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Fitzgerald H, Kennedy B, Fitzgerald DA, Selvadurai H. A comparison of peak cough flow and peak expiratory flow in children with neuromuscular disorders. Paediatr Respir Rev 2024:S1526-0542(24)00026-5. [PMID: 38616459 DOI: 10.1016/j.prrv.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/03/2024] [Indexed: 04/16/2024]
Abstract
Spirometry and peak cough flow testing (PCF) are commonly used in the respiratory assessment of children with a neuromuscular disorder (NMD). Testing uses two different machines, increases laboratory time, costs and resource utilisation. No studies have assessed the correlation between peak expiratory flow (PEF) obtained from spirometry and PCF in children with NMD using one device. An audit of children with a NMD managed at the Children's Hospital at Westmead in 2022-2024 aged < 20 years who performed spirometry and PCF testing on the same device (Vyaire Body BoxTM, Ultrasonic flow meter-based, or Vyaire PneumotachographTM, Pneumotach flow meter-based; Germany) was conducted to assess the correlation between PCF and PEF. Fifty-one sets of testing were identified, and 40 subjects (9F) had reproducible testing and were included. Median (range) age was 14.95 (7.20-19.00) years. Median PEF (L/min) was 4.05 (1.22-10.26) and median PCF (L/min) was 4.29 (1.69-10.82). PEF and PCF had a strong Pearson's correlation coefficient, (R = 0.97, p = 0.03). The coefficient of determination was 0.93. If laboratory resources permit, spirometry should be the test of choice for children with NMD. On average, spirometry required multiple practices to achieve reproducibility to meet ATS/ERS standards. PCF testing can be utilised for children where performing technically acceptable spirometry is not possible.
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Affiliation(s)
- H Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Sydney, NSW, 2145, Australia.
| | - B Kennedy
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Sydney, NSW, 2145, Australia
| | - D A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Sydney, NSW, 2145, Australia; Discipline of Paediatrics and Child Health, Faculty of Medicine, University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
| | - H Selvadurai
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, Sydney, NSW, 2145, Australia; Discipline of Paediatrics and Child Health, Faculty of Medicine, University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
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Pandit C, Kennedy B, Waters K, Young H, Jones K, Fitzgerald DA. Can postural changes in spirometry in children with Duchenne muscular dystrophy predict sleep hypoventilation? Paediatr Respir Rev 2024; 49:9-13. [PMID: 37696714 DOI: 10.1016/j.prrv.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Abstract
AIM To explore the relationship between postural changes in lung function and polysomnography (PSG) in children with Duchenne muscular dystrophy (DMD). METHODS In this prospective cross-sectional study, children with DMD performed spirometry in sitting and supine positions. A control group of age and gender matched healthy children also underwent postural lung function testing. PSG was performed within six months of spirometry. RESULTS Seventeen children with DMD, aged 12.3 ± 3 years performed sitting spirometry. 14 (84%) performed acceptable spirometry in the supine position. Mean FEV1sit and FVCsit were 77% (SD ± 22) and 74% (SD ± 20.4) respectively, with mean% ΔFVC(sit-sup) 9% (SD ± 11) (range 2% to 20%), and was significantly greater than healthy controls 4% (n = 30, SD ± 3, P < 0.001). PSG data on the 14 DMD children with acceptable supine spirometry showed total AHI 6.9 ± 5.9/hour (0.3 to 29), obstructive AHI 5.2 ± 4.0/hour (0.2 to 10), and REM AHI 14.1 ± -5.3/hour (0.1 to 34.7). ΔFVC(sit-sup) had poor correlation with hypoventilation on polysomnography. CONCLUSION Children with DMD and mild restrictive lung disease showed greater postural changes in spirometry than healthy controls but lower supine spirometry was not predictive of sleep hypoventilation.
