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Wolff R, Dudoignon B, Naudin J, Madani A, Delclaux C, Bokov P, Dauger S. Airway obstruction in two children with congenital central hypoventilation syndrome and review of the literature. Arch Pediatr 2024; 31:205-208. [PMID: 38538464 DOI: 10.1016/j.arcped.2023.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 07/28/2023] [Accepted: 12/30/2023] [Indexed: 04/07/2024]
Abstract
Congenital central hypoventilation syndrome (CCHS) is an autosomal dominant disease that is caused by heterozygous mutations in the paired-like homeobox 2B gene (PHOX2B). Madani et al. described an abnormally high degree of not only central apnea but also obstructive and mixed apnea in Phox2b27Ala/+newborn mice. Newborns with CCHS must undergo polysomnography for obstructive respiratory events in order to guide the optimal ventilation strategy if oxygen desaturation, bradycardia, and malaise persist under noninvasive ventilation. Newborns and infants with CCHS must be systematically tested for obstructive apnea, especially in cases of inefficient noninvasive ventilation.
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Affiliation(s)
- Richard Wolff
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, Service de Médecine intensive et réanimation pédiatriques, F-75019 Paris, France
| | - Benjamin Dudoignon
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique-Centre du Sommeil - CRMR Maladies respiratoires rares - Hypoventilations alvéolaires rares - Syndrome d'Ondine, INSERM NeuroDiderot, F-75019 Paris, France; Université de Paris-Cité, AP-HP, Hôpital Robert Debré, INSERM NeuroDiderot, F-75019 Paris, France.
| | - Jérôme Naudin
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, Service de Médecine intensive et réanimation pédiatriques, F-75019 Paris, France
| | - Amélia Madani
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, INSERM NeuroDiderot, F-75019 Paris, France
| | - Christophe Delclaux
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique-Centre du Sommeil - CRMR Maladies respiratoires rares - Hypoventilations alvéolaires rares - Syndrome d'Ondine, INSERM NeuroDiderot, F-75019 Paris, France; Université de Paris-Cité, AP-HP, Hôpital Robert Debré, INSERM NeuroDiderot, F-75019 Paris, France
| | - Plamen Bokov
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique-Centre du Sommeil - CRMR Maladies respiratoires rares - Hypoventilations alvéolaires rares - Syndrome d'Ondine, INSERM NeuroDiderot, F-75019 Paris, France; Université de Paris-Cité, AP-HP, Hôpital Robert Debré, INSERM NeuroDiderot, F-75019 Paris, France
| | - Stéphane Dauger
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, Service de Médecine intensive et réanimation pédiatriques, F-75019 Paris, France; Université de Paris-Cité, AP-HP, Hôpital Robert Debré, INSERM NeuroDiderot, F-75019 Paris, France
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DeRusso M, Miller AG, Caccamise M, Alibrahim O. Negative-Pressure Ventilation in the Pediatric ICU. Respir Care 2024; 69:354-365. [PMID: 38164590 PMCID: PMC10984599 DOI: 10.4187/respcare.11193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
Negative-pressure ventilation (NPV) is a form of noninvasive ventilation that has been recently utilized in pediatric acute respiratory failure. Negative-pressure ventilators apply negative pressure onto the chest wall via a cuirass to recruit areas of atelectasis. Continuous negative extrathoracic pressure, the most common mode, is similar to CPAP, where negative pressure is maintained at a constant level throughout the respiratory cycle while patients initiate their own breaths and continue to breathe spontaneously throughout. Control mode, which is similar to bi-level positive airway pressure, alternates negative pressure with positive pressure and controls both phases of breathing at a mandatory frequency set higher than the patient's spontaneous frequency. Supplemental oxygen is provided through a nasal cannula or face mask due of the lack of NPV devices' interface with the mouth or nose. NPV can improve preload to the heart and cardiac output (CO) in patients with restrictive right-ventricular physiology requiring CO augmentation and those with Fontan physiology. The purpose of this article is to review the physiological principles of spontaneous and NPV, examine the evidence supporting the use of NPV, give practical and meaningful guidance on its clinical application in the pediatric ICU, and summarize areas for future studies on its uses.
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Affiliation(s)
- Michelle DeRusso
- Drs DeRusso and Alibrahim are affiliated with Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina. Mr Miller is affiliated with Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina; and Respiratory Care Services, Duke University, Durham, North Carolina. Ms Caccamise is affiliated with Respiratory Care Services, Duke University, Durham, North Carolina
| | - Andrew G Miller
- Drs DeRusso and Alibrahim are affiliated with Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina. Mr Miller is affiliated with Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina; and Respiratory Care Services, Duke University, Durham, North Carolina. Ms Caccamise is affiliated with Respiratory Care Services, Duke University, Durham, North Carolina
| | - Melissa Caccamise
- Drs DeRusso and Alibrahim are affiliated with Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina. Mr Miller is affiliated with Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina; and Respiratory Care Services, Duke University, Durham, North Carolina. Ms Caccamise is affiliated with Respiratory Care Services, Duke University, Durham, North Carolina
| | - Omar Alibrahim
- Drs DeRusso and Alibrahim are affiliated with Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina. Mr Miller is affiliated with Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina; and Respiratory Care Services, Duke University, Durham, North Carolina. Ms Caccamise is affiliated with Respiratory Care Services, Duke University, Durham, North Carolina.
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Schupper AJ, Devarajan A, Lee DS, Perez E, Shrivastava RK. Ondine's curse: clinical presentation with diaphragmatic pacing and spontaneous respiratory recovery. Illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE233. [PMID: 37218735 PMCID: PMC10550651 DOI: 10.3171/case233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/16/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND The complexity of posterior fossa surgery can often lead to rare complications due to the anatomy involved. Vestibular schwannoma resection is a common pathology in the posterior fossa, often requiring surgical intervention. Given the proximity of this space to the brainstem, cranial nerve VII/VIII complex, and posterior inferior cerebellar artery (PICA), neurovascular complications are not infrequent. A rare vascular complication from this surgical approach is a lateral medullary infarction from injury to the lateral medullary segment of the proximal PICA, leading to central hypoventilation syndrome (CHS). OBSERVATIONS This report presents a unique case of a 51-year-old man who underwent a retrosigmoid craniectomy for resection of a vestibular schwannoma. Following surgery, the patient was unable to be weaned off the ventilator and was noted to become apneic while he slept, a clinical picture consistent with Ondine's curse. LESSONS This report discusses the anatomical considerations of this surgical corridor leading to this complication and the management of a patient with acquired Ondine's curse and reviews the scarce literature on this uncommon cause of acquired CHS.
