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Duiverman ML, Jesus F, Bladder G, Wijkstra PJ. Initiation of Chronic Non-invasive Ventilation. Sleep Med Clin 2024; 19:419-430. [PMID: 39095140 DOI: 10.1016/j.jsmc.2024.04.006] [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: 08/04/2024]
Abstract
Initiation of home non-invasive ventilation (NIV) requires careful consideration of the patient's condition, motivation, expectations, wishes, and social circumstances. The decision to start NIV depends on a combination of factors including patient symptoms and objective evidence of nocturnal hypoventilation. A solid understanding of the underlying pathophysiology is key to a systematic and well-balanced clinical approach to titrating NIV. The location where NIV is initiated is not the most relevant issue, provided that it is a comfortable, safe environment in which adequate monitoring can be assured. The majority of patients prefer their own home for treatment initiation.
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Affiliation(s)
- Marieke L Duiverman
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Filipa Jesus
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; Pulmonology Department, Unidade Local de Saúde da Guarda EPE, Rainha D. Amélia, s/n 6301-857 Guarda, Portugal
| | - Gerrie Bladder
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Peter J Wijkstra
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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2
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Weber FJ, Latshang TD, Blum MR, Kohler M, Wertli MM. Prognostic factors, disease course, and treatment efficacy in Duchenne muscular dystrophy: A systematic review and meta-analysis. Muscle Nerve 2022; 66:462-470. [PMID: 35860996 PMCID: PMC9804574 DOI: 10.1002/mus.27682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/10/2022] [Accepted: 07/17/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION/AIMS Prognostic factors in Duchenne muscular dystrophy (DMD) predict the disease course and may help individualize patient care. The aim was to summarize the evidence on prognostic factors that may support treatment decisions. METHODS We searched six databases for prospective studies that each included ≥50 DMD patients with a minimum follow-up of 1 y. Primary outcomes were age at loss of ambulation (LoA), pulmonary function (forced vital capacity percent of predicted, FVC%p), and heart failure. RESULTS Out of 5074 references, 59 studies were analyzed. Corticosteroid use was associated with a delayed LoA (pooled effect hazard ratio [HR] 0.42, 95% confidence interval [CI] 0.23-0.75, I2 94%), better pulmonary function tests (higher peak FVC%, prolonged time with FVC%p > 50%, and reduced need for assisted ventilation) and delayed cardiomyopathy. Longer corticosteroid treatment was associated with later LoA (>1 y compared to <1 y; pooled HR: 0.50, 95% CI 0.27-0.90) and early treatment start (aged <5 y) may be associated with early cardiomyopathy and higher fracture risk. Genotype appeared to be an independent driver of LoA in some studies. Higher baseline physical function tests (e.g., 6-minute walk test) were associated with delayed LoA. Left ventricular dysfunction and FVC <1 L increased and the use of angiotensin-converting enzyme (ACE) inhibitors reduced the risk of heart failure and death. Fusion surgery in scoliosis may potentially preserve pulmonary function. DISCUSSION Prognostic factors that may inform clinical decisions include age at corticosteroid treatment initiation and treatment duration, ACE-inhibitor use, baseline physical function tests, pulmonary function, and cardiac dysfunction.
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Affiliation(s)
- Fabio J Weber
- Sleep Disorders Center and Pulmonary Division, University Hospital Zurich, Zurich, Switzerland
| | - Tsogyal D Latshang
- Sleep Disorders Center and Pulmonary Division, University Hospital Zurich, Zurich, Switzerland.,Sleep Disorders Center and Pulmonary Division, Kantonsspital Graubuenden, Chur, Switzerland
| | - Manuel R Blum
- Department of General Internal Medicine, University Hospital Bern, University of Bern, Bern, Switzerland.,Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Malcolm Kohler
- Sleep Disorders Center and Pulmonary Division, University Hospital Zurich, Zurich, Switzerland.,Zurich Center for Interdisciplinary Sleep Research, University of Zurich, Zurich, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, University Hospital Bern, University of Bern, Bern, Switzerland.,Department of Internal Medicine, Cantonal Hospital Baden, Baden, Switzerland
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3
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Pennati F, LoMauro A, D’Angelo MG, Aliverti A. Non-Invasive Respiratory Assessment in Duchenne Muscular Dystrophy: From Clinical Research to Outcome Measures. Life (Basel) 2021; 11:life11090947. [PMID: 34575096 PMCID: PMC8468718 DOI: 10.3390/life11090947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 12/03/2022] Open
Abstract
Ventilatory failure, due to the progressive wasting of respiratory muscles, is the main cause of death in patients with Duchenne muscular dystrophy (DMD). Reliable measures of lung function and respiratory muscle action are important to monitor disease progression, to identify early signs of ventilatory insufficiency and to plan individual respiratory management. Moreover, the current development of novel gene-modifying and pharmacological therapies highlighted the urgent need of respiratory outcomes to quantify the effects of these therapies. Pulmonary function tests represent the standard of care for lung function evaluation in DMD, but provide a global evaluation of respiratory involvement, which results from the interaction between different respiratory muscles. Currently, research studies have focused on finding novel outcome measures able to describe the behavior of individual respiratory muscles. This review overviews the measures currently identified in clinical research to follow the progressive respiratory decline in patients with DMD, from a global assessment to an individual structure–function muscle characterization. We aim to discuss their strengths and limitations, in relation to their current development and suitability as outcome measures for use in a clinical setting and as in upcoming drug trials in DMD.
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Affiliation(s)
- Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milano, Italy; (A.L.); (A.A.)
- Correspondence:
| | - Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milano, Italy; (A.L.); (A.A.)
| | | | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milano, Italy; (A.L.); (A.A.)
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4
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Angliss ME, Sclip KD, Gauld L. Early NIV is associated with accelerated lung function decline in Duchenne muscular dystrophy treated with glucocorticosteroids. BMJ Open Respir Res 2021; 7:7/1/e000517. [PMID: 32079608 PMCID: PMC7047482 DOI: 10.1136/bmjresp-2019-000517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/21/2020] [Accepted: 01/31/2020] [Indexed: 12/11/2022] Open
Abstract
Background Use of non-invasive ventilation (NIV) in adolescents with Duchenne muscular dystrophy (DMD) has increased with concomitant extended survival. Aim To describe lung function (LF) changes with NIV in adolescents with DMD and to assess differences between Steroid Users and Steroid Naïve subjects. Method A retrospective cohort of adolescents with DMD initiating NIV over 10 years was conducted. Serial LF before and after NIV initiation was collated. Use of systemic glucocorticosteroids, adherence to NIV and presence of cardiac disease were assessed. Results Twenty-nine men started NIV, median age 14.66 years (IQR 2.35, 10.47–17.96). Nine were Steroid Users and eight were Steroid Naïve. Indications for NIV were apnoea–hypopnoea index >5 and/or nocturnal hypoventilation. LF is better (forced vital capacity (FVC) z-score −3.26 vs −5.41, p < 0.02) and decline slower (FVC z-score −0.58 per annum (pa) vs −0.68 pa, p<0.001) in Steroid Users compared with Steroid Naïve subjects. Following NIV initiation, FVC z-score decline slowed for the whole (−0.72 pa (95% CI −0.79 to 0.64) to −0.46 pa (95% CI −0.54 to 0.38) p < 0.001) and Steroid Naïve groups (−0.74 (95% CI −0.85 to 0.63) to −0.44 pa (95% CI −0.56 to 0.32) p < 0.001) but accelerated in the Steroid User group (−0.56 (95% CI −0.70 to 0.42) to −0.75 pa (95% CI −0.89 to 0.61) p < 0.001). Adherence to NIV and cardiac disease did not impact decline. Conclusion Overall, LF decline is reduced on NIV. Steroid Naïve patients have lower LF and faster decline, which slows following NIV initiation. An accelerated LF decline was seen on NIV in Steroid Users which requires further prospective research.
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Affiliation(s)
- Megan E Angliss
- Respiratory Medicine, Children's Health Queensland Hospital and Health Service, South Birsbane, Queensland, Australia
| | - Kiara D Sclip
- Respiratory Medicine, Children's Health Queensland Hospital and Health Service, South Birsbane, Queensland, Australia
| | - Leanne Gauld
- Respiratory Medicine, Children's Health Queensland Hospital and Health Service, South Birsbane, Queensland, Australia .,School of Medicine, University of Queensland, St. Lucia, Queensland, Australia
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5
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Chikkannaiah M, Reyes I. New diagnostic and therapeutic modalities in neuromuscular disorders in children. Curr Probl Pediatr Adolesc Health Care 2021; 51:101033. [PMID: 34281812 DOI: 10.1016/j.cppeds.2021.101033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Pediatric neuromuscular disorders are a diverse group of conditions that affect how muscle and nerve function. They involve the motor neurons, nerves, neuromuscular junction and muscles. Pathology of any of these regions leads to the inability to perform voluntary movements. Over time, the natural progression of most of these disorders is followed by significant disability, and at the most extreme, almost complete paralysis and death secondary to complications. Diagnostic measures for pediatric neuromuscular disorders, like that of most medical conditions, relies heavily on clinical presentation, history and a detailed physical examination. Primary additional diagnostic measures have included serum creatine kinase (CK) levels, electromyography (EMG), nerve conduction studies (NCS) and muscle or nerve biopsies, which has historically been the gold standard. In the last several decades less invasive testing has become more common such as muscle magnetic resonance imaging (MRI) and genetic testing. The advances of molecular genetics, such as next generation sequencing (NGS) which includes whole-exome sequencing (WES) and whole-genome sequencing (WGS), enable clinicians to pinpoint more accurately exact gene mutations. The advent of genetic testing enhances personalized medicine. The field of pediatric neuromuscular disorders is also undergoing a remarkable evolution in therapeutic modalities including novel targeted therapies such as exon skipping/inclusion and gene replacement therapies. This is a review of the initial approach to suspected neuromuscular disorders in children as well as up to date diagnostic and therapeutic modalities for the most common pediatric neuromuscular disorders. As the world enters the new decade, there are encouraging therapeutic results. However, there remain key challenges to these modalities including limitations in its applicability, optimization for delivery of gene replacement therapies and in its effectiveness.