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Affiliation(s)
- C Pandit
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - B Kennedy
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - K Waters
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - H Young
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Neurogenetics Service, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - K Jones
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Neurogenetics Service, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - D A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Lopes Vieira J, Miskovic A, Abel F. Interpretation of pulmonary function tests in children. BJA Educ 2023; 23:425-431. [PMID: 37876760 PMCID: PMC10591135 DOI: 10.1016/j.bjae.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 10/26/2023] Open
Affiliation(s)
- J.F. Lopes Vieira
- Chelsea and Westminster Hospital, London, UK
- Greate Ormond Stree Hospital, London, UK
| | | | - F. Abel
- Greate Ormond Stree Hospital, London, UK
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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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5
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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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Fauroux B, Griffon L, Amaddeo A, Stremler N, Mazenq J, Khirani S, Baravalle-Einaudi M. Respiratory management of children with spinal muscular atrophy (SMA). Arch Pediatr 2020; 27:7S29-7S34. [PMID: 33357594 DOI: 10.1016/s0929-693x(20)30274-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Spinal muscular atrophy (SMA) causes a predominantly bilateral proximal muscle weakness and atrophy. The respiratory muscles are also involved with a weakness of the intercostal muscles and a relatively spared diaphragm. This respiratory muscle weakness translates into a cough impairment, resulting in poor clearance of airway secretions and recurrent pulmonary infections, restrictive lung disease due to a poor or insufficient chest wall and lung growth, nocturnal hypoventilation and, finally, respiratory failure. Systematic and regular monitoring of respiratory muscle performance is necessary in children with SMA in order to anticipate respiratory complications, such as acute and chronic respiratory failure, and guide clinical care. This monitoring is based in clinical practice on volitional and noninvasive tests, such as vital capacity, sniff nasal inspiratory pressure, maximal static pressures, peak expiratory flow and peak cough flow because of their simplicity, availability and ease. In young children, those with poor cooperation or severe respiratory muscle weakness, other, mostly invasive, tests may be required to evaluate respiratory muscle performance. A sleep study, or at least overnight monitoring of nocturnal gas exchange is mandatory for detecting nocturnal alveolar hypoventilation. Training for patients and caregivers in cough-assisted techniques is recommended when respiratory muscle strength falls below 50% of predicted or in case of recurrent or severe respiratory infections. Noninvasive ventilation (NIV) should be initiated in case of isolated nocturnal hypoventilation and followed by a pediatric respiratory team with expertise in NIV. Multidisciplinary (neurology and respiratory) pediatric management is crucial for optimal care of children with SMA. © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.
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Affiliation(s)
- B Fauroux
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France.
| | - L Griffon
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France
| | - A Amaddeo
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France
| | - N Stremler
- Pediatric Ventilation Unit, Pediatric department, Timone-Enfants Hospital, 13385 Marseille AP-HM, Marseille, France
| | - J Mazenq
- Pediatric Ventilation Unit, Pediatric department, Timone-Enfants Hospital, 13385 Marseille AP-HM, Marseille, France
| | - S Khirani
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker-Enfants malades, F-75015 Paris, France; Université de Paris, VIFASOM, F-75004, Paris, France; ASV Sante, Gennevilliers, France
| | - M Baravalle-Einaudi
- Pediatric Ventilation Unit, Pediatric department, Timone-Enfants Hospital, 13385 Marseille AP-HM, Marseille, France
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Huguet-Rodríguez M, Arias-Buría JL, Huguet-Rodríguez B, Blanco-Barrero R, Braña-Sirgo D, Güeita-Rodríguez J. Impact of Aquatic Exercise on Respiratory Outcomes and Functional Activities in Children with Neuromuscular Disorders: Findings from an Open-Label and Prospective Preliminary Pilot Study. Brain Sci 2020; 10:brainsci10070458. [PMID: 32708972 PMCID: PMC7407397 DOI: 10.3390/brainsci10070458] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/15/2020] [Accepted: 07/15/2020] [Indexed: 01/08/2023] Open
Abstract