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Affiliation(s)
| | | | | | - Enrique Perez
- Otolaryngology, School of Medicine at Mount Sinai, New York, New York
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Chang GY, Salazar T, Karnwal A, Kun SS, Ellashek J, Shin CE, McComb JG, Keens TG, Perez IA. Perioperative outcomes and the effects of anesthesia in congenital central hypoventilation patients. Sleep Breath 2022; 27:505-510. [DOI: 10.1007/s11325-022-02632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 03/31/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
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Annunziata A, Calabrese C, Simioli F, Coppola A, Flora M, Marotta A, Di Spirito V, Didonna F, Cicalese M, Fiorentino G. Negative-Pressure Ventilation in Neuromuscular Diseases in the Acute Setting. J Clin Med 2022; 11:2589. [PMID: 35566729 PMCID: PMC9101364 DOI: 10.3390/jcm11092589] [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: 03/12/2022] [Revised: 04/23/2022] [Accepted: 04/29/2022] [Indexed: 11/16/2022] Open
Abstract
Mechanical ventilation started with negative-pressure ventilation (NPV) during the 1950s to assist patients with respiratory failure, secondary to poliomyelitis. Over the years, technological evolution has allowed for the development of more comfortable devices, leading to an increased interest in NPV. The patients affected by neuromuscular diseases (NMD) with chronic and acute respiratory failure (ARF) may benefit from NPV. The knowledge of the available respiratory-support techniques, indications, contraindications, and adverse effects is necessary to offer the patient a personalized treatment that considers the pathology's complexity.
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Affiliation(s)
- Anna Annunziata
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania ‘Luigi Vanvitelli’, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy;
| | - Francesca Simioli
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Antonietta Coppola
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Martina Flora
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Antonella Marotta
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Valentina Di Spirito
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Francesco Didonna
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
| | - Marcellino Cicalese
- Department of Surgery, Unit of Thoracic Surgery, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy;
| | - Giuseppe Fiorentino
- Department of Intensive Care, AORN Ospedali dei Colli, Via Leonardo Bianchi, 80131 Naples, Italy; (F.S.); (A.C.); (M.F.); (A.M.); (V.D.S.); (F.D.); (G.F.)
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Porcaro F, Paglietti MG, Cherchi C, Schiavino A, Chiarini Testa MB, Cutrera R. How the Management of Children With Congenital Central Hypoventilation Syndrome Has Changed Over Time: Two Decades of Experience From an Italian Center. Front Pediatr 2021; 9:648927. [PMID: 33855005 PMCID: PMC8039127 DOI: 10.3389/fped.2021.648927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 02/12/2021] [Indexed: 11/25/2022] Open
Abstract
Background: Congenital central hypoventilation syndrome (CCHS) is a rare disorder whose clinical phenotype is closely related to genotype. Methods: A retrospective analysis has been conducted on 22 patients with CCHS, who were referred to the Pediatric Pulmonology and Respiratory Intermediate Care Unit of Bambino Gesù Children's Hospital (Italy) for a multidisciplinary follow-up program between 2000 and 2020. Results: Apnea and cyanosis were the most frequent symptoms at onset (91%). Overall, 59% of patients required tracheostomy and invasive mechanical ventilation (IMV) in the first months of life. Thirty-two percent of patients had Hirschsprung disease (HSCR) that was associated with longer polyalanine repetitions or non-polyalanine repeat expansion mutations (NPARMs). Polyalanine repeat expansion mutations (PARMs) were more frequent and two novel NPARMs (c.780dupT and C.225-256delCT) were described in 14% of patients. Focal epilepsy was first described in 14% of patients and neurocognitive and neuromotor impairment involved 27% and 23% of children, respectively. Symptoms due to autonomic nervous system dysfunction/dysregulation (ANSD)-including strabismus (27%), dysphagia (27%), abnormal heart rhythm (10%), breath-holding spells (9%), and recurrent seizures due to hypoglycemia (9%)-were associated with an increased number of polyalanine repetitions of exon 3 or NPARMs of PHOX2B gene. Overall, the number of patients with moderate to severe phenotype initially treated with non-invasive ventilation (NIV) increased over time, and the decannulation program was concluded with 3 patients who started with IMV. Conclusions: Our study confirms that more severe phenotypes of CCHS are related to the number of polyalanine repetitions or to NPARMs. Although invasive ventilation is often required by patients with severe genotype/phenotype, gradual acquisition of specific skills in the management of patients with CCHS and technological improvements in mechanical ventilation allowed us to improve our therapeutic approach in this population.
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Affiliation(s)
- Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Giovanna Paglietti
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Claudio Cherchi
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandra Schiavino
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Beatrice Chiarini Testa
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep, and Long-Term Ventilation Unit, Academic Department of Pediatrics and Genetic Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Ogata T, Muramatsu K, Miyana K, Ozawa H, Iwasaki M, Arakawa H. Neurodevelopmental outcome and respiratory management of congenital central hypoventilation syndrome: a retrospective study. BMC Pediatr 2020; 20:342. [PMID: 32660452 PMCID: PMC7358189 DOI: 10.1186/s12887-020-02239-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/06/2020] [Indexed: 11/13/2022] Open
Abstract
Background Congenital central hypoventilation syndrome (CCHS) is a rare disease characterized by sleep apnea. Anoxia often occurs soon after birth, and it is important to prevent anoxia-mediated central nervous system complications; however, data on the relationship between respiratory management and the prognosis for intellectual development of patients with CCHS is not well yet investigate. Methods We performed a retrospective chart review cohort study of patients with CCHS in Japan. We investigated the risk and prognostic factors for developmental outcomes and examined the disease in terms of its symptoms, diagnosis, complications, and treatment. Results Of the 123 patients with CCHS included in the survey, 88 patients were 6 years old and older. They were divided into two group based on their intelligence quotient. Those treated using positive-pressure ventilation via tracheostomy in the first three months of life had a better developmental prognosis than those managed via tracheostomy after three months of age and those treated by ventilation using mask (OR = 3.80; 95% CI: 1.00–14.37, OR = 4.65; 95% CI: 1.11–19.37). There was no significant difference in physical development (P = 0.64). Conclusions The best respiratory treatment for patients with CCHS is ventilation via tracheostomy, initiated ideally before the age of three months.
