1
|
Khan A, Frazer-Green L, Amin R, Wolfe L, Faulkner G, Casey K, Sharma G, Selim B, Zielinski D, Aboussouan LS, McKim D, Gay P. Respiratory Management of Patients With Neuromuscular Weakness: An American College of Chest Physicians Clinical Practice Guideline and Expert Panel Report. Chest 2023; 164:394-413. [PMID: 36921894 DOI: 10.1016/j.chest.2023.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Respiratory failure is a significant concern in neuromuscular diseases (NMDs). This CHEST guideline examines the literature on the respiratory management of patients with NMD to provide evidence-based recommendations. STUDY DESIGN AND METHODS An expert panel conducted a systematic review addressing the respiratory management of NMD and applied the Grading of Recommendations, Assessment, Development, and Evaluations approach for assessing the certainty of the evidence and formulating and grading recommendations. A modified Delphi technique was used to reach a consensus on the recommendations. RESULTS Based on 128 studies, the panel generated 15 graded recommendations, one good practice statement, and one consensus-based statement. INTERPRETATION Evidence of best practices for respiratory management in NMD is limited and is based primarily on observational data in amyotrophic lateral sclerosis. The panel found that pulmonary function testing every 6 months may be beneficial and may be used to initiate noninvasive ventilation (NIV) when clinically indicated. An individualized approach to NIV settings may benefit patients with chronic respiratory failure and sleep-disordered breathing related to NMD. When resources allow, polysomnography or overnight oximetry can help to guide the initiation of NIV. The panel provided guidelines for mouthpiece ventilation, transition to home mechanical ventilation, salivary secretion management, and airway clearance therapies. The guideline panel emphasizes that NMD pathologic characteristics represent a diverse group of disorders with differing rates of decline in lung function. The clinician's role is to add evaluation at the bedside to shared decision-making with patients and families, including respect for patient preferences and treatment goals, considerations of quality of life, and appropriate use of available resources in decision-making.
Collapse
Affiliation(s)
- Akram Khan
- Division of Pulmonary Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR.
| | | | - Reshma Amin
- Department of Respiratory Medicine, The Hospital for Sick Kids, Toronto
| | - Lisa Wolfe
- Department of Medicine, Northwestern University, Chicago, IL
| | | | - Kenneth Casey
- Department of Sleep Medicine, William S. Middleton Memorial Veterans Hospital, Shorewood Hills, WI
| | - Girish Sharma
- Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | - Bernardo Selim
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - David Zielinski
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | | | - Douglas McKim
- Department of Medicine, The Ottawa Hospital Research Institute, Ottawa, ON
| | - Peter Gay
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
2
|
Guo W, Meng L, Cao L. Risk factors for recurrent respiratory tract infections and acute respiratory failure in children with spinal muscular atrophy. Pediatr Pulmonol 2023; 58:507-515. [PMID: 36367332 PMCID: PMC10098738 DOI: 10.1002/ppul.26218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/19/2022] [Accepted: 10/22/2022] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Assessment of and intervention for sleep-disordered breathing and malnutrition are related to the prevention of recurrent respiratory tract infections (RRTIs) and acute respiratory failure (ARF) in children with spinal muscular atrophy (SMA). However, specific standards for sleep-disordered breathing and malnutrition in the prevention of RRTIs and ARF have not been clarified. PURPOSE The study aimed to identify the risk factors and predictive indices for RRTIs and/or ARF in children with SMA. METHODS In this retrospective study, the differences in clinical characteristics between patients with and without RRTIs and ARF were compared, and binary logistic regression analysis was carried out. The optimal cutoff points for positive predictors were obtained. RESULTS SMA type 1 (odds ratio (OR) = 5.21, 95% confidence interval (CI) 1.50-18.17, p = 0.010) and the apnea-hypopnea index (AHI) (OR = 1.12, 95% CI 1.01-1.24, p = 0.026) were risk factors, while the body mass index z score (BMIz) (OR = 0.65, 95% CI 0.46-0.91, p = 0.013) and mean pulse oxygen saturation (MSpO2 ) (OR = 0.72, 95% CI 0.52-1.00, p = 0.049) were protective factors. A standard consisting of (i) MSpO2 < 96% and (ii) AHI > 10 events/h and/or BMIz < -1 predicted the occurrence of RRTIs and/or ARF in the next year with a sensitivity of 0.513 and a specificity of 0.957. CONCLUSION SMA type 1, BMIz, AHI and MSpO2 should be used to estimate the risk of RRTI and/or ARF in children with SMA. MSpO2 < 96% combined with AHI > 10 events/h or BMIz < -1 should be used as the intervention standard.
