Compositions and methods for treating x-linked myotubular myopathy

Abstract

The present invention provides compositions and methods for treating a neuromuscular disorder. In certain embodiments, the invention provides compositions and methods for assessing weaning readiness and continuation of weaning off of a mechanical ventilator in a subject with X-linked myotubular myopathy (XLMTM).

Description

[Technical Field]

[0001] This invention relates in general to a method for treating neuromuscular disorders. More specifically, this invention relates to a parameter system and method for assessing whether a patient is ready to start or continue weaning from a mechanical ventilator. [Previous Technology]

[0002] X-linked myotubular myopathy (XLMTM) is a fatal monogenic skeletal muscle disease caused by loss-of-function mutations in myotubulin 1 (MTM1) (Laporte et al., 1996, Nat Genet 13(2):175-82). Approximately one in 50,000 newborn boys has XLMTM, typically presenting with significant hypotonia and respiratory failure (Jungbluth et al., 2008, Orphanet J Rare Dis 3:26). Severe XLMTM can occur in women in extremely rare cases. Survival beyond the postnatal period requires intensive support, including respiratory support (i.e., mechanical ventilation) at birth in 85-90% of patients, continuous 24-hour ventilator dependence in 48% of patients, and tracheostomy in 60% of patients. There is no precedent for successfully weaning long-term ventilated patients with congenital neuromuscular diseases from mechanical ventilation.

[0003] Therefore, there is a need for a method to assess whether a patient is ready to be weaned off mechanical ventilation. The present invention addresses this unmet need. [Summary of the Invention]

[0005] This disclosure provides methods for assessing whether a patient is ready to begin or continue weaning from mechanical ventilation for the treatment of diseases and conditions associated with loss-of-function mutations in myotubulin 1 (MTM1). In some embodiments, the condition is X-linked myotubulopathy (XLMTM).

[0006] In one embodiment, this disclosure provides a method for weaning a human patient undergoing mechanical ventilation who has XLMTM, wherein the patient has previously been administered a therapeutically effective amount of a viral vector comprising a transgenic gene encoding MTM1, the method comprising: determining that the patient exhibits one or more of the following: (i) a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator, (iii) a positive end-expiratory pressure of about 5 cmH2O or lower on a ventilator, (iv) an indoor air oxygen saturation (SpO2) of about 94% or higher, (v) a transcutaneous CO2 (TcCO2) of about 35 mmHg to about 45 mmHg, (vi) an end-tidal CO2 (petCO2) of about 35 mmHg to about 45 mmHg, and (vii) a transcutaneous CO2 of about 22 mEq / L to about 27 mEq / L. Serum bicarbonate level of mEq / L; and to wean patients off mechanical ventilation during the daytime.

[0007] In some of the foregoing embodiments, the method includes determining that the patient exhibits a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator.

[0008] In some embodiments of any of the foregoing examples, the method includes determining that the patient exhibits a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator.

[0009] In some embodiments of any of the foregoing embodiments, the method includes determining that the patient exhibits a positive end-expiratory pressure of about 5 cmH2O or less on a ventilator.

[0010] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits about 94% or higher SpO2.

[0011] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg.

[0012] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg.

[0013] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

[0014] In some embodiments of any of the foregoing states, the method further includes determining that the patient exhibits vital signs and weight within age-adjusted criteria.

[0015] In some embodiments of any of the foregoing embodiments, the method further includes determining that the patient has a motor function score greater than 45 or has reached a neuromuscular development milestone on the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND).

[0016] In some embodiments of any of the foregoing embodiments, the method further comprises: determining that the patient exhibits one or more of the following: (i) a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of about 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) an apnea-hypopnea index (AHI) of less than 5 events / hour, as assessed by polysomnography (PSG) with an open tracheostomy; (v) a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by PSG with an open tracheostomy; (vi) a TcCO2 that has not increased by 10 mmHg or more relative to the patient's awake baseline, as assessed by PSG with an open tracheostomy; (vii) a TcCO2 of less than 50 mmHg. PetCO2 or partial pressure of CO2 (ptcCO2) of mmHg, as assessed by PSG with open tracheostomy, (viii) petCO2 or ptcCO2 does not increase by 10 mmHg or more relative to the patient's awake baseline during sleep, as assessed by PSG with tracheostomy, (ix) no intercostal contractions in the video recording of the breathing sprint, (x) no respiratory tachycardia in the video recording of the breathing sprint, (xi) no respiratory paradoxes in the video recording of the breathing sprint, (xii) no phase delay in the video recording of the breathing sprint, (xiii) SpO2 less than 94%, as assessed by video recording of the breathing sprint, (xiv) SpO2 does not differ by more than 3% relative to the patient's awake baseline, as assessed by video recording of the breathing sprint, (xv) TcCO2 greater than 45 mmHg, as assessed by video recording of the breathing sprint, and (xvi) TCO2 does not increase by 10 mmHg or more relative to the patient's awake baseline. mmHg or higher, as assessed by video recording of a respiratory sprint test; and continued weaning of the patient from mechanical ventilation during the daytime.

[0017] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg, such as by nighttime respiratory monitoring.

[0018] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring.

[0019] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits approximately 94% or higher SpO2, such as by assessment via nocturnal respiratory monitoring.

[0020] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits an AHI of less than 5 events / hour, such as by PSG assessment performed with an open tracheostomy.

[0021] In some embodiments of any of the foregoing examples, the method includes determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by PSG performed with an open tracheostomy.

[0022] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 that has not increased by 10 mmHg or more relative to the patient’s waking baseline, such as by PSG assessment performed with an open tracheostomy.

[0023] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a petCO2 or ptcCO2 of less than 50 mmHg, such as by PSG assessment performed with an open tracheostomy.

[0024] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a petCO2 or ptcCO2 that does not increase by 10 mmHg or more relative to the patient’s awake baseline during sleep, as assessed by PSG performed with a tracheostomy.

[0025] In some embodiments of any of the foregoing examples, the method includes determining that the patient does not exhibit intercostal contractions in a video recording of a respiratory sprint test.

[0026] In some embodiments of any of the foregoing states, the method includes determining that the patient does not exhibit respiratory tachycardia in the video recording of the respiratory sprint test.

[0027] In some embodiments of any of the foregoing states, the method includes determining that the patient does not exhibit respiratory abnormalities in the video recording of the breathing sprint test.

[0028] In some embodiments of any of the foregoing states, the method includes determining that the patient does not exhibit phase delay in the video recording of the breathing sprint test.

[0029] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits less than 94% SpO2, such as by assessing via video recording of a breathing sprint test.

[0030] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits an SpO2 difference of no more than 3% relative to the patient’s awake baseline, such as by video recording of a respiratory sprint test.

[0031] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TCO2 greater than 45 mmHg, such as by assessing via video recording of a respiratory sprint test.

[0032] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TCO2 that does not increase by 10 mmHg or more relative to the patient’s awake baseline, such as by video recording of a breathing sprint test.

[0033] In some embodiments of any of the foregoing states, the method further includes determining that the patient exhibits a respiratory rate within age-adjusted criteria, such as by nighttime respiratory monitoring.

[0034] In some embodiments of any of the foregoing states, the method further includes determining that the patient did not exhibit distress in the video recording of the breathing sprint test.

[0035] In some embodiments of any of the foregoing examples, the method further includes determining that the patient exhibits a respiratory rate within age-adjusted criteria, such as by PSG assessment performed with an open tracheostomy.