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Affiliation(s)
- Tomomi Ogata
- Department of Pediatrics, Graduate School of Medicine, Gunma University, 3-39-15 Showa-machi, Maebashi City, Gunma, 371-8511, Japan.
| | - Kazuhiro Muramatsu
- Department of Pediatrics, Graduate School of Medicine, Gunma University, 3-39-15 Showa-machi, Maebashi City, Gunma, 371-8511, Japan.,Department of Pediatrics, Jichi Medical University, Tochigi, Japan
| | - Kaori Miyana
- Department of Pediatrics, Japanese Red Cross Medical Center, Tokyo, Japan
| | | | - Motoki Iwasaki
- Division of Epidemiology, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Hirokazu Arakawa
- Department of Pediatrics, Graduate School of Medicine, Gunma University, 3-39-15 Showa-machi, Maebashi City, Gunma, 371-8511, Japan
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Paglietti MG, Esposito I, Goia M, Rizza E, Cutrera R, Bignamini E. Long Term Non-invasive Ventilation in Children With Central Hypoventilation. Front Pediatr 2020; 8:288. [PMID: 32637385 PMCID: PMC7316889 DOI: 10.3389/fped.2020.00288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/07/2020] [Indexed: 11/13/2022] Open
Abstract
Central hypoventilation (CH) is a quite rare disorder caused by some congenital or acquired conditions. It is featured by increased arterial concentration of serum carbon dioxide related to an impairment of respiratory drive. Patients affected by CH need to be treated by mechanical ventilation in order to achieve appropriate ventilation and oxygenation both in sleep and wakefulness. In fact, in severe form of Congenital Central Hypoventilation Syndrome (CCHS) hypercarbia can be present even during the day. Positive pressure ventilation via tracheostomy is the first therapeutic option in this clinical condition, especially in congenital forms. Non-Invasive ventilation is a an option that must be reserved for more stable clinical situations and that requires careful monitoring over time.
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Affiliation(s)
- Maria Giovanna Paglietti
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Irene Esposito
- Pediatric Pulmonology & Regional Reference Centre for Pediatric Respiratory Failure and Cystic Fibrosis, Regina Margherita's Hospital, AOU Città della Salute e della Scienza, Turin, Italy
| | - Manuela Goia
- Pediatric Pulmonology & Regional Reference Centre for Pediatric Respiratory Failure and Cystic Fibrosis, Regina Margherita's Hospital, AOU Città della Salute e della Scienza, Turin, Italy
| | - Elvira Rizza
- Pediatric Pulmonology & Regional Reference Centre for Pediatric Respiratory Failure and Cystic Fibrosis, Regina Margherita's Hospital, AOU Città della Salute e della Scienza, Turin, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Elisabetta Bignamini
- Pediatric Pulmonology & Regional Reference Centre for Pediatric Respiratory Failure and Cystic Fibrosis, Regina Margherita's Hospital, AOU Città della Salute e della Scienza, Turin, Italy
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Paglietti MG, Porcaro F, Sovtic A, Cherchi C, Verrillo E, Pavone M, Bottero S, Cutrera R. Decannulation in children affected by congenital central hypoventilation syndrome: A proposal of an algorithm from two European centers. Pediatr Pulmonol 2019; 54:1663-1669. [PMID: 31313536 DOI: 10.1002/ppul.24448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/16/2019] [Indexed: 11/08/2022]
Abstract
RATIONALE Long-life ventilatory assistance is necessary for survival in pediatric patients with congenital central hypoventilation syndrome (CCHS). Invasive mechanical ventilation (IMV) through tracheostomy is the most used method, especially in the first years of life when the central nervous system is maturing. Nevertheless, IMV via tracheostomy is not ideal because tracheostomy in children is associated with impaired speech and language development, also frequent infections of the lower airway tract occur. OBJECTIVE Only few reports describe the transition from IMV to the noninvasive method, ending with decannulation in CCHS affected patients. We aim to provide our experience regarding decannulation program in CCHS affected children and to describe a proposal of an algorithm concerning transition from invasive to noninvasive ventilation (NIV) in CCHS patients. METHODS The study has been conducted retrospectively. Four children from two European centers underwent tracheostomy removal and decannulation, upon request of patients and their families. RESULTS All children were trained to carry out tracheostomy capping before decannulation and underwent endoscopic assessment of upper and lower airway. Subsequently they started training to NIV at mean age of 106.25 months (±40.7 SD). Decannulation occurred 12 months after and no patients needed the reintroduction of tracheal cannula in either short or long term follow up. CONCLUSIONS our study shows that effective liberation from IMV, the transition to NIV and decannulation are possible in CCHS affected children and offers a proposal of an algorithm which can be applied in selected centers.
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Affiliation(s)
- Maria Giovanna Paglietti
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Aleksandar Sovtic
- Department of Pulmonology, Mother and Child Health Institute and School of Medicine University of Belgrade, Serbia
| | - Claudio Cherchi
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Elisabetta Verrillo
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Martino Pavone
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sergio Bottero
- Airway Surgery Unit, Department Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
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Bishara J, Keens TG, Perez IA. The genetics of congenital central hypoventilation syndrome: clinical implications. APPLICATION OF CLINICAL GENETICS 2018; 11:135-144. [PMID: 30532577 PMCID: PMC6241683 DOI: 10.2147/tacg.s140629] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder of the autonomic nervous system (ANS) and respiratory control. This disorder, formerly referred to as Ondine’s curse, is due to a mutation in the PHOX2B gene that affects the development of the neural crest cells. CCHS has an autosomal dominant pattern of inheritance. Majority of the patients have a polyalanine repeat mutation (PARM) of the PHOX2B, while a small group has non-PARM (NPARM). Knowledge of the patient’s PHOX2B gene mutation helps predict a patient’s clinical presentation and outcome and aids in anticipatory management of the respiratory and ANS dysfunction.