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Affiliation(s)
- Mahesh Chikkannaiah
- Department of Neurology, Dayton Children's Hospital, Wright State University Boonshoft School of Medicine, 1 Children's Plaza, Dayton, Ohio, 45404.
| | - Irma Reyes
- Department of Neurology, Dayton Children's Hospital, Wright State University Boonshoft School of Medicine, 1 Children's Plaza, Dayton, Ohio, 45404.
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6
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Dhargave P, Nalini A, Nagarathna R, Sendhilkumar R, James TT, Raju TR, Sathyaprabha TN. Effect of Yoga and Physiotherapy on Pulmonary Functions in Children with Duchenne Muscular Dystrophy - A Comparative Study. Int J Yoga 2021; 14:133-140. [PMID: 34188385 PMCID: PMC8191220 DOI: 10.4103/ijoy.ijoy_49_20] [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] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/17/2020] [Accepted: 12/23/2020] [Indexed: 11/12/2022] Open
Abstract
Context: Abnormal respiratory function is known to be detectable almost as soon as it can be measured reliably. Studies have identified the effect of respiratory muscle training as well as breathing exercises in improving pulmonary functions in children with Duchenne muscular dystrophy (DMD). Aims: This study aims to identify the add-on effect of yoga over physiotherapy on pulmonary functions in children with DMD. Settings and Design: One hundred and twenty-four patients with DMD were randomized to two groups. Group I received home-based physiotherapy and Group II received physiotherapy along with yoga intervention. Materials and Methods: Pulmonary function test (PFT) was assessed before the intervention (baseline data) and at regular intervals of 3 months for a period of 1 year. Statistical Analysis Used: Normality was assessed using Shapiro–Wilk normality test. The baseline data were analyzed using Mann–Whitney U-test to identify the homogeneity. Repeated measures analysis of variance was used to assess significant changes in study parameters during the assessment of every 3 months, both within and between the two groups of patients. Results: A total of 88 participants completed all the 5 assessments, with a mean age of 7.9 ± 1.5 years. PFT parameters such as forced vital capacity (FVC), peak expiratory flow rate, maximum voluntary ventilation (MVV), and tidal volume during maximum voluntary ventilation (MVt) demonstrated significant improvements in Group I. In Group II, FVC and MVt significantly improved from baseline up to 1 year, whereas MVV improved from baseline up to 9 months. Tidal volume did not show any changes in both the groups. Conclusions: The findings suggest that introduction of yoga with physiotherapy intervention at an early age can be considered as one of the therapeutic strategies in improving pulmonary functions in patients with DMD.
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Affiliation(s)
- Pradnya Dhargave
- Physiotherapy Centre, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Atchayaram Nalini
- Department of Neurology, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Raghuram Nagarathna
- Dean, Division of Yoga and Life Sciences, Swami Vivekanandha Yoga Research Foundation, Bengaluru, Karnataka, India
| | - Raghupathy Sendhilkumar
- Physiotherapy Centre, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Tittu Thomas James
- Physiotherapy Centre, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Trichur R Raju
- Department of Neurophysiology, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Talakad N Sathyaprabha
- Department of Neurophysiology, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
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7
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Gurbani N, Pascoe JE, Katz S, Sawnani H. Sleep disordered breathing: Assessment and therapy in the age of emerging neuromuscular therapies. Pediatr Pulmonol 2021; 56:700-709. [PMID: 32720756 DOI: 10.1002/ppul.24988] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/24/2020] [Indexed: 11/10/2022]
Abstract
The term neuromuscular disease (NMD) encompasses a large variety of disorders that result in abnormal muscle function. Although it may be conventional to relate the use of this term to the most common muscular diseases (Duchenne muscular dystrophy [DMD], spinal muscular atrophy [SMA], and amyotrophic lateral sclerosis, etc), it is important to extend the term to pathologies manifested by severe neurologic (brain and spinal cord) malformations and injuries. In many of these scenarios, there are common mechanisms that contribute to sleep disordered breathing (SDB) and respiratory insufficiency although comorbidities may be somewhat different. Advances in the understanding of these diseases and their natural history, and increasing availability of mechanical ventilation to these patients have improved survival. The development of novel genetic and molecular therapies (as in the cases of DMD, SMA, and X-linked myotubular myopathy) provides an opportunity to use SDB as a reasonable outcome measure while also allowing the use of polysomnography as a validation tool in the assessments of effectiveness of therapies. We seek to provide an understanding of SDB in NMDs, and in the same light, would like to begin the conversation of thinking about weaning respiratory support when possible.
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Affiliation(s)
- Neepa Gurbani
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John E Pascoe
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sherri Katz
- Division of Respiratory Medicine, Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario/University of Ottawa, Ottawa, Ontario, Canada
| | - Hemant Sawnani
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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8
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Mackenzie SJ, Nicolau S, Connolly AM, Mendell JR. Therapeutic Approaches for Duchenne Muscular Dystrophy: Old and New. Semin Pediatr Neurol 2021; 37:100877. [PMID: 33892842 DOI: 10.1016/j.spen.2021.100877] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 12/13/2022]
Abstract
Duchenne muscular dystrophy (DMD) is marked by pathogenic variants in the DMD gene, leading to reduced or absent dystrophin translation, muscle fiber destruction, loss of ambulation, cardiomyopathy, respiratory failure, and eventually death. Disease progression is slowed with use of prednisone or other corticosteroid agents. Gene replacement therapy, which is one of the focus points of this review, has emerged as the most promising potential treatment for DMD, though alternative RNA-based strategies have been employed for patients with specific pathogenic variants. While challenges remain, many of these novel therapeutic approaches hold promise for treating this devastating disease.
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Affiliation(s)
- Samuel J Mackenzie
- Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics and Neurology; The Ohio State University, Columbus, OH.
| | - Stefan Nicolau
- Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH
| | - Anne M Connolly
- Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics and Neurology; The Ohio State University, Columbus, OH
| | - Jerry R Mendell
- Center for Gene Therapy, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics and Neurology; The Ohio State University, Columbus, OH
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9
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De Braekeleer K, Toussaint M. Transcutaneous Carbon Dioxide Measurement in Adult Patients with Neuromuscular Disorders: A quality Level Assessment. J Neuromuscul Dis 2021; 8:305-313. [DOI: 10.3233/jnd-200516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Carbon dioxide tension (PCO2) monitoring during sleep, is crucial to identify respiratory failure in patients with neuromuscular disorders (NMD). Transcutaneous PCO2 monitoring is an available technique to measure PCO2. Objectives: To assess the quality level of transcutaneous blood gas measurements via SenTec monitor. Methods: A 12-month analysis of SenTec measurements was conducted in a Belgian Centre for Home Mechanical Ventilation (HMV). Over two consecutive nights; SpO2 and PCO2 measurements, the presence of PCO2 drift and drift correction with SenTec, were reviewed and scores (0, 1, 2 for poor, medium and high level) were assigned to estimate the quality of measurements. Results: Sixty-nine NMD patients met the inclusion criteria, of which 48/69 used HMV. PCO2 drift and drift correction were present in 15% and 68% of the 138 recordings, respectively. The quality level of measurements throughout night 1, scored 1.55 (0–2). The relevance of our clinical findings from SenTec scoring 1.94 (1–2); was considered highly satisfactory. HMV was ineffective in 24/48 patients. Among 12 patients with hypercapnia, 8 patients improved PCO2 between night 1 and 2. Among 12 patients with hypocapnia, PCO2 improved in 4/12 patients, who reached the range of normal PCO2 (35–47 mmHg). Conclusions: The quality of SenTec measurements was acceptable in the majority of recordings and clinical findings were deemed satisfactory in all cases. A single SenTec measurement was sufficient to determine the need for NIV. However, two SenTec registrations were insufficient to both improve NIV effectiveness in 50% of cases, and, to ensure follow-up of our interventions.
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Affiliation(s)
- Katrien De Braekeleer
- Centre for Home Mechanical Ventilation and Neuromuscular Disorders, Department of Rehabilitation, Rehabilitation Hospital Inkendaal, Vlezenbeek, Belgium
| | - Michel Toussaint
- Centre for Home Mechanical Ventilation and Neuromuscular Disorders, Department of Rehabilitation, Rehabilitation Hospital Inkendaal, Vlezenbeek, Belgium
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10
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Vincenzi U. A new mode of mechanical ventilation: positive + negative synchronized ventilation. Multidiscip Respir Med 2021; 16:788. [PMID: 34584691 PMCID: PMC8441538 DOI: 10.4081/mrm.2021.788] [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: 06/01/2021] [Accepted: 07/14/2021] [Indexed: 11/23/2022] Open
Abstract
Supporting patients suffering from severe respiratory diseases with mechanical ventilation, obstacles are often encountered due to pulmonary and/or thoracic alterations, reductions in the ventilable lung parenchyma, increases in airway resistance, alterations in thoraco-pulmonary compliance, advanced age of the subjects. All this involves difficulties in finding the right ventilation parameters and an adequate driving pressure to guarantee sufficient ventilation. Therefrom, new mechanical ventilation techniques were sought that could help overcome the aforementioned obstacles. A new mode of mechanical ventilation is being presented, i.e., a Positive + Negative Synchronized Ventilation (PNSV), characterized by the association and integration of two pulmonary ventilators; one acting inside the chest with positive pressures and one externally with negative pressure. The peculiarity of this combination is the complete synchronization, which takes place with specific electronic modifications. The PNSV can be applied both in a completely non-invasive and invasive way and, therefore, be used both in acute care wards and in ICU. The most relevant effect found, due to the compensation of opposing pressures acting on the chest, is that, during the entire inspiratory act created by the ventilators, the pressure at the alveolar level is equal to zero even if adding together the two ventilators' pressures; thus, the transpulmonary pressure is doubled. The application of this pressure for 1 hour on elderly patients suffering from severe acute respiratory failure, resulted in a significant improvement in blood gas analytical and clinical parameters without any side effects. An increased pulmonary recruitment, including posterior lung areas, and a reduction in spontaneous ventilatory rate have also been demonstrated with PNSV. This also paves the way to the search for the best ventilatory treatment in critically ill or ARDS patients. The compensation of intrathoracic pressures should also lead, although not yet proven, to an improvement in venous return, systolic and cardiac output. In the analysis of the study in which this method was applied, the total transpulmonary pressure delivered was the sum of the individual pressures applied by the two ventilators. However, this does not exclude the possibility of reducing the pressures of the two machines to modulate a lower but balanced total transpulmonary pressure within the chest.