[0036] In another embodiment, this disclosure provides a method for weaning a human patient undergoing mechanical ventilation who has XLMTM, wherein the patient has previously been administered a therapeutically effective amount of a viral vector comprising a transgenic gene encoding MTM1, the method comprising: measuring one or more of the following in the patient: (i) maximum inspiratory pressure on the ventilator, (ii) maximum expiratory pressure on the ventilator, (iii) positive end-expiratory pressure on the ventilator, (iv) SpO2 level, (v) TcCO2 level, (vi) petCO2 level, and (vii) serum bicarbonate level of about 22 mEq / L to about 27 mEq / L; and weaning the patient from mechanical ventilation during the daytime if the patient exhibits: (i) a maximum inspiratory pressure of about 50 cmH2O or higher on the ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on the ventilator, (iii) a maximum inspiratory pressure of about 5 cmH2O or higher on the ventilator. (iv) positive end-expiratory pressure of cmH2O or lower, (v) SpO2 of about 94% or higher, (v) transcutaneous TcCO2 of about 35 mmHg to about 45 mmHg, (vi) petCO2 of about 35 mmHg to about 45 mmHg, and (vii) serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

[0037] In some of the foregoing embodiments, the method includes determining that the patient exhibits a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator.

[0038] In some embodiments of any of the foregoing examples, the method includes determining that the patient exhibits a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator.

[0039] In some embodiments of any of the foregoing examples, the method includes determining that the patient exhibits a positive end-expiratory pressure of about 5 cmH2O or less on a ventilator.

[0040] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits about 94% or higher SpO2.

[0041] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg.

[0042] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg.

[0043] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

[0044] In some embodiments of any of the foregoing states, the method further includes determining that the patient exhibits vital signs and weight within age-adjusted criteria.

[0045] In some embodiments of any of the foregoing examples, the method further includes determining that the patient has a motor function score greater than 45 on CHOP INTEND or has reached a neuromuscular development milestone.

[0046] In another embodiment, this disclosure provides a method for treating a human patient with XLMTM who is on mechanical ventilation, the method comprising administering to the patient a therapeutically effective amount of a viral vector comprising a transgenic gene encoding MTM1; determining that the patient exhibits one or more of the following: (i) a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator, (iii) a positive end-expiratory pressure of about 5 cmH2O or lower on a ventilator, (iv) about 94% or higher of SpO2, (v) a TcCO2 of about 35 mmHg to about 45 mmHg, (vi) an end-tidal petCO2 of about 35 mmHg to about 45 mmHg, and (vii) a serum bicarbonate level of about 22 mEq / L to about 27 mEq / L; and weaning the patient off mechanical ventilation during daytime hours.

[0047] In some of the foregoing embodiments, the method includes determining that the patient exhibits a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator.

[0048] In some embodiments of any of the foregoing examples, the method includes determining that the patient exhibits a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator.

[0049] In some embodiments of any of the foregoing examples, the method includes determining that the patient exhibits a positive end-expiratory pressure of about 5 cmH2O or less on a ventilator.

[0050] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits about 94% or higher SpO2.

[0051] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg.

[0052] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg.

[0053] In some embodiments of any of the foregoing examples, the method includes determining that the patient exhibits a serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

[0054] In some embodiments of any of the foregoing states, the method further includes determining that the patient exhibits vital signs and weight within age-adjusted criteria.

[0055] In some embodiments of any of the foregoing examples, the method further includes determining that the patient has a motor function score greater than 45 on CHOP INTEND or has reached a neuromuscular development milestone.

[0056] In some embodiments of any of the foregoing states, the method further includes: determining that the patient exhibits one or more of the following: (i) a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of about 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) an AHI of less than 5 events / hour, as assessed by PSG with an open tracheostomy; (v) a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by PSG with an open tracheostomy; (vi) a TcCO2 that has not increased by 10 mmHg or more relative to the patient's awake baseline, as assessed by PSG with an open tracheostomy; (vii) a TcCO2 of less than 50 mmHg. (viii) petCO2 or ptcCO2 of mmHg, as assessed by PSG with open tracheostomy, (ix) no intercostal contractions in the video recording of the breathing sprint, (x) no respiratory tachycardia in the video recording of the breathing sprint, (xi) no respiratory paradoxes in the video recording of the breathing sprint, (xii) no phase delay in the video recording of the breathing sprint, (xiii) SpO2 less than 94%, as assessed by video recording of the breathing sprint, (xiv) SpO2 not greater than 3% of the patient's awake baseline, (xv) TcCO2 greater than 45 mmHg, as assessed by video recording of the breathing sprint, and (xvi) TcCO2 not greater than 10 mmHg of the patient's awake baseline. mmHg or higher, as assessed by video recording of a respiratory sprint test; and continued weaning of the patient from mechanical ventilation during the daytime.

[0057] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg, such as by nighttime respiratory monitoring.

[0058] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring.

[0059] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits approximately 94% or higher SpO2, such as by assessment via nocturnal respiratory monitoring.

[0060] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits an AHI of less than 5 events / hour, such as by PSG assessment performed with an open tracheostomy.

[0061] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by PSG with an open tracheostomy.

[0062] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 that has not increased by 10 mmHg or more relative to the patient’s awake baseline, such as by PSG assessment performed with an open tracheostomy.

[0063] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a petCO2 or ptcCO2 of less than 50 mmHg, such as by PSG assessment performed with an open tracheostomy.

[0064] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits no increase of 10 mmHg or more in petCO2 or ptcCO2 during sleep relative to the patient’s awake baseline, such as by PSG assessment performed with tracheostomy.

[0065] In some embodiments of any of the foregoing examples, the method includes determining that the patient does not exhibit intercostal contractions in a video recording of a respiratory sprint test.

[0066] In some embodiments of any of the foregoing states, the method includes determining that the patient does not exhibit respiratory tachycardia in the video recording of the respiratory sprint test.

[0067] In some embodiments of any of the foregoing states, the method includes determining that the patient does not exhibit respiratory abnormalities in the video recording of the respiratory sprint test.

[0068] In some embodiments of any of the foregoing states, the method includes determining that the patient does not exhibit phase delay in the video recording of the breathing sprint test.

[0069] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits SpO2 of less than 94%, as assessed by video recording of a respiratory sprint test.

[0070] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits an SpO2 difference of no more than 3% relative to the patient’s awake baseline, such as by video recording of a respiratory sprint test.

[0071] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 greater than 45 mmHg, such as by assessing via video recording of a respiratory sprint test.

[0072] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 that does not increase by 10 mmHg or more relative to the patient’s awake baseline, such as by video recording of a respiratory sprint test.

[0073] In some embodiments of any of the foregoing states, the method further includes determining that the patient exhibits a respiratory rate within age-adjusted criteria, such as by nighttime respiratory monitoring.

[0074] In some embodiments of any of the foregoing states, the method further includes determining that the patient did not exhibit distress in the video recording of the breathing sprint test.

[0075] In some embodiments of any of the foregoing examples, the method further includes determining that the patient exhibits a respiratory rate within age-adjusted criteria, such as by PSG assessment performed with an open tracheostomy.

[0076] In another embodiment, this disclosure provides a method for treating a human patient with XLMTM who is undergoing mechanical ventilation, the method comprising: administering to the patient a therapeutically effective amount of a viral vector comprising a transgenic gene encoding MTM1; measuring one or more of the following in the patient: (i) maximum inspiratory pressure on the ventilator, (ii) maximum expiratory pressure on the ventilator, (iii) positive end-expiratory pressure on the ventilator, (iv) SpO2 level, (v) TcCO2 level, (vi) petCO2 level, and (vii) serum bicarbonate level; and weaning the patient from mechanical ventilation during the daytime if the patient exhibits: (i) a maximum inspiratory pressure of about 50 cmH2O or higher on the ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on the ventilator, (iii) a positive end-expiratory pressure of about 5 cmH2O or lower on the ventilator, (iv) about 94% or higher SpO2, (v) about 35 (vi) TcCO2 of approximately 35 mmHg to approximately 45 mmHg, (vii) petCO2 of approximately 35 mmHg to approximately 45 mmHg, and (vii) serum bicarbonate level of approximately 22 mEq / L to approximately 27 mEq / L.

[0077] In some of the foregoing embodiments, the method includes determining that the patient exhibits a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator.