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Affiliation(s)
- John Bishara
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA,
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA, .,Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, CA, USA,
| | - Iris A Perez
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA, .,Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, CA, USA,
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Bedi PK, Castro-Codesal ML, Featherstone R, AlBalawi MM, Alkhaledi B, Kozyrskyj AL, Flores-Mir C, MacLean JE. Long-term Non-Invasive Ventilation in Infants: A Systematic Review and Meta-Analysis. Front Pediatr 2018; 6:13. [PMID: 29484287 PMCID: PMC5816035 DOI: 10.3389/fped.2018.00013] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/12/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The use of long-term non-invasive ventilation (NIV) to treat sleep and breathing disorders in children has increased substantially in the last decade; however, less data exist about its use in infants. Given that infants have distinct sleep and breathing patterns when compared to older children, the outcomes of infants on long-term NIV may differ as well. The aim of this study is to systematically review the use and outcomes of long-term NIV in infants. METHODS Ovid Medline, Ovid Embase, CINAHL (via EbscoHOST), PubMed, and Wiley Cochrane Library were systematically searched from January 1990 to July 2017. Studies on infants using long-term NIV outside of an acute care setting were included. Data were extracted on study design, population characteristics, and NIV outcomes. RESULTS A total of 327 studies were full-text reviewed, with final inclusion of 60. Studies were distributed across airway (40%), neuromuscular (28%), central nervous system (10%), cardio-respiratory (2%), and multiple (20%) disease categories. Of the 18 airway studies reporting on NIV outcomes, 13 (72%) reported improvements in respiratory parameters. Of the 12 neuromuscular studies exclusively on spinal muscular atrophy type 1 (SMA1), six (50%) reported decreased hospitalizations and nine (75%) reported on mortality outcomes. Risk of bias was moderate to serious, and quality of the evidence was low to very low for all studies. Most studies had an observational design with no control group, limiting the potential for a meta-analysis. CONCLUSION The outcomes reported in studies differed by the disease category being studied. Studies on airway conditions showed improvements in respiratory parameters for infants using NIV. Studies on neuromuscular disorder, which were almost exclusively on SMA1, reported decreased hospitalizations and prolonged survival. Overall, it appears that NIV is an effective long-term therapy for infants. However, the high risk of bias and low quality of the available evidence limited strong conclusions.
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Affiliation(s)
- Prabhjot K. Bedi
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Maria Luisa Castro-Codesal
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Robin Featherstone
- Alberta Research Centre for Health Evidence, University of Alberta, Knowledge Translation Platform, Alberta SPOR SUPPORT Unit, Edmonton, AB, Canada
| | - Mohammed M. AlBalawi
- Department of Pediatrics, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Bashar Alkhaledi
- Pediatric Pulmonary and Sleep Unit, Al-Sabah Hospital, Kuwait City, Kuwait
| | - Anita L. Kozyrskyj
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Carlos Flores-Mir
- Faculty of Medicine and Dentistry, School of Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Joanna E. MacLean
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Women and Children’s Health Research Institute, University of Alberta, Edmonton, AB, Canada
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12
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Khayat A, Medin D, Syed F, Moraes TJ, Bin-Hasan S, Narang I, Al-Saleh S, Amin R. Intelligent volume-assured pressured support (iVAPS) for the treatment of congenital central hypoventilation syndrome. Sleep Breath 2017; 21:513-519. [PMID: 28190166 DOI: 10.1007/s11325-017-1478-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/19/2017] [Accepted: 02/01/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE Congenital central hypoventilation syndrome (CCHS) is characterized by ventilatory insensitivity to hypercapnia and hypoxemia during sleep and/or wakefulness. Management of CCHS includes a long-term ventilation. However, ventilation can be challenging given differences in the control of breathing during different sleep stages. Intelligent volume-assured pressure support (iVAPS) is a mode of Bi-level positive airway pressure (BPAP) ventilation in which the pressure support is modulated to ensure a constant alveolar ventilation. The aim of this study was to determine if BPAP with iVAPS mode is more effective at controlling hypercapnia than BPAP with spontaneous/timed (S/T) mode. METHODS A retrospective chart review of CCHS patients who underwent both a titration polysomnogram (PSG) with standard BPAP S/T mode and a consecutive follow-up study with BPAP iVAPS mode at The Hospital for Sick Children, Toronto, Canada, between January 1, 2013 and September 30, 2015 were included. Comparisons were made between S/T mode and iVAPS mode. RESULTS Eight (four males) children with CCHS were included. The median (IQR) age at the time of PSG using Bi-level ventilation with S/T mode for study participants was 10.0 (IQR 8.4, 11.6) years followed by PSGs with iVAPS mode, median age 10.6 (IQR 9.1, 12.5) years. The non-rapid eye movement (NREM) peak transcutaneous CO2 (tcCO2) median (IQR) for iVAPS was 43.0 (40.0-46.0-) mmHg versus 46.5 (45.0-48.0) mmHg for S/T mode, (p value <0.05). CONCLUSION iVAPS was associated with a reduction in the maximum tcCO2 during NREM sleep as compared to traditional S/T mode. Prospective, longitudinal studies are needed to evaluate the benefits of BPAP therapy iVAPS mode for the treatment of pediatric CCHS.
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Affiliation(s)
- Abdullah Khayat
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Debra Medin
- Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Faiza Syed
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Theo J Moraes
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.,University of Toronto, Toronto, ON, Canada
| | - Saadoun Bin-Hasan
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Indra Narang
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.,University of Toronto, Toronto, ON, Canada
| | - Suhail Al-Saleh
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada.,University of Toronto, Toronto, ON, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada. .,University of Toronto, Toronto, ON, Canada.
