Critical care management of neuromuscular disease, including long-term ventilation

Perioperative management of patients with amyotrophic lateral sclerosis: A narrative review

Amyotrophic lateral sclerosis, or motor neuron disease, is an uncommon progressive neurological disorder. Professionals working in the perioperative field may encounter patients with amyotrophic lateral sclerosis only rarely. The relevant published literature on amyotrophic lateral sclerosis is broad in scope, but a contemporary review focused on the perioperative period is absent. This structured narrative review seeks to provide a summary of the contemporary management of patients and then focuses on eliciting if there are perioperative management considerations specific to amyotrophic lateral sclerosis that can be optimised. A comprehensive structured narrative literature review, including grey literature searching, indicated worsening ventilatory failure is of prime concern but that patients may present with a broad range of neurological symptoms, and that cardiovascular and cognitive dysfunction specific to amyotrophic lateral sclerosis may exist and be occult. Exacerbation of neuromuscular weakness during the perioperative period is multifaceted and requires the application of a high standard of the core principles of surgical and anaesthetic management of neuromuscular disease. Standard perioperative approaches require rigorous attention and potential exists for significant alteration. There is a potential high risk of postoperative increased morbidity from neurological decline and mortality from pulmonary complications. A meticulous approach to planning preoperative assessment, shared decision-making, intraoperative and postoperative care is required.

Telemedicine for Facio-Scapulo-Humeral Muscular Dystrophy: A multidisciplinary approach to improve quality of life and reduce hospitalization rate?

BACKGROUND

Facio-Scapulo-Humeral Muscular Dystrophy (FSHD) is an autosomal dominant inherited disorder characterized by a variable and asymmetric involvement of facial, trunk, upper and lower extremity muscles. Although respiratory weakness is a relatively unknown feature of FSHD, it is not rare. Telemedicine has been used in a variety of health care fields, but only recently, with the advent of sophisticated technology, its interest among health professionals became evident, even in such diseases.

OBJECTIVE

To demonstrate the telemedicine efficacy in FSHD.

METHODS

Four siblings affected by a severe form of FSHD, living in a rural area far away from the referral center for neuromuscular diseases, who used a wheelchair, suffered from chronic respiratory failure and were provided with long-term non-invasive mechanical ventilation, received a 6-month period of telemedicine support. This consisted of video conferencing (respiratory physiotherapy, psychological support, neurological and pneumological assessment, nurse-coach supervision) and telemonitoring of cardiorespiratory variables (oxygen saturation, blood pressure, and heart rate).

RESULTS

We performed 540 video conference sessions per patient, including three daily contacts with short monitoring oximetry measurements, blood pressure, and heart-rate measurements, psychological support, neurological and pneumological assessment, nurse-coach supervision.

CONCLUSIONS

Our findings indicate that our telemedicine system was user-friendly, efficient for the home treatment of FSHD, and allowed reducing hospital admissions.

Telemedicine system for the care of patients with neuromuscular disease and chronic respiratory failure

INTRODUCTION

Neuromuscular diseases cause a number of limitations which may be improved by using a telemedicine system. These include functional impairment and dependence associated with muscle weakness, the insidious development of respiratory failure and episodes of exacerbation.

MATERIAL AND METHODS

The present study involved three patients with severe neuromuscular disease, chronic respiratory failure and long-term mechanical ventilation, who were followed up using a telemedicine platform. The telemedicine system is based on videoconferencing and telemonitoring of cardiorespiratory variables (oxygen saturation, heart rate, blood pressure and electrocardiogram). Two different protocols were followed depending on whether the patient condition was stable or unstable.

RESULTS

Over a period of 5 years, we analyzed a series of variables including use of the system, patient satisfaction and clinical impact. Overall we performed 290 videoconference sessions, 269 short monitoring oximetry measurements and 110 blood pressure measurements. With respect to the clinical impact, after enrolment in the telemedicine program, the total number of hospital admissions fell from 18 to 3.

CONCLUSIONS

Our findings indicate that the system was user friendly for patients and care givers. Patient satisfaction scores were acceptable. The telemedicine system was effective for the home treatment of three patients with severe neuromuscular diseases and reduced the need for hospital admissions.

Evaluation of peak cough flow in Brazilian healthy adults

INTRODUCTION

In this study we aimed to evaluate the peak cough flow (PCF) in healthy Brazilian subjects.

METHODS

We evaluated 484 healthy subjects between 18 and 40 years old. Subjects were seated and oriented were asked to perform a maximal inspiration followed by a quick, short and explosive expiration on the peak flow meter. Three measures were carried out and recorded the average of the three results for each individual.

RESULTS

The PCF values ranged between 240 and 500 L/min. The PCF values were lower in females than in males. The PCF was inversely proportional to age.

CONCLUSION

The values for Brazilian adult healthy subjects regarding PCF were between 240 and 500 L/min.

National trends in hospital outcomes among patients with Guillain-Barré syndrome requiring mechanical ventilation

Several new treatments have been introduced for Guillain-Barré syndrome over the last decade. To assess the impact of these new strategies on outcomes and hospitalization charges among patients with Guillain-Barré syndrome requiring mechanical ventilation, we compared pertinent variables between nationally representative data derived from 1992 and 2002. Compared with patients admitted in 1992, the patients admitted in 2002 showed an increase in hospital charges ($168,600 versus $116,300, P = 0.007), longer hospitalization (52.6 +/- 23.3 versus 40.3 +/- 36.3 days, P = 0.017), and greater in-hospital mortality (11.1% versus 7.6%, P = 0.003). Thus, improvements in therapeutic strategies over that decade are not reflected in mortality, length of hospitalization, or hospital charges in the current study. This outcome may be more reflective of changing patterns of hospitalization rather than relatively futility of new treatments.