[0078] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator.

[0079] In some embodiments of any of the foregoing examples, the method includes determining that the patient exhibits a positive end-expiratory pressure of about 5 cmH2O or less on a ventilator.

[0080] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits about 94% or higher SpO2.

[0081] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg.

[0082] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg.

[0083] In some embodiments of any of the foregoing states, the method includes determining that the patient exhibits a serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

[0084] In some embodiments of any of the foregoing states, the method further includes determining that the patient exhibits vital signs and weight within age-adjusted criteria.

[0085] In some embodiments of any of the foregoing examples, the method further includes determining that the patient has a motor function score greater than 45 on CHOP INTEND or has reached a neuromuscular development milestone.

[0086] In some of the foregoing embodiments, weaning from mechanical ventilation includes gradually reducing one or more of the ventilator support parameters, including pressure, volume and rate, followed by a gradual sprint to wean off the ventilator, with no more than one ventilator support parameter changed at a time, as appropriate.

[0087] In some embodiments of any of the foregoing states, after administration of the viral vector to the patient, the patient exhibits a change in ventilation support hours over time relative to baseline, wherein, as of approximately 24 weeks after administration of the viral vector to the patient, the patient exhibits a change in ventilation support hours over time relative to baseline.

[0088] In some of the foregoing embodiments, after administration of the viral vector to the patient, the patient achieves functionally independent sitting for at least 30 seconds, wherein the patient achieves functionally independent sitting up to approximately 24 weeks after administration of the viral vector.

[0089] In some of the foregoing embodiments, after administration of the viral vector to the patient, the patient exhibited a reduction in required ventilator support to about 16 hours or less per day, wherein, as of about 24 weeks after administration of the viral vector, the patient exhibited a reduction in required ventilator support.

[0090] In some embodiments of any of the foregoing states, after administration of the viral vector to the patient, the patient exhibits a change in CHOP INTEND relative to baseline, wherein, as of approximately 24 weeks after administration of the viral vector to the patient, the patient exhibits a change in CHOP INTEND relative to baseline.

[0091] In some embodiments of any of the foregoing states, after administration of the viral vector to the patient, the patient exhibits a change in maximum inspiratory pressure relative to baseline, wherein, as of approximately 24 weeks after administration of the viral vector to the patient, the patient exhibits a change in maximum inspiratory pressure relative to baseline.

[0092] In some embodiments of any of the foregoing examples, after administration of the viral vector to a patient, the patient exhibited a change in the quantitative analysis of tubulin expression in the muscle biopsy relative to baseline, wherein, as of approximately 24 weeks after administration of the viral vector to the patient, the patient exhibited a change in the quantitative analysis of tubulin expression in the muscle biopsy relative to baseline.

[0093] In some embodiments of any of the foregoing states, the transgene encoding MTM1 is operatively linked to a muscle-specific promoter.

[0094] In some embodiments of any of the foregoing states, the muscle-specific promoter is a desmin promoter, a phosphoglycerate kinase (PGK) promoter, a muscle creatine kinase promoter, a myosin light chain promoter, a myosin heavy chain promoter, a cardiac troponin C promoter, a troponin I promoter, a myoD gene family promoter, an actin α promoter, an actin β promoter, an actin γ promoter, or a promoter within intron 1 of the eye pair-like homology domain 3 (PITX3).

[0095] In some of the embodiments of any of the foregoing states, the muscle-specific promoter is the desmin promoter.

[0096] In some embodiments of any of the foregoing embodiments, the viral vector is selected from the group consisting of: adeno-associated virus (AAV), adenovirus, lentivirus, retrovirus, poxvirus, baculovirus, herpes simplex virus, vaccinia virus and synthetic virus.

[0097] In some of the embodiments of any of the foregoing states, the viral vector is AAV.

[0098] In some embodiments of any of the foregoing states, AAV is AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAVrh10 or AAVrh74 serotype.

[0099] In some of the embodiments of any of the foregoing states, the viral vector is pseudo-AAV.

[0100] In some embodiments of any of the foregoing states, the pseudo-AAV is AAV2 / 8.

[0101] In some embodiments of any of the foregoing states, the viral vector is resamirigene bilparvovec.

[0102] In another embodiment, this disclosure provides a method for treating a human patient with XLMTM who is undergoing mechanical ventilation, the method comprising: administering to the patient a therapeutically effective amount of an AAV2 / 8 viral vector comprising a transgenic gene encoding MTM1 operatively linked to a desmin promoter; determining that the patient exhibits (i) a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator, (iii) a positive end-expiratory pressure of about 5 cmH2O or lower on a ventilator, (iv) about 94% or higher SpO2, (v) about 35 mmHg to about 45 mmHg TcCO2, (vi) about 35 mmHg to about 45 mmHg petCO2, and (vii) about 22 mEq / L to about 27 mEq / L. (viii) serum bicarbonate level within age-adjusted range, and (ix) motor function score greater than 45 or having reached the neuromuscular developmental milestone; wean the patient off mechanical ventilation during the day; determine if the patient exhibits (i) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of approximately 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) no intercostal contractions in the video recording of the respiratory sprint test; (v) no respiratory tachycardia in the video recording of the respiratory sprint test; (vi) no respiratory paradoxes in the video recording of the respiratory sprint test; (vii) no phase delay in the video recording of the respiratory sprint test; (viii) less than 94% SpO2, as assessed by the video recording of the respiratory sprint test; (ix) SpO2 is no more than 3% different from the patient's awake baseline, as assessed by video recording of a respiratory sprint test; (x) TCO2 greater than 45 mmHg, as assessed by video recording of a respiratory sprint test; (xi) TCO2 does not increase by 10 mmHg or more relative to the patient's awake baseline, as assessed by video recording of a respiratory sprint test; (xii) respiratory rate within age-adjusted criteria, as assessed by nocturnal respiratory monitoring; (xiii) no distress recorded in the video recording of a respiratory sprint test; and (xiv) respiratory rate within age-adjusted criteria, as assessed by PSG performed with an open tracheostomy; and the patient continues to be weaned from mechanical ventilation during the daytime.

[0103] In another embodiment, this disclosure provides a method for treating a human patient with XLMTM who is undergoing mechanical ventilation, the method comprising administering to the patient a therapeutically effective amount of an AAV2 / 8 viral vector, including a transgenic gene encoding MTM1 operatively linked to a desmin promoter; determining that the patient exhibits (i) a maximum inspiratory pressure of about 50 cmH2O or greater on a ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or greater on a ventilator, (iii) a positive end-expiratory pressure of about 5 cmH2O or less on a ventilator, (iv) about 94% or greater SpO2, (v) about 35 mmHg to about 45 mmHg TcCO2, (vi) about 35 mmHg to about 45 mmHg petCO2, (vii) about 22 mEq / L to about 27 mEq / L (viii) serum bicarbonate level of mEq / L, (ix) vital signs and weight within age-adjusted range, and (ix) motor function score greater than 45 or reaching the neuromuscular development milestone; enabling patients to be weaned off mechanical ventilation during the day;The patient is identified as exhibiting (i) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of approximately 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) an AHI of less than 5 events / hour, as assessed by PSG with an open tracheostomy; (v) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by PSG with an open tracheostomy; (vi) a TcCO2 not increasing by 10 mmHg or more relative to the patient's awake baseline, as assessed by PSG with an open tracheostomy; (vii) a petCO2 or ptcCO2 less than 50 mmHg, as assessed by PSG with an open tracheostomy; and (viii) a petCO2 or ptcCO2 not increasing by 10 mmHg or more relative to the patient's awake baseline during sleep. mmHg or more, as assessed by PSG during tracheostomy, (ix) no intercostal contractions in the video recording of the breathing sprint test, (x) no respiratory tachycardia in the video recording of the breathing sprint test, (xi) no respiratory paradoxes in the video recording of the breathing sprint test, (xii) no phase delay in the video recording of the breathing sprint test, (xiii) SpO2 less than 94%, as assessed by the video recording of the breathing sprint test, (xiv) SpO2 not greater than 3% from the patient's awake baseline, as assessed by the video recording of the breathing sprint test, (xv) TCO2 greater than 45 mmHg, as assessed by the video recording of the breathing sprint test, (xvi) TCO2 not increased by more than 10% from the patient's awake baseline. mmHg or higher, as assessed by video recording of a respiratory sprint test; (xvii) respiratory rate within age-adjusted criteria, as assessed by nocturnal respiratory monitoring; (xviii) no distress in video recording of a respiratory sprint test; and (xix) respiratory rate within age-adjusted criteria, as assessed by PSG performed with an open tracheostomy; and continued daytime weaning of the patient from mechanical ventilation.