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13
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Healy F, Marcus CL. Care of the Child with Congenital Central Hypoventilation Syndrome. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_17] [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: 11/30/2022]
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14
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Herrera-Flores EH, Rodríguez-Tejada A, Reyes-Zúñiga MM, Torres-Fraga MG, Castorena-Maldonado A, Carrillo-Alduenda JL. [Congenital central alveolar hypoventilation syndrome]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2015; 72:262-270. [PMID: 29421146 DOI: 10.1016/j.bmhimx.2015.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/25/2015] [Accepted: 07/02/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Congenital central alveolar hypoventilation syndrome (CCAHS) is a rare sleep-related breathing disorder. Although increasingly frequently diagnosed in sleep clinics and pediatric pulmonology services, its epidemiology is not known. There are about 300 reported cases reported in the literature with an incidence of 1 case per 200,000 live births. CCAHS is characterized by alveolar hypoventilation that occurs or worsens during sleep and is secondary to a reduction/absence of the ventilatory response to hypercapnia and/or hypoxemia. In 90% of the cases it is due to a PARM-type mutation of the PHOX2B gene. Treatment includes mechanical ventilation and diaphragmatic pacemaker. If therapy is not initiated promptly the patient can evolve to chronic respiratory failure, pulmonary hypertension, cor pulmonale and death. CASE REPORTS In this paper we present three cases of CCAHS diagnosed, treated and followed up at the Sleep Disorders Clinic of the National Institute of Respiratory Diseases in Mexico. CONCLUSIONS Early diagnosis is important to initiate ventilatory support so as to prevent any complications and to reduce mortality.
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Affiliation(s)
- Edwin Hernando Herrera-Flores
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Alfredo Rodríguez-Tejada
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Martha Margarita Reyes-Zúñiga
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Martha Guadalupe Torres-Fraga
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - Armando Castorena-Maldonado
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México
| | - José Luis Carrillo-Alduenda
- Clínica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias, México D.F., México.
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15
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Diep B, Wang A, Kun S, McComb JG, Shaul DB, Shin CE, Keens TG, Perez IA. Diaphragm Pacing without Tracheostomy in Congenital Central Hypoventilation Syndrome Patients. Respiration 2015; 89:534-8. [DOI: 10.1159/000381401] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 03/03/2015] [Indexed: 11/19/2022] Open
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Reverdin AK, Mosquera R, Colasurdo GN, Jon CK, Clements RM. Airway obstruction in congenital central hypoventilation syndrome. BMJ Case Rep 2014; 2014:bcr-2013-200911. [PMID: 24842348 DOI: 10.1136/bcr-2013-200911] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) is the failure of the autonomic system to control adequate ventilation while asleep with preserved ventilatory response while awake. We report a case of a patient with CCHS who presented with intrathoracic and extrathoracic airway obstruction after tracheostomy tube decannulation and phrenic nerve pacer placement. Nocturnal polysomnography (NPSG) revealed hypoxia, hypercapnia and obstructive sleep apnoea, which required bilevel positive airway pressure titration. Airway endoscopy demonstrated tracheomalacia and paretic true vocal cords in the paramedian position during diaphragmatic pacing. Laryngeal electromyography demonstrated muscular electrical impulses that correlated with diaphragmatic pacer settings. Thus, we surmise that the patient's upper and lower airway obstruction was secondary to diaphragmatic pacer activity. Thorough airway evaluation, including NPSG and endoscopy, may help identify the side effects of diaphragmatic pacing, such as airway obstruction, in patients with CCHS.
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Affiliation(s)
- Alexandra K Reverdin
- Department of Pediatrics, Division of Pediatric Pulmonary Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ricardo Mosquera
- Department of Pediatrics, Division of Pediatric Pulmonary Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Giuseppe N Colasurdo
- Department of Pediatrics, Division of Pediatric Pulmonary Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Cindy K Jon
- Department of Pediatrics, Division of Pediatric Pulmonary Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Roya M Clements
- Department of Pediatrics, Division of Pediatric Pulmonary Medicine, The University of Texas Health Science Center at Houston, Houston, Texas, USA
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17
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Affiliation(s)
- Christopher Cielo
- Division of Pulmonary Medicine, The Children's Hospital of Philadelphia, Colket Translational Research Building, 11th Floor Pulmonary Medicine, 3501 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Carole L Marcus
- Sleep Center, The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, 9 Northwest 50 Main Building, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
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18
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Shah PS, Ohlsson A, Shah JP. Continuous negative extrathoracic pressure or continuous positive airway pressure compared to conventional ventilation for acute hypoxaemic respiratory failure in children. Cochrane Database Syst Rev 2013; 2013:CD003699. [PMID: 24186774 PMCID: PMC6464907 DOI: 10.1002/14651858.cd003699.pub4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Acute hypoxaemic respiratory failure (AHRF) is an important cause of mortality and morbidity in children. Positive pressure ventilation is currently the standard care, however, it does have complications. Continuous negative extrathoracic pressure (CNEP) ventilation or continuous positive airway pressure (CPAP) ventilation delivered via non-invasive approaches (Ni-CPAP) have shown certain beneficial effects in animal and uncontrolled human studies. OBJECTIVES To assess the effectiveness of CNEP or Ni-CPAP compared to conventional ventilation in children (at least one month old and less than 18 years of age) with AHRF due to non-cardiogenic causes for improving the mortality or morbidity associated with AHRF. SEARCH METHODS We searched CENTRAL 2013, Issue 6, MEDLINE (January 1966 to June week 3, 2013), EMBASE (1980 to July 2013) and CINAHL (1982 to July 2013). SELECTION CRITERIA Randomised or quasi-randomised clinical trials of CNEP or Ni-CPAP versus standard therapy (including positive pressure ventilation) involving children (from one month old to less than 18 years at time of randomisation) who met the criteria for diagnosis of AHRF with at least one of the outcomes reported. DATA COLLECTION AND ANALYSIS We assessed risk of bias of the included studies using allocation concealment, blinding of intervention, completeness of follow-up and blinding of outcome measurements. We abstracted data on relevant outcomes and estimated the effect size by calculating risk ratio (RR) and risk difference (RD) with 95% confidence intervals (CI). MAIN RESULTS We identified two eligible studies: one of CPAP and one of CNEP (published as an abstract). Both were unblinded studies with mainly unclear risk of bias due to lack of adequate information to assess this. The CPAP study enrolled 37 children to oxygen mask and CPAP and reported improvement in respiratory rate and oxygen saturation in both arms after 30 minutes of application. The CNEP study was published as an abstract and included 33 infants with bronchiolitis. In the CNEP study there was a reduction in the fraction of inspired oxygen (FiO2) (less than 30% within one hour of initiation of therapy) in four participants in the CNEP group compared to none in the control group (RR 10.7, 95% CI 0.6 to 183.9). One infant required CPAP and mechanical ventilation in the control group while all infants in the CNEP group were managed without intubation (RR for both outcomes 0.40, 95% CI 0.02 to 9.06). None of the trials reported on mortality. No adverse events were reported in ether of the included trials. AUTHORS' CONCLUSIONS There is a lack of well-designed, controlled trials of non-invasive modes of respiratory support in children with AHRF. Studies assessing the outcomes mortality, avoidance of intubation and its associated complications, hospital stay and patient comfort are needed.
