Respiratory management of pediatric patients with neuromuscular disease

Palliative care in children with spinal muscular atrophy type I: What do they need?

OBJECTIVE

Our aim was to describe the clinical evolution and needs of children with spinal muscular atrophy type I treated in a domiciliary palliative care program.

METHOD

We undertook a retrospective chart review of nine consecutive patients. Descriptions of the clinical and demographic profile of children with spinal muscular atrophy (SMA) type I were referred to a pediatric palliative care team (PPCT).

RESULTS

Six males and three females were admitted to the PPCT, all before six months of age, except for one afflicted with SMA type I with respiratory distress. The median time of attention was 57 days (range 1-150). The domiciliary attention mainly consisted of respiratory care. The patient with SMA type I with respiratory distress required domiciliary mechanical ventilation by tracheotomy. In all cases, a nasogastric tube (NT) was indicated. As end-of-life care, eight required morphine to manage the dyspnea, four received it only by enteral (oral or NT) administration, and four received it first by enteral administration with continuous subcutaneous infusion (CSI) later. Three of the four patients with CSI also received benzodiazepines. While they were attended by the PPCT, none required hospital admission. All the patients died at home except for the one attended to for just one day.

SIGNIFICANCE OF RESULTS

Domiciliary care for these patients is possible. The respiratory morbidity and its management are the main issues. Application of an NT is useful to maintain nutritional balance. Morphine administration is necessary to manage the dyspnea. Palliative sedation is not always necessary.

Effects of respiratory muscle training on pulmonary functions in patients with slowly progressive neuromuscular disease: a randomized controlled trial

Objective:

To investigate the effects of inspiratory and expiratory muscle training on pulmonary functions in patients with slowly progressive neuromuscular disease.

Design:

Prospective randomized controlled double-blinded study.

Setting:

Chest diseases clinic of university hospital.

Subjects:

Twenty-six patients with slowly progressive neuromuscular disease followed for respiratory problems were included in the study. Patients were randomly divided into two groups; experimental ( n = 14; age 31.6 ±12.3 years) and sham ( n = 12; age 26.5 ±8.6 years) groups.

Methods:

Spirometry, peak cough flow, maximal inspiratory pressure, maximal expiratory pressure, and sniff nasal inspiratory pressure were measured before the eighth week of study, and subsequently at end of it. Respiratory muscle training was performed by inspiratory (Threshold Inspiratory Muscle Trainer) and expiratory (Threshold Positive Expiratory Pressure) threshold loading methods. Training intensities were increased according to maximal inspiratory and expiratory pressures in the experimental group, while the lowest loads were used for training in the sham group. Patients performed 15 minutes inspiratory muscle training and 15 minutes expiratory muscle training, twice a day, five days/week, for a total of eight weeks at home. Training intensity was adjusted in the training group once a week.

Results:

Maximal inspiratory and expiratory pressures (cmH2O, % predicted) (respectively p = 0.002, p = 0.003, p = 0.04, p = 0.03) and sniff nasal inspiratory pressure ( p = 0.04) were improved in the experimental group when compared with the sham group. However, there was no improvement in spirometric measurements when groups were compared ( p > 0.05).

Conclusions:

As a conclusion of our study, we found that respiratory muscle strength improved by inspiratory and expiratory muscle training in patients with slowly progressive neuromuscular disease.