Collapse
Affiliation(s)
- Wenhui Guo
- Department of Pulmonology, Affiliated Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| | - Linghui Meng
- Center for Evidence-Based Medicine, Capital Institute of Pediatrics, Beijing, China
| | - Ling Cao
- Department of Pulmonology, Affiliated Children's Hospital, Capital Institute of Pediatrics, Beijing, China
| |
Collapse
|
3
|
Carmona H, Graustein AD, Benditt JO. Chronic Neuromuscular Respiratory Failure and Home Assisted Ventilation. Annu Rev Med 2023; 74:443-455. [PMID: 36706747 DOI: 10.1146/annurev-med-043021-013620] [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: 01/28/2023]
Abstract
Chronic respiratory failure is a common, important complication of many types of neuromuscular and chest wall disorders. While the pathophysiology of each disease may be different, these disorders can variably affect all muscles involved in breathing, including inspiratory, expiratory, and bulbar muscles, ultimately leading to chronic respiratory failure and hypoventilation. The use of home assisted ventilation through noninvasive interfaces aims to improve the symptoms of hypoventilation, improve sleep quality, and, when possible, improve mortality. An increasing variety of interfaces has allowed for improved comfort and compliance. In a minority of scenarios, noninvasive ventilation is either not appropriate or no longer effective due to disease progression, and a transition to tracheal ventilation should be considered.
Collapse
Affiliation(s)
- Hugo Carmona
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington, USA; ,
| | - Andrew D Graustein
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington, USA; , .,VA Puget Sound Health Care System, Seattle, Washington, USA;
| | - Joshua O Benditt
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine, Seattle, Washington, USA; ,
| |
Collapse
|
4
|
Patel N, Chong K, Baydur A. Methods and Applications in Respiratory Physiology: Respiratory Mechanics, Drive and Muscle Function in Neuromuscular and Chest Wall Disorders. Front Physiol 2022; 13:838414. [PMID: 35774289 PMCID: PMC9237333 DOI: 10.3389/fphys.2022.838414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Individuals with neuromuscular and chest wall disorders experience respiratory muscle weakness, reduced lung volume and increases in respiratory elastance and resistance which lead to increase in work of breathing, impaired gas exchange and respiratory pump failure. Recently developed methods to assess respiratory muscle weakness, mechanics and movement supplement traditionally employed spirometry and methods to evaluate gas exchange. These include recording postural change in vital capacity, respiratory pressures (mouth and sniff), electromyography and ultrasound evaluation of diaphragmatic thickness and excursions. In this review, we highlight key aspects of the pathophysiology of these conditions as they impact the patient and describe measures to evaluate respiratory dysfunction. We discuss potential areas of physiologic investigation in the evaluation of respiratory aspects of these disorders.
Collapse
|
5
|
Wolfe LF, Benditt JO, Aboussouan L, Hess DR, Coleman JM. Optimal Noninvasive Medicare Access Promotion: Patients with Thoracic Restrictive Diseases A Technical Expert Panel Report from the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society. Chest 2021; 160:e399-e408. [PMID: 34339688 DOI: 10.1016/j.chest.2021.05.075] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/30/2022] Open
Abstract
The existing coverage criteria for Non-Invasive Ventilation (NIV) do not recognize the benefits of early initiation of NIV for those with Thoracic Restrictive Disease (TRD) and do not address the unique needs for daytime support as the patient's progress to ventilator dependence. This document summarizes the work of the Thoracic Restrictive Disease Technical Expert Panel working group. The most pressing current coverage barriers identified were: 1) Delays in implementing NIV treatment 2) Lack of coverage for many non-progressive Neuro-Muscular Disease (NMD) and 3) Lack of clear policy indications for Home -Mechanical Ventilation (HMV) Support in TRD. To best address these issues we make the following key recommendations: 1) Given the need to encourage early initiation of NIV with Bi-level Positive Airway Pressure (BPAP) devices, we recommend that symptoms be considered as a reason to initiate therapy even at mildly reduced FVC's.; 2) Broaden CO2 measurements to include surrogates such as transcutaneous, end-tidal or Venous Blood Gas (VBG); 3) Expand the diagnostic category to include Phrenic Nerve injuries and Disorders of Central Drive; 4) Allow a BPAP device to be advanced to an HMV when the VC is <30% or to address severe daytime respiratory symptoms; 5) Provide an additional HMV when the patient is ventilator dependent with use >18 hours/ day. Adoption of these proposed recommendations would result in the right device, at the right time, for the right type of patients with hypoventilation syndromes.
