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Pavone M, Misseri G, Ippolito M, Gregoretti C, Cutrera R. New noninvasive modalities in long-term pediatric ventilation: a scoping review. Monaldi Arch Chest Dis 2024. [PMID: 39058015 DOI: 10.4081/monaldi.2024.2841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 05/06/2024] [Indexed: 07/28/2024] Open
Abstract
Long-term noninvasive ventilation modalities for the pediatric population have undergone a continuous evolution. Hybrid noninvasive ventilation modalities have been recently introduced in clinical practice. Combining the advantages of conventional ventilation, hybrid modes use algorithms that automatically adjust the ventilator's settings to achieve a predefined ventilation target. Most of the recommendations on the use and settings of hybrid noninvasive ventilation modalities in children are derived from adult experience. Therefore, there is a lack of evidence on its implementation in pediatric chronic respiratory diseases. This scoping review aims to map the existing information regarding the use of hybrid ventilation modalities in the pediatric population and identify knowledge or research gaps. We performed a literature search using MEDLINE and Pubmed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. We included 13 studies (ten studies on average volume-assured pressure-support ventilation; two studies on intelligent volume-assured pressure-support ventilation; and one study on adaptive servoventilation). The use of new noninvasive ventilation modes in the pediatric population has been applied for the treatment of neuromuscular and hypoventilation syndromes as an alternative therapeutic option in the case of the failure of conventional noninvasive ventilation. Their widespread use has been hampered by the limited evidence available. Longitudinal studies on a larger number of patients are needed to confirm their effectiveness and evaluate their long-term clinical and functional outcomes.
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Affiliation(s)
- Martino Pavone
- Pediatric Pulmonology and Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Pediatric Hospital "Bambino Gesù" Research Institute, Rome.
| | | | | | - Cesare Gregoretti
- Fondazione Istituto "G. Giglio", Cefalù, Palermo; Department of Surgical, Oncological and Oral Science, University of Palermo.
| | - Renato Cutrera
- Pediatric Pulmonology and Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Pediatric Hospital "Bambino Gesù" Research Institute, Rome.
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2
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Chang GY, Salazar T, Karnwal A, Kun SS, Ellashek J, Shin CE, McComb JG, Keens TG, Perez IA. Perioperative outcomes and the effects of anesthesia in congenital central hypoventilation patients. Sleep Breath 2022; 27:505-510. [DOI: 10.1007/s11325-022-02632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 03/31/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
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3
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Saddi V, Thambipillay G, Martin B, Blecher G, Teng A. Pediatric Average Volume Assured Pressure Support. Front Pediatr 2022; 10:868625. [PMID: 35601414 PMCID: PMC9114489 DOI: 10.3389/fped.2022.868625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
Average volume assured pressure support (AVAPS) is a modality of non-invasive ventilation that enables the machine to deliver a pre-set tidal volume by adjusting the inspiratory pressure support within a set range. Data on its use in the pediatric population are limited to case reports and single centre case series. This article reviews paediatric data on use of AVAPS and highlights the need for validation to help develop specific guidelines on use of AVAPS in children.
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Affiliation(s)
- Vishal Saddi
- Sydney Children's Hospital, Department of Sleep Medicine, Sydney, NSW, Australia.,University of New South Wales, School of Women's and Children's Health, Kensington, NSW, Australia
| | - Ganesh Thambipillay
- Sydney Children's Hospital, Department of Sleep Medicine, Sydney, NSW, Australia.,University of New South Wales, School of Women's and Children's Health, Kensington, NSW, Australia
| | - Bradley Martin
- Sydney Children's Hospital, Department of Sleep Medicine, Sydney, NSW, Australia.,University of New South Wales, School of Women's and Children's Health, Kensington, NSW, Australia
| | - Gregory Blecher
- Sydney Children's Hospital, Department of Sleep Medicine, Sydney, NSW, Australia.,University of New South Wales, School of Women's and Children's Health, Kensington, NSW, Australia
| | - Arthur Teng
- Sydney Children's Hospital, Department of Sleep Medicine, Sydney, NSW, Australia.,University of New South Wales, School of Women's and Children's Health, Kensington, NSW, Australia
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4
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Lovejoy H, Geib LN, Walters CB. Perioperative Pulmonary Optimization With Average Volume-Assured Pressure Support of a Pediatric Patient With Ullrich Congenital Muscular Dystrophy: A Case Report. A A Pract 2021; 15:e01504. [PMID: 34293794 DOI: 10.1213/xaa.0000000000001504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Patients with preexisting respiratory compromise are at risk for perioperative respiratory failure. Adult literature has shown benefit with prophylactic postoperative use of noninvasive mechanical ventilation (NIMV). While pediatric literature has documented the increasing use of postoperative NIMV, there is no literature on prophylactic preoperative NIMV in patients with preexisting respiratory compromise. Further, surgical literature does not address preoperative prophylactic use of NIMV, as well as use of the newest modality of NIMV, average volume-assured pressure support (AVAPS). Here, we describe the first report of pre- and postoperative use of AVAPS in a pediatric patient with respiratory compromise from Ullrich disease.
