Assessing and managing lung disease and sleep disordered breathing in children with cerebral palsy

Fitzgerald, Dominic A.; Follett, Jennifer; Asperen, Peter P Van

doi:10.1016/j.prrv.2008.10.003

Cited by 110 publications

(127 citation statements)

References 37 publications

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“…28 The reasons for this are multifactorial and include a combination of altered upper airway tone, difficulties clearing secretions and swallowing, potential sleepdisordered breathing, and reactive airway disease secondary to often silent aspiration. 5,17,[29][30][31][32] Sedation scores were similar between the groups, in keeping with the study by Cucchiaro et al 9 that demonstrated (using a lower clonidine dose) similar sedation scores in children receiving fentanyl and clonidine.Systolic and diastolic blood pressures were lower in the clonidine group. A 20% reduction in systolic blood pressure was recorded in four patients in each group.…”

supporting

confidence: 88%

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single‐event multilevel surgery

Chalkiadis

Sommerfield

Low

et al. 2015

Develop Med Child Neuro

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AUCArea under the curve SEMLS Single-event multilevel surgery AIM To compare diazepam use, muscle spasm, analgesia, and side effects when clonidine or fentanyl are added to epidural bupivacaine in children with cerebral palsy after multilevel orthopaedic surgery.METHOD Fifty children were prospectively randomized to receive clonidine (n=24, mean age 10y 10mo [SD 2y 11mo]) or fentanyl (n=26, mean age 10y 11mo [SD 2y 10mo]).RESULTS There was no difference in primary outcome measures: median diazepam use (fentanyl 0, interquartile range [IQR] 0-0; clonidine 0, IQR 0-0; p=0.46), any muscle spasm (no muscle spasms in: fentanyl, 36%; clonidine, 62%; p=0.11), painful muscle spasm (fentanyl 40%; clonidine 25%; p=0.46), or pain score ≥6 (none: fentanyl 44%; clonidine 42%; p=0.29). There were differences in secondary outcome measures: no vomiting (clonidine 63%; fentanyl 20%); vomiting occurred more frequently with fentanyl (32% vomited more than three times; clonidine none; p=0.001). Fentanyl resulted in more oxygen desaturation (at least two episodes: fentanyl 20%; clonidine 0; p<0.001). Clonidine resulted in lower mean (SD) area under the curve for systolic blood pressure (fentanyl 106.5 [11.0]; clonidine 95.7mmHg [7.9]) and heart rate (fentanyl 104.9 beats per minute [13.6]; clonidine 85.3 [11.5]; p<0.001).INTERPRETATION Clonidine and fentanyl provide adequate analgesia with low rates of muscle spasm, resulting in low diazepam use. The choice of epidural additive should be based upon the most tolerable side-effect profile.Cerebral palsy (CP) by definition is a disorder of movement and posture, caused by a non-progressive brain injury or lesion. 1 However, although the causative brain lesion is defined as a static encephalopathy, the musculoskeletal pathology in the limbs is progressive during the child's growth and maturation, with the development of contractures, bony torsion, and joint instability. Children with CP may undergo extensive orthopaedic surgery of the lower extremities to correct deformity and improve function. Single-event multilevel surgery (SEMLS), defined as at least one surgical procedure, performed on two different anatomical levels (hip, knee, or ankles), has been shown to result in dramatic improvements in gait and functioning, which are sustained at 5-year follow-up and reduce the need for serial surgeries and periods of rehabilitation. 2,3 Good pain control is important for patient comfort and facilitates early rehabilitation and discharge. Effective pain management is challenging because of multiple surgical incisions, associated comorbidities (chronic lung disease, risk of aspiration, epilepsy, gastro-oesophageal reflux), and impairments in communication and/or cognition that may make pain assessment difficult. In addition, the surgical nociceptive input is likely to lead to wind-up of spinal reflexes and worsening of muscle spasm 4 and possibly to an escalating pain-spasm cycle. Epidural analgesia is the preferred modality of regional anaesthesia in our institution but there are limited data...

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supporting

confidence: 88%

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single‐event multilevel surgery

Chalkiadis

Sommerfield

Low

et al. 2015

Develop Med Child Neuro

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“…67 Cerebral palsy is associated with increased pulmonary aspiration along with increased risk of upper airway obstruction, including obstructive sleep apnea. 24,81 Restrictive pulmonary disease secondary to spinal deformity further contributes to poor inspiratory effort. Pulmonary function tests in this setting are usually not helpful as in adolescent scoliosis, mainly due to poor cooperative effort in many children with CP.…”

