Publications by authors named "Joshua O Benditt"

52 Publications

Mouthpiece ventilation in neuromuscular disorders: Narrative review of technical issues important for clinical success.

Respir Med 2021 Mar 24;180:106373. Epub 2021 Mar 24.

Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway. Electronic address:

In neuromuscular disorders (NMDs), nocturnal non-invasive ventilation (NIV) via a nasal mask is offered when hypercapnic respiratory failure occurs. With disease progression, nocturnal NIV needs to be extended into the daytime. Mouthpiece ventilation (MPV) is an option for daytime NIV. MPV represents a difficult task for home ventilators due to rapidly changing load conditions resulting from intermittent connections and disconnections from MPV circuit. The 252nd ENMC International Expert Workshop, held March 6th to 8th 2020 in Amsterdam, reported general guidelines for management of daytime MPV in NMDs. This report could not present all the detail regarding the technical issues important for clinical success of MPV. Based on the expert workshop discussions and the evidence from existing studies, the current narrative review aims to identify the technical issues of MPV and offers guidance via a decisional algorithm and educational figures providing relevant information that is important for successful implementation of MPV.
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http://dx.doi.org/10.1016/j.rmed.2021.106373DOI Listing
March 2021

Effects of Mouthpiece Noninvasive Ventilation on Speech in Men With Muscular Dystrophy: A Pilot Study.

Am J Speech Lang Pathol 2021 Mar 2:1-9. Epub 2021 Mar 2.

Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center, Seattle.

Purpose The use of noninvasive ventilation (NIV) is on the rise as an alternative to tracheostomy for individuals with neuromuscular disorders with life-prolonging and quality-of-life benefits. This pilot study was designed to determine if mouthpiece NIV (M-NIV) alters speech in individuals with muscular dystrophy (MD). Method Eight men (23-44 years), seven with Duchenne MD and one with Becker MD, who used daytime M-NIV, were asked to sustain phonation, count, and read under three conditions: (a) (no instructions), (b) (cued to use M-NIV with all speaking breaths), and (c) (as tolerated). Breath group and inspiratory durations, syllables/breath group, and relative sound pressure level were determined from audio and video recordings. Results Uncued condition: Participants used the ventilator for all inspirations that preceded sustained phonation and counting. During reading, four participants used M-NIV for all inspirations, one never used it, and three used it for some (19%-41%) inspirations. With- versus Without-M-NIV conditions: Breath group duration was significantly longer across all tasks, syllables per breath group were significantly greater during reading, and inspiratory pause duration during reading was significantly longer with M-NIV than without. Sound pressure level was significantly higher during the first second of sustained phonation with M-NIV (though not for counting and reading). Two participants were unable to complete the reading task audibly without using their M-NIV. Conclusions Speech may be better with M-NIV than without because it is possible to produce longer breath groups and some people with severe respiratory muscle weakness may not be able to speak at all without ventilator-supplied air. Nevertheless, the longer inspiratory pauses that accompany M-NIV may interrupt the flow of speech. Future research is needed to determine the most effective way to use M-NIV for speaking and whether training participants in its use can bring even greater speech benefits.
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http://dx.doi.org/10.1044/2020_AJSLP-20-00146DOI Listing
March 2021

Lifetime Care of Duchenne Muscular Dystrophy.

Sleep Med Clin 2020 Dec 5;15(4):485-495. Epub 2020 Oct 5.

Respiratory Care Services and General Pulmonary Clinic, Department of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, UW Medical Center, 1959 Northeast Pacific Street, Seattle, WA 98195, USA.

Individuals with Duchenne muscular dystrophy (DMD) have evolving sleep and respiratory pathophysiology over their lifetimes. Across the lifespan of DMD, various sleep-related breathing disorders (SRBD) have been described, including obstructive sleep apnea, central sleep apnea, and nocturnal hypoventilation. In addition to SRBD, individuals with DMD can be affected by insomnia, chronic pain and other factors interfering with sleep quality, and daytime somnolence. The natural progression of DMD pathophysiology has changed with the introduction of therapies for downstream pathologic pathways and will continue to evolve with the development of therapies that target function and expression of dystrophin.
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http://dx.doi.org/10.1016/j.jsmc.2020.08.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534837PMC
December 2020

Saliva, Swallowing, and Breathing: The Ultimate Challenge of Amyotrophic Lateral Sclerosis.