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Affiliation(s)
- Hannah Lovejoy
- From the Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
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5
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Saddi V, Thambipillay G, Pithers S, Moody M, Martin B, Blecher G, Teng A. Average volume-assured pressure support vs conventional bilevel pressure support in pediatric nocturnal hypoventilation: a case series. J Clin Sleep Med 2021; 17:925-930. [PMID: 33393900 DOI: 10.5664/jcsm.9084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Average volume-assured pressure support (AVAPS) is a modality of noninvasive ventilation that provides a targeted tidal volume by automatically adjusting the inspiratory pressure support within a set range. Pediatric studies evaluating the efficacy of AVAPS in treating nocturnal hypoventilation are confined to case reports. The aim of this study was to compare AVAPS to conventional bilevel positive airway pressure (BPAP) support in improving hypercarbia in a cohort of pediatric patients with nocturnal hypoventilation. METHODS Retrospective review of patient records at an established tertiary pediatric sleep laboratory over a 6-year period. Ventilatory and sleep study parameters from AVAPS and conventional BPAP titration studies were compared. AVAPS was used only if hypoventilation was not controlled using conventional BPAP. Inspiratory pressures, tidal volumes, and adherence were downloaded on final titrated ventilatory settings. Comparisons were made using paired t test. RESULTS A total of 19 patients (11 boys, 8 girls; median age 10.5 years, range 1 to 20 years) were identified. Diagnoses included neuromuscular disease (n = 9), obstructive hypoventilation (n = 5), parenchymal lung disease (n = 4), and congenital central hypoventilation syndrome (n = 2). AVAPS demonstrated significant improvement in peak (P = .009) and mean (P = .001). Transcutaneous CO₂ parameters compared to conventional bilevel. Oxygenation on AVAPS showed positive trend but did not reach statistical significance. AVAPS delivered higher tidal volumes (P = .04) using similar pressures. There was no statistically significant difference in obstructive apnea-hypopnea index, respiratory arousal index, sleep efficiency, and adherence between AVAPS and conventional BPAP. CONCLUSIONS AVAPS was an effective alternative to conventional BPAP in improving hypercarbia in our selective cohort of pediatric patients. Prospective, longitudinal studies are needed to evaluate the benefits of AVAPS feature in the pediatric population.