[0104] In another embodiment, this disclosure provides a method for weaning a human patient undergoing mechanical ventilation who has XLMTM, wherein the patient has previously been administered a therapeutically effective amount of an AAV2 / 8 viral vector comprising a transgenic gene encoding MTM1 operatively linked to a desmin promoter, the method comprising: determining that the patient exhibits (i) a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator, (iii) a positive end-expiratory pressure of about 5 cmH2O or lower on a ventilator, (iv) about 94% or higher SpO2, (v) about 35 mmHg to about 45 mmHg TcCO2, (vi) about 35 mmHg to about 45 mmHg petCO2, and (vii) about 22 mEq / L to about 27 mEq / L. (viii) serum bicarbonate level within age-adjusted range, and (ix) motor function score greater than 45 or reaching the neuromuscular developmental milestone; wean the patient off mechanical ventilation during the day; confirm that the patient exhibits (i) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of approximately 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) no intercostal contractions in the video recording of the respiratory sprint test; (v) no respiratory tachycardia in the video recording of the respiratory sprint test; (vi) no respiratory paradoxes in the video recording of the respiratory sprint test; (vii) no phase delay in the video recording of the respiratory sprint test; (viii) less than 94% SpO2, as assessed by the video recording of the respiratory sprint test; (ix) SpO2 is no more than 3% different from the patient's awake baseline, as assessed by video recording of a respiratory sprint test; (x) TCO2 greater than 45 mmHg, as assessed by video recording of a respiratory sprint test; (xi) TCO2 does not increase by 10 mmHg or more relative to the patient's awake baseline, as assessed by video recording of a respiratory sprint test; (xii) respiratory rate within age-adjusted criteria, as assessed by nocturnal respiratory monitoring; (xiii) no distress recorded in the video recording of a respiratory sprint test; and (xiv) respiratory rate within age-adjusted criteria, as assessed by PSG performed with an open tracheostomy; and the patient continues to be weaned from mechanical ventilation during the daytime.

[0105] In another embodiment, this disclosure provides a method for weaning a human patient undergoing mechanical ventilation who has XLMTM, wherein the patient has previously been administered a therapeutically effective amount of an AAV2 / 8 viral vector comprising a transgenic gene encoding MTM1 operatively linked to a desmin promoter, the method comprising: determining that the patient exhibits (i) a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator, (iii) a positive end-expiratory pressure of about 5 cmH2O or lower on a ventilator, (iv) about 94% or higher SpO2, (v) about 35 mmHg to about 45 mmHg TcCO2, (vi) about 35 mmHg to about 45 mmHg petCO2, and (vii) about 22 mEq / L to about 27 mEq / L. (viii) serum bicarbonate level within age-adjusted range, (ix) motor function score greater than 45 or having reached the neuromuscular developmental milestone; wean the patient off mechanical ventilation during the day; determine if the patient exhibits (i) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of approximately 94% or higher, as assessed by nocturnal respiratory monitoring;(iv) AHI less than 5 events / hour, as assessed by PSG with open tracheostomy; (v) TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by PSG with open tracheostomy; (vi) TcCO2 not increased by 10 mmHg or more relative to the patient's awake baseline, as assessed by PSG with open tracheostomy; (vii) petCO2 or ptcCO2 less than 50 mmHg, as assessed by PSG with open tracheostomy; (viii) petCO2 or ptcCO2 not increased by 10 mmHg or more relative to the patient's awake baseline during sleep. mmHg or more, as assessed by PSG with open tracheostomy, (ix) no intercostal contractions in the video recording of the breathing sprint test, (x) no respiratory tachycardia in the video recording of the breathing sprint test, (xi) no respiratory paradoxes in the video recording of the breathing sprint test, (xii) no phase delay in the video recording of the breathing sprint test, (xiii) SpO2 less than 94%, as assessed by the video recording of the breathing sprint test, (xiv) SpO2 not greater than 3% from the patient's awake baseline, as assessed by the video recording of the breathing sprint test, (xv) TCCO2 greater than 45 mmHg, as assessed by the video recording of the breathing sprint test, (xvi) TcCO2 not increased by more than 10% from the patient's awake baseline. mmHg or higher, as assessed by video evaluation of a respiratory sprint test; (xvii) respiratory rate within age-adjusted criteria, as assessed by nighttime respiratory monitoring; (xviii) no distress recorded in the video recording of a respiratory sprint test; and (xix) respiratory rate within age-adjusted criteria, as assessed by PSG performed with an open tracheostomy; and continued daytime weaning of the patient from mechanical ventilation.

Implementation Method

[0149] This disclosure provides compositions and methods for treating neuromuscular disorders, particularly X-linked myotubular myopathy (XLMTM). According to the compositions and methods described herein, a viral vector, such as an adeno-associated virus (AAV) vector, containing a transgenic gene encoding tubulin 1 (MTM1) can be administered to a patient (e.g., a human patient) suffering from XLMTM. The AAV vector can be, for example, a pseudo-AAV vector, such as an AAV vector (AAV2 / 8) containing an AAV2 inverted terminal repeat sequence packaged within a capsid protein derived from AAV8. In some embodiments, the transgenic gene is operatively linked to a transcriptional regulatory element, such as a promoter that induces gene expression in muscle cells. An exemplary promoter that can be used in conjunction with the compositions and methods of this disclosure is a desmin promoter.

[0150] This disclosure is partly based on the discovery of a parametric algorithm that enables physicians skilled in this technology to successfully discontinue mechanical ventilator support in children with XLMTM treated with gene therapy. Using the compositions and methods of this disclosure, a patient can be administered an amount of AAV vector sufficient to enhance the patient's MTM1 performance, and the assessment parameters described herein can then be used to assess whether the patient is ready to begin weaning from mechanical ventilation. The patient can then be weaned from mechanical ventilation, and the assessment parameters described herein can then be used to further assess whether the patient is ready to continue weaning from mechanical ventilation.

[0151] In some embodiments, the assessment parameters described herein are used to determine that a patient is ready to begin daytime weaning from mechanical ventilation when the patient exhibits vital signs and weight within age-adjusted criteria; maximum inspiratory pressure (MIP) > -50 cmH2O, maximum expiratory pressure (MEP) > 40 cmH2O, and positive end-expiratory pressure (PEEP) ≤ 5 cmH2O on the ventilator; room air oxygen saturation (SpO2) > 94%, transcutaneous CO2 (TcCO2) within 35-45 mmHg, end-tidal CO2 (ETCO2) within 35-45 mmHg, and serum bicarbonate level within 22-27 mEq / L; and a motor function score > 45 or has reached the neuromuscular development milestone of the Children's Hospital of Philadelphia Neuromuscular Disorder Infant Test (CHOP INTEND).

