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SUPPLEMENT ARTICLES:
David J. Birnkrant
The American College of Chest Physicians Consensus Statement on the Respiratory and Related Management of Patients With Duchenne Muscular Dystrophy Undergoing Anesthesia or Sedation
Pediatrics 2009; 123: S242-S244 [Abstract] [Full text] [PDF]
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[Read eLetters] Neuromuscular Disease Anesthesia Respiratory Risk
Joyce Cheng, John R. Bach, MD   (17 July 2009)

Neuromuscular Disease Anesthesia Respiratory Risk 17 July 2009
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Joyce Cheng,
Medical student
Drexel University College of Medicine,
John R. Bach, MD

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Re: Neuromuscular Disease Anesthesia Respiratory Risk

jcc92{at}drexel.edu Joyce Cheng, et al.

We read with interest the summary of the ACCP consensus statement on respiratory management of Duchenne dystrophy (DMD) for general anesthesia.(1) The review was comprehensive but the association of pre- operative vital capacity (VC) with respiratory risk and, in particular, stratifying risk with VC <50% and <30% is somewhat tenuous. The author did not consider the outcomes of 150 consecutive successful extubations of patients with little or no measurable VC or autonomous ability to breathe but who satisfied specific criteria for cooperation and bulbar-innervated muscle function. This included some with no measurable VC. All were successfully extubated to NIV and mechanically assisted coughing (MAC).(2) In another study, 5 children with neuromuscular disease who underwent scoliosis surgery despite VC<30% and little or no autonomous ability to breathe pre-op or post-op were successfully extubated.(3) One SMA type 1 child had been continuously NIV dependent for 2 years pre-op. We have subsequently performed spinal fusion for a continuously NIV dependent DMD patient with 130 ml of VC. Thus, the association of VC with respiratory risk, although intuitive, is tenuous when patients are experienced in full support NIV and MAC pre-op and extubated to NIV and aggressive MAC provided by optimally trained staff, post-op.

References:

1. Birnkrant DJ. The American College of Chest Physicians Consensus Statement on the respiratory and related management of patients with Duchenne muscular dystrophy undergoing anesthesia or sedation. Pediatrics 2009;123:S242-S244.

2. 105th International Conference of the American Thoracic Society, Poster: Handami I, Bach JR, Goncalves MR. "Extubation of unweanable patients with neuromuscular weakness: a new management paradigm,” May 18, 2009, San Diego, Ca.

3. Bach JR, Sabharwal S. High pulmonary risk scoliosis surgery: role of noninvasive ventilation and related techniques. J Spinal Disord Tech 2005;18:527-530.

Conflict of Interest:

None declared