Multimedia support in the education of clinical and health care disciplines :: Portal of Pavol Jozef Šafárik University in Košice Faculty of Medicine
Lekárska fakulta Univerzity Pavla Jozefa Šafárika v Košiciach
MEFANET Project (MEdical FAculties Educational NETwork)

Home mechanical ventilation in a patient with Duchenne muscular dystrophy

Home mechanical ventilation in a patient with Duchenne muscular dystrophy

Duchenne muscular dystrophy (DMD) is a hereditary progressive neuromuscular disorder that is inherited in X-linked recessive pattern. Mutation of dystrophin gene results into a loss of integrity and function of muscular fibres and their replacement by adipose and connective tissue. Muscle degeneration leads to motoric impairment and loss of walk around 12th year of age. Myocardium is also frequently affected. Respiratory muscles impairment and other complications lead to respiratory failure. If left untreated, death occurs around 20th year of life, usually due to cardiac or respiratory causes. Respiratory insufficiency development is treated by mechanical ventilation support.

Are the case reports useful for you? Would you also require case reports from other clinical disciplines? Do you have any comments or suggestions for improvement? Please provide your feedback by filling out a short questionnaire.


 

Anamnesis:

Current disease: 20-year old student with DMD was examined in the respiratory department in order to assess development of respiratory failure and need to initiate noninvasive ventilation. Motoric damage prevents him to turn in bed, he is able to move his head, he can write. He denies dyspnoea, nocturnal awakenings, choking, but he complains about being unrefreshed after 7-hour sleep. He has been using cough assistant for a year.
Personal history: severe quadruparesis, severe kyphoscoliosis of thoracic and lumbar spine, sinus tachycardia
Medication: none

Laboratory results:

Anthropometry: Height: 178 cm Weight 36 kg BMI: 11.36 kg/m2
Physical examination: eupnoea, normosthenic, kyphoscoliosis, flection conctrations of upper and lower limbs, cold extremities, tachycardia 118/min
Spirometry: “restrictive” ventilatory impairment – based on FVC and FEV1, since body plethysmography could not be conducted due to physical limitations (Figure 1)
Blood gases: arterialised capillary blood: pH 7.393, pCO2 6.21 kPa, pO2 8.23 kPa, HCO3 27.80 mmol/L, SaO2 91.30%

Imaging methods:

Chest X-ray: no infiltrations or shadows, significant deforming sinistrokyphoscoliosis (Figure 2)
Polygraphy: moderate obstructive sleep apnoea with apnoea-hypopnoea index 19.7 episodes/h, oxygen desaturation index 13.3 episodes/h, mean saturation 93%, time with saturation below 90% was 36.5 min (Figure 3).

Therapy:

Patient was treated by mechanical home ventilation, machine that enables to distinct ventilation modes (Figure 4). Primary – nocturnal regime was ventilation by bi-level positive airway pressure (BiPAP) in spontaneous-timed mode (ST), inspiratory pressure was set on 10 cmH2O, expiratory pressure 5 cmH2O, backup frequency 12 breaths/min, with nasal mask (Figure 5). Secondary – daytime regime was the mouthpiece ventilation (MPV) with tidal volume of 850 ml (Figure 6). On these settings we achieved good tolerance of the patient, complete elimination of apnoeic and hypopnoeic episodes, reduction of oxygen desaturation index from 13.3 to 0.5 episodes/h, increase of mean nightime saturation from 93% to 95.4%. In blood gases we observed reduction of hypercapnia from 6.21 to 6.13 kPa, elevation of pO2 from 8.23 to 10.16 kPa and saturation from 91.3 to 94.5% (Figure 7).

Diagnosis:

Duchenne muscular dystrophy
Severe levokyphoscoliosis
Chronic respiratory failure
Moderate obstructive sleep apnoea

Discussion:

In DMD natural history of illness includes progressive worsening of pulmonary functions and development of respiratory failure. Respiratory failure appears at first during sleep and that is why it is recommended to conduct full overnight polysomnography, preferably with capnography. This allows for monitoring not only night time hypoventilation due to respiratory muscle weakness and decrease of respiratory drive in brainstem, but also apnoeic and hypopnoeic episodes. The episodes occur frequently in DMD and they are predominantly present in REM sleep in the phase of muscle atonia. They are often of central type. Worsening of nocturnal saturations can be effectively predicted by spirometry.

International guidelines for the management of respiratory failure propose a combination of noninvasive ventilation, cough assistant (Figure 8) and home oximetry monitoring. Saturations should be kept over 95% by these methods. Usually the patients are at first ventilated on mask only at night and they use mouthpiece ventilation at daytime as required by their needs. Mouthpiece ventilation is a method that provides deep breath similar to sigh or yawn. It enables patients to talk or eat without exhaustion. However, it requires firm seal of lips around mouthpiece and patient´s cooperation.

Gradually, night time ventilation cedes to be sufficient in keeping adequate blood gases and patients require continuous ventilation on mask. International experience shows that noninvasive ventilation in DMD slows down worsening of pulmonary functions, reduces need of switching to tracheostomy, frequency of hospitalisations and prolongs life. In noninvasively ventilated patients the median of survival is about 27 years with some living up to 40 years.
In Slovakia noninvasive ventilation is recommended in DMD patient with daytime hypercapnia or in presence of signs of respiratory distress.
In this patient we started noninvasive ventilation at the first signs of respiratory failure in order to decrease progression of disease sequelae and improve quality of life.

Authors declare the case report will not be published in any national or international publications.

Classification ICD-10: G71.0 Muscular dystrophy, J96.11 Chronic respiratory failure type II - hypercapnic, G47.31 Obstructive sleep apnoea

 

4-D assessment:

typ
Textbooks and manuals
typ
Educational websites and atlases
typ
Digital video
typ
Presentations and animations
typ
Casuistics in images
typ
E-learning courses (LMS)
result
Unreviewed

level
Undergraduate level
level
Graduate
level
Advanced Graduated
level
Complex
   
Please select achieved education degree and then evaluate the teaching material particularly in light of material suitability for self-learning.
Student – student of bachelor or master degree
Graduate – graduate of bachelor or master degree
PhD. Graduate – Ph.D. student, Ph.D. graduate, researcher, ...
 
Evaluate
this contribution first!
evaluate

Creative Commons LicenseContribution content is subject to licence Creative Commons Uveďte autora-Neužívejte dílo komerčně-Nezasahujte do díla Attribution 3.0 Czech Republic
author: Ivana Paraničová | organization: Department of Pneumology and Phtiseology | published on: 23.12.2017 | last modified on: 16.4.2018
citation: Paraničová Ivana: Home mechanical ventilation in a patient with Duchenne muscular dystrophy. Multimedia support in the education of clinical and health care disciplines :: Portal of Faculty of Medicine [online] 2017-12-23, last modif. 2018-04-16 [cit. 2018-08-21] Available from WWW: <http://portal.lf.upjs.sk/articles.php?aid=327>. ISSN 1337-7000.
 

Comments and discussion

Insert new entry:

Author / e-mail: [ user login / verification ]
Title:
Text:
 
 Add tag:   The tag has been submitted, thank you