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Affiliation(s)
- Umberto Vincenzi
- Former Director of Operative Unit of Pneumology and Intensive Respiratory Care Unit, "Ospedali Riuniti" University Hospital, Foggia, Italy
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11
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Fiala JA, Coleman JM. Tailoring the Sleep Laboratory for Chronic Respiratory Failure. Sleep Med Clin 2020; 15:557-568. [PMID: 33131665 DOI: 10.1016/j.jsmc.2020.08.009] [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: 11/19/2022]
Abstract
"Many seemingly mundane aspects of the sleep laboratory can have outsized effects on the quality of polysomnographic data obtained from, and care provided to, patients. This is particularly true when performing polysomnography on patients with chronic respiratory failure due to various causes. This article uses a disease-based approach to review physical and protocol-based accommodations that should be considered when performing polysomnography on this patient population."
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Affiliation(s)
- Justin A Fiala
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North Street Clair Street, Suite 1400, Chicago, IL 60611, USA
| | - John M Coleman
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North Street Clair Street, Suite 1400, Chicago, IL 60611, USA.
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12
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Baltaxe E, Embid C, Aumatell E, Martínez M, Barberan-Garcia A, Kelly J, Eaglesham J, Herranz C, Vargiu E, Montserrat JM, Roca J, Cano I. Integrated Care Intervention Supported by a Mobile Health Tool for Patients Using Noninvasive Ventilation at Home: Randomized Controlled Trial. JMIR Mhealth Uhealth 2020; 8:e16395. [PMID: 32281941 PMCID: PMC7186864 DOI: 10.2196/16395] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 01/19/2020] [Accepted: 02/04/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Home-based noninvasive ventilation has proven cost-effective. But, adherence to therapy still constitutes a common clinical problem. We hypothesized that a behavioral intervention supported by a mobile health (mHealth) app could enhance patient self-efficacy. It is widely accepted that mHealth-supported services can enhance productive interactions among the stakeholders involved in home-based respiratory therapies. OBJECTIVE This study aimed to measure changes in self-efficacy in patients with chronic respiratory failure due to diverse etiologies during a 3-month follow-up period after the intervention. Ancillary objectives were assessment of usability and acceptability of the mobile app as well as its potential contribution to collaborative work among stakeholders. METHODS A single-blind, single-center, randomized controlled trial was conducted between February 2019 and June 2019 with 67 adult patients with chronic respiratory failure undergoing home-based noninvasive ventilation. In the intervention group, a psychologist delivered a face-to-face motivational intervention. Follow-up was supported by a mobile app that allowed patients to report the number of hours of daily noninvasive ventilation use and problems with the therapy. Advice was automatically delivered by the mobile app in case of a reported problem. The control group received usual care. The primary outcome was the change in the Self Efficacy in Sleep Apnea questionnaire score. Secondary outcomes included app usability, app acceptability, continuity of care, person-centered care, and ventilatory parameters. RESULTS Self-efficacy was not significantly different in the intervention group after the intervention (before: mean 3.4, SD 0.6; after: mean 3.4, SD 0.5, P=.51). No changes were observed in adherence to therapy nor quality of life. Overall, the mHealth tool had a good usability score (mean 78 points) and high acceptance rate (mean score of 7.5/10 on a Likert scale). It was considered user-friendly (mean score of 8.2/10 on a Likert scale) and easy to use without assistance (mean score of 8.5/10 on a Likert scale). Patients also scored the perception of continuity of care and person-centered care as high. CONCLUSIONS The integrated care intervention supported by the mobile app did not improve patient self-management. However, the high acceptance of the mobile app might indicate potential for enhanced communication among stakeholders. The study identified key elements required for mHealth tools to provide effective support to collaborative work and personalized care. TRIAL REGISTRATION ClinicalTrials.gov NCT03932175; https://clinicaltrials.gov/ct2/show/NCT03932175.
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Affiliation(s)
- Erik Baltaxe
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Center for Biomedical Research Network in Respiratory Diseases, Madrid, Spain
| | - Cristina Embid
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Center for Biomedical Research Network in Respiratory Diseases, Madrid, Spain
| | - Eva Aumatell
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - María Martínez
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain
| | - Anael Barberan-Garcia
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Center for Biomedical Research Network in Respiratory Diseases, Madrid, Spain
| | - John Kelly
- Advanced Digital Innovation (UK) Ltd, Salts Mill, United Kingdom
| | - John Eaglesham
- Advanced Digital Innovation (UK) Ltd, Salts Mill, United Kingdom
| | - Carmen Herranz
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Center for Biomedical Research Network in Respiratory Diseases, Madrid, Spain
| | - Eloisa Vargiu
- Eurecat Technological Center of Catalonia, Barcelona, Spain
| | - Josep Maria Montserrat
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Center for Biomedical Research Network in Respiratory Diseases, Madrid, Spain
| | - Josep Roca
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Center for Biomedical Research Network in Respiratory Diseases, Madrid, Spain
| | - Isaac Cano
- Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.,Center for Biomedical Research Network in Respiratory Diseases, Madrid, Spain
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13
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Banfi P, Pierucci P, Volpato E, Nicolini A, Lax A, Robert D, Bach J. Daytime noninvasive ventilatory support for patients with ventilatory pump failure: a narrative review. Multidiscip Respir Med 2019; 14:38. [PMID: 31798866 PMCID: PMC6884796 DOI: 10.1186/s40248-019-0202-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/31/2019] [Indexed: 12/12/2022] Open
Abstract
Over the past three decades, the use of noninvasive ventilation or "NIV" to assuage symptoms of hypoventilation for patients with early onset or mild ventilatory pump failure has been extended to up to the use of continuous noninvasive ventilatory support (CNVS) at full ventilatory support settings as a definitive alternative to tracheostomy mechanical ventilation. NVS, along with mechanical insufflation-exsufflation, now provides a noninvasive option for the management of both chronic and acute respiratory failure for these patients. The most common diagnoses for which these methods are useful include chest wall deformities, neuromuscular diseases, morbid obesity, high level spinal cord injury and idiopathic, primary or secondary disorders of the ventilatory control. Thus, NVS is being used in diverse settings: critical care units, medical wards, at home, and in extended care. The aim of this review is to examine the techniques used for daytime support.
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Affiliation(s)
- Paolo Banfi
- IRCCS Fondazione Don Carlo Gnocchi, via Capecelatro, 66 20148 Milan, Italy
| | - Paola Pierucci
- Cardio Thoracic Department, Respiratory and Sleep Disorders Unit, Bari Policlinic, Bari, Italy
| | - Eleonora Volpato
- IRCCS Fondazione Don Carlo Gnocchi, via Capecelatro, 66 20148 Milan, Italy
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Antonello Nicolini
- Respiratory Rehabilitation Unit, ASL 4 Chiavarese, Hospital of Sestri Levante, Sestri Levante, Italy
| | - Agata Lax
- IRCCS Fondazione Don Carlo Gnocchi, via Capecelatro, 66 20148 Milan, Italy
| | - Dominique Robert
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service de Réanimation Médicale, Lyon, France
- Université de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - John Bach
- Department of Physical Medicine and Rehabilitation, Rutgers University New Jersey Medical School, Newark, USA
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14
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Crimi C, Pierucci P, Carlucci A, Cortegiani A, Gregoretti C. Long-Term Ventilation in Neuromuscular Patients: Review of Concerns, Beliefs, and Ethical Dilemmas. Respiration 2019; 97:185-196. [PMID: 30677752 DOI: 10.1159/000495941] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/03/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Noninvasive mechanical ventilation (NIV) is an effective treatment in patients with neuromuscular diseases (NMD) to improve symptoms, quality of life, and survival. SUMMARY NIV should be used early in the course of respiratory muscle involvement in NMD patients and its requirements may increase over time. Therefore, training on technical equipment at home and advice on problem solving are warranted. Remote monitoring of ventilator parameters using built-in ventilator software is recommended. Telemedicine may be helpful in reducing hospital admissions. Anticipatory planning and palliative care should be carried out to lessen the burden of care, to maintain or withdraw from NIV, and to guarantee the most respectful management in the last days of NMD patients' life. Key Message: Long-term NIV is effective but challenging in NMD patients. Efforts should be made by health care providers in arranging a planned transition to home and end-of-life discussions for ventilator-assisted individuals and their families.
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Affiliation(s)
- Claudia Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Paola Pierucci
- Cardiothoracic Department, Respiratory and Sleep Medicine Unit, Policlinico University Hospital, Bari, Italy
| | - Annalisa Carlucci
- Respiratory Intensive Care Unit, Pulmonary Rehabilitation Unit, IRCCS Fondazione S. Maugeri, Pavia, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy,
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
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15
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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.
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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
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Abstract
PURPOSE OF REVIEW Breathlessness is a common symptom in many chronic diseases and may be refractory to pharmacotherapy. In this review, we discuss the pathophysiology of breathlessness and the role of positive airway pressure (PAP) devices to ameliorate it. RECENT FINDINGS Breathlessness is directly related to neural respiratory drive, which can be modified by addressing the imbalance between respiratory muscle load and capacity. Noninvasive PAP devices have been applied to patients limited by exertional breathless and, as the disease progresses, breathlessness at rest. The application of PAP is focussed on addressing the imbalance in load and capacity, aiming to reduce neural respiratory drive and breathlessness. Indeed, noninvasive bi-level PAP devices have been employed to enhance exercise capacity by enhancing pulmonary mechanics and reduce neural drive in chronic obstructive pulmonary disease (COPD) patients, and reduce breathlessness for patients with progressive neuromuscular disease (NMD) by enhancing respiratory muscle capacity. Novel continuous PAP devices have been used to maintain central airways patency in patients with excessive dynamic airway collapse (EDAC) and target expiratory flow limitation in severe COPD. SUMMARY PAP devices can reduce exertional and resting breathlessness by reducing the load on the system and enhancing capacity to reduce neural respiratory drive.