Authors:
Joshua O Benditt

Respir Care 2020 Aug;65(8):1221-1222

Respiratory Care ServicesUniversity of Washington Medical CenterSeattle, Washington.

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http://dx.doi.org/10.4187/respcare.08298DOI Listing
August 2020

Optimizing Mechanical Insufflation-Exsufflation - Much More than Cough Peak Flow.

Respir Care 2020 02;65(2):265-268

Department of Medicine University of Washington Medical Center.

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http://dx.doi.org/10.4187/respcare.07682DOI Listing
February 2020

Experiences of Speaking With Noninvasive Positive Pressure Ventilation: A Qualitative Investigation.

Am J Speech Lang Pathol 2019 07 15;28(2S):784-792. Epub 2019 Jul 15.

Department of Rehabilitation Medicine, University of Washington, Seattle.

Purpose The aim of this study was to describe experiences of speaking with 2 forms of noninvasive positive pressure ventilation (NPPV)-mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP)-in people with neuromuscular disorders who depend on NPPV for survival. Method Twelve participants (ages 22-68 years; 10 men, 2 women) with neuromuscular disorders (9 Duchenne muscular dystrophy, 1 Becker muscular dystrophy, 1 postpolio syndrome, and 1 spinal cord injury) took part in semistructured interviews about their speech. All subjects used M-NPPV during the day, and all but 1 used BPAP at night for their ventilation needs. Interviews were audio-recorded, transcribed, and verified. A qualitative descriptive phenomenological approach was used to code and develop themes. Results Three major themes emerged from the interview data: (a) M-NPPV aids speaking (by increasing loudness, utterance duration, clarity, and speaking endurance), (b) M-NPPV interferes with the flow of speaking (due to the need to pause to take a breath, problems with mouthpiece placement, and difficulty in using speech recognition software), and (c) nasal BPAP interferes with speaking (by causing abnormal nasal resonance, muffled speech, mask discomfort, and difficulty in coordinating speaking with ventilator-delivered inspirations). Conclusion These qualitative data from chronic NPPV users suggest that both M-NPPV and nasal BPAP may interfere with speaking but that speech is usually better and speaking is usually easier with M-NPPV. These findings can be explained primarily by the nature of the 2 ventilator delivery systems and their interfaces.
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http://dx.doi.org/10.1044/2019_AJSLP-MSC18-18-0101DOI Listing
July 2019

Respiratory Care of Patients With Neuromuscular Disease.

Authors:
Joshua O Benditt

Respir Care 2019 Jun;64(6):679-688

Pulmonary and Critical Care Medicine, University of Washington Medical Center, Seattle, Washington.

Neuromuscular diseases are a heterogeneous group of neurologic diseases that affect a number of neural structures including the motor nerves, neuromuscular junctions, or the muscles themselves. Although many of the diseases are rare, the total number of individuals who present to a pulmonologist or respiratory care provider is significant. Approaches to care include regular and careful clinical follow-up of symptoms of sleep-disordered breathing, daytime hypoventilation, as well as cough and swallowing effectiveness. Noninvasive support with nocturnal mask ventilation and a pressure support device can be extraordinarily helpful and delay daytime ventilatory failure. When daytime ventilatory failure develops, other noninvasive methods are available for portable assistance. Support of cough function with manual assistance, a resuscitator bag, and/or mechanical insufflation-exsufflation can help prevent and treat infection. Referral for swallowing evaluation and treatment is very important for those with impaired bulbar function. This comprehensive respiratory care approach to individuals with neuromuscular disease and respiratory system involvement is essential to maintaining the health and longevity of these individuals.
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http://dx.doi.org/10.4187/respcare.06827DOI Listing
June 2019

Swallowing with Noninvasive Positive-Pressure Ventilation (NPPV) in Individuals with Muscular Dystrophy: A Qualitative Analysis.

Dysphagia 2020 02 11;35(1):32-41. Epub 2019 Mar 11.

Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA.