Collapse
Affiliation(s)
| | | | | | - Dean R Hess
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | |
Collapse
|
6
|
Ayhan Y, Yuksel Karatoprak E, Onay ZR, Can Oksay S, Girit S. Assessment of Nocturnal Hypoventilation by Different Methods and Definitions in Children with Neuromuscular Disease: Oxycapnography and Blood Gas Analysis. Medeni Med J 2021; 36:106-116. [PMID: 34239762 PMCID: PMC8226400 DOI: 10.5222/mmj.2021.42385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/24/2021] [Indexed: 11/06/2022] Open
Abstract
Objective To investigate whether partial arterial carbon dioxide pressure (PaCO2) level in arterial blood gas analysis that was used to predict nocturnal hypoventilation (NH) is concordant with nocturnal end-tidal CO2 (PetCO2) measurement obtained by a noninvasive method of oxycapnography in children with neuromuscular disease (NMD). Methods Twenty-one patients aged 6-18 years with a confirmed diagnosis of NMD were enrolled. Each patient underwent a nocturnal oxycapnography study using an orinasal probe and a pulse oximetry finger probe to record PetCO2, oxygen saturation (SpO2), pulse rate, and respiratory rate. Arterial blood gas analysis was performed to record PaCO2 levels on three occasions at night (23:00 pm, 03:00 am, 07:00 am). Results The mean overnight PaCO2 level of the three blood gas analyses (mean PaCO2noct) was 41.78±4.69 mmHg. A significant change was observed between mean PaCO2 23:00 and PaCO2 07:00 levels (p=0.032). There was no significant difference between PaCO2, PetCO2, and SpO2 levels in the NMD group. The interclass correlation coefficient between PaCO2 07:00 and PetCO2 levels was 0.791 (95% CI: 0.533-0.923); the interclass correlation coefficient between overnight mean PaCO2 and PetCO2 levels was 0.811 (95% CI:0.533-0.923). Conclusion Our study indicates that nocturnal PetCO2 and PaCO2 levels were statistically comparable but the use of PaCO2 alone is not adequate to make an early diagnosis of NH in NMD. There is a need for making more restrictive definitions for NH, and conducting studies with larger study populations to reach an agreement on the best definition of hypoventilation, and updating consensus guidelines.
Collapse
Affiliation(s)
- Yetkin Ayhan
- Istanbul Medeniyet University Faculty of Medicine, Department of Pediatric Pulmonology, Istanbul, Turkey
| | - Elif Yuksel Karatoprak
- Istanbul Medeniyet University, Faculty of Medicine, Depatment of Pediatric Neurology, Istanbul, Turkey
| | - Zeynep Reyhan Onay
- Istanbul Medeniyet University Faculty of Medicine, Department of Pediatric Pulmonology, Istanbul, Turkey
| | - Sinem Can Oksay
- Istanbul Medeniyet University Faculty of Medicine, Department of Pediatric Pulmonology, Istanbul, Turkey
| | - Saniye Girit
- Istanbul Medeniyet University Faculty of Medicine, Department of Pediatric Pulmonology, Istanbul, Turkey
| |
Collapse
|
7
|
Kim EY, Kang SW, Suh MR, Jung J, Park J, Choi WA. Safety of Gastrostomy Tube Placement in Patients with Advanced Amyotrophic Lateral Sclerosis With Noninvasive Ventilation. JPEN J Parenter Enteral Nutr 2020; 45:1338-1346. [PMID: 32914883 DOI: 10.1002/jpen.2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/08/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND In patients with amyotrophic lateral sclerosis (ALS), bulbar muscle dysfunction can occur, which eventually requires the initiation of enteral tube feeding. However, there is no consensus on the optimal timing for the gastrostomy or the proper ventilator support method during the procedure. We aimed to investigate the safe range of gastrostomy according to respiratory support status and forced vital capacity (FVC) % of predicted values classification and to compare the safety of noninvasive and invasive mechanical ventilation during the procedure in ALS patients with FVC < 30% of predicted. METHODS A total of 477 patients diagnosed with ALS at our institution from January 1, 2009, to December 31, 2018, were evaluated, and 105 patients were enrolled in this study. All medical records covering ventilation status and complications within 6 months to 1 year after the initial gastrostomy were gathered and reviewed. RESULTS The gastrostomy procedure was considered safe regardless of FVC status or modality of respiratory support. There were complications related to the gastrostomy procedure in 6 of 105 patients and all were managed through conservative care. The incidence of complications, including respiratory ones, for noninvasive and invasive positive pressure ventilation was 5.5% and 9.6%, respectively, which were not statistically significantly different (P = .294). CONCLUSION The procedure and tube placement of a gastrostomy can be safely performed in ALS patients with minimal FVC regardless of ventilation invasiveness. We suggest that there should be a new standard for FVC % of predicted to facilitate performing gastrostomy in ALS patients.