[0152] In some embodiments, the assessment parameters described herein are used to determine a patient's readiness for continued daytime weaning from mechanical ventilation when the patient exhibits the following: TcCO2 within 35-45 mmHg, ETCO2 within 35-45 mmHg, >94% SpO2, and respiratory rate (RR) within age-adjusted range when monitoring respiration at night; apnea-hypopnea index (AHI) <5 events / hour when performing polysomnography (PSG) with a tracheostomy opening, TcCO2 within 35-45 mmHg or not exceeding 10 mmHg or more from awake baseline, and <50% SpO2 during sleep. mmHg or no increase of <10 in end-tidal CO2 (petCO2) or partial pressure of CO2 (ptcCO2) relative to waking baseline, and RR within age-adjusted criteria; and when no distress, no intercostal contractions, no respiratory tachycardia, no respiratory paradox, no phase delay, <94% or no greater than 3% SpO2 relative to baseline, >45 mmHg or no increase of 10 mmHg or greater in TcCO2 relative to waking baseline are observed in the video recording of the respiratory sprint test.

[0153] The following sections provide a description of the therapeutic agents and weaning assessment parameters that determine whether a patient is ready to begin or continue weaning from the mechanical ventilator described above. The following sections also describe various transduction agents that can be used in conjunction with the compositions and methods disclosed herein. Treatment Method X Linked Muscle Microtubule Myopathy

[0154] X-linked myomicrotubule myopathy (XLMTM) is a rare, life-threatening congenital myopathy caused by loss-of-function mutations in the MTM1 gene. It is characterized by most patients presenting with severe muscle weakness and hypotonia at birth, leading to severe respiratory failure, inability to sit up, stand or walk, and early death.

[0155] Myopathy associated with XLMTM can impair motor skills, such as the development of sitting, standing, and walking. Affected infants may also have difficulty feeding due to muscle weakness. Individuals with this condition typically lack the muscle strength to breathe independently and require mechanical ventilation. Some affected individuals only require periodic mechanical ventilation, such as during sleep, while others require continuous mechanical ventilation. Patients with XLMTM may also have weakness of the muscles controlling eye movement (ophthalmoplegia), weakness of other facial muscles, and loss of reflexes (absence of reflexes).

[0156] In XLMTM, muscle weakness often disrupts normal skeletal development and can lead to brittle bones, abnormal spinal curvature (scoliosis), and joint deformities (contractile deformities) in the hips and knees. Patients with XLMTM may have a large head, a narrow and elongated face, and a high and arched mouth (upper palate). Patients may also have liver disease, recurrent ear and respiratory infections, or seizures.

[0157] Due to severe respiratory distress, patients with XLMTM typically only survive into early childhood. However, some patients with this condition live into adulthood. The compositions and methods disclosed herein provide the significant medical benefit of extending the lifespan of such patients by restoring functional MTM1 performance. Furthermore, the compositions and methods described herein can be used to improve patients' quality of life after treatment, as this disclosure provides a set of guidelines for determining a patient's eligibility for weaning from mechanical ventilation. Vectors for delivering exogenous nucleic acids to target cells; viral vectors for nucleic acid delivery.

[0158] Viral genomic bodies provide a rich source of vectors for the efficient delivery of genes of interest (e.g., transgenic genes encoding MTM1) into the genomes of target cells (e.g., mammalian cells, such as human cells). Viral genomic bodies are particularly useful vectors for gene delivery because the polynucleotides contained in such genomic bodies are typically incorporated into the genomes of target cells via general or specific transduction. These processes occur as part of the natural viral replication cycle and do not require the addition of proteins or reagents to induce gene integration. Examples of viral vectors include AAV, retroviruses, adenoviruses (e.g., Ad5, Ad26, Ad34, Ad35, and Ad48), microviruses (e.g., adeno-associated virus), coronaviruses, negative-strand RNA viruses (e.g., orthomyxoviruses, such as influenza viruses), rod-shaped viruses (e.g., rabies and vesicular stomatitis viruses), paramyxoviruses (e.g., measles and Sendai virus), positive-strand RNA viruses (e.g., microRNAs and alpha viruses), and double-stranded DNA viruses (including adenoviruses, herpesviruses (e.g., herpes simplex virus type 1 and 2, Epstein-Barr virus, cytomegalovirus)), and poxviruses (e.g., cowpox, modified vaccinia Ankara (MVA), fowlpox, and canarypox). Other viruses that can be used to deliver polynucleotides encoding the antibody light and heavy chains or antibody fragments of the present invention include, for example, Norwalk virus, chlamydia virus, flavivirus, reovirus, papillomavirus, hepatotropic DNA virus, and hepatitis virus. Examples of retroviruses include: avian leukosis sarcoma, mammalian type C virus, type B virus, type D virus, HTLV-BLV group, lentivirus, and foam virus (Coffin, JM, Retroviridae: The viruses and their replication, In Fundamental Virology, 3rd edition, BN Fields et al., eds., Lippincott-Raven Publishers, Philadelphia, 1996). Other examples include murine leukemia virus, murine sarcoma virus, mouse mammary tumor virus, bovine leukemia virus, feline leukemia virus, feline sarcoma virus, avian leukemia virus, human T-cell leukemia virus, baboon endogenous virus, gibbon leukemia virus, Mason Pfizer monkey virus, simian immunodeficiency virus, simian sarcoma virus, Rous sarcoma virus, and lentiviruses.Other examples of vectors are described, for example, in U.S. Patent No. 5,801,030, the disclosure of which relating to viral vectors for use in gene therapy is incorporated herein by reference. AAV vectors for nucleic acid delivery.

[0159] In some embodiments, the nucleic acids of the compositions and methods described herein are incorporated into recombinant AAV (rAAV) vectors and / or virions to facilitate their introduction into cells. The rAAV vectors used in this invention are recombinant nucleic acid constructs comprising (1) a transgenic gene to be expressed (e.g., a polynucleotide encoding the MTM1 protein) and (2) viral nucleic acids to promote the stability and expression of the heterologous gene. The viral sequence may include the AAV sequences required for cis-replication and packaging of DNA (e.g., a functional ITR) into the virion. In typical applications, the transgenic gene encodes MTM1, which can be used to correct MTM1 mutations in patients with neuromuscular disorders (e.g., XLMTM). Such rAAV vectors may also contain biomarkers or reporter genes. Useful rAAV vectors have one or more wholly or partially deleted AAV wild-type genes, but retain functional flanking ITR sequences. The AAV ITR may have any serotype suitable for a particular application (e.g., derived from serotype 2). Methods for using rAAV vectors are described, for example, in Tal et al., J. Biomed. Sci. 7:279-291 (2000) and Monahan and Samulski, Gene Delivery 7:24-30 (2000), and the disclosures of each of these documents regarding AAV vectors for gene delivery are incorporated herein by reference.

[0160] The nucleic acids and vectors described herein can be incorporated into rAAV virions to facilitate the introduction of nucleic acids or vectors into cells. The capsid protein of AAV constitutes the external non-nucleic acid portion of the virion and is encoded by the AAV cap gene. The cap gene encodes three viral capsid proteins, VP1, VP2, and VP3, which are essential for virion assembly. The construction of rAAV virions has been described, for example, in US 5,173,414; US 5,139,941; US ​​5,863,541; US ​​5,869,305; US 6,057,152; and US 6,376,237; as well as Rabinowitz et al., J. Virol. 76:791-801 (2002) and Bowles et al., J. Virol. 77:423-432 (2003), the disclosures of each of these documents regarding AAV vectors for gene delivery are incorporated herein by reference.

[0161] Pseudotyped rAAV vectors that can be used in conjunction with the compositions and methods described herein include virions derived from multiple AAV serotypes, including AAV 1, 2, 3, 4, 5, 6, 7, 8, and 9. For targeting muscle cells, rAAV virions comprising at least one serotype 1 capsid protein can be particularly useful. rAAV virions comprising at least one serotype 6 capsid protein are also particularly useful because the serotype 6 capsid protein is structurally similar to the serotype 1 capsid protein, and is therefore expected to lead to high expression of MTM1 in muscle cells. rAAV serotype 9 has also been found to be an effective sensor for muscle cells. The construction and applications of AAV vectors and AAV proteins for different serotypes are described in, for example, Chao et al., Mol. Ther. 2:619-623 (2000); Davidson et al., Proc. Natl. Acad. Sci. USA 97:3428-3432 (2000); Xiao et al., J. Virol. 72:2224-2232 (1998); Halbert et al., J. Virol. 74:1524-1532 (2000); Halbert et al., J. Virol. 75:6615-6624 (2001); and Auricchio et al., Hum. Molec. Genet. 10:3075-3081 (2001). The details of AAV vectors for gene delivery in each of these publications are incorporated herein by reference.