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Conway K, Trout C, Westfield C, Fox D, Pandya S. A Pilot Survey Study of Adherence to Care Considerations for Duchenne Muscular Dystrophy. PLOS CURRENTS 2018; 10. [PMID: 30254788 PMCID: PMC6128678 DOI: 10.1371/currents.md.5f533e6e60ee172d6bf6b2b8375dfadf] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction Care Considerations supported by the Centers for Disease Control and Prevention for the management of Duchenne muscular dystrophy were published in 2010, but there has been limited study of implementation in the United States. Methods A questionnaire collecting information about standard care practices and perceived barriers was piloted by 9 clinic directors of facilities within the Muscular Dystrophy Surveillance, Tracking and Research network. Results Six clinic directors completed the questionnaire; 1 adult-only clinic was excluded. Over 80% adherence was found for 30 of 55 recommendations examined. Greatest variability was for initiation of corticosteroids, bone health monitoring, type of pulmonary function testing, and psychosocial management. Barriers included unclear guidelines, inadequate time and funding, family-specific barriers and lack of empirical support for some recommendations. Discussion This pilot study showed implementation of the 2010 Care Considerations, except for recommendations based largely on expert consensus. Complete adherence requires more studies and active promotion.
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Affiliation(s)
- Kristin Conway
- Department of Epidemiology, University of Iowa, Iowa City, IA, USA
| | - Christina Trout
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA
| | - Christina Westfield
- Bureau of Environmental and Occupational Epidemiology, New York State Department of Health, Buffalo, New York, USA
| | - Deborah Fox
- Department of Malformations Registry, New York State Department of Health, Albany, New York, USA
| | - Shree Pandya
- Department of Neurology, University of Rochester, Rochester, New York, USA
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18
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Zhang S, Mei QQ, Xin J, Zhang HY, Wu SW, Liu CF. The assessment of sniff nasal inspiratory pressure in patients with Duchenne muscular dystrophy in China. Brain Dev 2018; 40:391-396. [PMID: 29477801 DOI: 10.1016/j.braindev.2018.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/23/2018] [Accepted: 01/27/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Progressive weakness of respiratory muscles remains one of the leading causes of death among patients with Duchenne muscular dystrophy (DMD). Currently, there are few pulmonary function data among Chinese DMD patients. This study was carried out to evaluate the sniff nasal inspiratory pressure (SNIP) change among a group of Chinese DMD patients, and compare it with the SNIP value of patients with neuromuscular disorders in other countries. METHODS SNIP data were collected in three research groups that consists of 581 subjects: 125 DMD boys who have taken steroid (Age 5.0-13.3, DMD-steroid group), 145 DMD steroid-naive boys (Age 5.0-13.9, DMD-nonsteroid group), and 311 healthy controls (Age 5.0-14.0, Control group). RESULTS The SNIP for DMD-nonsteroid group, DMD-steroid group and Control group were: 56.5 (±14.3) cm H2O,66.4 (±15.5) cm H2O and 78.9 (±21.5) respectively. The SNIP in the DMD-nonsteroid group became significantly different from that of the healthy controls since age 7.0-8.9. The significant difference of SNIP between DMD-steroid group and DMD-nonsteroid group at age 7.0-10.9. The peak value of SNIP in the DMD-nonsteroid group appeared at age 8.7, and decreased dramatically thereafter, while in DMD-steroid group and the Control group peaked at 10.2 years and 12.2 years respectively. There was a bit difference between SNIP in this group and that in previous researches which may be due to geographical distribution and ethnic backgrounds. CONCLUSION This study strengthens the previous findings that SNIP can be used to evaluate respiratory dysfunction during the early stage of young patients with neuromuscular disorders, and demonstrates that steroid is effective in slowing the decrease of SNIP in this group of Chinese DMD boys.
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Affiliation(s)
- Shu Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, China; Department of Neurology, General Hospital of Chinese People's Armed Police force, China
| | - Qian-Qian Mei
- Department of Neurology, General Hospital of Chinese People's Armed Police force, China
| | - Jing Xin
- Department of Neurology, General Hospital of Chinese People's Armed Police force, China
| | - Hong-Ying Zhang
- Department of Neurology, General Hospital of Chinese People's Armed Police force, China
| | - Shi-Wen Wu
- Department of Neurology, General Hospital of Chinese People's Armed Police force, China.
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, China.
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19
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Abstract
PURPOSE OF REVIEW In numerous neuromuscular disorders (NMDs), respiratory muscle weakness is present, and acute or chronic respiratory failure may evolve. Very often, respiratory involvement substantially adds to the burden of disease, impairs quality of life, or reduces life expectancy. This article summarizes new aspects of both diagnosis and management of respiratory muscle weakness in patients with NMDs. RECENT FINDINGS Drugs like deflazacort, ataluren, eteplirsen, and nusinersen are now approved treatments for Duchenne Muscular Dystrophy and Spinal Muscular Atrophy, and others are on their way in NMDs. Although observing how innovative drugs will change the natural history of these diseases, including respiratory function over time, adequate symptomatic treatment remains meaningful and is strongly recommended. Physicians should systematically take respiratory involvement into account to improve patients' quality of life and prognosis. SUMMARY First, it is outlined in which subtypes of NMD respiratory muscle dysfunction is particularly relevant. Second, new developments regarding diagnostic procedures, including respiratory muscle strength testing, spirometry, and sleep studies, are covered. Third, this article gives an overview on current concepts of ventilatory support and management of secretions in patients with NMD.
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20
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LoMauro A, Romei M, Gandossini S, Pascuzzo R, Vantini S, D'Angelo MG, Aliverti A. Evolution of respiratory function in Duchenne muscular dystrophy from childhood to adulthood. Eur Respir J 2018; 51:51/2/1701418. [PMID: 29437939 DOI: 10.1183/13993003.01418-2017] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/21/2017] [Indexed: 11/05/2022]
Abstract
In Duchenne muscular dystrophy (DMD), it is still to be determined if specific timepoints can be identified during the natural evolution of respiratory dysfunction from childhood to adulthood and if scoliosis, steroid therapy and nocturnal noninvasive mechanical ventilation (NIMV) have any effect on it.In a 7-year retrospective study performed on 115 DMD patients (6-24 years), evaluated once or twice per year, with 574 visits in total, evolution mean curves of spirometry, lung volumes, spontaneous breathing and thoraco-abdominal pattern (measured by optoelectronic plethysmography) parameters were obtained by nonlinear regression model analysis.While predicted values of forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow decline continuously since childhood, during spontaneous breathing the following parameters become significantly different than normal in sequence: abdominal contribution to tidal volume (lower after 14.8 years), tidal volume (lower after 17.2 years), minute ventilation (lower after 18.1 years) and respiratory rate (higher after 22.1 years). Restrictive lung pattern and diaphragmatic impairment are exacerbated by scoliosis severity, slowed by steroids treatment and significantly affected by NIMV.Spirometry, lung volumes, breathing pattern and thoraco-abdominal contributions show different evolution curves over time. Specific timepoints of respiratory impairment are identified during disease progression. These should be considered when defining outcome measures in clinical trials and treatment strategies in DMD.
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Affiliation(s)
- Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
| | - Marianna Romei
- Istituto di Ricerca e Cura a Carattere Scientifico "E. Medea", Bosisio Parini, Italy
| | - Sandra Gandossini
- Istituto di Ricerca e Cura a Carattere Scientifico "E. Medea", Bosisio Parini, Italy
| | | | - Simone Vantini
- MOX-Department of Mathematics, Politecnico di Milano, Milano, Italy
| | - Maria Grazia D'Angelo
- Istituto di Ricerca e Cura a Carattere Scientifico "E. Medea", Bosisio Parini, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milano, Italy
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21
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Operation of a P300-based brain-computer interface in patients with Duchenne muscular dystrophy. Sci Rep 2018; 8:1753. [PMID: 29379140 PMCID: PMC5788861 DOI: 10.1038/s41598-018-20125-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 01/09/2018] [Indexed: 11/18/2022] Open
Abstract
A brain-computer interface (BCI) or brain-machine interface is a technology that enables the control of a computer and other external devices using signals from the brain. This technology has been tested in paralysed patients, such as those with cervical spinal cord injuries or amyotrophic lateral sclerosis, but it has not been tested systematically in Duchenne muscular dystrophy (DMD), which is a severe type of muscular dystrophy due to the loss of dystrophin and is often accompanied by progressive muscle weakness and wasting. Here, we investigated the efficacy of a P300-based BCI for patients with DMD. Eight bedridden patients with DMD and eight age- and gender-matched able-bodied controls were instructed to input hiragana characters. We used a region-based, two-step P300-based BCI with green/blue flicker stimuli. EEG data were recorded, and a linear discriminant analysis distinguished the target from other non-targets. The mean online accuracy of inputted characters (accuracy for the two-step procedure) was 71.6% for patients with DMD and 80.6% for controls, with no significant difference between the patients and controls. The P300-based BCI was operated successfully by individuals with DMD in an advanced stage and these findings suggest that this technology may be beneficial for patients with this disease.
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22
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Fiorentino G, Annunziata A, Cauteruccio R, Frega GSD, Esquinas A. Mouthpiece ventilation in Duchenne muscular dystrophy: a rescue strategy for noncompliant patients. J Bras Pneumol 2017; 42:453-456. [PMID: 28117478 PMCID: PMC5344096 DOI: 10.1590/s1806-37562016000000050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 07/07/2016] [Indexed: 11/30/2022] Open
Abstract
Objective: To evaluate mouthpiece ventilation (MPV) in patients with Duchenne muscular dystrophy (DMD) who are noncompliant with noninvasive ventilation (NIV). Methods: We evaluated four young patients with DMD who had previously refused to undergo NIV. Each patient was reassessed and encouraged to try MPV. Results: The four patients tolerated MPV well and were compliant with NIV at home. MPV proved to be preferable and more comfortable than NIV with any other type of interface. Two of the patients required overnight NIV and eventually agreed to use a nasal mask during the night. Conclusions: The advantages of MPV over other types of NIV include fewer speech problems, better appearance, and less impact on the patient, eliminating the risk of skin breakdown, gastric distension, conjunctivitis, and claustrophobia. The use of a mouthpiece interface should be always considered in patients with DMD who need to start NIV, in order to promote a positive approach and a rapid acceptance of NIV. Using MPV during the daytime makes patients feel safe and more likely to use NIV at night. In addition, MPV increases treatment compliance for those who refuse to use other types of interfaces.