Collapse
Affiliation(s)
- Eun Young Kim
- 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
| | - Mi Ri Suh
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jiho Jung
- 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
| | - 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
| | - 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
| |
Collapse
|
8
|
Bach JR, Pronello D. Oxyhemoglobin desaturation as a function of age and hypercapnia from ventilatory pump failure (VPF). JOURNAL OF NEURORESTORATOLOGY 2020. [DOI: 10.26599/jnr.2020.9040013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Supplemental O2 is often administered without knowledge of CO2 levels for patients with ventilatory pump failure (VPF). This can render oximetry ineffective as a gauge of alveolar ventilation, airway secretions, and lung disease. We have noted that diurnal hypoventilation with hypercapnia tends to be symptomatic when O2 saturation levels decrease below 95% and patients extend sleep noninvasive ventilatory support (NVS) into daytime hours. We also noted that with advancing age, less hypercapnia results in desaturation. This study was designed to explore oxyhemoglobin desaturations (O2 desats) as a function of age and hypercapnia for patients with VPF. Methods: A retrospective analysis of 8933 consecutive patient visits for whom end-tidal CO2 and O2 sats were measured. O2 sats < 95% at CO2 levels of 45, 50, and 60 cmH2O were correlated with 10 years age intervals to age 80. Results: Of 8933 visits, 8642 had complete data. Outcomes for CO2 levels > 50 cmH2O were the most significant including for visit-ages < 30 and ≥ 30 years. There was a statistically significant 4% decrease in the odds of O2 desat for every one-year increase in age to age 30 (OR = 0.96, 95% CI = [0.93, 0.99], p = 0.02) and for visit-ages ≥ 30 a significant 30% increase in the odds of O2 desat for every 10-year increase in age (OR 1.3, 95% CI = [1.1, 1.6], p = 0.006). Relationship for ages ≥ 30 years were also significant for CO2 levels over 45 mmHg also. 40% of the time when CO2 was greater than 45 mmHg O2 sat was low. Discussion: This study demonstrated a significantly lower risk of O2 desat occurring at EtCO2 levels ≥ 50 mmHg for patients from 10 to 20 years of age than those younger than 10 and a significantly greater risk of O2 desat for 10 years intervals after age 20. Thus, with age, less hypercapnia results in desats and dyspnea with patients tending to extend NVS into daytime hours. This may be due to increases in physiological shunting, decreased pulmonary elasticity, and worsening ventilation/perfusion ratios with age.
Collapse
|
9
|
Suh MR, Kim DH, Jung J, Kim B, Lee JW, Choi WA, Kang SW. Clinical implication of maximal voluntary ventilation in myotonic muscular dystrophy. Medicine (Baltimore) 2019; 98:e15321. [PMID: 31045770 PMCID: PMC6504256 DOI: 10.1097/md.0000000000015321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Patients with myotonic muscular dystrophy type 1 (DM1) tend to exhibit earlier respiratory insufficiency than patients with other neuromuscular diseases at similar or higher forced vital capacity (FVC). This study aimed to analyze several pulmonary function parameters to determine which factor contributes the most to early hypercapnia in patients with DM1.We analyzed ventilation status monitoring, pulmonary function tests (including FVC, maximal voluntary ventilation [MVV], and maximal inspiratory and expiratory pressure), and polysomnography in subjects with DM1 who were admitted to a single university hospital. The correlation of each parameter with hypercapnia was determined. Subgroup analysis was also performed by dividing the subjects into 2 subgroups according to usage of mechanical ventilation.Final analysis included 50 patients with a mean age of 42.9 years (standard deviation = 11.1), 46.0% of whom were male. The hypercapnia was negatively correlated with MVV, FVC, forced expiratory volume in 1 second (FEV1), and their ratios to predicted values in subjects with myotonic muscular dystrophy type 1. At the same partial pressure of carbon dioxide, the ratio to the predicted value was lowest for MVV, then FEV1, followed by FVC. Moreover, the P values for differences in MVV and its ratio to the predicted value between ventilator users and nonusers were the lowest.When screening ventilation failure in patients with DM1, MVV should be considered alongside other routinely measured parameters.