Section: Pulmonary Assessmentmentioning

confidence: 99%

Surgical management of spinal deformities in cerebral palsy

Jones-Quaidoo¹,

Yang²,

Arlet³

2010

SPI

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Cerebral palsy is a nonprogressive encephalopathy caused by a brain dysfunction that occurs during the pre-, peri-, or postnatal phase of development. Cerebral palsy can be characterized by a lack of muscle control with increased spasticity or decreased tone, seizure disorder, and variable mental retardation. The overall incidence of CP is estimated to range from 1 to 5 children per 1000 live births. 49 The overall incidence of scoliosis in the CP population is estimated to range from 21% to 76% depending on the series and whether the patient is a walker or is relegated to sitting due to extensive CP. The incidence and severity of the spinal curve appears to be related to the degree of CP involvement. 39,40 Males are more commonly affected, which is in contrast to idiopathic scoliosis with a female predominance. 49 Scoliotic Curve CharacteristicsPatients with neuromuscular scoliosis may have a variety of scoliotic curve types depending on the severity of CP involvement. Lonstein and Akbarnia 37 characterized the deformity into 2 groups that were most common: 1) Group 1 curves are single thoracic or double thoracic and lumbar curves with a level pelvis, commonly noted in ambulatory patients with CP; and 2) Group 2 curves are long thoracolumbar or C-shaped curves with associated pelvic obliquity, often noted in more involved and dependent patients with CP. Hyperlordosis of the lumbar spine or kyphoscoliosis of the thoracic spine is also a common Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VirginiaCerebral palsy (CP) spinal deformities encompass a spectrum of deformities that are often initially treated nonoperatively, only to result in progression of scoliotic curves and further morbidity. Various surgical interventions have been devised to address the progressive curvature of the spine. This endeavor cannot be taken lightly and at times can be encumbered by prior treatments such as the use of baclofen pumps or dorsal rhizotomies. Care of these patients requires a multidisciplinary approach and comprehensive preoperative and postoperative management, including nutritional status, orthopedic assessment of functional level with specific emphasis on the hips and pelvic obliquity, and wheelchair modifications. The surgical techniques in CP scoliosis have progressively evolved from the classic LuqueGalveston fixation methods, the use of unit rods, and lately the use of pedicle screws, to modern sacropelvic fixation. With the latter method, the spinal deformity in patients with CP can usually be almost completely corrected.

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“…14,15 Previous studies have reported that comprehensive pulmonary rehabilitation programs, including regular assessment of respiratory status, chest physical therapy to assist airway clearance, and home noninvasive ventilation to manage sleep-disordered breathing, can significantly improve pulmonary function and sleeping patterns in subjects with CP, reducing exacerbations and the need for hospitalization. 14,16,17 Identifying the patients who are at an increased risk of developing respiratory complications and thus more likely to benefit from pulmonary rehabilitation could improve timely treatment/rehabilitation for those most in need. Selecting appropriate candidates for pulmonary rehabilitation programs is particularly important, as these are costly and time-consuming, both relevant considerations for families already burdened with caring for a disabled child.…”

Section: Introductionmentioning

confidence: 99%

“…Pulmonary aspiration syndrome, which is signaled by a positive salivagram or barium videofluoroscopy test, has been found to be a useful marker of high exacerbation risk. 16 Other studies have demonstrated that both decreased chest-wall motility and reduced respiratory-muscle strength are sensitive markers of poor respiratory outcome. 18 The paucity of information on this topic prompted us to investigate what single factor or combination of factors may signal an increased risk of respiratory exacerbations in subjects with quadriplegic CP.…”

Section: Introductionmentioning

confidence: 99%

Clinical and Pulmonary Function Markers of Respiratory Exacerbation Risk in Subjects With Quadriplegic Cerebral Palsy

Vianello¹,

Carraro

Pipitone

et al. 2015

Respir Care

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BACKGROUND: Although respiratory exacerbations are common in patients with quadriplegic cerebral palsy (CP), little is known about the factors that are related to increased exacerbation risk. This study aimed to identify the clinical and pulmonary function variables signaling risk of exacerbation in this type of patient. METHODS: Thirty-one children and young adults with quadriplegic CP underwent a comprehensive history, physical examination, and pulmonary function test, including arterial blood gas analysis, airway resistance using the interrupter technique, and home overnight S pO 2 monitoring. Subjects were divided into 2 groups depending on the number of respiratory exacerbations reported during the year before study entry: frequent exacerbators (ie, > 2 exacerbations) and infrequent exacerbators (ie, < 2 exacerbations). RESULTS: The frequent exacerbators were more likely to require hospitalization due to respiratory disorders compared with the infrequent exacerbators (13/14 vs 9/17, P ‫؍‬ .02). Respiratory exacerbation was found to be associated with diagnosis of gastroesophageal reflux (adjusted odds ratio of 23.95 for subjects with confirmed diagnosis, P ‫؍‬ .02) and higher P aCO 2 levels (adjusted odds ratio of 12.60 for every 5-mm Hg increase in P aCO 2 , P ‫؍‬ .05). Subjects with P aCO 2 > 35 mm Hg showed an exacerbation odds ratio of 15.2 (95% CI 1.5-152.5, P ‫؍‬ .01). CONCLUSIONS: Gastroesophageal reflux and increased P aCO 2 can be considered simple, clinically useful markers of increased exacerbation risk in young subjects with quadriplegic CP.

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Assessing and managing lung disease and sleep disordered breathing in children with cerebral palsy

Cited by 110 publications

References 37 publications

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single‐event multilevel surgery

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single‐event multilevel surgery

Surgical management of spinal deformities in cerebral palsy

Clinical and Pulmonary Function Markers of Respiratory Exacerbation Risk in Subjects With Quadriplegic Cerebral Palsy

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