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Affiliation(s)
- Giuseppe Fiorentino
- . Dipartimento di Fisiopatologia Respiratoria, Ospedale Monaldi di Napoli, Napoli, Italia
| | - Anna Annunziata
- . Dipartimento di Fisiopatologia Respiratoria, Ospedale Monaldi di Napoli, Napoli, Italia
| | - Rosa Cauteruccio
- . Dipartimento di Fisiopatologia Respiratoria, Ospedale Monaldi di Napoli, Napoli, Italia
| | | | - Antonio Esquinas
- . Unidad de Terapia Intensiva, Hospital General Morales Meseguer, Murcia, España
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23
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Abstract
This review aims to explain the inevitable imbalance between respiratory load, drive, and muscular force that occurs in the natural aging of Duchenne muscular dystrophy and that predisposes these patients to sleep disordered breathing (SDB). In DMD, SDB is characterized by oxygen desaturation, apneas, hypercapnia, and hypoventilation during sleep and ultimately develops into respiratory failure during wakefulness. It can be present in all age groups. Young patients risk obstructive apneas because of weight gain, secondary to progressive physical inactivity and prolonged corticosteroid therapy; older patients hypoventilate and desaturate because of respiratory muscle weakness, in particular the diaphragm. These conditions are further exacerbated during REM sleep, the phase of maximal muscle hypotonia during which the diaphragm has to provide most of the ventilation. Evidence is given to the daytime predictors of early symptoms of SDB, important indicators for the proper time to initiate mechanical ventilation.
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24
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Pinto T, Chatwin M, Banfi P, Winck JC, Nicolini A. Mouthpiece ventilation and complementary techniques in patients with neuromuscular disease: A brief clinical review and update. Chron Respir Dis 2017; 14:187-193. [PMID: 27932555 DOI: 10.1177/1479972316674411] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Noninvasive ventilatory support (NVS) is sometimes reported as suboptimal in patients with neuromuscular disease (NMD). The reasons for this include inadequate ventilator settings and/or lack of interface tolerance. NVS has been used for many years in patients with NMD disorders as a viable alternative to continuous ventilatory support via a tracheostomy tube. The mouthpiece ventilation (MPV) is a ventilatory mode that is used as daytime ventilatory support in combination with other ventilatory modalities and interfaces for nocturnal NVS. However, there is still a poor understanding of this method's benefits compared with other modalities. This review aims to highlight the indications and advantages along with the disadvantages of MPV.
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Affiliation(s)
- Tiago Pinto
- 1 Lung Function and Ventilation Unit, Department of Pulmonary Medicine, Porto, Portugal
| | - Michelle Chatwin
- 2 Clinical and Academic Department of Sleep and Breathing, Royal Brompton Hospital, London, UK
| | - Paolo Banfi
- 3 Don Gnocchi Foundation IRCSS, Milan, Italy
| | | | - Antonello Nicolini
- 5 Respiratory Diseases Unit and ALS Centre, Hospital of Sestri Levante, Italy
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25
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Schenk P, Eber E, Funk GC, Fritz W, Hartl S, Heininger P, Kink E, Kühteubl G, Oberwaldner B, Pachernigg U, Pfleger A, Schandl P, Schmidt I, Stein M. [Non-invasive and invasive out of hospital ventilation in chronic respiratory failure : Consensus report of the working group on ventilation and intensive care medicine of the Austrian Society of Pneumology]. Wien Klin Wochenschr 2016; 128 Suppl 1:S1-36. [PMID: 26837865 DOI: 10.1007/s00508-015-0899-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The current consensus report was compiled under the patronage of the Austrian Society of Pneumology (Österreichischen Gesellschaft für Pneumologie, ÖGP) with the intention of providing practical guidelines for out-of-hospital ventilation that are in accordance with specific Austrian framework parameters and legal foundations. The guidelines are oriented toward a 2004 consensus ÖGP recommendation concerning the setup of long-term ventilated patients and the 2010 German Respiratory Society S2 guidelines on noninvasive and invasive ventilation of chronic respiratory insufficiency, adapted to national experiences and updated according to recent literature. In 11 chapters, the initiation, adjustment, and monitoring of out-of-hospital ventilation is described, as is the technical equipment and airway access. Additionally, the different indications-such as chronic obstructive pulmonary diseases, thoracic restrictive and neuromuscular diseases, obesity hypoventilation syndrome, and pediatric diseases-are discussed. Furthermore, the respiratory physiotherapy of adults and children on invasive and noninvasive long-term ventilation is addressed in detail.
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Affiliation(s)
- Peter Schenk
- Abteilung für Pulmologie, Landesklinikum Hochegg, Hocheggerstraße 88, 2840, Grimmenstein, Österreich.
| | - Ernst Eber
- Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Georg-Christian Funk
- I. Interne Lungenabteilung, Pulmologisches Zentrum, Sozialmedizinisches Zentrum Baumgartner Höhe, Otto Wagner Spital, Wien, Österreich
| | - Wilfried Fritz
- Klinische Abteilung für Lungenkrankheiten, Universitätsklinik für Innere Medizin, Universitätsklinikum Graz, Graz, Österreich
| | - Sylvia Hartl
- I. Interne Lungenabteilung, Pulmologisches Zentrum, Sozialmedizinisches Zentrum Baumgartner Höhe, Otto Wagner Spital, Wien, Österreich
| | | | - Eveline Kink
- Abteilung für Lungenkrankheiten, Landeskrankenhaus Hörgas-Enzenbach, Eisbach, Österreich
| | - Gernot Kühteubl
- Abteilung für Pulmologie, Landesklinikum Hochegg, Hocheggerstraße 88, 2840, Grimmenstein, Österreich
| | | | - Ulrike Pachernigg
- Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Andreas Pfleger
- Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Petra Schandl
- 1. Allgemeine Intensivstation, Wilhelminenspital, Wien, Österreich
| | - Ingrid Schmidt
- I. Interne Lungenabteilung, Pulmologisches Zentrum, Sozialmedizinisches Zentrum Baumgartner Höhe, Otto Wagner Spital, Wien, Österreich
| | - Markus Stein
- Abteilung für Pneumologie, Landeskrankenhaus Hochzirl-Natters, Standort Natters, Natters, Österreich
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Boussaïd G, Lofaso F, Santos DB, Vaugier I, Pottier S, Prigent H, Bahrami S, Orlikowski D. Impact of invasive ventilation on survival when non-invasive ventilation is ineffective in patients with Duchenne muscular dystrophy: A prospective cohort. Respir Med 2016; 115:26-32. [PMID: 27215500 DOI: 10.1016/j.rmed.2016.04.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 04/15/2016] [Accepted: 04/17/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many patients with DMD undergo tracheostomy. Tracheostomy is associated with certain complications, however its effect on prognosis is not known. METHODS The relationship between type of mechanical ventilation and survival at 12 years was evaluated in a prospective cohort of patients with Duchenne muscular dystrophy followed in a French reference center for Neuromuscular Diseases. Cox proportional-hazards regressions were used to estimate the hazard ratios associated with risk of switching from non-invasive to invasive ventilation, and with risk of death. RESULTS One hundred and fifty patients were included. Initial use of invasive ventilation was associated with an episode of acute respiratory failure (p < 0.0001) and with a severe clinical status (p < 0.05). Risk of death was associated with swallowing disorders (2.51, IC [1.12-5.66], p < 0.03) and cardiac failure (p < 0.05) but not with type of mechanical ventilation. CONCLUSION Switching to invasive ventilation is appropriate when non-invasive ventilation is ineffective.
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Affiliation(s)
- Ghilas Boussaïd
- CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Université de Versailles Saint Quentin en Yvelines, INSERM U1179, France; Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France.
| | - Frédéric Lofaso
- Université de Versailles Saint Quentin en Yvelines, INSERM U1179, France; Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Service d'Explorations Fonctionnelles Respiratoires, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France
| | - Dante Brasil Santos
- Université de Versailles Saint Quentin en Yvelines, INSERM U1179, France; Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Service d'Explorations Fonctionnelles Respiratoires, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France
| | - Isabelle Vaugier
- CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France
| | - Sandra Pottier
- CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France
| | - Hélène Prigent
- Université de Versailles Saint Quentin en Yvelines, INSERM U1179, France; Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Service d'Explorations Fonctionnelles Respiratoires, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France
| | - Stéphane Bahrami
- CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Université de Versailles Saint Quentin en Yvelines, EA 4047, France; Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Service de Santé Publique, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France
| | - David Orlikowski
- CIC 1429, INSERM, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Université de Versailles Saint Quentin en Yvelines, INSERM U1179, France; Pôle de ventilation à domicile, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France; Service de Santé Publique, AP-HP, Hôpital Raymond Poincaré, 92380, Garches, France
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LoMauro A, D'Angelo MG, Aliverti A. Assessment and management of respiratory function in patients with Duchenne muscular dystrophy: current and emerging options. Ther Clin Risk Manag 2015; 11:1475-88. [PMID: 26451113 PMCID: PMC4592047 DOI: 10.2147/tcrm.s55889] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Duchenne muscular dystrophy (DMD) is an X-linked myopathy resulting in progressive weakness and wasting of all the striated muscles including the respiratory muscles. The consequences are loss of ambulation before teen ages, cardiac involvement and breathing difficulties, the main cause of death. A cure for DMD is not currently available. In the last decades the survival of patients with DMD has improved because the natural history of the disease can be changed thanks to a more comprehensive therapeutic approach. This comprises interventions targeted to the manifestations and complications of the disease, particularly in the respiratory care. These include: 1) pharmacological intervention, namely corticosteroids and idebenone that significantly reduce the decline of spirometric parameters; 2) rehabilitative intervention, namely lung volume recruitment techniques that help prevent atelectasis and slows the rate of decline of pulmonary function; 3) scoliosis treatment, namely steroid therapy that is used to reduce muscle inflammation/degeneration and prolong ambulation in order to delay the onset of scoliosis, being an additional contribution to the restrictive lung pattern; 4) cough assisted devices that improve airway clearance thus reducing the risk of pulmonary infections; and 5) non-invasive mechanical ventilation that is essential to treat nocturnal hypoventilation, sleep disordered breathing, and ultimately respiratory failure. Without any intervention death occurs within the first 2 decades, however, thanks to this multidisciplinary therapeutic approach life expectancy of a newborn with DMD nowadays can be significantly prolonged up to his fourth decade. This review is aimed at providing state-of-the-art methods and techniques for the assessment and management of respiratory function in DMD patients.