Neuromuscular disorders (NMD) lead to the progressive loss of motor and respiratory functions and a decline in daily activities and participation. We aimed to evaluate respiratory changes and functional outcomes in children attending an aquatic therapy program. Eleven patients diagnosed with NMD (4-18 years, Vignos scale 1-9) were involved in a 10-week aquatic exercise program. The ventilation variables were: peak cough flow, volumes (forced expiratory volume in one second-FEV1 and inspiratory volume) and respiratory pressures to evaluate strength and oxygen saturation (O2 sat). Functional skills were measured in the aquatic environment (Water Orientation Test Alyn 1) and on dry land, (Pediatric Evaluation of Disability Inventory), together with quality of life (Pediatric Quality of Life Inventory). Our evaluation included several 2 × 6 mixed-model repeated measures analysis of covariance (ANCOVA) with time (baseline, post 1 session, pre-post at five weeks and pre-post at 10 weeks). Important improvements in functional skills were observed in and out of the water and children under the age of 11 displayed a significant difference for inspirational volume (p = 0.002) and O2 sat (p = 0.029). Clinical, statistically insignificant changes were found for peak cough flow and expiratory pressures values after aquatic exercise. These results may support a relationship between aquatic exercise in NMD, respiratory outcomes and functional activities in water and on land.
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Affiliation(s)
- Marta Huguet-Rodríguez
- San José Institute Foundation, aquatic therapy unit, 28054 Madrid, Spain; (M.H.-R.); (R.B.-B.); (D.B.-S.)
| | - José Luis Arias-Buría
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, 28922 Madrid, Spain;
| | | | - Rocío Blanco-Barrero
- San José Institute Foundation, aquatic therapy unit, 28054 Madrid, Spain; (M.H.-R.); (R.B.-B.); (D.B.-S.)
| | - Daniel Braña-Sirgo
- San José Institute Foundation, aquatic therapy unit, 28054 Madrid, Spain; (M.H.-R.); (R.B.-B.); (D.B.-S.)
| | - Javier Güeita-Rodríguez
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, 28922 Madrid, Spain;
- Research Group of Humanities and Qualitative Research in Health Science of Universidad Rey Juan Carlos (Hum & QRinHS), Universidad Rey Juan Carlos, Alcorcón, 28922 Madrid, Spain
- Correspondence: ; Tel.: +34-91-488-86-00
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Fleck D, Curry C, Donnan K, Logue O, Graham K, Jackson K, Keown K, Winder J, Shields MD, Hughes CM. Investigating the clinical use of structured light plethysmography to assess lung function in children with neuromuscular disorders. PLoS One 2019; 14:e0221207. [PMID: 31449525 PMCID: PMC6709884 DOI: 10.1371/journal.pone.0221207] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 08/01/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Children and young people with neuromuscular disorders (NMD), such as Duchenne Muscular Dystrophy (DMD), develop progressive respiratory muscles weakness and pulmonary restriction. Pulmonary function monitoring of the decline in lung function allows for timely intervention with cough assist techniques and nocturnal non-invasive ventilation (NIV). NMD may find the measurement of lung function difficult using current techniques. Structured Light Plethysmography (SLP) has been proposed as a novel, non-contact, self-calibrating, non-invasive method of assessing lung function. The overarching aim of this study was to investigate the use of SLP as a novel method for monitoring respiratory function in children with neuromuscular disease. METHODS SLP thoraco-abdominal (TA) displacement was correlated with forced vital capacity measurements recorded by spirometry and the repeatability of the measurements with both methods examined. SLP tidal breathing parameters were investigated to assess the range and repeatability of regional right and left side TA displacement and rib cage and abdominal wall displacement. RESULTS The comparison of the FVC measured with SLP and with spirometry, while having good correlation (R = 0.78) had poor measurement agreement (95% limits of agreement: -1.2 to 1.2L) The mean relative contribution of right and left TA displacement in healthy controls was 50:50 with a narrow range. Repeatability of this measure with SLP was found to be good in healthy controls and moderate in NMD children with/without scoliosis but with a wider range. The majority of the control group displayed a predominant rib cage displacement during tidal breathing and those who displayed predominant abdominal wall displacement showed displacement of both regions close to 50:50 with similar results for the rib cage and abdomen. In comparison, children with NMD have a more variable contribution for all of these parameters. In addition, SLP was able to detect a reduction in abdominal contribution to TA displacement with age in the DMD group and detect paradoxical breathing in children with NMD. Using SLP tracings during tidal breathing we were able to identify three specific patterns of breathing amongst healthy individuals and in children with NMD. CONCLUSIONS SLP is a novel method for measuring lung function that requires limited patient cooperation and may be especially useful in children with neuromuscular disorders. Measuring the relative contributions of the right and left chest wall and chest versus abdominal movements allows a more detailed assessment.