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Affiliation(s)
- Vishal Saddi
- Department of Sleep Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Ganesh Thambipillay
- Department of Sleep Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Sonia Pithers
- Department of Sleep Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Miles Moody
- Department of Sleep Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia
| | - Bradley Martin
- Department of Sleep Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Gregory Blecher
- Department of Sleep Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Arthur Teng
- Department of Sleep Medicine, Sydney Children's Hospital, Randwick, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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6
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Kasi AS, Anand N, Harford KL, Landry AM, Alfonso KP, Taylor M, Keens TG, Leu RM. Tracheostomy decannulation to noninvasive positive pressure ventilation in congenital central hypoventilation syndrome. Sleep Breath 2021; 26:133-139. [PMID: 33852109 DOI: 10.1007/s11325-021-02368-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/13/2021] [Accepted: 04/01/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Noninvasive positive pressure ventilation (NPPV) may permit tracheostomy decannulation (TD) in patients with congenital central hypoventilation syndrome (CCHS) requiring nocturnal positive pressure ventilation via tracheostomy (PPV-T). There is limited evidence on optimal strategies for transitioning patients from PPV-T to NPPV. This study aimed to describe the clinical course and outcome of children with CCHS who underwent TD and transitioned from PPV-T to NPPV. METHODS Retrospective review was conducted on patients with CCHS using nocturnal PPV-T who underwent TD to NPPV. The results of clinical evaluations, airway endoscopy, polysomnography, and clinical course leading to TD were analyzed. RESULTS We identified 3 patients with CCHS aged 8-17 years who required PPV-T only during sleep. Patients underwent systematic multidisciplinary evaluations with a pediatric psychologist, pulmonologist, sleep physician, and otolaryngologist utilizing a TD algorithm. These included evaluation in the sleep clinic, NPPV mask fitting and desensitization, endoscopic airway evaluation, daytime tracheostomy capping, acclimatization to low-pressure NPPV, polysomnography with capped tracheostomy and NPPV titration, and if successful, TD. All patients underwent successful TD following optimal titration of NPPV during polysomnography. The duration to TD from decision to pursue NPPV was between 2.4 and 10.6 months, and the duration of hospitalization for TD was between 4 and 5 days. There were no NPPV-related complications; however, all patients required surgical closure of tracheocutaneous fistula. CONCLUSION NPPV may be an effective and feasible option for patients with CCHS requiring PPV-T during sleep and permits TD. In patients with CCHS, a systematic multidisciplinary algorithm may optimize successful transition to NPPV and TD.
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Affiliation(s)
- Ajay S Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA.
| | - Neesha Anand
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA
| | - Kelli-Lee Harford
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA
| | - April M Landry
- Division of Pediatric Otorhinolaryngology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kristan P Alfonso
- Division of Pediatric Otorhinolaryngology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Melissa Taylor
- Pediatric Sleep Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Thomas G Keens
- Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Roberta M Leu
- Division of Pediatric Pulmonology and Sleep Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA
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7
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Saddi V, Thambipillay G, Teng A. Non-invasive home ventilation using the average volume assured pressure support feature in an infant with severe bronchopulmonary dysplasia and chronic respiratory failure. Pediatr Investig 2020; 4:222-224. [PMID: 33150318 PMCID: PMC7520108 DOI: 10.1002/ped4.12221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/09/2020] [Indexed: 11/06/2022] Open
Abstract
Introduction While majority of infants with bronchopulmonary dysplasia (BPD) can be discharged home without low flow oxygen or on supplemental low flow oxygen, some require long term home mechanical ventilation. Case presentation We present a case of an extremely premature infant with severe bronchopulmonary dysplasia who was successfully managed at home on a new feature of non-invasive ventilation called average volume assured pressure support (AVAPS) without the need for tracheostomy. The AVAPS feature enables the machine to deliver a consistent tidal volume by automatically adjusting the inspiratory pressure within a set range. Conclusion The use of AVAPS feature in our case improved ventilation as indicated by a more stable gas exchange profile, making home non-invasive ventilation a more practicable method of managing severe BPD in this infant.
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Affiliation(s)
- Vishal Saddi
- Department of Sleep Medicine Sydney Children's Hospital Sydney New South Wales Australia.,School of Women and Children's Health Faculty of Medicine University of New South Wales Sydney New South Wales Australia
| | - Ganesh Thambipillay
- Department of Sleep Medicine Sydney Children's Hospital Sydney New South Wales Australia.,School of Women and Children's Health Faculty of Medicine University of New South Wales Sydney New South Wales Australia
| | - Arthur Teng
- Department of Sleep Medicine Sydney Children's Hospital Sydney New South Wales Australia.,School of Women and Children's Health Faculty of Medicine University of New South Wales Sydney New South Wales Australia
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Pavone M, Verrillo E, Onofri A, Caggiano S, Cutrera R. Ventilators and Ventilatory Modalities. Front Pediatr 2020; 8:500. [PMID: 32984212 PMCID: PMC7492667 DOI: 10.3389/fped.2020.00500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/15/2020] [Indexed: 11/13/2022] Open
Abstract
Non-invasive ventilation is increasingly used in children for acute and chronic respiratory failure. Ventilators available for clinical use have different levels of complexity, and clinicians need to know in detail their characteristics, setting variables, and performances. A wide range of ventilators are currently used in non-invasive ventilation including bi-level ventilators, intermediate ventilators, and critical care ventilators. Simple or advanced continuous positive airway pressure devices are also available. Differences between ventilators may have implications on the development of asynchronies and air leaks and may be associated with discomfort and poor patient tolerance. Although pressure-targeted (controlled) mode is preferable in children because of barotrauma concerns, volume-targeted (controlled) ventilators are also available. Pressure support ventilation represents the most used non-invasive ventilation mode, as it is more physiological. The newest ventilators allow the clinicians to use the hybrid modes that combine the advantages of volume- and pressure-targeted (controlled) ventilation while limiting their drawbacks. The use of in-built software may help clinicians to optimize the ventilator setting as well as to objectively monitor patient adherence to the treatment. The present review aims to help the clinician with the choice of the ventilator and its ventilation modalities to ensure a successful non-invasive ventilation program.
