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Kamalaporn H, Preutthipan A, Coates AL. Weaning strategies for children on home invasive mechanical ventilation. Pediatr Pulmonol 2024. [PMID: 38593235 DOI: 10.1002/ppul.27008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 03/28/2024] [Accepted: 03/30/2024] [Indexed: 04/11/2024]
Abstract
Children who require home mechanical ventilation (HMV) with an artificial airway or invasive mechanical ventilation (HMV) have a possibility of successful weaning due to the potential of compensatory lung growth. Internationally accepted guidelines on how to wean from HMV in children is not available, we summarize the weaning strategies from the literature reviews combined with our 27-year experience in the Pediatric Home Respiratory Care program at the tertiary care center in Thailand. The readiness to wean is considered in patients with hemodynamic stability, having effective cough measured by maximal inspiratory pressure, requiring a fraction of inspired oxygen (FiO2) < 40%, positive end expiratory pressure <5 cmH2O, and acceptable arterial blood gases. The strategies of weaning is start weaning during the daytime while the child is awake and close monitoring is feasible. Disconnect time is gradually increased through naps and sleeping hours. Weaning from the conventional mechanical ventilator to Bilevel PAP or CPAP are optional. Factors affected the successful weaning are mainly the underlying diseases, complications, growth and development, caregivers, and resources. Weaning should be stopped during acute illness or increased work of breathing. The readiness for decannulation could be determined by using the speaking devices, tracheostomy capping, and measurement of end-expiratory pressure. Polysomnography and airway evaluation by bronchoscopy are recommended before decannulation. Weaning when the child is ready is crucial because living with HMV can be challenging and stressful. Failure to remove a tracheostomy when indicated can result in delayed speech, social problems as well as risk for infection.
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Affiliation(s)
- Harutai Kamalaporn
- Department of Pediatrics, Division of Pulmonology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Aroonwan Preutthipan
- Department of Pediatrics, Division of Pulmonology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Allan L Coates
- The Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Canada
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Fain ME, Westbrook AL, Kasi AS. Congenital Central Hypoventilation Syndrome: Diagnosis and Long-Term Ventilatory Outcomes. Clin Med Insights Pediatr 2023; 17:11795565231169556. [PMID: 37256017 PMCID: PMC10226304 DOI: 10.1177/11795565231169556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/27/2023] [Indexed: 06/01/2023] Open
Abstract
Background Congenital central hypoventilation syndrome (CCHS), a rare disease caused by variants in the paired-like homeobox 2B (PHOX2B) gene, affects regulation of respiration necessitating lifelong assisted ventilation (AV). Most patients require full-time AV during infancy and some patients may sustain adequate spontaneous ventilation during wakefulness and change AV modalities at a later age. The aims of this study were to assess the changes in duration and modalities of AV, long-term respiratory outcomes, and to correlate them with PHOX2B genotypes. Methods We conducted a retrospective study of patients with CCHS treated at our institution between January 1997 and May 2022. Results analyzed included: clinical presentation, PHOX2B genotype, modality and duration of AV at diagnosis and follow-up, survival, and transition to adult care. Results We identified 30 patients with CCHS-8 with PHOX2B nonpolyalanine repeat mutations (NPARMs), 21 with polyalanine repeat mutations (PARMs), and 1 with unknown PHOX2B genotype. The median age at presentation was 0.25 months (IQR 0.1-0.7 months). At diagnosis of CCHS, 24 (80%) patients required continuous AV and 28 (93%) received AV via tracheostomy. Twenty-six patients required sleep-only AV at a median age of 9 months (IQR 6-14 months). Nine patients requiring sleep-only AV underwent tracheostomy decannulation at a median age of 11.2 years (IQR 5.9-15.7 years) and used noninvasive positive pressure ventilation or diaphragm pacing. There was insufficient evidence to conclude that patients with PARMs and NPARMs differed by age at presentation (P = .39), tracheostomy (P = .06), and transition to sleep-only AV (P = .9). Six patients transitioned to adult care, 23 continued receiving pediatric care, and 1 patient died due to complications from Hirschsprung's disease. Conclusion Our study demonstrates prolonged survival and good long-term respiratory outcomes possibly related to the early diagnosis of CCHS, optimizing AV strategies, and multidisciplinary care. The increasing number of patients attaining adulthood highlights the necessity for multidisciplinary care for adults with CCHS.