Collapse
Affiliation(s)
- Mi Ri Suh
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University School of Medicine, GyeongGi-do
- Rehabilitation and Regeneration Research Center, CHA University School of Medicine, GyeongGi-do
- Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul
- The Graduate School, Yonsei University College of Medicine, Seoul
| | - Dong Hyun Kim
- Department of Physical Medicine and Rehabilitation, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul
| | - Jiho Jung
- Department of Rehabilitation Medicine and Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Bitnarae Kim
- Department of Rehabilitation Medicine and Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
- Department of Physical Therapy, Graduate School of Yonsei University, Gangwon-do
| | - Jang Woo Lee
- Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul
- Department of Physical Medicine and Rehabilitation, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Won Ah Choi
- Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul
- Department of Rehabilitation Medicine and Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| | - Seong-Woong Kang
- Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul
- Department of Rehabilitation Medicine and Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul
| |
Collapse
|
10
|
Nakamura Y, Saito Y, Kubota N, Matsumura W, Hosoda C, Tamasaki-Kondo A, Nishimura Y, Sunada Y, Fukada M, Ohno T, Maegaki Y, Matsuo M, Tokita Y. Identification of sleep hypoventilation in young individuals with Becker muscular dystrophy: A pilot study. Brain Dev 2018. [PMID: 29526517 DOI: 10.1016/j.braindev.2018.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIM To report on sleep hypercapnia in Becker muscular dystrophy (BMD) at earlier stages than ever recognized. SUBJECTS AND METHODS This retrospective study examined nocturnal hypercapnia in six young Becker muscular dystrophy (BMD) patients with deletions of one or more exons of DMD gene. Clinical information, consecutive data on forced vital capacity (FVC%), forced expiratory volume in one second (FEV1%), peak expiratory flow (PEF%), peak cough flow (PCF), average PCO2 in all-night monitoring, and left ventricular ejection fraction (LVEF) were reviewed. RESULTS In five BMD patients, including three who were still ambulant, nocturnal average PCO2 was elevated to >45 mmHg at 12-31 years of age. Noninvasive positive pressure ventilation was initiated in four patients. Gradual declines in FVC% and PEF% were evident in one BMD patient with exon 3-7 deletion, whereas these functions did not change in the remaining BMD patients. PCF, FEV1%, and LVEF were less informative for the assessment of respiratory function in this patient series. CONCLUSION Sleep hypercapnia was present in certain BMD patients, which was unexpected from the routine pulmonary function tests. Individualized assessment of nocturnal PCO2, partly based on the deletion types, should be further explored in the clinical practice of BMD patients.
Collapse
Affiliation(s)
- Yuko Nakamura
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan; Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan
| | - Yoshiaki Saito
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan.
| | - Norika Kubota
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan
| | - Wataru Matsumura
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan; Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan
| | - Chika Hosoda
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan; Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan; Department of Pediatrics, Tottori Rehabilitation Center for Children with Disabilities, 7-13-3 Kamifukubara, Yonago 683-0004, Japan
| | - Akiko Tamasaki-Kondo
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan; Department of Pediatrics, Shimane Prefectural Central Hospital, 4-1-1 Himebara, Izumo 693-8555, Japan
| | - Yoko Nishimura
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan
| | - Yoshihide Sunada
- Department of Neurology, Kawasaki Medical School, 577 Matsushima, Kurashiki 701-0192, Japan
| | | | - Takako Ohno
- Western Shimane Medical and Welfare Center for the Disabled, 1926 Watazu, Gotsu 695-0001, Japan
| | - Yoshihiro Maegaki
- Division of Child Neurology, Department of Brain and Neurosciences, Faculty of Medicine, Tottori University, 36-1 Nishi-cho, Yonago 683-8504, Japan
| | - Masafumi Matsuo
- Department of Medical Rehabilitation, Faculty of Rehabilitation, Kobe Gakuin University, 518 Arise, Ikawadani-cho, Nishi-ku, Kobe 651-2180, Japan
| | - Yasuko Tokita
- Department of Pediatrics, Matsue Medical Center, 5-8-31 Agenogi, Matsue 690-8556, Japan
| |
Collapse
|
11
|
Abstract
The goal of sleep doctors has been to titrate away apneas and hypopneas using noninvasive ventilation, a term that has become synonymous with continuous positive airway pressure and bilevel positive airway pressure at the lowest effective bilevel settings. It is now time to appreciate noninvasive ventilatory support as an alternative to invasive mechanical ventilation. This article discusses mechanisms of action, two paradigms, and ancillary techniques for noninvasive ventilatory support.
Collapse
|
12
|
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: 51] [Impact Index Per Article: 7.3] [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.
Collapse
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
| |
Collapse
|