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Affiliation(s)
- Antonella LoMauro
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | | | - Andrea Aliverti
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
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Rahbek J, Steffensen BF, Bushby K, de Groot IJM. 206th ENMC International Workshop: Care for a novel group of patients - adults with Duchenne muscular dystrophy Naarden, The Netherlands, 23-25 May 2014. Neuromuscul Disord 2015; 25:727-38. [PMID: 26099652 DOI: 10.1016/j.nmd.2015.05.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/19/2015] [Indexed: 01/23/2023]
Affiliation(s)
- Jes Rahbek
- The National Rehabilitation Centre for Neuromuscular Diseases, Aarhus, Denmark.
| | - Birgit F Steffensen
- The National Rehabilitation Centre for Neuromuscular Diseases, Aarhus, Denmark
| | - Kate Bushby
- Newcastle University, Newcastle upon Tyne, UK
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van Westering TLE, Betts CA, Wood MJA. Current understanding of molecular pathology and treatment of cardiomyopathy in duchenne muscular dystrophy. Molecules 2015; 20:8823-55. [PMID: 25988613 PMCID: PMC6272314 DOI: 10.3390/molecules20058823] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/08/2015] [Accepted: 05/11/2015] [Indexed: 12/27/2022] Open
Abstract
Duchenne muscular dystrophy (DMD) is a genetic muscle disorder caused by mutations in the Dmd gene resulting in the loss of the protein dystrophin. Patients do not only experience skeletal muscle degeneration, but also develop severe cardiomyopathy by their second decade, one of the main causes of death. The absence of dystrophin in the heart renders cardiomyocytes more sensitive to stretch-induced damage. Moreover, it pathologically alters intracellular calcium (Ca2+) concentration, neuronal nitric oxide synthase (nNOS) localization and mitochondrial function and leads to inflammation and necrosis, all contributing to the development of cardiomyopathy. Current therapies only treat symptoms and therefore the need for targeting the genetic defect is immense. Several preclinical therapies are undergoing development, including utrophin up-regulation, stop codon read-through therapy, viral gene therapy, cell-based therapy and exon skipping. Some of these therapies are undergoing clinical trials, but these have predominantly focused on skeletal muscle correction. However, improving skeletal muscle function without addressing cardiac aspects of the disease may aggravate cardiomyopathy and therefore it is essential that preclinical and clinical focus include improving heart function. This review consolidates what is known regarding molecular pathology of the DMD heart, specifically focusing on intracellular Ca2+, nNOS and mitochondrial dysregulation. It briefly discusses the current treatment options and then elaborates on the preclinical therapeutic approaches currently under development to restore dystrophin thereby improving pathology, with a focus on the heart.
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Affiliation(s)
- Tirsa L E van Westering
- Department of Physiology, Anatomy and Genetics, University of Oxford, South Parks Road, Oxford, OX1 3QX, UK
| | - Corinne A Betts
- Department of Physiology, Anatomy and Genetics, University of Oxford, South Parks Road, Oxford, OX1 3QX, UK.
| | - Matthew J A Wood
- Department of Physiology, Anatomy and Genetics, University of Oxford, South Parks Road, Oxford, OX1 3QX, UK.
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Bell CF, Kurosky SK, Candrilli SD. Muscular dystrophy-related hospitalizations among male pediatric patients in the United States. Hosp Pract (1995) 2015; 43:180-185. [PMID: 25833749 DOI: 10.1080/21548331.2015.1033375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE While the economic burden of muscular dystrophy (MD) has been well documented, little is known of specific costs associated with Duchenne muscular dystrophy (DMD), the most prevalent form of MD. This study assessed trends in MD-related hospitalizations and costs among young males, which may reflect utilization of the DMD population in the United States. STUDY DESIGN A retrospective observational study of hospitalizations of males aged 0-20 years with a primary diagnosis code for MD was conducted using data from a weighted, nationally representative database of pediatric hospitalizations in the US. Rates, characteristics and cost of MD-related hospitalizations were compared to hospitalizations not related to MD. RESULTS The rate of MD-related hospitalizations increased by 9% between 2000 and 2006 and then decreased by 13% in 2009. The mean length of stay for discharges related to MD was approximately 9 days during each study year. The most frequent observed diagnoses (other than MD) and procedures were for respiratory-related complications. The mean total costs for MD-related discharges increased across the study period from $26,785 in 2000 to $42,751 in 2009. CONCLUSION This study provides baseline and trend data describing hospitalizations of male pediatric patients with MD that may be used as baseline measurements for assessment of the impact of new strategies for managing the disease. Further assessment of the burden and the clinical, economic, and humanistic impacts of DMD is warranted.
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Cancelinha C, Madureira N, Mação P, Pleno P, Silva T, Estêvão MH, Félix M. Long-term ventilation in children: ten years later. REVISTA PORTUGUESA DE PNEUMOLOGIA 2015; 21:16-21. [PMID: 25854131 DOI: 10.1016/j.rppnen.2014.03.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 03/28/2014] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Home mechanical ventilation (HMV) represents a treatment option for patients with chronic respiratory failure and has changed prognosis and survival of many disorders in children. The aim of this study was to characterize a group of children on long-term mechanical ventilation (LTMV) for a period longer than 10 years. METHODS A retrospective analysis was carried out including patients on LTMV for more than 10 years (LTMV-10) in a tertiary pediatric hospital. STATISTICAL ANALYSIS PASW Statistics 18(®). RESULTS Thirty-one children (61% female) belong to the LTMV-10 group. Median age at the beginning of ventilatory support was 3 years (birth to 13 years). Main indications for assisted ventilation were neuromuscular disease (n=12, 39%), metabolic disease (n=7, 23%) and central hypoventilation (n=6, 19%). Volume ventilation was used in 2 children, and positive pressure ventilation in the others, mainly bilevel positive airway pressure (n=25, 81%). Invasive ventilation via tracheostomy was used since the beginning in four cases, and subsequently in two other children. The mean time of ventilatory support was 146 months and the maximum was 219 months. Respiratory morbidity was the most frequent cause of hospitalization and the annual rate of such episodes was 0.17 per child. Global mortality rate was 19%. CONCLUSIONS HMV programs provide necessary and safe assistance for children with severe chronic respiratory failure. As shown in our series, it is possible to be kept on this respiratory support modality for long periods with good compliance and a small number of hospitalizations.
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Affiliation(s)
- C Cancelinha
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal.
| | - N Madureira
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal; Sleep and Ventilation Laboratory, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - P Mação
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - P Pleno
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - T Silva
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - M H Estêvão
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal; Sleep and Ventilation Laboratory, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - M Félix
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
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32
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Subjective sleep quality in stable neuromuscular patients under non-invasive ventilation. Sleep Med 2014; 15:1259-63. [DOI: 10.1016/j.sleep.2014.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 05/07/2014] [Accepted: 06/05/2014] [Indexed: 11/22/2022]
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34
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Wolfe LF, Patwari PP, Mutlu GM. Sleep Hypoventilation in Neuromuscular and Chest Wall Disorders. Sleep Med Clin 2014. [DOI: 10.1016/j.jsmc.2014.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Cancelinha C, Madureira N, Mação P, Pleno P, Silva T, Estêvão MH, Félix M. WITHDRAWN: Long-term ventilation in children: Ten years later. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014:S0873-2159(14)00070-1. [PMID: 24932698 DOI: 10.1016/j.rppneu.2014.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 03/14/2014] [Accepted: 03/28/2014] [Indexed: 12/01/2022] Open
Abstract
This article has been withdrawn for editorial reasons because the journal will be published only in English. In order to avoid duplicated records, this article can be found at http://dx.doi.org/10.1016/j.rppnen.2014.03.017. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
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Affiliation(s)
- Cândida Cancelinha
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal.
| | - Núria Madureira
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal; Sleep and Ventilation Laboratory, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Patrícia Mação
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Paula Pleno
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Teresa Silva
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - M Helena Estêvão
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal; Sleep and Ventilation Laboratory, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Miguel Félix
- Pediatric Pulmonology Unit, Pediatric Hospital, Coimbra University and Hospital Centre, Coimbra, Portugal
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Open circuit mouthpiece ventilation: Concise clinical review. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:211-8. [PMID: 24841239 DOI: 10.1016/j.rppneu.2014.03.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/16/2014] [Accepted: 03/24/2014] [Indexed: 11/22/2022] Open
Abstract
In 2013 new "mouthpiece ventilation" modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece. Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via "mask" interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22mm angled mouthpieces and straw-type mouthpieces are the most commonly used. NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates "air-stacking" to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.
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DeVanna JC, Kornegay JN, Bogan DJ, Bogan JR, Dow JL, Hawkins EC. Respiratory dysfunction in unsedated dogs with golden retriever muscular dystrophy. Neuromuscul Disord 2013; 24:63-73. [PMID: 24295812 DOI: 10.1016/j.nmd.2013.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 10/14/2013] [Accepted: 10/16/2013] [Indexed: 12/30/2022]
Abstract
Golden retriever muscular dystrophy (GRMD) is a well-established model of Duchenne muscular dystrophy. The value of this model would be greatly enhanced with practical tools to monitor progression of respiratory dysfunction during treatment trials. Arterial blood gas analysis, tidal breathing spirometry, and respiratory inductance plethysmography (RIP) were performed to determine if quantifiable abnormalities could be identified in unsedated, untrained, GRMD dogs. Results from 11 dogs with a mild phenotype of GRMD and 11 age-matched carriers were compared. Arterial blood gas analysis was successfully performed in all dogs, spirometry in 21 of 22 (95%) dogs, and RIP in 18 of 20 (90%) dogs. Partial pressure of carbon dioxide and bicarbonate concentration were higher in GRMD dogs. Tidal breathing peak expiratory flows were markedly higher in GRMD dogs. Abnormal abdominal motion was present in 7 of 10 (70%) GRMD dogs. Each technique provided objective, quantifiable measures that will be useful for monitoring respiratory function in GRMD dogs during clinical trials while avoiding the influence of sedation on results. Increased expiratory flows and the pattern of abdominal breathing are novel findings, not reported in people with Duchenne muscular dystrophy, and might be a consequence of hyperinflation.
