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Akoumianaki E, Bolaki M, Prinianakis G, Konstantinou I, Panagiotarakou M, Vaporidi K, Georgopoulos D, Kondili E. Hiccup-like Contractions in Mechanically Ventilated Patients: Individualized Treatment Guided by Transpulmonary Pressure. J Pers Med 2023; 13:984. [PMID: 37373973 DOI: 10.3390/jpm13060984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
Hiccups-like contractions, including hiccups, respiratory myoclonus, and diaphragmatic tremor, refer to involuntary, spasmodic, and inspiratory muscle contractions. They have been repeatedly described in mechanically ventilated patients, especially those with central nervous damage. Nevertheless, their effects on patient-ventilator interaction are largely unknown, and even more overlooked is their contribution to lung and diaphragm injury. We describe, for the first time, how the management of hiccup-like contractions was individualized based on esophageal and transpulmonary pressure measurements in three mechanically ventilated patients. The necessity or not of intervention was determined by the effects of these contractions on arterial blood gases, patient-ventilator synchrony, and lung stress. In addition, esophageal pressure permitted the titration of ventilator settings in a patient with hypoxemia and atelectasis secondary to hiccups and in whom sedatives failed to eliminate the contractions and muscle relaxants were contraindicated. This report highlights the importance of esophageal pressure monitoring in the clinical decision making of hiccup-like contractions in mechanically ventilated patients.
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Affiliation(s)
- Evangelia Akoumianaki
- Department of Intensive Care Unit, University Hospital of Heraklion, 71110 Crete, Greece
- School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Maria Bolaki
- Department of Intensive Care Unit, University Hospital of Heraklion, 71110 Crete, Greece
| | - Georgios Prinianakis
- Department of Intensive Care Unit, University Hospital of Heraklion, 71110 Crete, Greece
| | - Ioannis Konstantinou
- Department of Intensive Care Unit, University Hospital of Heraklion, 71110 Crete, Greece
| | - Meropi Panagiotarakou
- Department of Intensive Care Unit, University Hospital of Heraklion, 71110 Crete, Greece
| | - Katerina Vaporidi
- Department of Intensive Care Unit, University Hospital of Heraklion, 71110 Crete, Greece
- School of Medicine, University of Crete, 71003 Heraklion, Greece
| | | | - Eumorfia Kondili
- Department of Intensive Care Unit, University Hospital of Heraklion, 71110 Crete, Greece
- School of Medicine, University of Crete, 71003 Heraklion, Greece
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Vaishakh A, Juhi G, Sonali S, Prashant J, Manisha J, Biswaroop C, Sheffali G. Diaphragmatic Flutter: An Unusual Sign of Multifarious Etiologic Entities. Neurol India 2022; 70:2137-2140. [PMID: 36352623 DOI: 10.4103/0028-3886.359180] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Diaphragmatic flutter (DF) is an unusual movement disorder with involuntary and repetitive contractions of the diaphragm with or without other abdominal muscle involvement. The disorder is known to occur across all ages including newborns. The etiology is diverse and so are the therapeutic options. Reaching an etiological diagnosis is considerably delayed. Response to therapy is variable and is governed by the underlying etiology. We describe three children with diaphragmatic flutter. The etiology was diverse with unrelated pathologies such as hypocalcemia, striatal necrosis, and idiopathic. All three children responded promptly and completely to calcium, high dose thiamine and biotin, and clonazepam, respectively. Our case series underscores the importance of clinical identification of such rare movement disorders. It also emphasizes that directed etiological evaluation may lead to successful amelioration of DF which is otherwise considered refractory to therapy.
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Affiliation(s)
- Anand Vaishakh
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Gupta Juhi
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Singh Sonali
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jauhari Prashant
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Jana Manisha
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Chakrabarty Biswaroop
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Gulati Sheffali
- Child Neurology Division, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
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Abstract
While the traditional lung function tests are used to assess lung capacity and pulmonary function, they cannot evaluate respiratory driving function and the integrity of the conduction pathway from the central nervous system to the respiratory motor neuron in the spinal cord and to the diaphragm. The inspiratory trigger is sent from the central nervous system through the phrenic nerve and drives the diaphragm to generate inspiratory movement. Therefore, phrenic nerve stimulation and diaphragmatic electromyography are two fundamental methods to assess respiratory function. There are several useful tools to assess respiratory motor system including electrical or magnetic phrenic nerve stimulation, diaphragmatic needle electromyography, and diaphragmatic ultrasound. By these means, physicians can assess current respiratory status in different neurological diseases that affect respiratory muscles, follow-up of the severity of respiratory impairment, help to predict the chance of successfully weaning from ventilatory support, and confirm clinical diagnoses such as diaphragmatic myoclonus. Although some of these tests require special training, applying these neurophysiological assessments in clinical practice is highly recommended.