Automatic selection of breathing pattern using adaptive support ventilation

OBJECTIVE

In a cohort of mechanically ventilated patients to compare the automatic tidal volume (VT)-respiratory rate (RR) combination generated by adaptive support ventilation (ASV) for various lung conditions.

DESIGN AND SETTING

Prospective observational cohort study in the 11-bed medicosurgical ICU of a general hospital.

PATIENTS

243 patients receiving 1327 days of invasive ventilation on ASV.

MEASUREMENTS

Daily collection of ventilator settings, breathing pattern, arterial blood gases, and underlying clinical respiratory conditions categorized as: normal lungs, ALI/ARDS, COPD, chest wall stiffness, or acute respiratory failure.

RESULTS

Overall the respiratory mechanics differed significantly with the underlying conditions. In passive patients ASV delivered different VT-RR combinations based on the underlying condition, providing higher VT and lower RR in COPD than in ALI/ARDS: 9.3ml/kg (8.2-10.8) predicted body weight (PBW) and 13 breaths/min (11-16) vs. 7.6ml/kg (6.7-8.8) PBW and 18 breaths/min (16-22). In patients actively triggering the ventilator the VT-RR combinations did not differ between COPD, ALI/ARDS, and normal lungs.

CONCLUSIONS

ASV selects different VT-RR combinations based on respiratory mechanics in passive, mechanically ventilated patients.

Multipotential mesoangioblast stem cell therapy in the mdx/utrn-/- mouse model for Duchenne muscular dystrophy

Background: Duchenne muscular dystrophy is a progressive, lethal muscle-wasting disease for which there is no treatment. Materials & methods: We have isolated wild-type mesoangioblasts from aorta and tested their effectiveness in alleviating severe muscle disease in the dystrophin/utrophin knockout (mdx/utrn-/-) mouse model for Duchenne muscular dystrophy. Results: Mesoangioblast clones express Sca-1 and Flk-1 and differentiate into smooth and skeletal muscle, glial cells and adipocytes in vitro. Mesoangioblasts proliferate in vivo, incorporate into muscle fibers, form new fibers, and promote synthesis of dystrophin and utrophin. Muscle fibers that have incorporated mesoangioblasts, as well as surrounding fibers, are protected from damage, with approximately 50-fold less damage than fibers in muscle injected with saline. Some mesoangioblasts localize beneath the basal lamina and express c-met, whereas others differentiate into smooth muscle cells at the periphery of vessels and express α-smooth muscle actin. In mdx/utrn-/- muscle, some mesoangioblasts also form Schwann cells. Discussion & conclusion: Mesoangioblasts differentiate into multiple cell types damaged during the progression of severe muscle disease and protect fibers from damage. As such, they are good candidates for therapy of Duchenne muscular dystrophy and perhaps other neuromuscular diseases.

Cardiopulmonary support in duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is an X-linked, rapidly progressive myopathy affecting the limb muscles, the respiratory muscles, the heart, the intestines, and the brain. Since about 90% of DMD patients die from muscular respiratory failure or cardiomyopathy, early and adequate therapy is essential. Ventilatory failure from muscle weakness requires mechanical support for ventilation and coughing as soon as there is symptomatic nocturnal hypoventilation. Today noninvasive positive-pressure ventilation (NIPPV) is the method of choice for supportive long-term mechanical ventilation in DMD. For assisted coughing, various methods are available, among which the mechanical in-exsufflator is the most widely used device. There is large nonrandomized clinical trial evidence that NIPPV improves quality of life and prolongs the lives of DMD patients if medical, social, economic, and ethical issues, raised by the availability of long-term NIPPV, are adequately addressed. Cardiac involvement in DMD manifests as impulse generation or impulse conduction abnormalities or cardiomyopathy. Cardiac abnormalities in DMD respond well to adequate therapy. Though DMD is ultimately a fatal disease, quality of life and life expectancy can be markedly improved if cardiopulmonary manifestations are adequately treated.

Bi-level positive airway pressure ventilation reduces the oxygen cost of breathing in long-standing post-polio patients on invasive home mechanical ventilation

BACKGROUND

Today, patients with chronic respiratory failure are commonly treated with non-invasive bi-level positive airway pressure ventilation, supporting spontaneous breathing. However, in conformity with previous clinical routine, many post-polio patients with chronic respiratory failure are still treated with invasive (i.e. via a tracheostomy) controlled mechanical ventilation (CMV). The aim of the study was to investigate the effect of invasive bi-level positive airway pressure ventilation on the work of breathing compared with that during the patients' ordinary CMV and spontaneous breathing without mechanical support.

METHODS

Nine post-polio patients on invasive (tracheostomy) nocturnal CMV were investigated. Work of breathing was analysed by assessing differences in oxygen consumption (VO2) using indirect calorimetry. Hereby, the oxygen cost of breathing during the various ventilatory modes could be estimated and related to one another. Data on energy expenditure were also obtained.

RESULTS

The oxygen cost of breathing decreased by approximately 15% during bi-level positive airway pressure ventilation compared with CMV and spontaneous breathing. There was no difference between predicted (Harris-Benedict equation) and measured energy expenditure.

CONCLUSION

Invasive bi-level positive airway pressure ventilation reduces the oxygen cost of breathing in long-standing tracheostomized post-polio patients, compared with CMV. Furthermore, the Harris-Benedict equation provides a reasonable prediction of energy expenditure in this group of patients.