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Affiliation(s)
- Deborah Fleck
- Nursing and Health Research Institute, School of Health Sciences, Ulster University, Belfast, Northern Ireland, United Kingdom
| | - Chistopher Curry
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Kate Donnan
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Orla Logue
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Kathryn Graham
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Kate Jackson
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust, Belfast, Northern Ireland, United Kingdom
| | - Karen Keown
- Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust, Belfast, Northern Ireland, United Kingdom
| | - John Winder
- Nursing and Health Research Institute, School of Health Sciences, Ulster University, Belfast, Northern Ireland, United Kingdom
| | - Michael D. Shields
- Centre for Experimental Medicine, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- Royal Belfast Hospital for Sick Children, Belfast Health & Social Care Trust, Belfast, Northern Ireland, United Kingdom
- * E-mail:
| | - Ciara M. Hughes
- Nursing and Health Research Institute, School of Health Sciences, Ulster University, Belfast, Northern Ireland, United Kingdom
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Camela F, Gallucci M, Ricci G. Cough and airway clearance in Duchenne muscular dystrophy. Paediatr Respir Rev 2019; 31:35-39. [PMID: 30553655 DOI: 10.1016/j.prrv.2018.11.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/26/2018] [Accepted: 11/16/2018] [Indexed: 01/14/2023]
Abstract
People with Duchenne muscular dystrophy (DMD), develop a respiratory muscle weakness that results in weakened cough, airway clearance impairment and over time respiratory failure and death. Assessment of cough effectiveness through vital capacity, peak cough flow and maximal inspiratory and expiratory pressures has been used to identify the optimal timing of cough augmentation techniques initiation. The choice of therapies depends on physician knowledge, and patient/care giver abilities. The purpose of this review is to clarify mechanisms of action, benefits and disadvantages of available techniques, such as manual cough-assisting manoeuvres, glossopharyngeal breathing, air stacking by resuscitator bag or by volume-cycle ventilator, and mechanical insufflator-exsufflator. Mechanisms of mucus mobilization, like intrapulmonary percussive ventilation, may have a therapeutic role in the case of persistent atelectasis. It is also crucial to recognize the initial phase of an acute respiratory exacerbation, increase the use of these techniques which may reduce morbidity and mortality.
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Affiliation(s)
- F Camela
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
| | - M Gallucci
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy
| | - G Ricci
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 11, 40138 Bologna, Italy.