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Affiliation(s)
- Justin C DeVanna
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, United States
| | - Joe N Kornegay
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States; Department of Neurology, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States; The Gene Therapy Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Daniel J Bogan
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States; Department of Neurology, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States; The Gene Therapy Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Janet R Bogan
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States; Department of Neurology, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States; The Gene Therapy Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Jennifer L Dow
- Department of Pathology and Laboratory Medicine, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States; Department of Neurology, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States; The Gene Therapy Center, School of Medicine, University of North Carolina, Chapel Hill, NC 27599, United States
| | - Eleanor C Hawkins
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC 27607, United States.
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Archer SK, Garrod R, Hart N, Miller S. Dysphagia in Duchenne muscular dystrophy assessed by validated questionnaire. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2013; 48:240-246. [PMID: 23472962 DOI: 10.1111/j.1460-6984.2012.00197.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Duchenne muscular dystrophy (DMD) leads to progressive muscular weakness and death, most typically from respiratory complications. Dysphagia is common in DMD; however, the most appropriate swallowing assessments have not been universally agreed and the symptoms of dysphagia remain under-reported. AIMS To investigate symptoms of dysphagia in DMD and to determine the potential of the validated Sydney Swallow Questionnaire (SSQ) to diagnose dysphagia in this patient group. METHODS & PROCEDURES Three participant groups completed the SSQ and the results were compared: nine DMD participants with dysphagia, six DMD participants without dysphagia and 12 healthy controls. OUTCOMES & RESULTS The questionnaire scores for dysphagic DMD participants were significantly higher than for non-dysphagic DMD participants (p = 0.039) and for healthy controls (p ≤ 0.001). The diagnostic ability of the questionnaire was good for detecting dysphagia in participants with DMD (receiver operating characteristic (ROC) area under the curve = 0.89, p = 0.013), with a cut-off score of 224.5 (13.2%) giving a sensitivity of 0.78 and a specificity of 0.83 for determining dysphagia. Dysphagic participants rated time to eat a meal, swallowing hard food, swallowing thick liquids and needing to cough up or spit during meals with the highest severity of all questionnaire items. Results of the questionnaire by item are presented to inform the clinician of the symptoms of dysphagia in DMD. CONCLUSIONS & IMPLICATIONS DMD leads to pervasive symptoms of dysphagia. The simple SSQ is a clinically informative assessment tool for patients with DMD.
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Affiliation(s)
- Sally K Archer
- Centre of Human and Aerospace Physiological Sciences, School of Biomedical Sciences, King's College London, London, UK.
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Edwards EA, Nixon GM. Paediatric home ventilatory support: changing milieu, proactive solutions. J Paediatr Child Health 2013; 49:13-8. [PMID: 23252372 DOI: 10.1111/jpc.12040] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2012] [Indexed: 11/29/2022]
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Enwere EK, Boudreault L, Holbrook J, Timusk K, Earl N, LaCasse E, Renaud JM, Korneluk RG. Loss of cIAP1 attenuates soleus muscle pathology and improves diaphragm function in mdx mice. Hum Mol Genet 2012. [PMID: 23184147 DOI: 10.1093/hmg/dds493] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The cellular inhibitor of apoptosis 1 (cIAP1) protein is an essential regulator of canonical and noncanonical nuclear factor κB (NF-κB) signaling pathways. NF-κB signaling is known to play important roles in myogenesis and degenerative muscle disorders such as Duchenne muscular dystrophy (DMD), but the involvement of cIAP1 in muscle disease has not been studied directly. Here, we asked whether the loss of cIAP1 would influence the pathology of skeletal muscle in the mdx mouse model of DMD. Double-mutant cIAP1(-/-);mdx mice exhibited reduced muscle damage and decreased fiber centronucleation in the soleus, compared with single-mutant cIAP1(+/+);mdx mice. This improvement in pathology was associated with a reduction in muscle infiltration by macrophages and diminished expression of inflammatory cytokines such as IL-6 and tumor necrosis factor-α. Furthermore, the cIAP1(-/-);mdx mice exhibited reduced serum creatine kinase, and improved exercise endurance associated with improved exercise resilience by the diaphragm. Mechanistically, the loss of cIAP1 was sufficient to drive constitutive activation of the noncanonical NF-κB pathway, which led to increased myoblast fusion in vitro and in vivo. Collectively, these results show that the loss of cIAP1 protects skeletal muscle from the degenerative pathology resulting from systemic loss of dystrophin.
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Affiliation(s)
- Emeka K Enwere
- Department of Biochemistry, Microbiology and Immunology, University of Ottawa, Ottawa, Ontario, Canada
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Predictors of failure in infants with viral bronchiolitis treated with high-flow, high-humidity nasal cannula therapy*. Pediatr Crit Care Med 2012; 13:e343-9. [PMID: 22805160 DOI: 10.1097/pcc.0b013e31825b546f] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Viral bronchiolitis is an acute infection and inflammatory disease of the respiratory tract, with infants typically presenting with the most severe symptoms. Medical management of bronchiolitis is mostly supportive. Several preliminary studies suggest potential benefit from the use of high-flow nasal cannula systems. Although high-flow nasal cannula is a well-established modality in the newborn intensive care unit, its use in the pediatric intensive care unit for acute respiratory failure is far less established. The objective of this study was to identify any laboratory and clinical variables that may predict high-flow nasal cannula failure in management of bronchiolitis in the pediatric intensive care unit. DESIGN The study design was a retrospective chart review of all patients admitted to the pediatric intensive care unit from 2006 to 2010 with a diagnosis of viral bronchiolitis. Inclusion criteria included the initiation of high flow nasal cannula therapy at the time of admission and age ≤ 12 months. Exclusion criteria were intubation prior to admission, age >12 months, and the presence of a tracheostomy. PATIENTS A total of 113 patients with viral bronchiolitis met the inclusion criteria. SETTING Academic free standing Children's Hospital in the Midwest. INTERVENTIONS Retrospective chart review. MEASUREMENTS AND MAIN RESULTS The data were analyzed by comparing those patients who responded to high-flow nasal cannula (n = 92) with those who were nonresponders to high-flow nasal cannula and required intubation (n = 21). No differences were noted between the groups for age, sex, or ethnicity. Mean weight and weight-for-corrected-age percentiles were significantly lower for patients who failed high-flow nasal cannula (p = .016 and .031, respectively), but weight-for-corrected-age percentile was not significant in logistic regression controlling for other variables. Respiratory rate prior to the initiation of high-flow nasal cannula also correlated strongly with respiratory deterioration (p < .001). The PCO2 was significantly higher for both before (p < .001) and after (p < .001) initiation of therapy in the nonresponder group. Pediatric Risk of Mortality III scores for the patients who failed high-flow nasal cannula were significantly higher (p < .001) than those of patients who tolerated this therapy. CONCLUSIONS History of prematurity and the patient's age did not increase a patient's risk of failure. Nonresponders to high-flow nasal cannula therapy were on the onset, more hypercarbic, were less tachypnic prior to the start of high-flow nasal cannula, and had no change in their respiratory rate after the initiation of high-flow nasal cannula therapy. Nonresponders had higher pediatric risk of mortality scores in the first 24 hrs.
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Muir JF, Lamia B, Molano C, Declercq PL, Cuvelier A. [Non-invasive ventilation era: is there still a place for long-term tracheostomy?]. Rev Mal Respir 2012; 29:994-1006. [PMID: 23101641 DOI: 10.1016/j.rmr.2012.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 04/23/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION At a time when non-invasive ventilation (NIV) is commonly used in acute as well as chronic respiratory failure, it is important to consider the current place, if any, of long-term tracheostomy. BACKGROUND Except in emergency situations where tracheostomy is mandatory to ensure safe access to the airway, long-term ventilation with tracheostomy (LTVT) is generally considered in the case of inability to wean from NIV after an episode of acute respiratory failure requiring endotracheal ventilation or because of the development of bulbar signs (swallowing, phonation) in advanced neuromuscular disease. It is also appropriate when ventilatory dependence on NIV exceeds 20 hours per day. Historical retrospective studies confirmed the feasibility of LTVT, but this has to be seen in perspective with the results obtained 20 years later with NIV. VIEWPOINT AND CONCLUSION Even if the indications for LTVT have diminished considerably since the emergence of NIV, tracheostomy remains mandatory in some situations of respiratory distress and it should be considered as a potential resource, possibly temporary in some cases in the light of recent work on the possibility of decanulation after LTVT.
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Affiliation(s)
- J-F Muir
- UPRES EA 3830, unité de soins intensifs respiratoires, service de pneumologie, institut hospitalo-universitaire de recherche biomédicale et d'innovation, université de Rouen, CHU de Rouen, 76031 Rouen cedex, France.
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Polat M, Sakinci O, Ersoy B, Sezer RG, Yilmaz H. Assessment of sleep-related breathing disorders in patients with duchenne muscular dystrophy. J Clin Med Res 2012; 4:332-7. [PMID: 23024736 PMCID: PMC3449431 DOI: 10.4021/jocmr1075w] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Respiratory failure is a significant cause of morbidity and mortality in neuromuscular diseases. Although clinical findings and respiratory function tests aid in diagnosing sleep-related breathing disorders, polysomnography is the gold standard for the diagnosis of these disorders. We aimed to investigate the role of sleep-wake symptoms and clinical findings of patients with Duchenne muscular dystrophy (DMD) in predicting sleep-related breathing disorders through the comparison of polysomnography findings. In addition, we evaluated the sleep architecture of our patients. METHODS A total of 35 children (12 patients with DMD and 23 controls) were included in this cross-sectional study. Activity status and clinical severity of the patients were determined by history and clinical findings such as scoliosis, obesity. All subjects were hospitalized for one night in the Sleep Unit and their polysomnography examinations were performed. Sleep, breathing, arousals and limb movements were scored manually according to the American Sleep Disorders Association criteria. RESULTS Nocturnal and daytime symptoms were present in 50% of patients with DMD, 40.8% were wheelchair-bound and 58% had scoliosis. Obstructive sleep apnea was noted in 16.6% of patients with DMD. The apnea-hypopnea index, leg movement index were significantly higher in the DMD group as compared to the control group (P < 0.05). The number of desaturations, total arousal index and the percentage of total superficial sleep were significantly higher in patients with wheelchair, scoliosis, sleep-wake symptoms. CONCLUSIONS Being wheelchair-bound or having scoliosis do not predict sleep-related breathing disorders, so patients with DMD should be followed-up via polysomnography. Sleep-wake symptoms should be carefully questioned in these patients and symptomatic patients should be referred to pediatric respiratory units.