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Affiliation(s)
- Martino Pavone
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Pediatric Hospital "Bambino Gesù Research Institute, Rome, Italy
| | - Elisabetta Verrillo
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Pediatric Hospital "Bambino Gesù Research Institute, Rome, Italy
| | - Alessandro Onofri
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Pediatric Hospital "Bambino Gesù Research Institute, Rome, Italy
| | - Serena Caggiano
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Pediatric Hospital "Bambino Gesù Research Institute, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Academic Department of Pediatrics (DPUO), Pediatric Hospital "Bambino Gesù Research Institute, Rome, Italy
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9
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Stowe RC, Afolabi‐Brown O. Pulmonary hypertension and chronic hypoventilation in ROHHAD syndrome treated with average-volume assured pressure support. Pediatr Investig 2019; 3:253-256. [PMID: 32851331 PMCID: PMC7331430 DOI: 10.1002/ped4.12168] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 10/20/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome is an exceptionally rare clinical entity with significant morbidity and high mortality with challenging-to-treat hypoventilation. CASE PRESENTATION An 11-year-old morbidly obese Chinese female presented with a putative diagnosis of ROHHAD associated with a left psoas ganglioneuroma. Initial polysomnography showed severe obstructive sleep apnea and hypoventilation. She was not adherent to prescribed non-invasive positive pressure ventilation (NIPPV). Echocardiography demonstrated evidence of pulmonary hypertension, likely secondary to chronic hypoventilation. With behavioral modification and trial of average volume-assured pressure support (AVAPS), adherence improved with eventual improvement of her pulmonary hypertension. CONCLUSION AVAPS may improve ventilation and NIPPV adherence in central hypoventilation disorders such as ROHHAD, reducing risk of morbidity and mortality.
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Affiliation(s)
- Robert C. Stowe
- Division of NeurologyChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
- Children's Hospital of Philadelphia Sleep CenterPhiladelphiaPAUSA
| | - Olufunke Afolabi‐Brown
- Children's Hospital of Philadelphia Sleep CenterPhiladelphiaPAUSA
- Division of Pulmonary and Sleep MedicineChildren's Hospital of PhiladelphiaPhiladelphiaPAUSA
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10
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Paglietti MG, Porcaro F, Sovtic A, Cherchi C, Verrillo E, Pavone M, Bottero S, Cutrera R. Decannulation in children affected by congenital central hypoventilation syndrome: A proposal of an algorithm from two European centers. Pediatr Pulmonol 2019; 54:1663-1669. [PMID: 31313536 DOI: 10.1002/ppul.24448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 06/16/2019] [Indexed: 11/08/2022]
Abstract
RATIONALE Long-life ventilatory assistance is necessary for survival in pediatric patients with congenital central hypoventilation syndrome (CCHS). Invasive mechanical ventilation (IMV) through tracheostomy is the most used method, especially in the first years of life when the central nervous system is maturing. Nevertheless, IMV via tracheostomy is not ideal because tracheostomy in children is associated with impaired speech and language development, also frequent infections of the lower airway tract occur. OBJECTIVE Only few reports describe the transition from IMV to the noninvasive method, ending with decannulation in CCHS affected patients. We aim to provide our experience regarding decannulation program in CCHS affected children and to describe a proposal of an algorithm concerning transition from invasive to noninvasive ventilation (NIV) in CCHS patients. METHODS The study has been conducted retrospectively. Four children from two European centers underwent tracheostomy removal and decannulation, upon request of patients and their families. RESULTS All children were trained to carry out tracheostomy capping before decannulation and underwent endoscopic assessment of upper and lower airway. Subsequently they started training to NIV at mean age of 106.25 months (±40.7 SD). Decannulation occurred 12 months after and no patients needed the reintroduction of tracheal cannula in either short or long term follow up. CONCLUSIONS our study shows that effective liberation from IMV, the transition to NIV and decannulation are possible in CCHS affected children and offers a proposal of an algorithm which can be applied in selected centers.