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LoMauro A, Banfi P, Mastella C, Alberti K, Baranello G, Aliverti A. A New Method for Measuring Bell-Shaped Chest Induced by Impaired Ribcage Muscles in Spinal Muscular Atrophy Children. Front Neurol 2018; 9:703. [PMID: 30271372 PMCID: PMC6146085 DOI: 10.3389/fneur.2018.00703] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 08/03/2018] [Indexed: 11/16/2022] Open
Abstract
The involvement of the respiratory muscular pump makes SMA children prone to frequent hospitalization and morbidity, particularly in type 1. Progressive weakness affects ribcage muscles resulting in bell-shaped chest that was never quantified. The aims of the present work were: (1) to quantify the presence of bell-shaped chest in SMA infants and children and to correlate it with the action of ribcage muscles, assessed by the contribution of pulmonary ribcage to tidal volume (ΔVRC, p); (2) to verify if and how the structure of the ribcage and ΔVRC, p change after 1-year in SMA type 2. 91 SMA children were studied in supine position during awake spontaneous breathing: 32 with type 1 (SMA1, median age: 0.8 years), 51 with type 2 (SMA2, 3.7 years), 8 with type 3 (SMA3, 5.4 years) and 20 healthy children (HC, 5.2 years). 14 SMA2 showed negative ΔVRC, p (SMA2px), index of paradoxical inspiratory inward motion. The bell-shaped chest index was defined as the ratio between the distance of the two anterior axillary lines at sternal angle and the distance between the right and left 10th costal cartilage. If this index was < < 1, it indicated bell shape, if ~1 it indicated rectangular shape, while if >> 1 an inverted triangle shape was identified. While the bell-shaped index was similar between HC (0.92) and SMA3 (0.91), it was significantly (p < 0.05) reduced in SMA2 (0.81), SMA2px (0.74) and SMA1 (0.73), being similar between the last two. There was a good correlation (Spearman's rank correlation coefficient, ρ = 0.635, p < 0.001) between ribcage geometry and ΔVRC, p. After 1 year, ΔVRC, p reduced while bell-shaped chest index did not change being significantly lower than HC. The shape of the ribcage was quantified and correlated with the action of ribcage muscles in SMA children. The impaired ribcage muscles function alters the ribcage structure. HC and SMA3 show an almost rectangular ribcage shape, whereas SMA2, SMA2px and SMA1 are characterized by bell-shaped chest. In SMA, therefore, a vicious cycle starts since infancy: the disease progressively affects ribcage muscles resulting in reduced expansion of lung and ribcage that ultimately alters ribcage shape. This puts the respiratory muscles at mechanical disadvantage.
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Affiliation(s)
- Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Piazza Leonardo Da Vinci, Milan, Italy
| | - Paolo Banfi
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Chiara Mastella
- Fondazione IRCCS Cà' Granda Ospedale Maggiore Policlinico, SAPRE-UONPIA, Neuropsichiatria dell'Infanzia e dell'Adolescenza, Milan, Italy
| | - Katia Alberti
- Fondazione IRCCS Cà' Granda Ospedale Maggiore Policlinico, SAPRE-UONPIA, Neuropsichiatria dell'Infanzia e dell'Adolescenza, Milan, Italy
| | - Giovanni Baranello
- UO Neurologia dello Sviluppo, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Piazza Leonardo Da Vinci, Milan, Italy
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11
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Respiratory insight to congenital muscular dystrophies and congenital myopathies and its relation to clinical trial. Neuromuscul Disord 2018; 28:731-740. [DOI: 10.1016/j.nmd.2018.06.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 05/22/2018] [Accepted: 06/26/2018] [Indexed: 12/11/2022]
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12
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Respiratory Diagnostic Tools in Neuromuscular Disease. CHILDREN-BASEL 2018; 5:children5060078. [PMID: 29914128 PMCID: PMC6025604 DOI: 10.3390/children5060078] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/09/2018] [Accepted: 06/11/2018] [Indexed: 01/05/2023]
Abstract
Children with neuromuscular disease (NMD) are at risk of acquiring respiratory complications. Both clinical assessments and respiratory diagnostic tests are important to optimize the respiratory health and care of such children. The following respiratory diagnostic tools and their utility for evaluating children with NMD are discussed in this article: lung function testing (spirometry and lung volumes), peak cough flow (PCF), respiratory muscle strength testing, oximetry, capnography, and polysomnography.