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Affiliation(s)
- Mary Ellen Fain
- Department of Pediatrics, Division of
Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of
Atlanta, Atlanta, GA, USA
| | - Adrianna L Westbrook
- Pediatric Biostatistics Core,
Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta,
Atlanta, GA, USA
| | - Ajay S Kasi
- Department of Pediatrics, Division of
Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of
Atlanta, Atlanta, GA, USA
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Finch CE, Leu RM, Harford KL, Westbrook AL, Kasi AS. Sleep disturbances in parental caregivers and patients with congenital central hypoventilation syndrome. J Clin Sleep Med 2023; 19:549-554. [PMID: 36541215 PMCID: PMC9978429 DOI: 10.5664/jcsm.10384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 12/24/2022]
Abstract
STUDY OBJECTIVES Congenital central hypoventilation syndrome (CCHS) is a rare disease characterized by impaired control of breathing caused by paired-like homeobox 2B (PHOX2B) gene variants, necessitating lifelong assisted ventilation (AV). This study aimed to assess sleep quality in patients with CCHS and their parents using sleep questionnaires. METHODS Parents of patients with CCHS completed the Pittsburgh Sleep Quality Index (PSQI) regarding their sleep and the Sleep Disturbance Scale for Children (SDSC) regarding their child's sleep. RESULTS Twenty participants completed the questionnaires. The median (interquartile range) ages of the parents and patients were 41.5 (38.5-51.5) and 11.5 (7.4-16.7) years, respectively. The median (interquartile range) PSQI and SDSC scores were elevated at 6.5 (4-10) and 41.5 (34-51.5), respectively, suggesting that parents and patients with CCHS can experience sleep disturbances and poor sleep quality. There were no significant differences in SDSC (P = 1.0) and PSQI (P = .76) scores for AV with or without tracheostomy. Similarly, there were no significant differences in SDSC (P = .22) and PSQI (P = .34) scores based on PHOX2B genotypes. There was a moderately strong, significant, and positive correlation between the CCHS SDSC scores and parental PSQI scores (r = .48, P = .03), suggesting that sleep disturbances in patients with CCHS were associated with poor parental sleep quality. There was no difference in the median parental sleep duration between those with and without nighttime home nursing (P = .09). CONCLUSIONS Patients with CCHS and their parents are at risk for sleep disturbances regardless of their AV modality and PHOX2B genotype. In addition to AV management, patients with CCHS and their parents should be assessed for sleep disturbances. CITATION Finch CE, Leu RM, Harford K-L, Westbrook AL, Kasi AS. Sleep disturbances in parental caregivers and patients with congenital central hypoventilation syndrome. J Clin Sleep Med. 2023;19(3):549-554.
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Affiliation(s)
- Christina E. Finch
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Roberta M. Leu
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Kelli-Lee Harford
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Adrianna L. Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Ajay S. Kasi
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, Georgia
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Ghosh RN, Guglani L, Westbrook AL, Mao CY, Bai S, Keens TG, Kasi AS. Impaired ventilation during 6-min walk test in congenital central hypoventilation syndrome. Pediatr Pulmonol 2022; 57:1660-1667. [PMID: 35460211 DOI: 10.1002/ppul.25940] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients with congenital central hypoventilation syndrome (CCHS) can develop hypoxemia and hypercapnia during exercise. However, there is limited literature on cardiorespiratory responses during submaximal exercise and their correlation with paired-like homeobox 2B (PHOX2B) genotype. OBJECTIVES To assess oxygen saturation (SpO2 ), end-tidal carbon dioxide (ETCO2 ), heart rate (HR), and 6-min walk distance (6MWD) during a 6-min walk test (6MWT) in CCHS subjects and to correlate them with PHOX2B genotypes and assisted ventilation (AV) via tracheostomy. METHODS In this cross-sectional study, subjects with CCHS performed 6MWT with continuous pulse oximetry, HR, and capnography recorded before and during the 6MWT. Medical records were reviewed for PHOX2B genotype and phenotype data. Patients were categorized based on PHOX2B genotype and AV via tracheostomy. RESULTS Fifteen subjects aged 10.5 (interquartile range 7.9-16.2) years completed the 6MWT. Nine subjects used AV via tracheostomy. Seven (47%) subjects developed hypoxemia (SpO2 ≤ 90%, n = 7) and hypoventilation (ETCO2 ≥ 50 mmHg, n = 3) during the 6MWT. There was a significant decline from baseline SpO2 , increase from baseline ETCO2 , and increase in HR during the 6MWT (all p < 0.05). Subjects had decreased median percent predicted 6MWD (59.7% [50.6%-62.5%]). Nadir SpO2 (p = 0.029) and peak ETCO2 (p = 0.046) differed significantly between PHOX2B genotype groups but 6MWD did not (p = 0.8). CONCLUSION Despite normal oxygenation and ventilation at rest and during sleep on AV, patients with CCHS can develop hypoxemia and hypercapnia during submaximal exercise. Our study highlights the importance of assessing ventilatory responses during submaximal exercise in patients with CCHS regardless of their PHOX2B genotype.