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Affiliation(s)
- Maria Giovanna Paglietti
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Federica Porcaro
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Aleksandar Sovtic
- Department of Pulmonology, Mother and Child Health Institute and School of Medicine University of Belgrade, Serbia
| | - Claudio Cherchi
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Elisabetta Verrillo
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Martino Pavone
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sergio Bottero
- Airway Surgery Unit, Department Pediatric Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Renato Cutrera
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long-Term Ventilation Unit, Academic Department of Pediatrics, Bambino Gesù Children's Hospital, Rome, Italy
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11
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Saddi V, Teng A, Thambipillay G, Allen H, Pithers S, Sullivan C. Nasal mask average volume-assured pressure support in an infant with congenital central hypoventilation syndrome. Respirol Case Rep 2019; 7:e00448. [PMID: 31285823 PMCID: PMC6589097 DOI: 10.1002/rcr2.448] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 05/07/2019] [Accepted: 05/16/2019] [Indexed: 11/07/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare disorder characterized by alveolar hypoventilation and autonomic dysregulation secondary to mutations of the PHOX 2B genes. Treatment consists of assisted ventilation using positive pressure ventilators via tracheostomy, bi-level positive airway pressure (BPAP), negative pressure ventilators, or diaphragm pacing. Previous case reports have highlighted early use of nasal non-invasive BPAP use in infants with CCHS. We present a case of a 10-month-old infant who was successfully managed on a new feature of non-invasive ventilation called average volume assured pressure support (AVAPS) without the need for tracheostomy. The AVAPS feature enables the machine to automatically adjust the inspiratory pressures to deliver a constant targeted tidal volume. This feature enabled a better control of ventilation as indicated by a more stable transcutaneous carbon dioxide profile compared to conventional nasal non-invasive BPAP, making non-invasive ventilation a more accessible method of managing sleep hypoventilation in CCHS.
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Affiliation(s)
- Vishal Saddi
- Department of Sleep MedicineSydney Children's HospitalSydneyNew South WalesAustralia
- School of Women and Children's Health, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - Arthur Teng
- Department of Sleep MedicineSydney Children's HospitalSydneyNew South WalesAustralia
- School of Women and Children's Health, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - Ganesh Thambipillay
- Department of Sleep MedicineSydney Children's HospitalSydneyNew South WalesAustralia
- School of Women and Children's Health, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
| | - Hugh Allen
- Department of Sleep MedicineSydney Children's HospitalSydneyNew South WalesAustralia
| | - Sonia Pithers
- Department of Sleep MedicineSydney Children's HospitalSydneyNew South WalesAustralia
| | - Colin Sullivan
- Department of Sleep MedicineSydney Children's HospitalSydneyNew South WalesAustralia
- School of Women and Children's Health, Faculty of MedicineUniversity of New South WalesSydneyNew South WalesAustralia
- David Read Laboratory, Discipline of Sleep MedicineUniversity of SydneySydneyNew South WalesAustralia
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12
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Use of Noninvasive Ventilation with Volume-Assured Pressure Support to Avoid Tracheostomy in Severe Obstructive Sleep Apnea. Case Rep Pediatr 2018; 2018:4701736. [PMID: 30402319 PMCID: PMC6198579 DOI: 10.1155/2018/4701736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 09/12/2018] [Indexed: 11/17/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a common disorder in children but can occasionally present with life-threatening hypoxemia. Obesity is a significant risk factor for poor outcomes of OSA treatment. Continuous positive airway pressure (CPAP) is indicated in children who are not candidates for or have an unsatisfactory response to adenotonsillectomy. Children acutely at risk for significant morbidity with other therapies are candidates for a tracheostomy. An eight-year-old patient with morbid obesity and severe OSA refractory to CPAP therapy was treated successfully with a novel noninvasive ventilation (NIV) mode with volume-assured pressure support (VAPS) and avoided tracheostomy.