[0162] Pseudotyped rAAV vectors may also be used in conjunction with the compositions and methods described herein. Pseudotyped vectors include AAV vectors of a given serotype (e.g., AAV9) whose capsid genes have been pseudotyped from serotypes other than a given serotype (e.g., AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, etc.). For example, a representative pseudotyped vector is an AAV8 vector encoding a therapeutic protein pseudotyped from a capsid gene derived from AAV serotype 2. Techniques involving the construction and use of pseudotyped rAAV virions are known in this art and described, for example, in Duan et al., J. Virol. 75:7662-7671 (2001); Halbert et al., J. Virol. 74:1524-1532 (2000); Zolotukhin et al., Methods, 28:158-167 (2002); and Auricchio et al., Hum. Molec. Genet., 10:3075-3081 (2001).

[0163] AAV virions with mutations within the virospinal capsid can infect specific cell types more effectively than non-mutated capsid virions. For example, suitable AAV mutants may have ligand insertion mutations that facilitate AAV targeting of specific cell types. The construction and characterization of AAV capsid mutants (including insertion mutants, alanine-selective mutants, and antigenic determinant tag mutants) are described in Wu et al., J. Virol. 74:8635-45 (2000). Other rAAV virions that can be used in the methods of this invention include capsid heterozygotes produced by molecular breeding of the virus and by exon shuffling. See, for example, Soong et al., Nat. Genet., 25:436-439 (2000) and Kolman and Stemmer, Nat. Biotechnol. 19:423-428 (2001). Resamirigene Bilparvovec

[0164] As described herein, the pseudo-AAV vector comprises a nucleic acid sequence encoding an MTM1 gene (SEQ ID NO:4) operatively linked to a desmin promoter (SEQ ID NO:3; FIG.1) and other genetic components listed in Table 1, the desmin promoter being side-linked to an AAV2 ITR and packaged within a capsid protein (AAV2 / 8) derived from AAV8, and the pseudo-AAV vector refers to the compound named under the International Nonproprietary Name (INN) resamirigene bilparvovec.

[0165] In some embodiments, a method of treating a condition (e.g., XLMTM) or alleviating one or more symptoms of a condition (e.g., XLMTM) in a human patient in need includes administering a therapeutically effective amount of resamirigene bilparvovec to the patient during treatment.

[0166] In some embodiments, the method of weaning a human patient from mechanical ventilation includes a patient who has previously been given a therapeutically effective dose of resamirigene bilparvovec. Table 1. Nucleic acid sequence of Resamirigene Bilparvovec (SEQ ID NO: 5) Scope (nucleotides, relative to SEQ ID NO: 5) Length (nucleotides) Genetic components 3080-3198 119 AAV2 ITR 3199-3256 58 Connect subsequences 3257-4316 1,060 Human desmin promoter (SEQ ID NO:3) 4317-4354 38 Connect subsequences 4355-4460 106 Human β-globin introns 4373-4848 476 Human β-globin introns 4458-4902 445 Human β-globin introns 4917-6738 1,822 Human MTM1 coding sequence (SEQ ID NO:4) 6739-6759 twenty one Connect subsequences 6760-7519 760 Human β-globin polyadenylation sequence 7520-7551 32 Connect subsequences 7552 7,696 AAV2 ITR

[0167] As described herein, resamirigene bilparvovec refers to an AAV vector having the nucleic acid sequence SEQ ID NO:5 shown below: a method for delivering exogenous nucleic acids to target cells.

[0168] Techniques for introducing transgenic genes (such as the MTM1 transgenic gene described herein) into target cells (e.g., mammalian cells) are well known in this art. For example, electroporation can be used to permeate mammalian cells (e.g., human target cells) by applying an electrostatic potential to the cell of interest. Mammalian cells (e.g., human cells) subjected to an external electric field in this manner then readily take up exogenous nucleic acids (e.g., nucleic acids that can be expressed in, for example, neurons, glial cells, or non-neuronal cells such as colon and kidney cells). Electroporation of mammalian cells is described in detail, for example, in Chu et al., Nucleic Acids Research 15:1311 (1987), the contents of which are incorporated herein by reference. A similar technique, NUCLEOFECTION™, utilizes an applied electric field to stimulate the uptake of exogenous polynucleotides into the nucleus of eukaryotic cells. NucleoFection™ and the methods that can be used to implement this technology are described in detail in, for example, Distler et al., Experimental Dermatology 14:315 (2005) and US 2010 / 0317114, the contents of which are incorporated herein by reference.

[0169] Other techniques that can be used to transfect target cells include the squeeze-perforation method. This technique induces rapid mechanical deformation of cells to stimulate the uptake of exogenous DNA through membrane pores formed in response to applied stress. An advantage of this technique is that the vector is not required for the delivery of nucleic acids to cells (e.g., human target cells). Squeeze-perforation is described in detail, for example, in Sharei et al., Journal of Visualized Experiments 81:e50980 (2013), the contents of which are incorporated herein by reference.

[0170] Lipid transfection represents another technique that can be used to transfect target cells. This method involves loading nucleic acids into liposomes, which typically exhibit cationic functional groups, such as quaternary or protonated amines, facing outwards. This promotes electrostatic interactions between the liposomes and the cell due to the anionic nature of the cell membrane, ultimately leading to the uptake of exogenous nucleic acids, for example, by guiding the liposomes to fuse with the cell membrane or by endocytosis of the complex. Lipid transfection is described in detail, for example, in US 7,442,386, the disclosure of which is incorporated herein by reference. A similar technique that utilizes ionic interactions with the cell membrane to induce the uptake of exogenous nucleic acids involves contacting the cell with a cationic polymer-nucleic acid complex. Exemplary cationic molecules that associate with polynucleotides to impart a positive charge that facilitates interaction with the cell membrane include activated dendritic polymers (described, for example, in Dennig, Topics in Current Chemistry 228:227 (2003), the contents of which are incorporated herein by reference), polyethyleneimine, and DEAE-polydextrose, the use of which as transfection agents is described in detail, for example, in Gulick et al., Current Protocols in Molecular Biology 40:1:9.2:9.2.1 (1997), the contents of which are incorporated herein by reference.

[0171] Another tool that can be used to induce the uptake of exogenous nucleic acids by target cells is laser transfection, also known as optical transfection. It is a technique that involves exposing cells to electromagnetic radiation of a specific wavelength to gently permeate the cells and allow polynucleotides to pass through the cell membrane. The bioactivity of this technique is similar to that of electroporation and has been found to be superior to electroporation in some cases.

[0172] Impalefection is another technique that can be used to deliver genetic material to target cells. It relies on the use of nanomaterials such as carbon nanofibers, carbon nanotubes, and nanowires. Needle-like nanostructures are synthesized perpendicular to the surface of a substrate. DNA containing the gene to be delivered intracellularly is attached to the surface of the nanostructure. A wafer with an array of such needles is then pressed onto a cell or tissue. Cells pierced by the nanostructure can express the delivered gene. An example of this technique is described in Shalek et al., PNAS 107:25 1870 (2010), the disclosure of which is incorporated herein by reference.