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Affiliation(s)
- Muzaffer Polat
- Department of Pediatric Neurology, Celal Bayar University School of Medicine, 45040 Manisa, Turkey
| | - Ozcan Sakinci
- Resident, Department of Pediatrics, Celal Bayar University School of Medicine, 45040 Manisa, Turkey
| | - Betul Ersoy
- Department of Pediatric Endocrinology, Celal Bayar University School of Medicine, 45040 Manisa, Turkey
| | - Rabia Gonul Sezer
- Department of Pediatrics, Zeynep Kamil Maternity and Childrens Diseases Training and Research State Hospital, Uskudar 34668, Istanbul, Turkey
| | - Hikmet Yilmaz
- Department of Neurology, Celal Bayar University School of Medicine, 45040 Manisa, Turkey
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Abstract
PURPOSE OF REVIEW The heterogeneous nature of neuromuscular disorders (NMDs) continues to promote slow but steady advances in diagnosis, classification, and treatment. This review focuses on the updates in the general management and treatment of NMDs, with emphasis on key updates in muscular dystrophy, myotonic dystrophy, mitochondrial myopathy, spinal muscular atrophy, and hereditary neuropathies. RECENT FINDINGS Current research shows that improvements in morbidity and mortality in various NMDs may be possible. Key components include advances in identification and classification of individual NMDs; attention to anesthetic and surgical risks; aggressive pulmonary care; and implementations of a proactive, multidisciplinary, standard-of-care approach. Innovative molecular and pharmaceutical therapeutic options are being investigated in many of these disorders, but unfortunately no new intervention has borne out. SUMMARY Important advances were made in the last year in the field of neuromuscular disease. However, because of their heterogeneous nature and rarity, diagnosis and treatment of these disorders either as a single disorder or as a group continue to be both a clinical and a research challenge. It is of utmost importance that clinicians and researchers be aware of these disorders to aid in identification and treatment.
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Romei M, D'Angelo MG, LoMauro A, Gandossini S, Bonato S, Brighina E, Marchi E, Comi GP, Turconi AC, Pedotti A, Bresolin N, Aliverti A. Low abdominal contribution to breathing as daytime predictor of nocturnal desaturation in adolescents and young adults with Duchenne Muscular Dystrophy. Respir Med 2011; 106:276-83. [PMID: 22083092 DOI: 10.1016/j.rmed.2011.10.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 10/18/2011] [Accepted: 10/19/2011] [Indexed: 11/25/2022]
Abstract
In the respiratory management of DMD patients it is still under debate what parameter should indicate the correct timing for institution of nocturnal non-invasive ventilation (NIV), in addition to forced vital capacity, which is generally considered as a prognostic marker of disease progression. The aim of this study was to determine if volume variations of rib cage and abdominal compartments measured by Opto-Electronic Plethysmography can be helpful to distinguish between those patients who are in the early stages of nocturnal oxygen desaturation development and those who do not yet. Pulmonary function, abdominal contribution to tidal volume and to inspiratory capacity (%Abd IC) and a set of breathing pattern indexes were assessed in 40 DMD patients older than 14 years and not yet under nocturnal NIV. ROC analysis revealed that among all the considered parameters, %Abd IC in supine position was the best discriminator between DeSat (at least 10% of the night time with SpO(2) < 95%) and NonDeSat patients, providing an area under the curve with 95%CI equal to 0.752. In conclusion, in adolescents and adults DMD patients who present either no sign or only mild nocturnal oxygen desaturation, a reduced abdominal contribution to inspiratory capacity is a marker of the onset of diaphragm weakness and should be considered to identify the correct timing for the institution of nocturnal NIV.
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Affiliation(s)
- M Romei
- IRCCS E. Medea, Bosisio Parini (Lc), Italy
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Wehling-Henricks M, Tidball JG. Neuronal nitric oxide synthase-rescue of dystrophin/utrophin double knockout mice does not require nNOS localization to the cell membrane. PLoS One 2011; 6:e25071. [PMID: 22003386 PMCID: PMC3189177 DOI: 10.1371/journal.pone.0025071] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Accepted: 08/26/2011] [Indexed: 02/03/2023] Open
Abstract
Survival of dystrophin/utrophin double-knockout (dko) mice was increased by muscle-specific expression of a neuronal nitric oxide synthase (nNOS) transgene. Dko mice expressing the transgene (nNOS TG+/dko) experienced delayed onset of mortality and increased life-span. The nNOS TG+/dko mice demonstrated a significant decrease in the concentration of CD163+, M2c macrophages that can express arginase and promote fibrosis. The decrease in M2c macrophages was associated with a significant reduction in fibrosis of heart, diaphragm and hindlimb muscles of nNOS TG+/dko mice. The nNOS transgene had no effect on the concentration of cytolytic, CD68+, M1 macrophages. Accordingly, we did not observe any change in the extent of muscle fiber lysis in the nNOS TG+/dko mice. These findings show that nNOS/NO (nitric oxide)-mediated decreases in M2c macrophages lead to a reduction in the muscle fibrosis that is associated with increased mortality in mice lacking dystrophin and utrophin. Interestingly, the dramatic and beneficial effects of the nNOS transgene were not attributable to localization of nNOS protein at the cell membrane. We did not detect any nNOS protein at the sarcolemma in nNOS TG+/dko muscles. This important observation shows that sarcolemmal localization is not necessary for nNOS to have beneficial effects in dystrophic tissue and the presence of nNOS in the cytosol of dystrophic muscle fibers can ameliorate the pathology and most importantly, significantly increase life-span.
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Affiliation(s)
- Michelle Wehling-Henricks
- Department of Integrative Biology and Physiology, University of California, Los Angeles, California, United States of America
| | - James G. Tidball
- Department of Integrative Biology and Physiology, University of California, Los Angeles, California, United States of America
- Molecular, Cellular and Integrative Physiology Program, University of California, Los Angeles, California, United States of America
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California, Los Angeles, California, United States of America
- * E-mail:
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Simon VA, Resende MBD, Simon MAVP, Zanoteli E, Reed UC. Duchenne muscular dystrophy: quality of life among 95 patients evaluated using the Life Satisfaction Index for Adolescents. ARQUIVOS DE NEURO-PSIQUIATRIA 2011; 69:19-22. [PMID: 21359417 DOI: 10.1590/s0004-282x2011000100005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Accepted: 08/20/2010] [Indexed: 11/22/2022]
Abstract
The purpose of this study was to evaluate the quality of life (QoL) of patients with Duchenne muscular dystrophy (DMD) in different stages of the disease, by means of the Life Satisfaction Index for Adolescents (LSI-A). The practicality of this scale was also verified. The LSI-A was applied four times to 95 patients with DMD who were undergoing steroid therapy, at three-month intervals. The patients were divided into four groups according to age. The results from the four applications and the inter and intra-examiner concordance were treated statistically. Comparing the different age groups, patients with DMD did not lose QoL, even with disease progression. We concluded that, in spite of the progressive course of the disease, the QoL in patients with DMD does not get worse. The use of a scale that embraces a great diversity of circumstances in patients' lives, without considering clinical aspects excessively, is a good alternative for assessing the QoL of these patients.
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Affiliation(s)
- Valdecir A Simon
- Department of Neurology, School of Medicine, University of São Paulo, SP, Brazil.
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McKim DA, Road J, Avendano M, Abdool S, Côté F, Duguid N, Fraser J, Maltais F, Morrison DL, O’Connell C, Petrof BJ, Rimmer K, Skomro R. Home mechanical ventilation: a Canadian Thoracic Society clinical practice guideline. Can Respir J 2011; 18:197-215. [PMID: 22059178 PMCID: PMC3205101 DOI: 10.1155/2011/139769] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Increasing numbers of patients are surviving episodes of prolonged mechanical ventilation or benefitting from the recent availability of userfriendly noninvasive ventilators. Although many publications pertaining to specific aspects of home mechanical ventilation (HMV) exist, very few comprehensive guidelines that bring together all of the current literature on patients at risk for or using mechanical ventilatory support are available. The Canadian Thoracic Society HMV Guideline Committee has reviewed the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. The guideline provides a disease-specific review of illnesses including amyotrophic lateral sclerosis, spinal cord injury, muscular dystrophies, myotonic dystrophy, kyphoscoliosis, post-polio syndrome, central hypoventilation syndrome, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease as well as important common themes such as airway clearance and the process of transition to home. The guidelines have been extensively reviewed by international experts, allied health professionals and target audiences. They will be updated on a regular basis to incorporate any new information.
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Affiliation(s)
- Douglas A McKim
- Division of Respirology, University of Ottawa, and Respiratory Rehabilitation Services, Ottawa Hospital Sleep Centre, Ottawa, Ontario
| | - Jeremy Road
- Division of Respiratory Medicine and The Lung Centre, University of British Columbia, Provincial Respiratory Outreach Program, Vancouver, British Columbia
| | - Monica Avendano
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
| | - Steve Abdool
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
- Centre for Clinical Ethics at St Michael’s Hospital, West Park Healthcare Centre, and University of Toronto, Toronto, Ontario
| | | | - Nigel Duguid
- Eastern Health, Memorial University, St John’s, Newfoundland and Labrador
| | - Janet Fraser
- Respiratory Therapy Services, West Park Healthcare Centre, Toronto, Ontario
| | - François Maltais
- Research Centre, University Institute of Cardiology and Lung Health for Québec, Laval University, Québec, Québec
| | - Debra L Morrison
- Sleep Clinic and Laboratory, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia
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CRESCIMANNO GRAZIA, MARRONE ORESTE, VIANELLO ANDREAW. Efficacy and comfort of volume-guaranteed pressure support in patients with chronic ventilatory failure of neuromuscular origin. Respirology 2011; 16:672-9. [DOI: 10.1111/j.1440-1843.2011.01962.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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