuromuscular disease: the case for mechanical insufflation–exsufflation. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/108331905x43454] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Twenty-four hour noninvasive ventilation in Duchenne muscular dystrophy: a safe alternative to tracheostomy. Can Respir J 2013; 20:e5-9. [PMID: 23457679 DOI: 10.1155/2013/406163] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Almost all patients with Duchenne muscular dystrophy (DMD) eventually develop respiratory failure. Once 24 h ventilation is required, either due to incomplete effectiveness of nocturnal noninvasive ventilation (NIV) or bulbar weakness, it is common practice to recommend invasive tracheostomy ventilation; however, noninvasive daytime mouthpiece ventilation (MPV) as an addition to nocturnal mask ventilation is also an alternative. METHODS The authors' experience with 12 DMD patients who used 24 h NIV with mask NIV at night and MPV during daytime hours is reported. RESULTS The mean (± SD) age and vital capacity (VC) at initiation of nocturnal (only) NIV subjects were 17.8±3.5 years and 0.90±0.40 L (21% predicted), respectively; and, at the time of MPV, 19.8±3.4 years and 0.57 L (13.2% predicted), respectively. In clinical practice, carbon dioxide (CO2) levels were measured using different methods: arterial blood gas analysis, transcutaneous partial pressure of CO2 and, predominantly, by end-tidal CO2. While the results suggested improved CO2 levels, these were not frequently confirmed by arterial blood gas measurement. The mean survival on 24 h NIV has been 5.7 years (range 0.17 to 12 years). Of the 12 patients, two deaths occurred after 3.75 and four years, respectively, on MPV; the remaining patients continue on 24 h NIV (range two months to 12 years; mean 5.3 years; median 3.5 years). CONCLUSIONS Twenty-four hour NIV should be considered a safe alternative for patients with DMD because its use may obviate the need for tracheostomy in patients with chronic respiratory failure requiring more than nocturnal ventilation alone.
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Bolikal P, Bach JR, Goncalves M. Electrophrenic pacing and decannulation for high-level spinal cord injury: a case series. J Spinal Cord Med 2012; 35:170-4. [PMID: 22333657 PMCID: PMC3324834 DOI: 10.1179/2045772311y.0000000056] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND In 1997, guidelines were developed for the management of high-level ventilator-dependent patients with spinal cord injury who had little or no ventilator-free breathing ability (VFBA). This article describes the three categories of patients, the decannulation criteria, and the successful decannulation of four patients with no VFBA and electrophrenic/diaphragm pacing, using these criteria. METHOD Case series. CONCLUSION Lack of VFBA in patients with high-level spinal cord injury does not mandate tracheostomy or electrophrenic/diaphragm pacing.
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Affiliation(s)
- Priya Bolikal
- Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, University Hospital, Newark, NJ 07103, USA
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De Vito EL, Suárez AA, Monteiro SG. The use of full-setting non-invasive ventilation in the home care of people with amyotrophic lateral sclerosis-motor neuron disease with end-stage respiratory muscle failure: a case series. J Med Case Rep 2012; 6:42. [PMID: 22289290 PMCID: PMC3295643 DOI: 10.1186/1752-1947-6-42] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 01/30/2012] [Indexed: 12/14/2022] Open
Abstract
Introduction Little has been written about the use of non-invasive ventilation in the home care of amyotrophic lateral sclerosis-motor neuron disease patients with end-stage respiratory muscle failure. Nocturnal use of non-invasive ventilation has been reported to improve daytime blood gases but continuous non-invasive ventilation dependence has not been studied in this regard. There continues to be great variation by country, economics, physician interest and experience, local concepts of palliation, hospice requirements, and resources available for home care. We report a case series of home-based amyotrophic lateral sclerosis-motor neuron disease patients who refused tracheostomy and advanced non-invasive ventilation to full-setting, while maintaining normal alveolar ventilation and oxygenation in the course of the disease. Since this topic has been presented in only one center in the United States and nowhere else, it is appropriate to demonstrate that this can be done in other countries as well. Case presentation We present here the cases of three Caucasian patients (a 51-year-old Caucasian man, a 45-year-old Caucasian woman and a 57-year-old Caucasian woman) with amyotrophic lateral sclerosis who developed continuous non-invasive ventilation dependence for 15 to 27 months without major complications and were able to maintain normal CO2 and pulse oxyhemoglobin saturation despite a non-measurable vital capacity. All patients were wheelchair-dependent and receiving riluzole 50 mg twice a day. Patient one developed mild-to-moderate bulbar-innervated muscle weakness. He refused tracheostomy but accepted percutaneous gastrostomy. Patient two had two lung infections, acute bronchitis and pneumonia, which were treated with antibiotics and cough assistance at home. Patient three had three chest infections (bronchitis and pneumonias) and asthmatic episodes treated with antibiotics, bronchodilators and cough assistance at home. All patients had normal speech while receiving positive pressure; they died suddenly and with normal oxygen saturation. Conclusions Although warned that prognosis was poor as vital capacity diminished, our patients survived without invasive airway tubes and despite non-measurable vital capacity. No patient opted for tracheostomy. Our patients demonstrate the feasibility of resorting to full-setting non-invasive management to prolong survival, optimizing wellness and management at home, and the chance to die peacefully.
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Affiliation(s)
- Eduardo L De Vito
- Laboratorio Pulmonar de Enfermedades Neuromusculares, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CONICET Combatientes de Malvinas 3150, CP 1427, Buenos Aires, Argentina.