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Affiliation(s)
- Prakeshkumar S Shah
- University of Toronto Mount Sinai HospitalDepartment of Paediatrics and Health Policy, Management and Evaluation600 University AvenueTorontoCanadaM5G 1XB
| | - Arne Ohlsson
- University of TorontoDepartments of Paediatrics, Obstetrics and Gynaecology and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoCanadaM5G 1X5
| | - Jyotsna P Shah
- Mount Sinai HospitalDepartment of Paediatrics52 James Edward DriveMarkhamCanadaL3S 1Z8
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19
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Weese-Mayer DE, Berry-Kravis EM, Ceccherini I, Keens TG, Loghmanee DA, Trang H. [ATS clinical policy statement: congenital central hypoventilation syndrome. Genetic basis, diagnosis and management]. Rev Mal Respir 2013; 30:706-33. [PMID: 24182656 DOI: 10.1016/j.rmr.2013.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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20
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Weese-Mayer DE, Berry-Kravis EM, Ceccherini I, Keens TG, Loghmanee DA, Trang H. An official ATS clinical policy statement: Congenital central hypoventilation syndrome: genetic basis, diagnosis, and management. Am J Respir Crit Care Med 2010; 181:626-44. [PMID: 20208042 DOI: 10.1164/rccm.200807-1069st] [Citation(s) in RCA: 315] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Congenital central hypoventilation syndrome (CCHS) is characterized by alveolar hypoventilation and autonomic dysregulation. PURPOSE (1) To demonstrate the importance of PHOX2B testing in diagnosing and treating patients with CCHS, (2) to summarize recent advances in understanding how mutations in the PHOX2B gene lead to the CCHS phenotype, and (3) to provide an update on recommendations for diagnosis and treatment of patients with CCHS. METHODS Committee members were invited on the basis of their expertise in CCHS and asked to review the current state of the science by independently completing literature searches. Consensus on recommendations was reached by agreement among members of the Committee. RESULTS A review of pertinent literature allowed for the development of a document that summarizes recent advances in understanding CCHS and expert interpretation of the evidence for management of affected patients. CONCLUSIONS A PHOX2B mutation is required to confirm the diagnosis of CCHS. Knowledge of the specific PHOX2B mutation aids in anticipating the CCHS phenotype severity. Parents of patients with CCHS should be tested for PHOX2B mutations. Maintaining a high index of suspicion in cases of unexplained alveolar hypoventilation will likely identify a higher incidence of milder cases of CCHS. Recommended management options aimed toward maximizing safety and optimizing neurocognitive outcome include: (1) biannual then annual in-hospital comprehensive evaluation with (i) physiologic studies during awake and asleep states to assess ventilatory needs during varying levels of activity and concentration, in all stages of sleep, with spontaneous breathing, and with artificial ventilation, and to assess ventilatory responsiveness to physiologic challenges while awake and asleep, (ii) 72-hour Holter monitoring, (iii) echocardiogram, (iv) evaluation of ANS dysregulation across all organ systems affected by the ANS, and (v) formal neurocognitive assessment; (2) barium enema or manometry and/or full thickness rectal biopsy for patients with a history of constipation; and (3) imaging for neural crest tumors in individuals at greatest risk based on PHOX2B mutation.
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21
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Shah PS, Ohlsson A, Shah JP. Continuous negative extrathoracic pressure or continuous positive airway pressure for acute hypoxemic respiratory failure in children. Cochrane Database Syst Rev 2008:CD003699. [PMID: 18254028 DOI: 10.1002/14651858.cd003699.pub3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute hypoxemic respiratory failure (AHRF) is an important cause of mortality and morbidity in children. Positive pressure ventilation is currently the standard care, however, it does have complications. Continuous negative extrathoracic pressure ventilation (CNEP) or continuous positive airway pressure (CPAP) ventilation delivered via non-invasive approaches (Ni-CPAP) have shown certain beneficial effects in animal and uncontrolled human studies. OBJECTIVES The primary objective was to assess the effectiveness of CNEP or Ni-CPAP in pediatric patients with AHRF from non-cardiogenic causes. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2007, Issue 3); MEDLINE (January 1966 to July 2007); EMBASE (1980 to July 2007); CINAHL (1982 to July 2007); and published abstracts from the meetings of the American Thoracic Society and Pediatric Critical Care Meetings (1992 to 2007). SELECTION CRITERIA Randomized or quasi-randomized clinical trials of either CNEP or Ni-CPAP versus standard therapy (including positive pressure ventilation) involving children (at least 1 month old and less than 18 years of age at the time of randomization) who met the criteria for diagnosis of AHRF with at least one of the outcomes reported were included. DATA COLLECTION AND ANALYSIS Risks of bias of the included study was assessed using: concealment of allocation, blinding of intervention, completeness of follow up and blinding of outcome measurements. Data on relevant outcomes were abstracted and the effect size was estimated by calculating relative risk (RR) with 95% confidence intervals (CI) and risk difference (RD). MAIN RESULTS One eligible study published in an abstract format was identified. It studied 33 infants (18 controls, 15 receiving CNEP) with a clinical diagnosis of bronchiolitis and fraction of inspired oxygen (FiO(2)) > 40% were studied. This allowed a reduction in the FiO(2) (< 30% within one hour of initiation of therapy) in four patients in the CNEP group compared to none in the control group (RR 10.7, 95% CI 0.6 to 183.9). One infant required CPAP and one infant required nasal CPAP in the control group while all infants in the CNEP group were managed without intubation (RR for both outcomes 0.40, 95% CI 0.02 to 9.06). AUTHORS' CONCLUSIONS There is a lack of well designed, controlled experiments of non-invasive modes of respiratory support in children with AHRF. Reduction of in-hospital mortality is an important outcome and even a small reduction would be beneficial. Studies assessing other outcomes such as avoidance of intubation and its associated complications, reduction in hospital stay and improvement in patient comfort are also valuable in gauging the overall impact of these strategies.