The purpose of the study is to describe experiences of swallowing with two forms of noninvasive positive-pressure ventilation (NPPV): mouthpiece NPPV (M-NPPV) and nasal bilevel positive airway pressure (BPAP) in people with muscular dystrophy. Ten men (ages 22-42 years; M = 29.3; SD = 7.1) with muscular dystrophy (9 with Duchenne's; 1 with Becker's) completed the Eating Assessment Tool (EAT-10; Ann Otol Rhinol Laryngol 117(12):919-924 [33]) and took part in semi-structured interviews. The interviews were audio recorded, transcribed, and verified. Phenomenological qualitative research methods were used to code (Dedoose.com) and develop themes. All participants affirmed dysphagia symptoms via responses on the EAT-10 (M = 11.3; SD = 6.38; Range = 3-22) and reported eating and drinking with M-NPPV and, to a lesser extent, nasal BPAP. Analysis of interview data revealed three primary themes: (1) M-NPPV improves the eating/drinking experience: Most indicated that using M-NPPV reduced swallowing-related dyspnea. (2) NPPV affects breathing-swallowing coordination: Participants described challenges and compensations in coordinating swallowing with ventilator-delivered inspirations, and that the time needed to chew solid foods between ventilator breaths may lead to dyspnea and fatigue. (3) M-NPPV aids cough effectiveness: Participants described improved cough strength following large M-NPPV delivered inspirations (with or without breath stacking). Although breathing-swallowing coordination is challenging with NPPV, participants reported that eating and drinking is more comfortable than when not using it. Overall, eating and drinking with NPPV delivered via a mouthpiece is preferred and is likely safer for swallowing than with nasal BPAP. M-NPPV (but not nasal BPAP) is reported to improve cough effectiveness, an important pulmonary defense in this population.
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http://dx.doi.org/10.1007/s00455-019-09997-6DOI Listing
February 2020

Respiratory Management of the Patient With Duchenne Muscular Dystrophy.

Pediatrics 2018 10;142(Suppl 2):S62-S71

Department of Medicine, Northwestern University, Evanston, Illinois.

In 2010, Care Considerations for Duchenne Muscular Dystrophy, sponsored by the Centers for Disease Control and Prevention, was published in , and in 2018, these guidelines were updated. Since the publication of the first set of guidelines, survival of individuals with Duchenne muscular dystrophy has increased. With contemporary medical management, survival often extends into the fourth decade of life and beyond. Effective transition of respiratory care from pediatric to adult medicine is vital to optimize patient safety, prognosis, and quality of life. With genetic and other emerging drug therapies in development, standardization of care is necessary to accurately assess treatment effects in clinical trials. This revision of respiratory recommendations preserves a fundamental strength of the original guidelines: namely, reliance on a limited number of respiratory tests to guide patient assessment and management. A progressive therapeutic strategy is presented that includes lung volume recruitment, assisted coughing, and assisted ventilation (initially nocturnally, with the subsequent addition of daytime ventilation for progressive respiratory failure). This revision also stresses the need for serial monitoring of respiratory muscle strength to characterize an individual's respiratory phenotype of severity as well as provide baseline assessments for clinical trials. Clinical controversies and emerging areas are included.
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http://dx.doi.org/10.1542/peds.2018-0333HDOI Listing
October 2018

Mechanical Insufflation-Exsufflation: More Than Just Cough Assist.

Authors:
Joshua O Benditt

Respir Care 2018 08;63(8):1076-1077

Respiratory Care Services University of Washington Medical Center Seattle, Washington

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http://dx.doi.org/10.4187/respcare.06439DOI Listing
August 2018

Progress in the Treatment of Patients with Neuromuscular and Nonmuscular Chest Wall Diseases.

Clin Chest Med 2018 06;39(2):xv-xvi

University of Washington, School of Medicine, UWMC, Box 356522, 1959 Northeast Pacific Street, Seattle, WA 98195, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ccm.2018.03.001DOI Listing
June 2018

Pathophysiology of Neuromuscular Respiratory Diseases.

Authors:
Joshua O Benditt

Clin Chest Med 2018 06;39(2):297-308

Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98119, USA. Electronic address:

Gas exchange between the atmosphere and the human body depends on the lungs and the function of the respiratory pump. The respiratory pump consists of the respiratory control center located in the brain, bony rib cage, diaphragm, and intercostal, accessory, and abdominal muscles. A variety of muscles serve to fine-tune adjustments of ventilation to metabolic demands. Appropriate evaluation and interventions can prevent respiratory complications and prolong life in individuals with neuromuscular diseases. This article discusses normal function of the respiratory pump, general pathophysiologic issues, and abnormalities in more common neuromuscular diseases.
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http://dx.doi.org/10.1016/j.ccm.2018.01.011DOI Listing
June 2018

Utility of Pulse Oximetry to Detect Aspiration: An Evidence-Based Systematic Review.