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Ditunno JF, Cardenas DD, Formal C, Dalal K. Advances in the rehabilitation management of acute spinal cord injury. HANDBOOK OF CLINICAL NEUROLOGY 2012; 109:181-95. [PMID: 23098713 DOI: 10.1016/b978-0-444-52137-8.00011-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Aggressive assessment and management of the secondary complications in the hours and days following spinal cord injury (SCI) leads to restoration of function in patients through intervention by a team of rehabilitation professionals. The recent certification of SCI physicians, newly validated assessments of impairment and function measures, and international databases agreed upon by SCI experts should lead to documentation of improved rehabilitation care. This chapter highlights recent advances in assessment and treatment based on evidence-based classification of literature reviews and expert opinion in the acute phase of SCI. A number of these reviews are the product of the Consortium for Spinal Cord Medicine, which offers clinical practice guidelines for healthcare professionals. Recognition of and early intervention for problems such as bradycardia, orthostatic hypotension, deep vein thrombosis/pulmonary embolism, and early ventilatory failure will be addressed although other chapters may discuss some issues in greater detail. Early assessment and intervention for neurogenic bladder and bowel function has proven effective in the prevention of renal failure and uncontrolled incontinence. Attention to overuse and disuse with training and advanced technology such as functional electrical stimulation have reduced pain and disability associated with upper extremity deterioration and improved physical fitness. Topics such as chronic pain, spasticity, sexual dysfunction, and pressure sores will be covered in more detail in additional chapters. However, the comprehensive and integrated rehabilitation by specialized SCI teams of physicians, nurses, therapists, social workers, and psychologists immediately following SCI has become the standard of care throughout the world.
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Affiliation(s)
- John F Ditunno
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadelphia, PA, USA
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Racca F, Berta G, Sequi M, Bignamini E, Capello E, Cutrera R, Ottonello G, Ranieri VM, Salvo I, Testa R, Wolfler A, Bonati M. Long-term home ventilation of children in Italy: a national survey. Pediatr Pulmonol 2011; 46:566-72. [PMID: 21560263 DOI: 10.1002/ppul.21401] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 09/10/2010] [Accepted: 09/13/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Improved technology, as well as professional and parental awareness, enable many ventilator-dependent children to live at home. However, the profile of this growing population, the quality and adequacy of home care, and patients' needs still require thorough assessment. OBJECTIVES To define the characteristics of Italian children receiving long-term home mechanical ventilation (HMV) in Italy. METHODS A detailed questionnaire was sent to 302 National Health Service hospitals potentially involved in the care of HVM in children (aged <17 years). Information was collected on patient characteristics, type of ventilation, and home respiratory care. RESULTS A total of 362 HMV children was identified. The prevalence was 4.2 per 100,000 (95% CI: 3.8-4.6), median age was 8 years (interquartile range 4-14), median age at starting mechanical ventilation was 4 years (1-11), and 56% were male. The most frequent diagnostic categories were neuromuscular disorders (49%), lung and upper respiratory tract diseases (18%), hypoxic (ischemic) encephalopathy (13%), and abnormal ventilation control (12%). Medical professionals with nurses (for 62% of children) and physiotherapists (20%) participated in the patients' discharge from hospital, though parents were the primary care giver, and in 47% of cases, the sole care giver. Invasive ventilation was used in 41% and was significantly related to young age, southern regional residence, longer time spent under mechanical ventilation, neuromuscular disorders, or hypoxic (ischemic) encephalopathy. CONCLUSIONS Care and technical assistance of long-term HMV children need assessment, planning, and resources. A wide variability in pattern of HMV was found throughout Italy. An Italian national ventilation program, as well as a national registry, could be useful in improving the care of these often critically ill children.
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Affiliation(s)
- F Racca
- Department of Anesthesiology and Intensive Care Medicine, San Giovanni Battista-Molinette Hospital, University of Turin, Turin, Italy
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Duchenne muscular dystrophy: survival by cardio-respiratory interventions. Neuromuscul Disord 2010; 21:47-51. [PMID: 21144751 DOI: 10.1016/j.nmd.2010.09.006] [Citation(s) in RCA: 184] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 09/07/2010] [Accepted: 09/16/2010] [Indexed: 11/21/2022]
Abstract
We describe survival in Duchenne dystrophy by invasive and noninvasive ventilation vs. untreated. Patients were untreated prior to 1984 (Group 1), underwent tracheotomy from 1984 until 1991 (Group 2), and were managed by noninvasive mechanical ventilation and cardioprotective medications subsequently (Group 3). Symptoms, vital capacity, and blood gases were monitored for all and spirometry, cough peak flows, carbon dioxide tension, and oximetry for Group 3. Sleep nasal ventilation was initiated for symptomatic hypoventilation. An oximeter and mechanical cough assistance were prescribed for maximum assisted cough peak flow <300 L/m. Patients used continuous noninvasive ventilation and mechanically assisted coughing as needed to maintain pulse oxyhemoglobin saturation ≥95%. Survival was compared by Kaplan-Meier analysis. The 56 of Group 1 died at 18.6±2.9, the 21 Group 2 at 28.1±8.3 years of age with three still alive, and the 88 using noninvasive ventilation had 50% survival to 39.6 years, p<0.001, respectively. We conclude that noninvasive mechanical ventilation and assisted coughing provided by specifically trained physicians and therapists, and cardioprotective medication can result in more favorable outcomes and better survival by comparison with invasive treatment.
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