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Affiliation(s)
- P S Shah
- University of Toronto, Department of Paediatrics, Rm 775A, 600 University Avenue, Toronto, Ontario, Canada M5G 1XB.
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22
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Naito S, Hiroma T, Nakamura T. Continuous negative extrathoracic pressure combined with high-frequency oscillation improves oxygenation with less impact on blood pressure than high-frequency oscillation alone in a rabbit model of surfactant depletion. Biomed Eng Online 2007; 6:40. [PMID: 17971241 PMCID: PMC2169239 DOI: 10.1186/1475-925x-6-40] [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: 05/10/2007] [Accepted: 10/31/2007] [Indexed: 11/10/2022] Open
Abstract
Background Negative air pressure ventilation has been used to maintain adequate functional residual capacity in patients with chronic muscular disease and to decrease transpulmonary pressure and improve cardiac output during right heart surgery. High-frequency oscillation (HFO) exerts beneficial effects on gas exchange in neonates with acute respiratory failure. We examined whether continuous negative extrathoracic pressure (CNEP) combined with HFO would be effective for treating acute respiratory failure in an animal model. Methods The effects of CNEP combined with HFO on pulmonary gas exchange and circulation were examined in a surfactant-depleted rabbit model. After induction of severe lung injury by repeated saline lung lavage, 18 adult white Japanese rabbits were randomly assigned to 3 groups: Group 1, CNEP (extra thoracic negative pressure, -10 cmH2O) with HFO (mean airway pressure (MAP), 10 cmH2O); Group 2, HFO (MAP, 10 cmH2O); and Group 3, HFO (MAP, 15 cmH2O). Physiological and blood gas data were compared among groups using analysis of variance. Results Group 1 showed significantly higher oxygenation than Group 2, and the same oxygenation with significantly higher mean blood pressure compared to Group 3. Conclusion Adequate CNEP combined with HFO improves oxygenation with less impact on blood pressure than high-frequency oscillation alone in an animal model of respiratory failure.
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Affiliation(s)
- Sachie Naito
- Division of Neonatology, Nagano Children's Hospital, Nagano, Japan.
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23
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Shah PS, Ohlsson A, Shah JP. Continuous negative extrathoracic pressure or continuous positive airway pressure for acute hypoxemic respiratory failure in children. Cochrane Database Syst Rev 2005:CD003699. [PMID: 16034907 DOI: 10.1002/14651858.cd003699.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Acute hypoxemic respiratory failure (AHRF) is an important cause of mortality and morbidity in the pediatric age group. Positive pressure ventilation is currently the standard of care, though is known to be associated with complications. Continuous negative extrathoracic pressure ventilation (CNEP) or continuous positive airway pressure ventilation delivered via non-invasive approaches (Ni-CPAP) have shown certain beneficial effects in animal and uncontrolled human studies. OBJECTIVES The primary objective of this review was to assess the effectiveness of CNEP and Ni-CPAP in pediatric patients with AHRF due to non-cardiogenic causes. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2005); MEDLINE (January 1966 to March 2005); EMBASE (1980 to March 2005); CINAHL (1982 to March 2005); published abstracts from the meetings of the American Thoracic Society and Pediatric Critical Care Meetings (1992 to 2005); and bibliographies of identified articles and asking the experts in the field. SELECTION CRITERIA Randomized or quasi-randomized clinical trials of either CNEP or Ni-CPAP versus standard therapy (positive pressure ventilation) involving children (at least 1 month old and less than 18 years of age at the time of randomization) who met the criteria for diagnosis of AHRF with at least one of the outcomes reported were included. DATA COLLECTION AND ANALYSIS The methodological quality of included study was assessed using the following criteria: concealment of randomization, blinding of intervention, completeness of follow up and blinding of outcome measurements. Data on relevant outcomes were abstracted and the effect size was estimated by calculating relative risk (RR) with 95% confidence intervals (CI) and risk difference (95% CI). MAIN RESULTS One eligible study was identified which was published in abstract format. Thirty-three infants (18 in the control group and 15 in the CNEP group) with a clinical diagnosis of bronchiolitis and fraction of inspired oxygen (FiO(2))()greater than 40% were studied. There was reduction in the FiO(2) (less than 30% within one hour of initiation of therapy) in four patients in the CNEP group compared to none in the control group (RR 10.7, 95% CI 0.6 to 183.9). One infant required positive pressure ventilation and one infant required nasal CPAP in the control group while all infants in the CNEP group were managed without intubation (RR for both outcomes 0.40, 95% CI 0.02 to 9.06). IMPLICATION FOR PRACTICE There is a lack of well designed, controlled experiments of noninvasive modes of respiratory support in children with AHRF. Implication for research: Reduction of in-hospital mortality is an important outcome and even a small reduction could be beneficial. Studies assessing other outcomes such as avoidance of intubation and its associated complications, reduction in hospital stay and improvement in patient comfort are also valuable in gauging the overall impact of these strategies.
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Affiliation(s)
- P S Shah
- Department of Paediatrics and Department of Health Policy, Management and Evaluation, University of Toronto, Rm 775A, 600 University Avenue, Toronto, Ontario, Canada, M5G 1XB.
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Tibballs J, Henning RD. Noninvasive ventilatory strategies in the management of a newborn infant and three children with congenital central hypoventilation syndrome. Pediatr Pulmonol 2003; 36:544-8. [PMID: 14618648 DOI: 10.1002/ppul.10392] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Four children with congenital central hypoventilation syndrome (CCHS) treated with noninvasive techniques of ventilation are presented. Two infants (one in the newborn period) were treated with nasal mask bilevel positive airway pressure (BiPAP), and then both were transitioned to negative pressure chamber ventilation at several years of age because of possible midface hypoplasia. Tracheostomies were not performed. Two older children were transitioned from mechanical ventilation via tracheostomy to nasal mask BiPAP, and then in one case to negative pressure chamber ventilation, and in the other to phrenic nerve pacing. Their tracheostomies were removed.
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Affiliation(s)
- James Tibballs
- Intensive Care Unit, Royal Children's Hospital, Parkville, Melbourne, Australia.