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Affiliation(s)
- Radhika N Ghosh
- Department of Pediatrics, Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Lokesh Guglani
- Department of Pediatrics, Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Adrianna L Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Chad Y Mao
- Department of Pediatrics, Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Shasha Bai
- Pediatric Biostatistics Core, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Thomas G Keens
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Ajay S Kasi
- Department of Pediatrics, Division of Pediatric Pulmonology, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
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Kasi AS, Li H, Harford KL, Lam HV, Mao C, Landry AM, Mitchell SG, Clifton MS, Leu RM. Congenital Central Hypoventilation Syndrome: Optimizing Care with a Multidisciplinary Approach. J Multidiscip Healthc 2022; 15:455-469. [PMID: 35360554 PMCID: PMC8963195 DOI: 10.2147/jmdh.s284782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 02/15/2022] [Indexed: 11/24/2022] Open
Abstract
Congenital central hypoventilation syndrome (CCHS) is a rare genetic disorder affecting respiratory control and autonomic nervous system function caused by variants in the paired-like homeobox 2B (PHOX2B) gene. Although most patients are diagnosed in the newborn period, an increasing number of patients are presenting later in childhood, adolescence, and adulthood. Despite hypoxemia and hypercapnia, patients do not manifest clinical features of respiratory distress during sleep and wakefulness. CCHS is a lifelong disorder. Patients require assisted ventilation throughout their life delivered by positive pressure ventilation via tracheostomy, noninvasive positive pressure ventilation, and/or diaphragm pacing. At different ages, patients may prefer to change their modality of assisted ventilation. This requires an individualized and coordinated multidisciplinary approach. Additional clinical features of CCHS that may present at different ages and require periodic evaluations or interventions include Hirschsprung’s disease, gastrointestinal dysmotility, neural crest tumors, cardiac arrhythmias, and neurodevelopmental delays. Despite an established PHOX2B genotype and phenotype correlation, patients have variable and heterogeneous clinical manifestations requiring the formulation of an individualized plan of care based on collaboration between the pulmonologist, otolaryngologist, cardiologist, anesthesiologist, gastroenterologist, sleep medicine physician, geneticist, surgeon, oncologist, and respiratory therapist. A comprehensive multidisciplinary approach may optimize care and improve patient outcomes. With advances in CCHS management strategies, there is prolongation of survival necessitating high-quality multidisciplinary care for adults with CCHS.
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Affiliation(s)
- Ajay S Kasi
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
- Correspondence: Ajay S Kasi, Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA, 30329, USA, Tel +1 404 785 5437, Fax +1 404 785 9087, Email
| | - Hong Li
- Department of Human Genetics, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kelli-Lee Harford
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Humphrey V Lam
- Division of Pediatric Anesthesiology, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Chad Mao
- Department of Pediatrics, Division of Pediatric Cardiology, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - April M Landry
- Division of Pediatric Otorhinolaryngology, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Sarah G Mitchell
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Matthew S Clifton
- Division of Pediatric Surgery, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Roberta M Leu
- Department of Pediatrics, Division of Pediatric Pulmonology and Sleep Medicine, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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