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Caggiano S, Khirani S, Verrillo E, Barnerias C, Amaddeo A, Gitiaux C, Thierry B, Desguerre I, Cutrera R, Fauroux B. Sleep in infants with congenital myasthenic syndromes. Eur J Paediatr Neurol 2017; 21:842-851. [PMID: 28755803 DOI: 10.1016/j.ejpn.2017.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/11/2017] [Accepted: 07/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES Infants with congenital myasthenic syndrome (CMS) are at risk of brief resolved unexplained event (BRUE) and sleep-disordered breathing. The aim of the study was to explore sleep in infants with CMS with a particular focus on heart rate (HR) variability. METHODS Overnight polygraphy was performed and HR variations associated with respiratory events were analysed. Bradycardia and tachycardia were defined as a variation of HR of ±10 bpm from baseline and analysed as events/hour. RESULTS The data of 5 infants with CMS were analysed. Two patients had known mutations (COLQ and RAPSN). One patient had a tracheostomy. The apnoea-hypopnoea index (AHI) was abnormal in all the patients (range 2.8-47.7 events/h), with the highest AHI being observed in the 3 youngest infants. Nocturnal transcutaneous gas exchange was normal in all patients except the tracheostomised patient. Mean HR was 114 ± 23 bpm with a mean HR index of 4.5 ± 4.3 events/h. The amplitudes of HR variations (bradycardia or tachycardia) were around 15-20 bpm, regardless of the type of respiratory event, and comparable between patients. No correlations were found between HR indexes or variations and the type and mean duration of respiratory events. Ventilatory support was initiated in 3 infants immediately after the sleep study because of a high AHI and/or nocturnal hypoventilation. CONCLUSIONS All 5 infants had an abnormal AHI with younger infants having the highest AHI. Three infants required ventilatory support after the polygraphy, underlining its clinical usefulness. No significant abnormalities of HR were observed during the sleep studies.
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Affiliation(s)
- Serena Caggiano
- Respiratory Unit, Academic Pediatric Department, Bambino Gesù Children's Hospital, Rome, Italy; AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France
| | - Sonia Khirani
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; ASV Santé, Gennevilliers, France
| | - Elisabetta Verrillo
- Respiratory Unit, Academic Pediatric Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Christine Barnerias
- AP-HP, Hôpital Necker-Enfants Malades, Referral Center for Neuromuscular Diseases, Paris, France
| | - Alessandro Amaddeo
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; INSERM U955, Equipe 13, Créteil, France; Paris Descartes University, Paris, France
| | - Cyril Gitiaux
- AP-HP, Hôpital Necker-Enfants Malades, Referral Center for Neuromuscular Diseases, Paris, France; Paris Descartes University, Paris, France
| | - Briac Thierry
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Head and Neck Surgery, Paris, France
| | - Isabelle Desguerre
- AP-HP, Hôpital Necker-Enfants Malades, Referral Center for Neuromuscular Diseases, Paris, France; Paris Descartes University, Paris, France
| | - Renato Cutrera
- Respiratory Unit, Academic Pediatric Department, Bambino Gesù Children's Hospital, Rome, Italy
| | - Brigitte Fauroux
- AP-HP, Hôpital Necker-Enfants Malades, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; INSERM U955, Equipe 13, Créteil, France; Paris Descartes University, Paris, France.