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13
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Selim B, Ramar K. Advanced positive airway pressure modes: adaptive servo ventilation and volume assured pressure support. Expert Rev Med Devices 2016; 13:839-51. [PMID: 27478974 DOI: 10.1080/17434440.2016.1218759] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Volume assured pressure support (VAPS) and adaptive servo ventilation (ASV) are non-invasive positive airway pressure (PAP) modes with sophisticated negative feedback control systems (servomechanism), having the capability to self-adjust in real time its respiratory controlled variables to patient's respiratory fluctuations. However, the widespread use of VAPS and ASV is limited by scant clinical experience, high costs, and the incomplete understanding of propriety algorithmic differences in devices' response to patient's respiratory changes. Hence, we will review and highlight similarities and differences in technical aspects, control algorithms, and settings of each mode, focusing on the literature search published in this area. AREAS COVERED One hundred twenty relevant articles were identified by Scopus, PubMed, and Embase databases from January 2010 to 2016, using a combination of MeSH terms and keywords. Articles were further supplemented by pearling. Recommendations were based on the literature review and the authors' expertise in this area. Expert commentary: ASV and VAPS differ in their respiratory targets and response to a respiratory fluctuation. The VAPS mode targets a more consistent minute ventilation, being recommended in the treatment of sleep related hypoventilation disorders, while ASV mode attempts to provide a more steady breathing airflow pattern, treating successfully most central sleep apnea syndromes.
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Affiliation(s)
- Bernardo Selim
- a Division of Pulmonary and Critical Care Medicine , Mayo Clinic , Rochester , MN , USA
| | - Kannan Ramar
- a Division of Pulmonary and Critical Care Medicine , Mayo Clinic , Rochester , MN , USA
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14
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Amin R, Al-Saleh S, Narang I. Domiciliary noninvasive positive airway pressure therapy in children. Pediatr Pulmonol 2016; 51:335-48. [PMID: 26663667 DOI: 10.1002/ppul.23353] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 11/09/2015] [Accepted: 11/21/2015] [Indexed: 12/28/2022]
Abstract
There has been a dramatic increase in the past few decades in the number of children receiving noninvasive positive airway pressure (PAP) therapy at home. Although PAP therapy was first prescribed for children with obstructive sleep apnea, the indications have rapidly widened to include treatment for central hypoventilation syndromes, neuromuscular and chest wall disorders as well as primary respiratory diseases. Given the rapidly expanding use of PAP therapy in children, pediatric pulmonologists need to be familiar with the indications, technical and safety considerations as well as potential complications and challenges that may arise when caring for children using PAP therapy. This review article covers the definition of PAP therapy, modes, interfaces, devices, indications, contraindications, suggested settings, complications as well as the factors influencing the adherence.
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Affiliation(s)
- Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Child Health and Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
| | - Suhail Al-Saleh
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Canada
| | - Indra Narang
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada.,Department of Paediatrics, University of Toronto, Toronto, Canada.,Department of Physiology and Experimental Medicine, The Hospital for Sick Children, Toronto, Canada
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15
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Healy F, Marcus CL. Care of the Child with Congenital Central Hypoventilation Syndrome. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Gentin N, Williamson B, Thambipillay G, Teng A. Nocturnal respiratory failure in a child with congenital myopathy - management using average volume-assured pressure support (AVAPS). Respirol Case Rep 2015; 3:115-7. [PMID: 26392861 PMCID: PMC4571743 DOI: 10.1002/rcr2.117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 07/12/2015] [Accepted: 07/14/2015] [Indexed: 11/18/2022] Open
Abstract
This is a case report of the effective use of bi-level positive airway pressure support (BPAP) using the volume-assured pressure support feature in a pediatric patient with a congenital myopathy and significant nocturnal hypoventilation. Our patient was started on nocturnal nasal mask BPAP but required high pressures to improve her oxygen saturations and CO2 baseline. She was then trialed on a BPAP machine with the volume-assured pressure support feature on. The ability of this machine to adjust inspiratory pressures to give a targeted tidal volume allowed the patient to be on lower pressure settings for periods of the night, with the higher pressures only when required. She tolerated the ventilation well and her saturations, CO2 profiles, and clinical condition improved. This case report highlights the benefits of the volume-assured pressure support feature on a BPAP machine in a child with a neuromuscular disorder.