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Affiliation(s)
- Yih-Chih Jacinta Kuo
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kai-Hsiang Stanley Chen
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.
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Colucci F, Carvalho V, Gonzalez-Robles C, Bhatia KP, Mulroy E. From Collar to Coccyx: Truncal Movement Disorders: A Clinical Review. Mov Disord Clin Pract 2021; 8:1027-1033. [PMID: 34631937 DOI: 10.1002/mdc3.13325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/24/2021] [Accepted: 07/27/2021] [Indexed: 12/25/2022] Open
Abstract
Background Movement disorders affecting the trunk remain a diagnostic challenge even for experienced clinicians. However, despite being common and debilitating, truncal movement disorders are rarely discussed and poorly reviewed in the medical literature. Objectives To review common movement disorders affecting the trunk and provide an approach for clinicians based on the truncal region involved (shoulder, chest, diaphragm, abdomen, pelvis, and axial disorders). For each disorder, clinical presentation, etiologic differential diagnosis, and "clinical clues" are discussed. Conclusion This review provides a clinically focused, practical approach to truncal movement disorders, which will be helpful for physicians in everyday practice.
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Affiliation(s)
- Fabiana Colucci
- Clinical and Biological Sciences Department, Neurology Unit San Luigi Gonzaga Hospital Turin Italy
| | - Vanessa Carvalho
- Department of Neurology Hospital Pedro Hispano/Unidade Local de Saúde de Matosinhos Matosinhos Portugal
| | - Cristina Gonzalez-Robles
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
| | - Eoin Mulroy
- Department of Clinical and Movement Neurosciences UCL Queen Square Institute of Neurology London United Kingdom
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Chen R. Peribuccal and pharyngeal myorhythmia as a presenting symptom of hypertrophic olivary degeneration: Expert commentary. Parkinsonism Relat Disord 2021; 85:144-145. [PMID: 33771463 DOI: 10.1016/j.parkreldis.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Robert Chen
- Division of Neurology, Department of Medicine, University of Toronto and the Edmond J. Safra Program in Parkinson's Disease, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.
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Affiliation(s)
- Harsh V Gupta
- From the Department of Neurology, Kansas University Medical Center, Kansas City.
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Lizarraga KJ, Thompson PD, Lang AE. Dancing Dorsal Quadrilaterals—Organic or Functional?—Reply. JAMA Neurol 2019; 76:985-986. [DOI: 10.1001/jamaneurol.2019.1720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Karlo J. Lizarraga
- The Edmond J. Safra Program in Parkinson’s Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Division of Neurology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philip D. Thompson
- Department of Medicine, University of Adelaide, Adelaide, South Australia
| | - Anthony E. Lang
- The Edmond J. Safra Program in Parkinson’s Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Division of Neurology, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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Diaphragm myoclonus-induced autotriggering during neurally adjusted ventilatory assist. Intensive Care Med 2018; 44:2309-2311. [DOI: 10.1007/s00134-018-5430-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2018] [Indexed: 10/28/2022]
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McAuley J, Taylor R, Simonds A, Chawda S. Respiratory difficulty with palatal, laryngeal and respiratory muscle tremor in adult-onset Alexander's disease. BMJ Case Rep 2017; 2017:bcr-2016-218484. [PMID: 28438749 DOI: 10.1136/bcr-2016-218484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Sleep apnoea and respiratory difficulties are reported in adult-onset Alexander's disease (AOAD), an autosomal-dominant leukodystrophy that presents mainly with progressive ataxia. We demonstrate for the first time that the respiratory symptoms can result from association of palatal tremor with a similar tremor of laryngeal and respiratory muscles that interrupts normal inspiration and expiration.A 60-year-old woman presented with progressive ataxia, palatal tremor and breathlessness. MRI revealed medullary atrophy, bilateral T2 hyperintensities in the dentate nuclei and hypertrophic olivary degeneration (HOD). AOAD was confirmed genetically with a positive glial fibrillary acidic protein (GFAP) mutation. Electrophysiological study revealed 1.5 Hz rhythmic laryngeal and respiratory muscle activity. Her respiratory symptoms were significantly improved at night with variable positive pressure ventilation.This case illustrates that palatal tremor in AOAD, and potentially in other conditions, may be associated with treatable breathlessness due to a similar tremor of respiratory muscles.