Dysphagia 2018 Jun 14;33(3):282-292. Epub 2017 Dec 14.

Northwest Clinic for Voice and Swallowing (NWCVS), Department of Otolaryngology - Head & Neck Surgery, Oregon Health & Sciences University (OHSU), Portland, OR, USA.

Pulse oximetry is a commonly used means to measure peripheral capillary oxyhemoglobin saturation (SpO). Potential use of pulse oximetry to detect aspiration is attractive to clinicians, as it is readily available, quick, and noninvasive. However, research regarding validity has been mixed. This systematic review examining evidence on the use of pulse oximetry to detect a decrease in SpO indicating aspiration during swallowing is undertaken to further inform clinical practice in dysphagia assessment. A multi-engine electronic search was conducted on 8/25/16 and updated on 4/8/17 in accordance with standards published by the Preferred Reporting for Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA). Inclusion criteria included use of pulse oximetry to detect aspiration with simultaneous confirmation of aspiration via a gold standard instrumental study. Keywords included dysphagia or aspiration AND pulse oximetry. Articles meeting criteria were reviewed by two blinded co-investigators. The search yielded 294 articles, from which 19 were judged pertinent and reviewed in full. Ten met the inclusion criteria and all were rated at Level III-2 on the Australian Diagnostic Levels of Evidence. Study findings were mixed with sensitivity ranging from 10 to 87%. Potentially confounding variables were observed in all studies reviewed, and commonly involved defining "desaturation" within a standard measurement error range (~ 2%), mixed populations, mixed viscosities/textures observed during swallowing, and lack of comparison group. The majority of studies failed to demonstrate an association between observed aspiration and oxygen desaturation. Current evidence does not support the use of pulse oximetry to detect aspiration.
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http://dx.doi.org/10.1007/s00455-017-9868-1DOI Listing
June 2018

Dysarthria of Spinal Cord Injury and Its Management.

Semin Speech Lang 2017 07 15;38(3):161-172. Epub 2017 Jun 15.

Division of Pulmonary and Critical Care Medicine, University of Washington Medical Center (UWMC), Seattle, Washington.

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http://dx.doi.org/10.1055/s-0037-1602835DOI Listing
July 2017

Death with dignity in Washington patients with amyotrophic lateral sclerosis.

Neurology 2016 Nov 21;87(20):2117-2122. Epub 2016 Oct 21.

From the Departments of Neurology (L.H.W., S.S., S.D., J.V., P.K., M.D.W.), Rehabilitative Medicine (E.G.-M.), and Medicine (J.O.B.), University of Washington, Seattle; Division of Neurology (M.A.E., P.P.), Virginia Mason Medical Center, Seattle; and Swedish Neuroscience Institute (L.J.H., K.K.), Seattle, WA. M.A.E. is currently affiliated with the Swedish Neuroscience Institute, Seattle, WA; L.J.H. is currently affiliated with Piedmont Healthcare, Atlanta, GA; and E.G.-M. is currently affiliated with the Montana Spine & Pain Center, Missoula, MT.

Objectives: To describe the amyotrophic lateral sclerosis (ALS) patients who sought medication under the Washington State Death with Dignity (DWD) Act since its inception in 2009.

Methods: Chart review at 3 tertiary medical centers in the Seattle/Puget Sound region and comparison to publicly available data of ALS and all-cause DWD cohorts from Washington and Oregon.

Results: In Washington State, 39 patients with ALS requested DWD from the University of Washington, Virginia Mason, and Swedish Medical Centers beginning in 2009. The median age at death was 65 years (range 46-86). Seventy-seven percent of the patients used the prescriptions. All of the patients who used the medications passed away without complications. The major reasons for patients to request DWD as reported by participating physicians were loss of autonomy and dignity and decrease in enjoyable activities. Inadequate pain control, financial cost, and loss of bodily control were less commonly indicated. These findings were similar to those of the 92 patients who sought DWD in Oregon. In Washington and Oregon, the percentage of patients with ALS seeking DWD is higher compared to the cancer DWD cohort. Furthermore, compared to the all-cause DWD cohort, patients with ALS are more likely to be non-Hispanic white, married, educated, enrolled in hospice, and to have died at home.