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Affiliation(s)
- Natalie Gentin
- Department of Sleep Medicine, Sydney Children's Hospital Sydney, New South Wales, Australia ; School of Women and Children's Health, Faculty of Medicine, University of New South Wales Sydney, New South Wales, Australia
| | - Bruce Williamson
- Department of Sleep Medicine, Sydney Children's Hospital Sydney, New South Wales, Australia ; School of Women and Children's Health, Faculty of Medicine, University of New South Wales Sydney, New South Wales, Australia
| | - Ganesh Thambipillay
- Department of Sleep Medicine, Sydney Children's Hospital Sydney, New South Wales, Australia ; School of Women and Children's Health, Faculty of Medicine, University of New South Wales Sydney, New South Wales, Australia
| | - Arthur Teng
- Department of Sleep Medicine, Sydney Children's Hospital Sydney, New South Wales, Australia ; School of Women and Children's Health, Faculty of Medicine, University of New South Wales Sydney, New South Wales, Australia ; School of Medicine, University of Tasmania Tasmania, Australia
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17
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Diaz-Abad M, Brown JE. Use of volume-targeted non-invasive bilevel positive airway pressure ventilation in a patient with amyotrophic lateral sclerosis. J Bras Pneumol 2015; 40:443-7. [PMID: 25210968 PMCID: PMC4201176 DOI: 10.1590/s1806-37132014000400013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 08/02/2013] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease in
which most patients die of respiratory failure. Although volume-targeted non-invasive
bilevel positive airway pressure (BPAP) ventilation has been studied in patients with
chronic respiratory failure of various etiologies, its use in ALS has not been
reported. We present the case of a 66-year-old woman with ALS and respiratory failure
treated with volume-targeted BPAP ventilation for 15 weeks. Weekly data downloads
showed that disease progression was associated with increased respiratory muscle
weakness, decreased spontaneous breathing, and increased use of non-invasive positive
pressure ventilation, whereas tidal volume and minute ventilation remained relatively
constant.
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18
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Combs D, Shetty S, Parthasarathy S. Advances in Positive Airway Pressure Treatment Modalities for Hypoventilation Syndromes. Sleep Med Clin 2014; 9:315-325. [PMID: 25346650 DOI: 10.1016/j.jsmc.2014.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
RATIONALE Positive airway pressure therapy for hypoventilation syndromes can significantly improve health-related quality of life (HR-QOL), healthcare costs, and even mortality. The sleep-disordered breathing in such individuals are quite complex and require sophisticated devices with algorithms that are designed to accurately detect and effectively treat respiratory events that includes hypoventilation, upper airway obstruction, lower airway obstruction, central apneas and central hypopneas and reduce the work of breathing while maintaining breathing comfort. OBJECTIVES The therapeutic physiological rationale for the various advanced PAP modalities and the details about the principles of operation and technology implementation are provided here. CONCLUSIONS The physiological rationale for advanced PAP modalities is sound considering the complexity of sleep-disordered breathing in patients with hypoventilation syndromes. Although such devices are increasingly used in clinical practice, the supporting clinical evidence - specifically comparative-effectiveness studies in real-life conditions -- needs to be performed. Moreover, there is much opportunity for further refining these devices that include the ability of the device to reliably monitor gas-exchange, sleep-wakefulness state, and for reducing variability in device efficacy due to provider-selected device-settings.