[0173] Nucleic acids can also be delivered to target cells using MAGNETOFECTION™. The principle of MAGNETOFECTION™ is to associate nucleic acids with cationic magnetic nanoparticles. These magnetic nanoparticles are made of fully biodegradable iron oxide and coated with specific cationic proprietary molecules, varying depending on the application. Association with gene vectors (DNA, siRNA, viral vectors, etc.) is achieved through salt-induced colloidal aggregation and electrostatic interactions. The magnetic particles are then focused onto the target cells by an external magnetic field generated by an influencing magnet. This technique is described in detail in Scherer et al., Gene Therapy 9:102 (2002), the disclosure of which is incorporated herein by reference. Magnetic beads are another tool that can be used to transfect target cells in a gentle and effective manner because this method utilizes an applied magnetic field to guide the uptake of nucleic acids. This technique is described in detail, for example, in US 2010 / 0227406, the disclosure of which is incorporated herein by reference.

[0174] Another tool that can be used to induce the uptake of exogenous nucleic acids by target cells is acoustic perforation, which involves using sound (usually ultrasound frequencies) to alter the permeability of the cell membrane to permeate the cell and allow polynucleotides to pass through the cell membrane. This technique is described in detail, for example, Rhodes et al., Methods in Cell Biology 82:309 (2007), the contents of which are incorporated herein by reference.

[0175] Microvesicles represent another potential medium for modifying the genome of target cells according to the methods described herein. For example, microvesicles induced by co-overexpression of the glycoprotein VSV-G and, for example, genome-modifying proteins (e.g., nucleases) can be used to efficiently deliver proteins into cells, subsequently catalyzing site-specific cleavage of endogenous polynucleotide sequences to prepare the cell's genome for covalent incorporation of polynucleotides of interest (e.g., genes or regulatory sequences). The use of such vesicles (also known as gesicles) for genetic modification of eukaryotic cells is described in detail in, for example, Quinn et al., Genetic Modification of Target Cells by Direct Delivery of Active Protein [Abstract]. Methylation changes in early embryonic genes in cancer [Abstract], Proceedings of the 18th Annual Meeting of the American Society of Gene and Cell Therapy; May 13, 2015, Abstract No. 122. Incorporation of target genes by gene editing technology.

[0176] In addition to the above, various tools have been developed for incorporating genes of interest into target cells, such as human cells. One method for incorporating a polynucleotide encoding a target gene into a target cell involves the use of transposons. A transposon is a polynucleotide encoding a transposase and contains a polynucleotide sequence flanked by 5' and 3' excision sites or the gene of interest. Once the transposon has been delivered to the cell, the transposase gene is expressed and produces an active enzyme that cleaves the gene of interest from the transposon. This activity is mediated by the site-specific recognition of the transposon excision site by the transposase. In some cases, these excision sites may be terminal repeats or inverted terminal repeats. Once excised from the transposon, the gene of interest can be integrated into the mammalian cell genome by catalytic cleavage of a similar excision site present in the nuclear genome. This allows the gene of interest to insert into the complementary excision site of the cleaved nuclear DNA, and the incorporation process is completed by the covalent linking of the gene of interest to the phosphodiester bonds of the mammalian cell genome DNA. In some cases, transposons can be retrotransposons, such that the gene encoding the target gene is first transcribed into an RNA product and then retrotranscribed into DNA, which is subsequently incorporated into the mammalian cell genome. Exemplary transposon systems are the piggybac transposon (described in detail, for example, WO 2010 / 085699) and the Sleeping Beauty transposon (described in detail, for example, US 2005 / 0112764), the disclosures of each of these documents relating to transposons used for delivering genes to cells of interest are incorporated herein by reference.

[0177] Another tool for integrating target genes into the target cell genome is the CRISPR / Cas system, which originally evolved as an adaptive defense mechanism against viral infection in bacteria and archaea. The CRISPR / Cas system comprises palindromic repeat sequences within plastid DNA and the associated Cas9 nuclease. This assembly of DNA and protein guides site-specific DNA cleavage of the target sequence by first incorporating the foreign DNA into the CRISPR locus. The polynucleotides containing these foreign sequences and the repeat spacer elements of the CRISPR locus are sequentially transcribed in the host cell to produce guide RNA, which can then anneal to the target sequence and localize the Cas9 nuclease to that site. In this way, highly site-specific Cas9-mediated DNA cleavage can be generated in the foreign polynucleotide because the interaction bringing Cas9 close to the target DNA molecule is controlled by RNA:DNA hybridization. Therefore, a CRISPR / Cas system can be designed to cleave any target DNA molecule of interest. This technology has been used to edit eukaryotic genomes (Hwang et al., Nature Biotechnology 31:227 (2013)) and can be used as an effective means of site-specific editing of target cell genomes to cut DNA before incorporating a gene encoding a target gene. The use of CRISPR / Cas in regulating gene expression has been described, for example, in U.S. Patent No. 8,697,359, the disclosure of which regarding the use of the CRISPR / Cas system for genome editing is incorporated herein by reference. Alternative methods for site-specific cutting of genome DNA before incorporating a gene of interest into a target cell include the use of zinc finger nucleases (ZFNs) and transcription activator-like effector nucleases (TALENs). Unlike the CRISPR / Cas system, these enzymes do not contain guide polynucleotides for locating specific target sequences. Instead, target specificity is controlled by a DNA-binding domain within these enzymes. The uses of ZFN and TALEN in genome editing applications are described in, for example, Urnov et al., Nature Reviews Genetics 11:636 (2010); and Joung et al., Nature Reviews Molecular Cell Biology 14:49 (2013), the disclosures of each of these documents regarding compositions and methods for genome editing are incorporated herein by reference.

[0178] Other gene editing techniques that can be used to incorporate polynucleotides encoding target genes into the gene body of target cells include the use of ARCUSTM broad-spectrum nucleases, which can be rationally designed to cleave gene body DNA at site specificity. Given the defined structure-activity relationships established for such enzymes, the use of these enzymes to incorporate genes encoding target genes into the gene body of mammalian cells is advantageous. Single-stranded broad-spectrum nucleases can be modified at certain amino acid positions to produce nucleases that selectively cleave DNA at desired positions, thereby enabling the target gene to be incorporated at site specificity into the nuclear DNA of the target cell. Such single-stranded nucleases have been extensively described, for example, in U.S. Patent Nos. 8,021,867 and 8,445,251, the disclosures of which relate to compositions and methods for gene editing are incorporated herein by reference. Pharmaceutical Compositions and Administration Routes

[0179] The gene therapy agents described herein may contain transgenic genes, such as transgenic genes encoding MTM1, and may be incorporated into vectors for administration to patients, such as human patients with neuromuscular disorders (e.g., XLMTM). Pharmaceutical compositions containing vectors such as viral vectors containing transcriptional regulatory elements described herein (e.g., desmin promoters) (which are operatively linked to therapeutic transgenic genes) may be prepared using methods known in the art. For example, such compositions may be prepared using, for instance, physiologically acceptable carriers, excipients, or stabilizers (Remington's Pharmaceutical Sciences, 16th edition, Osol, A., ed. (1980); which is incorporated herein by reference) and in the desired form (as a lyophilized formulation or an aqueous solution).

[0180] Viral vectors (e.g., AAV vectors and other vectors described herein) containing transcriptional regulatory elements operatively linked to therapeutic transgenic genes can be administered to patients (e.g., human patients) via a variety of routes of administration. Routes of administration may vary, for example, depending on the onset and severity of disease, and may include, for example, intradermal, percutaneous, non-enteric, intravenous, intramuscular, intranasal, subcutaneous, percutaneous, tracheal, intraperitoneal, intraarterial, intravascular, inhalation, perfusion, lavage, and oral administration. Intravascular administration includes delivery to the patient's vascular system. In some embodiments, administration is to a vessel considered a vein (intravenous), and in some administrations, administration is to a vessel considered an artery (intraarterial). Veins include, but are not limited to, the internal jugular vein, peripheral veins, coronary veins, hepatic veins, portal vein, great saphenous vein, pulmonary veins, superior vena cava, inferior vena cava, gastric vein, splenic vein, inferior mesenteric vein, superior mesenteric vein, cephalic vein, and / or femoral vein. Arteries include, but are not limited to, the coronary arteries, pulmonary artery, brachial artery, internal carotid artery, aortic arch, femoral artery, peripheral arteries, and / or ciliary arteries. Delivery is expected to be made via or to arterioles or capillaries.