Conclusions: Although a small number, ALS represents the disease with the highest proportion of patients seeking to participate in DWD. Patients with ALS who choose DWD are well-educated and have access to palliative or life-prolonging care. The use of the medications appears to be able to achieve the patients' goals without complications.
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http://dx.doi.org/10.1212/WNL.0000000000003335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109936PMC
November 2016

Beyond Tracheostomy: Noninvasive Ventilation and Potential Positive Implications for Speaking and Swallowing.

Semin Speech Lang 2016 08 27;37(3):173-84. Epub 2016 May 27.

Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson, Arizona.

For more than a decade, there has been a trend toward increased use of noninvasive positive pressure ventilation (NPPV) via mask or mouthpiece as a means to provide ventilatory support without the need for tracheostomy. All indications are that use of NPPV will continue to increase over the next decade and beyond. In this article, we review NPPV, describe two common forms of NPPV, and discuss the potential benefits and challenges of NPPV for speaking and swallowing based on the available literature, our collective clinical experience, and interviews with NPPV users. We also speculate on how future research may inform clinical practice on how to best maximize speaking and swallowing abilities in NPPV users over the next decade.
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http://dx.doi.org/10.1055/s-0036-1583545DOI Listing
August 2016

Associations between laryngeal and cough dysfunction in motor neuron disease with bulbar involvement.

Dysphagia 2014 Dec 19;29(6):637-46. Epub 2014 Jul 19.

Department of Rehabilitation Medicine, University of Washington, 1959 NE Pacific Street, Box 356490, Seattle, WA, 98195, USA,

True vocal fold (TVF) dysfunction may lead to cough ineffectiveness. In individuals with motor neuron disease (MND), cough impairment in the context of dysphagia increases risk for aspiration and respiratory failure. This study characterizes differences and associations between TVF kinematics and airflow during cough in individuals with bulbar MND. Sequential glottal angles associated with TVF movements during volitional cough were analyzed from laryngeal video endoscopy examinations of adults with bulbar MND (n = 12) and healthy controls (n = 12) and compared with simultaneously collected cough-related airflow measures. Significant group differences were observed with airflow and TVF measures: volume acceleration (p ≤ 0.001) and post-compression abduction TVF angle average velocity (p = 0.002) were lower and expiratory phase rise time (p = 0.001) was higher in the MND group. Reductions in maximum TVF angle during post-compression abduction in the MND group approached significance (p = 0.09). All subjects demonstrated complete TVF and supraglottic closure during the compression phase of cough, except for incomplete supraglottic closure in 2/12 MND participants. A strong positive relationship between post-compression maximum TVF abduction angle and peak expiratory cough flow was observed in the MND group, though it was not statistically significant (r = 0.55; p = 0.098). Reductions in the speed and extent of TVF abduction are seen during the expulsion phase of cough in individuals with MND. This may contribute to cough impairment and morbidity.
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http://dx.doi.org/10.1007/s00455-014-9554-5DOI Listing
December 2014

An official American Thoracic Society workshop report: assessment and palliative management of dyspnea crisis.

Ann Am Thorac Soc 2013 Oct;10(5):S98-106

In 2009, the American Thoracic Society (ATS) funded an assembly project, Palliative Management of Dyspnea Crisis, to focus on identification, management, and optimal resource utilization for effective palliation of acute episodes of dyspnea. We conducted a comprehensive search of the medical literature and evaluated available evidence from systematic evidence-based reviews (SEBRs) using a modified AMSTAR approach and then summarized the palliative management knowledge base for participants to use in discourse at a 2009 ATS workshop. We used an informal consensus process to develop a working definition of this novel entity and established an Ad Hoc Committee on Palliative Management of Dyspnea Crisis to further develop an official ATS document on the topic. The Ad Hoc Committee members defined dyspnea crisis as "sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the patient and caregivers' ability to achieve symptom relief." Dyspnea crisis can occur suddenly and is characteristically without a reversible etiology. The workshop participants focused on dyspnea crisis management for patients in whom the goals of care are focused on palliation and for whom endotracheal intubation and mechanical ventilation are not consistent with articulated preferences. However, approaches to dyspnea crisis may also be appropriate for patients electing life-sustaining treatment. The Ad Hoc Committee developed a Workshop Report concerning assessment of dyspnea crisis; ethical and professional considerations; efficient utilization, communication, and care coordination; clinical management of dyspnea crisis; development of patient education and provider aid products; and enhancing implementation with audit and quality improvement.
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http://dx.doi.org/10.1513/AnnalsATS.201306-169STDOI Listing
October 2013

Pulmonary issues in patients with chronic neuromuscular disease.