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Affiliation(s)
- Dan Combs
- Arizona Respiratory Center, University of Arizona, Tucson, AZ ; Department of Pediatrics, University of Arizona, Tucson, AZ
| | - Safal Shetty
- Arizona Respiratory Center, University of Arizona, Tucson, AZ ; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine of University of Arizona, Tucson, AZ
| | - Sairam Parthasarathy
- Arizona Respiratory Center, University of Arizona, Tucson, AZ ; Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine of University of Arizona, Tucson, AZ
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19
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Bhattacharjee R, Gozal D. Sleep Hypoventilation Syndromes and Noninvasive Ventilation in Children. Sleep Med Clin 2014. [DOI: 10.1016/j.jsmc.2014.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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20
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Kam K, Bjornson C, Mitchell I. Congenital central hypoventilation syndrome; safety of early transition to non-invasive ventilation. Pediatr Pulmonol 2014; 49:410-3. [PMID: 23843332 DOI: 10.1002/ppul.22848] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 05/28/2013] [Indexed: 11/11/2022]
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare disorder of autonomic dysregulation, characterized by alveolar hypoventilation especially during sleep. As a result, lifelong ventilatory assistance is necessary in these patients. Many infants and children initially require positive pressure ventilation via tracheostomy for support. Associated complications and psychosocial pressure may prompt early transition to non-invasive ventilation. We present the details of a patient with CCHS who successfully transitioned from tracheostomy to bilevel positive airway pressure ventilation at an early age of 3 years.
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Affiliation(s)
- Karen Kam
- Section of Respiratory Medicine, Alberta Children's Hospital, Calgary, Alberta, Canada
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21
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Okuda M, Kashio M, Tanaka N, Fujii T, Okuda Y. Positive outcome of average volume-assured pressure support mode of a Respironics V60 Ventilator in acute exacerbation of chronic obstructive pulmonary disease: a case report. J Med Case Rep 2012; 6:284. [PMID: 22963752 PMCID: PMC3485098 DOI: 10.1186/1752-1947-6-284] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2012] [Accepted: 05/17/2012] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION We were able to treat a patient with acute exacerbation of chronic obstructive pulmonary disease who also suffered from sleep-disordered breathing by using the average volume-assured pressure support mode of a Respironics V60 Ventilator (Philips Respironics: United States). This allows a target tidal volume to be set based on automatic changes in inspiratory positive airway pressure. This removed the need to change the noninvasive positive pressure ventilation settings during the day and during sleep. The Respironics V60 Ventilator, in the average volume-assured pressure support mode, was attached to our patient and improved and stabilized his sleep-related hypoventilation by automatically adjusting force to within an acceptable range. CASE PRESENTATION Our patient was a 74-year-old Japanese man who was hospitalized for treatment due to worsening of dyspnea and hypoxemia. He was diagnosed with acute exacerbation of chronic obstructive pulmonary disease and full-time biphasic positive airway pressure support ventilation was initiated. Our patient was temporarily provided with portable noninvasive positive pressure ventilation at night-time following an improvement in his condition, but his chronic obstructive pulmonary disease again worsened due to the recurrence of a respiratory infection. During the initial exacerbation, his tidal volume was significantly lower during sleep (378.9 ± 72.9mL) than while awake (446.5 ± 63.3mL). A ventilator that allows ventilation to be maintained by automatically adjusting the inspiratory force to within an acceptable range was attached in average volume-assured pressure support mode, improving his sleep-related hypoventilation, which is often associated with the use of the Respironics V60 Ventilator. Polysomnography performed while our patient was on noninvasive positive pressure ventilation revealed obstructive sleep apnea syndrome (apnea-hypopnea index = 14), suggesting that his chronic obstructive pulmonary disease was complicated by obstructive sleep apnea syndrome. CONCLUSION In cases such as this, in which patients with severe acute respiratory failure requiring full-time noninvasive positive pressure ventilation therapy also show sleep-disordered breathing, different ventilator settings must be used for waking and sleeping. On such occasions, the Respironics V60 Ventilator, which is equipped with an average volume-assured pressure support mode, may be useful in improving gas exchange and may achieve good patient compliance, because that mode allows ventilation to be maintained by automatically adjusting the inspiratory force to within an acceptable range whenever ventilation falls below target levels.
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Affiliation(s)
- Miyuki Okuda
- Osaka Hospital, Neyagawakoen 2276-1, Neyagawa City, Osaka, 572-0854, Japan
| | - Makoto Kashio
- Osaka Hospital, Neyagawakoen 2276-1, Neyagawa City, Osaka, 572-0854, Japan
| | - Nobuya Tanaka
- Osaka Hospital, Neyagawakoen 2276-1, Neyagawa City, Osaka, 572-0854, Japan
| | - Takashi Fujii
- Osaka Hospital, Neyagawakoen 2276-1, Neyagawa City, Osaka, 572-0854, Japan
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