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Mankodi A, Kovacs W, Norato G, Hsieh N, Bandettini WP, Bishop CA, Shimellis H, Newbould RD, Kim E, Fischbeck KH, Arai AE, Yao J. Respiratory magnetic resonance imaging biomarkers in Duchenne muscular dystrophy. Ann Clin Transl Neurol 2017; 4:655-662. [PMID: 28904987 PMCID: PMC5590523 DOI: 10.1002/acn3.440] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 06/28/2017] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To examine the diaphragm and chest wall dynamics with cine breathing magnetic resonance imaging (MRI) in ambulatory boys with Duchenne muscular dystrophy (DMD) without respiratory symptoms and controls. METHODS In 11 DMD boys and 15 controls, cine MRI of maximal breathing was recorded for 10 sec. The lung segmentations were done by an automated pipeline based on a Holistically-Nested Network model (HNN method). Lung areas, diaphragm, and chest wall motion were measured throughout the breathing cycle. RESULTS The HNN method reliably identified the contours of the lung and the diaphragm in every frame of each dataset (~180 frames) within seconds. The lung areas at maximal inspiration and expiration were reduced in DMD patients relative to controls (P = 0.02 and <0.01, respectively). The change in the lung area between inspiration and expiration correlated with percent predicted forced vital capacity (FVC) in patients (rs = 0.75, P = 0.03) and was not significantly different between groups. The diaphragm position, length, contractility, and motion were not significantly different between groups. Chest wall motion was reduced in patients compared to controls (P < 0.01). INTERPRETATION Cine breathing MRI allows independent and reliable assessment of the diaphragm and chest wall dynamics during the breathing cycle in DMD patients and controls. The MRI data indicate that ambulatory DMD patients breathe at lower lung volumes than controls when their FVC is in the normal range. The diaphragm moves normally, whereas chest wall motion is reduced in these boys with DMD.
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Affiliation(s)
- Ami Mankodi
- Neurogenetics Branch National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda Maryland
| | - William Kovacs
- Radiology and Imaging Sciences The National Institutes of Health Clinical Center Bethesda Maryland
| | - Gina Norato
- Office of Biostatistics National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda Maryland
| | - Nathan Hsieh
- Radiology and Imaging Sciences The National Institutes of Health Clinical Center Bethesda Maryland
| | - W Patricia Bandettini
- Advanced Cardiovascular Imaging National Heart Lung and Blood Institute National Institutes of Health Bethesda Maryland
| | - Courtney A Bishop
- Imanova Center for Imaging Sciences Imperial College London Hammersmith Hospital London United Kingdom
| | - Hirity Shimellis
- Neurogenetics Branch National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda Maryland
| | - Rexford D Newbould
- Imanova Center for Imaging Sciences Imperial College London Hammersmith Hospital London United Kingdom
| | - Eunhee Kim
- Office of Biostatistics National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda Maryland
| | - Kenneth H Fischbeck
- Neurogenetics Branch National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda Maryland
| | - Andrew E Arai
- Advanced Cardiovascular Imaging National Heart Lung and Blood Institute National Institutes of Health Bethesda Maryland
| | - Jianhua Yao
- Radiology and Imaging Sciences The National Institutes of Health Clinical Center Bethesda Maryland
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LoMauro A, Aliverti A, Mastella C, Arnoldi MT, Banfi P, Baranello G. Spontaneous Breathing Pattern as Respiratory Functional Outcome in Children with Spinal Muscular Atrophy (SMA). PLoS One 2016; 11:e0165818. [PMID: 27820869 PMCID: PMC5098831 DOI: 10.1371/journal.pone.0165818] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/18/2016] [Indexed: 12/21/2022] Open
Abstract
Introduction SMA is characterised by progressive motor and respiratory muscle weakness. We aimed to verify if in SMA children 1)each form is characterized by specific ventilatory and thoraco-abdominal pattern(VTAp) during quiet breathing(QB); 2)VTAp is affected by salbutamol therapy, currently suggested as standard treatment, or by the natural history(NH) of SMA; 3)the severity of global motor impairment linearly correlates with VTAp. Materials and methods VTAp was analysed on 32 SMA type I (SMA1,the most severe form), 51 type II (SMA2,the moderate), 8 type III (SMA3,the mildest) and 20 healthy (HC) using opto-electronic plethysmography. Spirometry, cough and motor function were measured in a subgroup of patients. Results In SMA1, a normal ventilation is obtained in supine position by rapid and shallow breathing with paradoxical ribcage motion. In SMA2, ventilation is within a normal range in seated position due to an increased respiratory rate(p<0.05) with reduced tidal volume(p<0.05) secondary to a poor contribution of pulmonary ribcage(%ΔVRC,P, p<0.001). Salbutamol therapy had no effect on VTAp during QB(p>0.05) while tachypnea occurred in type I NH. A linear correlation(p<0.001) was found between motor function scales and VTAp. Conclusion A negative or reduced %ΔVRC,P, indicative of ribcage muscle weakness, is a distinctive feature of SMA1 and SMA2 since infancy. Its quantitative assessment represents a non-invasive, non-volitional index that can be obtained in all children, even uncollaborative, and provides useful information on the action of ribcage muscles that are known to be affected by the disease.Low values of motor function scales indicate impairment of motor but also of respiratory function.