Am J Respir Crit Care Med 2013 May;187(10):1046-55

University of Washington School of Medicine, Seattle, WA, USA.

Patients with chronic neuromuscular diseases such as spinal cord injury, amyotrophic lateral sclerosis, and muscular dystrophies experience respiratory complications that are cared for by the respiratory practitioner. An organized anatomical approach for evaluation and treatment is helpful to provide appropriate clinical care. Effective noninvasive strategies for management of hypoventilation, sleep-disordered breathing, and cough insufficiency are available for these patients.
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http://dx.doi.org/10.1164/rccm.201210-1804CIDOI Listing
May 2013

Management of pulmonary complications in neuromuscular disease.

Phys Med Rehabil Clin N Am 2012 Nov;23(4):829-53

Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.

Restrictive lung disease occurs commonly in patients with neuromuscular disease. The earliest sign of respiratory compromise in the patient with neuromuscular disease is nocturnal hypoventilation, which progresses over time to include daytime hypoventilation and eventually the need for full-time mechanical ventilation. Pulmonary function testing should be done during regular follow-up visits to identify the need for assistive respiratory equipment and initiate early noninvasive ventilation. Initiation of noninvasive ventilation can improve quality of life and prolong survival in patients with neuromuscular disease.
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http://dx.doi.org/10.1016/j.pmr.2012.08.010DOI Listing
November 2012

Internet-based dyspnea self-management support for patients with chronic obstructive pulmonary disease.

J Pain Symptom Manage 2013 Jul 13;46(1):43-55. Epub 2012 Oct 13.

University of Washington, Seattle, Washington, USA.

Context: People with chronic obstructive pulmonary disease experience dyspnea with activities despite optimal medical management.

Objectives: The purpose of this study was to test the efficacy of two 12-month dyspnea self-management programs (DSMPs), Internet-based (eDSMP) and face-to-face (fDSMP), compared with a general health education (GHE) control on the primary outcome of dyspnea with activities.

Methods: Participants with chronic obstructive pulmonary disease were randomized to eDSMP (n=43), fDSMP (n=41), or GHE (n=41). The content of the DSMPs were similar and focused on education, skills training, and coaching on dyspnea self-management strategies, including exercise, and only differed in the delivery mode. Dyspnea with activities was measured with the Chronic Respiratory Questionnaire at three, six, and 12 months. Secondary outcomes included exercise behavior and performance, health-related quality of life, self-efficacy for dyspnea management, and perception of support for exercise. The study was registered at Clinicaltrials.gov (NCT00461162).

Results: There were no differences in dyspnea with activities across groups over 12 months (P=0.48). With the exception of arm endurance (P=0.04), exercise behavior, performance, and health-related quality of life did not differ across groups (P>0.05). Self-efficacy for managing dyspnea improved for the DSMPs compared with GHE (P=0.06). DSMP participants perceived high levels of support for initiating and maintaining an exercise program.

Conclusion: The DSMPs did not significantly reduce dyspnea with activities compared with attention control. However, the high participant satisfaction with the DSMPs combined with positive changes in other outcomes, including self-efficacy for managing dyspnea and exercise behavior, highlight the need for additional testing of individually tailored technology-enabled interventions to optimize patient engagement and improve clinically relevant outcomes.
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http://dx.doi.org/10.1016/j.jpainsymman.2012.06.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3548968PMC
July 2013

What is DIPNECH?

Clin Imaging 2012 Sep-Oct;36(5):647-9. Epub 2012 Jun 8.

Department of Radiology, University of Washington, Seattle, WA, USA.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare disorder that is being diagnosed more frequently with the increasing availability of advanced imaging and more accurate histopathology. It occurs most commonly in nonsmoking, middle-aged women. High-resolution computed tomography (HRCT) findings include mosaic attenuation due to constrictive bronchiolitis and small (<5 mm) randomly distributed pulmonary nodules. It is important to recognize this condition as it is considered a precursor of peripheral carcinoid tumors. This article will present a case of this uncommon condition with review of the literature, imaging findings, and clinical presentation.
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http://dx.doi.org/10.1016/j.clinimag.2011.11.011DOI Listing
February 2013

Not to invade: a better strategy?