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Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare and unique condition that may prompt unparalleled approaches to the discovery of genes involved in development of cardiorespiratory control and gas exchange homeostasis. Its higher risk of recurrence in families and its association with Hirschsprung's disease suggest that an underlying genetic mechanism is involved. However, screening for mutations of the receptor tyrosine kinase RET and endothelin 3 has revealed only occasional patients affected by these mutations, therefore suggesting that CCHS may result from disruption of more than a single gene. In recent years, three principal issues have become apparent: 1) the autonomic nervous system is involved universally in CCHS cases, albeit to a varying extent; 2) the use of novel functional imaging approaches incorporating refined stimulus paradigms may provide essential research and clinical insights into localization and assessment of neural sites underlying the phenotypic expression of this syndrome; and 3) efforts to transition patients' nocturnal respiratory support to a noninvasive ventilatory modality should be critically evaluated and pursued, when appropriate, to improve the quality of life for patients and families.
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Affiliation(s)
- D Gozal
- Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
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Noyes J, Hartmann H, Samuels M, Southall D. The experiences and views of parents who care for ventilator-dependent children. J Clin Nurs 1999; 8:440-50. [PMID: 10624261 DOI: 10.1046/j.1365-2702.1999.00258.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Discussion in this paper is drawn from the literature examining the management of children with long-term assisted ventilation, and a study of parents' experiences and views of caring for their ventilator-dependent child at home. Difficulties in undertaking research into this group of children are highlighted. Recommendations are proposed regarding future multidisciplinary, multiagency service development in order to meet the needs of ventilator-dependent children and their families.
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Affiliation(s)
- J Noyes
- Department of Nursing/Institute for Health Research, University of Salford, UK
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Abstract
We report on a 2 1/2-year-old boy who is currently ventilated at home by positive pressure ventilation through a nasal mask during the night because of congenital central hypoventilation syndrome (CCHS). Up to age 2 he had developed normally. A reevaluation was performed because of symptoms suggestive of obstructive sleep apnea syndrome (OSAS), including snoring, nocturnal sweating, frequent nighttime awakenings, speech impairment, daytime fatigue, and failure to thrive. A sleep study indicated obstructive apnea episodes lasting up to 40 s and arterial desaturations below 50% during spontaneous sleep. During mechanical ventilation snoring persisted, and capillary PCO2 rose to 60 mm Hg. Partial upper airway obstruction, leaking around the mask, and arousal movements developed on passive flexion of the neck to 20 degrees. After adenoidectomy, symptoms of OSAS resolved. There were no more obstructive apneas during spontaneous sleep, but obstructive apneas could be provoked by neck flexion to 20 degrees. During ventilation, neck flexion of 20 degrees was tolerated, but a 40 degrees flexion led to partial obstruction. In CCHS patients, the problem of upper airway obstruction is rarely noted because most patients are ventilated through a permanent tracheostomy. Today, noninvasive ventilation strategies are becoming more common. Reduced activity of upper airway muscles and impaired reflex mechanisms could lead to upper airway obstruction during face mask positive pressure ventilation in children with CCHS. Enlarged adenoids worsened this problem in our patient, leading to insufficient ventilation and OSAS. Adenoidectomy resolved symptoms of OSAS and enabled successful nasal mask ventilation. Close follow-up of the patient avoided hypoxia and sequelae from OSAS such as pulmonary hypertension.
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Affiliation(s)
- H Kurz
- Department of Pediatrics, Sozialmedizinisches Zantrum Ost, Danube Hospital, Vienna, Austria.
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28
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Abstract
Awareness of the existence of CCHS has led to increasingly frequent reports of such patients from all over the world. However, the exact pathophysiologic mechanisms underlying the clinical manifestations of this congenital disease entity remain unknown. For the respiratory physiologist, CCHS can be viewed as an experiment of nature that provides an important and unique window into central cardiorespiratory regulation. For the pediatrician, CCHS children represent an unique clinical challenge in coordinating the diagnostic and therapeutic procedures required to enhance the patients' quality of life.
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Affiliation(s)
- D Gozal
- Constance S. Kaufman Pediatric Pulmonary Research Laboratory, Department of Pediatrics, Tulane University School of Medicine, New Orleans, Louisiana 70112, USA.
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29
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Child F, Couriel J. The control of breathing with reference to congenital central hypoventilation syndrome. J R Soc Med 1998; 91:479-83. [PMID: 9849519 PMCID: PMC1296876 DOI: 10.1177/014107689809100907] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- F Child
- Department of Medicine, Booth Hall Children's Hospital (University of Manchester School of Medical Sciences), UK
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30
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Affiliation(s)
- A Thomson
- Department of Paediatrics, Oxford Radcliffe Hospital
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31
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Villa MP, Dotta A, Castello D, Piro S, Pagani J, Palamides S, Ronchetti R. Bi-level positive airway pressure (BiPAP) ventilation in an infant with central hypoventilation syndrome. Pediatr Pulmonol 1997; 24:66-9. [PMID: 9261857 DOI: 10.1002/(sici)1099-0496(199707)24:1<66::aid-ppul12>3.0.co;2-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A 4-month-old baby girl, after a period of apparent good health, began to have aphonia, dyspnea, difficulties with swallowing, cyanosis, apnea, and hypopnea during sleep that resulted in admission to an intensive care unit for intubation and mechanical ventilation. At the age of 9 months she was admitted to our hospital with a possible diagnosis of central hypoventilation syndrome. A polysomnographic study showed apnea and hypopnea (apnea + hypopnea index = 47.1), hypercapnia (mean end-tidal PCO2 89 +/- 15.0 mmHg), and arterial desaturation (mean SaO2 91 +/- 1.7%; lowest SaO2 < 50%; 68% of total sleep time at SaO2 below 93%); the study also showed an absent ventilatory response to CO2, absent cardiac responses to apnea during sleep, and right ventricular hypertrophy. Nocturnal nasal bi-level positive airway pressure (BIPAP), applied initially at 6 cmH2O and gradually increased to 16 cmH2O, caused the sleep-related abnormal respiratory events to disappear. End-tidal PCO2 decreased to 39 mmHg, and SaO2 increased to 94%. After 6 months of nocturnal BiPAP ventricular right hypertrophy reversed and arrested growth and hypotonia normalized. The child has tolerated and has remained on BiPAP support up to her current age of 3 years and continues to use this form of ventilatory assistance without difficulties.
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Affiliation(s)
- M P Villa
- TV Cattedra di Clinica Pediatrica, University La Sapienza, Rome, Italy
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