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Affiliation(s)
- John McAuley
- Department of Neuroscience, Barking Havering and Redbridge University Hospitals NHS Trust, Romford, UK.,Department of Neuroscience, Queen Mary University of London, London, UK
| | - Rowena Taylor
- Department of Respiratory Medicine, Barts Health NHS Trust, London, UK
| | - Anita Simonds
- Sleep + Ventilation Unit, Royal Brompton Hospital, London, UK
| | - Sanjiv Chawda
- Department of Neuroradiology, BHR Hospitals, Romford, UK
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Maramattom BV, Sreekumar P, Kumar RA. Diaphragmatic flutter masquerading as palpitations. Ann Indian Acad Neurol 2016; 19:402-3. [PMID: 27570399 PMCID: PMC4980970 DOI: 10.4103/0972-2327.186843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | | | - R Anil Kumar
- Department of Neurology, Aster Medcity, Kochi, Kerala, India
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Llaneza Ramos VFM, Considine E, Karp BI, Lungu C, Alter K, Hallett M. Ultrasound as Diagnostic Tool for Diaphragmatic Myoclonus. Mov Disord Clin Pract 2016; 3:282-284. [PMID: 27430001 DOI: 10.1002/mdc3.12295] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diaphragmatic myoclonus is a rare disorder of repetitive diaphragmatic contractions, acknowledged to be a spectrum that includes psychogenic features. Electromyography has been the diagnostic tool most commonly used in the literature. METHODS To test if we could perform a noninvasive technique to delineate the diaphragm as the source of abnormal movements and demonstrate distractibility and entrainability, we used B-mode ultrasound in a patient with diaphragmatic myoclonus. RESULTS Ultrasound imaging clearly delineated the diaphragm as the source of her abdominal movements. We were able to demonstrate entrainability of the diaphragm to hand tapping to a prescribed rhythm set by examiner. CONCLUSION We recommend the use of ultrasound as a noninvasive, convenient diagnostic tool for further studies of diaphragmatic myoclonus. We agree with previous findings that diaphragmatic myoclonus may be a functional movement disorder, as evidenced by distractibility and entrainability demonstrated on real-time video with ultrasonography.
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Affiliation(s)
| | - Elaine Considine
- Human Motor Control Section, National Institutes of Health, Bethesda, MD
| | | | - Codrin Lungu
- Office of the Clinical Director, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Katharine Alter
- Functional and Applied Biomechanics Section, Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD and Mount Washington Pediatric Hospital, Washington, DC
| | - Mark Hallett
- Human Motor Control Section, National Institutes of Health, Bethesda, MD
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Ramírez J, Gonzales M, Hoyos J, Grisales L. Diaphragmatic flutter: A case report and literature review. NEUROLOGÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.nrleng.2013.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Ramírez J, Gonzales M, Hoyos J, Grisales L. Aleteo diafragmático. Descripción de caso y revisión de la literatura. Neurologia 2015; 30:249-51. [DOI: 10.1016/j.nrl.2013.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 06/05/2013] [Accepted: 06/17/2013] [Indexed: 11/16/2022] Open
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Chen YH, Lee CS, Lin Y, Lin YJ, Sun IW. Successful Treatment of Tardive Diaphragmatic Flutter in an Elderly Man with Aripiprazole. INT J GERONTOL 2013. [DOI: 10.1016/j.ijge.2012.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Mehanna R, Jankovic J. Movement disorders in multiple sclerosis and other demyelinating diseases. J Neurol Sci 2013; 328:1-8. [DOI: 10.1016/j.jns.2013.02.007] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 02/05/2013] [Accepted: 02/13/2013] [Indexed: 02/08/2023]
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Abstract
This chapter reviews focal dyskinesias that affect a restricted region of the body in isolation. Focal dyskinesias often affect body parts not commonly involved in isolation by movement disorders and are not readily classified into one of the major categories of movement disorders or peripheral nerve excitability syndromes. The clinical features and phenomenology of these "unusual focal dyskinesias" are discussed according to the region affected (ear, lip, chin, jaw, tongue, abdomen, and diaphragm (belly dancer's dyskinesias), back, scapula, and limbs). The phenomenology and origin of the unusual focal dyskinesias remain the subject of debate. Most are characterized by slow semirhythmic jerky movements at variable (usually slow) frequencies superimposed on sustained postures, consistent with dystonic movements. However, the body parts affected and pattern of occurrence (in repose rather than during action) are different to those usually seen in primary dystonia. Many of the unusual focal dyskinesias are associated with trauma and pain to the affected region, prompting the suggestion that the movements follow central sensorimotor reorganization occurring spontaneously or secondary to changes in the peripheral nervous system. In other cases, inconsistent signs and spontaneous recovery suggest a psychogenic origin.
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Affiliation(s)
- Annu Aggarwal
- Department of Neurology, Royal Adelaide Hospital and University Department of Medicine, University of Adelaide, Adelaide, Australia
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Respiratory problems in neurologic movement disorders. Parkinsonism Relat Disord 2010; 16:628-38. [DOI: 10.1016/j.parkreldis.2010.07.004] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 07/03/2010] [Accepted: 07/07/2010] [Indexed: 01/31/2023]
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