Respir Care 2011 Jun;56(6):878

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http://dx.doi.org/10.4187/respcare.01337DOI Listing
June 2011

The respiratory management of patients with duchenne muscular dystrophy: a DMD care considerations working group specialty article.

Pediatr Pulmonol 2010 Aug;45(8):739-48

Department of Pediatrics, MetroHealth Medical Center, Cleveland, Ohio 44109, USA.

In 2001, the Muscular Dystrophy Community Assistance, Research and Education Amendments (MD-CARE Act) was enacted, which directed federal agencies to coordinate the development of treatments and cures for muscular dystrophy. As part of the mandate, the Centers for Disease Control and Prevention (CDC) initiated surveillance and educational activities, which included supporting development of care considerations for Duchenne muscular dystrophy (DMD) utilizing the RAND/UCLA Appropriateness Method (RAM). This document represents the consensus recommendations of the project's 10-member Respiratory Panel and includes advice on necessary equipment, procedures and diagnostics; and a structured approach to the assessment and management of the respiratory complications of DMD via assessment of symptoms of hypoventilation and identification of specific thresholds of forced vital capacity, peak cough flow and maximum expiratory pressure. The document includes a set of Figures adaptable as "pocket guides" to aid clinicians. This article is an expansion of the respiratory component of the multi-specialty article originally appearing in Lancet Neurology, comprising respiratory recommendations from the CDC Care Considerations project.
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http://dx.doi.org/10.1002/ppul.21254DOI Listing
August 2010

Anxiety is associated with diminished exercise performance and quality of life in severe emphysema: a cross-sectional study.

Respir Res 2010 Mar 9;11:29. Epub 2010 Mar 9.

Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.

Background: Anxiety in patients with chronic obstructive pulmonary disease (COPD) is associated with self-reported disability. The purpose of this study is to determine whether there is an association between anxiety and functional measures, quality of life and dyspnea.

Methods: Data from 1828 patients with moderate to severe emphysema enrolled in the National Emphysema Treatment Trial (NETT), collected prior to rehabilitation and randomization, were used in linear regression models to test the association between anxiety symptoms, measured by the Spielberger State Trait Anxiety Inventory (STAI) and: (a) six-minute walk distance test (6 MWD), (b) cycle ergometry peak workload, (c) St. Georges Respiratory Questionnaire (SRGQ), and (d) UCSD Shortness of Breath Questionnaire (SOBQ), after controlling for potential confounders including age, gender, FEV1 (% predicted), DLCO (% predicted), and the Beck Depression Inventory (BDI).

Results: Anxiety was significantly associated with worse functional capacity [6 MWD (B = -0.944, p < .001), ergometry peak workload (B = -.087, p = .04)], quality of life (B = .172, p < .001) and shortness of breath (B = .180, p < .001). Regression coefficients show that a 10 point increase in anxiety score is associated with a mean decrease in 6 MWD of 9 meters, a 1 Watt decrease in peak exercise workload, and an increase of almost 2 points on both the SGRQ and SOBQ.

Conclusion: In clinically stable patients with moderate to severe emphysema, anxiety is associated with worse exercise performance, quality of life and shortness of breath, after accounting for the influence of demographic and physiologic factors known to affect these outcomes.

Trial Registration: ClinicalTrials.gov NCT00000606.
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http://dx.doi.org/10.1186/1465-9921-11-29DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2848143PMC
March 2010

American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease.

Chest 2010 Mar;137(3):674-91

Dartmouth-Hitchcock Medical Center, Pulmonary and Critical Care Medicine, Lebanon, NH 03756-0001, USA.

Background: This consensus statement was developed based on the understanding that patients with advanced lung or heart disease are not being treated consistently and effectively for relief of dyspnea.

Methods: A panel of experts was convened. After a literature review, the panel developed 23 statements covering five domains that were considered relevant to the topic condition. Endorsement of these statements was assessed by levels of agreement or disagreement on a five-point Likert scale using two rounds of the Delphi method.

Results: The panel defined the topic condition as "dyspnea that persists at rest or with minimal activity and is distressful despite optimal therapy of advanced lung or heart disease." The five domains were: measurement of patient-reported dyspnea, oxygen therapy, other therapies, opioid medications, and ethical issues. In the second round of the Delphi method, 34 of 56 individuals (61%) responded, and agreement of at least 70% was achieved for 20 of the 23 statements.