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Affiliation(s)
- A. LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria; Politecnico di Milano, Italy
- * E-mail:
| | - A. Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria; Politecnico di Milano, Italy
| | - C. Mastella
- S.A.PRE., Ospedale Policlinico Maggiore Mangiagalli, and Regina Elena Foundation, Milan, Italy
| | - M. T. Arnoldi
- Developmental Neurology Unit, Carlo Besta Neurological Research Institute Foundation, Milan, Italy
| | - P. Banfi
- Pulmonary Rehabilitation Fondazione Don Carlo Gnocchi, Milan, Italy
| | - G. Baranello
- Developmental Neurology Unit, Carlo Besta Neurological Research Institute Foundation, Milan, Italy
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Griffon L, Amaddeo A, Mortamet G, Barnerias C, Abadie V, Olmo Arroyo J, de Sanctis L, Renolleau S, Fauroux B. Sleep study as a diagnostic tool for unexplained respiratory failure in infants hospitalized in the PICU. J Crit Care 2016; 42:317-323. [PMID: 28826082 DOI: 10.1016/j.jcrc.2016.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 03/31/2016] [Accepted: 04/04/2016] [Indexed: 11/17/2022]
Abstract
PURPOSE The aim of the study was to analyze the diagnostic and therapeutic value of a polygraphy (PG) in infants hospitalized for unexplained respiratory failure or life-threatening events in the PICU. MATERIAL AND METHODS The PG of 13 infants (4 girls), mean age 6.8±7.7months, were analyzed. RESULTS Eight infants were admitted for unexplained respiratory failure and 5 for life-threatening events. PG showed features suggestive of respiratory muscle weakness in 5 infants whose final diagnoses were nemaline rod myopathy (n=2), congenital myasthenia (n=2), and diaphragmatic dysfunction (n=1). Four of these patients were successfully treated with noninvasive ventilation (NIV). PG was suggestive of brainstem dysfunction in 4 infants; 2 were treated successfully with NIV and another with caffeine. PG showed obstructive sleep apnea in 3 infants; 2 were treated successfully with NIV and one patient was lost during follow up. A typical pattern of congenital central hypoventilation syndrome was observed in the last patient who was treated successfully with invasive ventilation. One patient with diaphragmatic dysfunction and one with brain stem dysfunction died. CONCLUSIONS PG may assist the diagnosis and guide the management of unexplained respiratory failure or life-threatening events in infants hospitalized in the PICU.
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Affiliation(s)
- Lucie Griffon
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
| | - Alessandro Amaddeo
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France; Paris Descartes University, Paris, France
| | - Guillaume Mortamet
- Paris Descartes University, Paris, France; Pediatric intensive care unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France; Inserm U 955, Team 13, Créteil University, Paris XII, Créteil, France
| | - Christine Barnerias
- Pediatric neurology unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
| | - Véronique Abadie
- Paris Descartes University, Paris, France; General pediatric unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
| | - Jorge Olmo Arroyo
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
| | - Livio de Sanctis
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
| | - Sylvain Renolleau
- Paris Descartes University, Paris, France; Pediatric intensive care unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France
| | - Brigitte Fauroux
- Pediatric noninvasive ventilation and sleep unit, AP-HP, Hôpital Necker Enfants-Malades, Paris, France; Paris Descartes University, Paris, France; Inserm U 955, Team 13, Créteil University, Paris XII, Créteil, 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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