Conclusions: For patients with advanced lung or heart disease, we suggest that: health-care professionals are ethically obligated to treat dyspnea, patients should be asked to rate the intensity of their breathlessness as part of a comprehensive care plan, opioids should be dosed and titrated for relief of dyspnea in the individual patient, both the patient and clinician should reassess whether specific treatments are serving the goal of palliating dyspnea without causing adverse effects, and it is important for clinicians to communicate about palliative and end-of-life care with their patients.
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http://dx.doi.org/10.1378/chest.09-1543DOI Listing
March 2010

Pilot study of a cell phone-based exercise persistence intervention post-rehabilitation for COPD.

Int J Chron Obstruct Pulmon Dis 2009 1;4:301-13. Epub 2009 Sep 1.

University of Washington, Seattle, WA 98199, USA.

Objective: To determine the feasibility and efficacy of a six-month, cell phone-based exercise persistence intervention for patients with chronic obstructive pulmonary disease (COPD) following pulmonary rehabilitation.

Methods: Participants who completed a two-week run-in were randomly assigned to either MOBILE-Coached (n = 9) or MOBILE-Self-Monitored (n = 8). All participants met with a nurse to develop an individualized exercise plan, were issued a pedometer and exercise booklet, and instructed to continue to log their daily exercise and symptoms. MOBILE-Coached also received weekly reinforcement text messages on their cell phones; reports of worsening symptoms were automatically flagged for follow-up. Usability and satisfaction were assessed. Participants completed incremental cycle and six minute walk (6MW) tests, wore an activity monitor for 14 days, and reported their health-related quality of life (HRQL) at baseline, three, and six months.

Results: The sample had a mean age of 68 +/-11 and forced expiratory volume in one second 18% predicted. Participants reported that logging their exercise and symptoms (FEV(1)) of 40 +/- was easy and that keeping track of their exercise helped them remain active. There were no differences between groups over time in maximal workload, 6MW distance, or HRQL (p > 0.05); however, MOBILE-Self-Monitored increased total steps/day whereas MOBILE-Coached logged fewer steps over six months (p =0.04).

Conclusions: We showed that it is feasible to deliver a cell phone-based exercise persistence intervention to patients with COPD post-rehabilitation and that the addition of coaching appeared to be no better than self-monitoring. The latter finding needs to be interpreted with caution since this was a purely exploratory study.

Trial Registration: ClinicalTrials.gov (NCT00373932).
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740952PMC
http://dx.doi.org/10.2147/copd.s6643DOI Listing
February 2010

Initiating noninvasive management of respiratory insufficiency in neuromuscular disease.

Authors:
Joshua O Benditt

Pediatrics 2009 May;123 Suppl 4:S236-8

University of Washington Medical Center, Pulmonary and Critical Care Medicine, Box 356522, Seattle, WA 98195-6522, USA.

This is a summary of the presentation on initiating noninvasive management of respiratory insufficiency in neuromuscular disease, presented as part of the program on pulmonary management of pediatric patients with neuromuscular disorders at the 30th annual Carrell-Krusen Neuromuscular Symposium on February 20, 2008.
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http://dx.doi.org/10.1542/peds.2008-2952HDOI Listing
May 2009

Novel uses of noninvasive ventilation.

Authors:
Joshua O Benditt

Respir Care 2009 Feb;54(2):212-19; discussion 219-22

Department of Medicine, University of Washington Medical Center, Seattle, Washington, USA.

Noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP) have been used in various unusual settings to assist breathing. NIV is now frequently used to treat exacerbations of chronic obstructive pulmonary disease and chronic respiratory failure in neuromuscular disease. This paper discusses CPAP and NIV for postoperative hypoxemia, preventing intubation in high-risk bronchoscopy, respiratory failure in pandemics, obesity hypoventilation syndrome, and respiratory support during percutaneous endoscopic gastrostomy tube placement.
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February 2009

Bilateral diaphragm paralysis: a challenging diagnosis.

Respir Care 2008 Oct;53(10):1368-71

Division of Pulmonary Critical Care, Box 359762, Harborview Medical Center, 325 9th Avenue, Seattle, WA 98104, USA.

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October 2008