[0181] The mixtures of nucleic acids and viral vectors described herein can be prepared in water and suitable mixtures of one or more excipients, carriers, or diluents. Dispersions can also be prepared in glycerol, liquid polyethylene glycol, mixtures thereof, and oils. Under normal storage and use conditions, these formulations may contain preservatives to prevent microbial growth. Suitable pharmaceutical forms for injectable use include sterile aqueous solutions or dispersions and sterile powders for the temporary preparation of sterile injectable solutions or dispersions (described in US 5,466,468, the disclosure of which is incorporated herein by reference). In any case, the formulation may be sterile and may be an injectable fluid. The formulation may be stable under manufacturing and storage conditions and protected against contamination by microorganisms (e.g., bacteria and fungi). The carrier may be a solvent or dispersion medium containing, for example, water, ethanol, polyols (e.g., glycerol, propylene glycol, and liquid polyethylene glycol), suitable mixtures thereof, and / or vegetable oils. Appropriate flowability can be achieved, for example, by using coatings (such as lecithin), maintaining the desired particle size in the case of dispersions, and by using surfactants. Prevention of microbial action can be achieved using various antibacterial and antifungal agents, such as parabens, chlorobutanol, phenol, sorbic acid, thimerosal, and their analogues. In many cases, isotonic agents, such as sugars or sodium chloride, are preferred. Prolonged absorption of injectable compositions can be achieved by using de-absorption agents (such as aluminum monostearate and gelatin) in these compositions.

[0182] For example, if necessary, solutions containing the pharmaceutical compositions described herein may be appropriately buffered and first made isotonic with a sufficient volume of saline or glucose to dilute the liquid. These specific aqueous solutions are particularly suitable for intravenous, intramuscular, subcutaneous, and intraperitoneal administration. In this regard, the sterile aqueous media that may be used according to this disclosure will be known to those skilled in the art. For example, a dose may be dissolved in 1 ml of isotonic NaCl solution and added to 1000 ml of subcutaneous infusion solution or injected at the proposed infusion site. The dosage will inevitably vary depending on the individual's condition. The individual responsible for administration will determine the appropriate dosage for each individual in any given situation. Furthermore, for human administration, the formulation should meet the sterility, pyrogenicity, general safety, and purity standards required by the FDA Office of Biological Standards. Kit

[0183] The compositions described herein may be provided in kits for treating neuromuscular disorders (e.g., XLMTM). The kit may include one or more viral vectors as described herein. The kit may include a packaging insert instructing the kit user (e.g., a physician familiar with the technique) to perform any of the methods described herein. The kit may, as appropriate, include a syringe or other means for administering the composition. In some embodiments, the kit may include one or more additional therapeutic agents. Recommended clinical parameters to consider before initiating daytime weaning from mechanical ventilation.

[0184] Before considering daytime weaning of a patient from mechanical ventilation, physicians familiar with this technique should establish patient-specific baselines for airway patency, oxygenation and ventilation capacity, nutritional status, and tolerance to rehabilitation therapy, and consider broader patient-specific and environmental factors, including those listed in Table 2. Table 2. Patient factors to consider before deciding to wean off mechanical ventilation Respiratory function (i.e., effectiveness, efficiency, strength, and endurance) Cardiopulmonary interaction (i.e., excluding primary or secondary pulmonary hypertension) Nature of respiratory failure or insufficiency Upper airway assessment (i.e., enlarged tonsils / pinnatifida, larynx and / or tracheomalacia) Respiratory function during wakefulness and sleep Tracheobronchial assessment (i.e., mucosal integrity, laryngeal cleft, tracheomalacia, granulomas, or stenosis) Long-term myopathic changes requiring continuous support (such as scoliosis) lead to restrictive respiratory mechanics Nutritional and metabolic needs Secretion management (i.e., oropharynx, nasopharynx, or trachea) Development status Swallowing research Tolerance to the intervention (i.e., invasive or non-invasive) or the need for other adjuvants Intermittent respiratory infections can be tolerated without ventilator support Environmental factors (i.e., cautious withdrawal of aircraft during peak infection seasons or pandemics) Health-related quality of life Immune status (i.e., complete immunity) Chronic lung diseases or complications unrelated to respiratory muscle function Surgery planned in the near future Recommended clinical parameters for starting daytime weaning from mechanical ventilator

[0185] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when the patient's vital signs (e.g., body temperature, heart rate (e.g., pulse), respiratory rate (RR), and blood pressure) and weight are within age-adjusted ranges, or when one or more patients' respiratory function indicators (e.g., maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), positive end-expiratory pressure (PEEP), room air oxygen saturation (SpO2), transcutaneous CO2 (TcCO2), or end-tidal CO2 (ETCO2)) or indirect gas exchange markers (e.g., serum bicarbonate level) are within the ranges described herein during a 12-week evaluation period following treatment with a gene therapy product (e.g., AAV2 encoding MTM1) as described herein. I. Vital Signs and Weight

[0186] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when their vital signs (e.g., body temperature, heart rate (e.g., pulse), respiratory rate (RR), and blood pressure) and weight are within age-adjusted criteria. Ia. Body temperature

[0187] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when the patient’s body temperature is within the age-adjusted criteria as described herein.

[0188] In some embodiments, the patient's temperature can be measured from the mouth, rectum, armpit (e.g., under the armpit), ear, or skin. In some embodiments, the patient's oral, rectal, and armpit temperatures can be measured using a glass or electronic thermometer.

[0189] In some embodiments, the patient's body temperature is measured orally and is considered normal when it falls within the range of about 36.0°C to 37.5°C (e.g., about 36.1°C to about 37.4°C, about 36.2°C to about 37.3°C, about 36.3°C to about 37.2°C, about 36.4°C to about 37.1°C, about 36.5°C to about 37.0°C, about 36.6°C to about 36.9°C, or about 36.7°C to about 36.8°C).

[0190] In some embodiments, the patient's body temperature is measured rectally and is considered normal when it falls within the range of about 36.5°C to 38.0°C (e.g., about 36.6°C to about 37.9°C, about 36.7°C to about 37.8°C, about 36.8°C to about 37.7°C, about 36.9°C to about 37.6°C, about 37.0°C to about 37.5°C, about 37.1°C to about 37.4°C, or about 37.2°C to about 37.3°C).

[0191] In some embodiments, the patient's body temperature is measured axillary and is considered normal when it falls within the range of approximately 35.5°C to 37.0°C (e.g., approximately 35.6°C to approximately 36.9°C, approximately 35.7°C to approximately 36.8°C, approximately 35.8°C to approximately 36.7°C, approximately 35.9°C to approximately 36.6°C, approximately 36.0°C to approximately 36.5°C, approximately 36.1°C to approximately 36.4°C, or approximately 36.2°C to approximately 36.3°C). Ib. Heart Rate

[0192] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when the patient’s heart rate is within the age-adjusted criteria as described herein.

[0193] In some embodiments, heart rate is obtained at the radial artery (e.g., wrist). In some embodiments, heart rate is obtained at the brachial artery (e.g., elbow), carotid artery (e.g., neck), popliteal artery (e.g., behind the knee), or dorsalis pedis artery or posterior tibial artery (e.g., foot).

[0194] In some embodiments, the pulse is obtained by pressing firmly but gently with the index and middle fingers at the above-mentioned location and counting the beats felt every 60 seconds. In some embodiments, the heart rate is obtained by pressing firmly but gently with the index and middle fingers at the above-mentioned location and counting the beats felt every 30 seconds and multiplying by two.

[0195] In some embodiments, heart rate is measured by directly listening to the heartbeat using a stethoscope.

[0196] In some embodiments, the patient is a newborn (e.g., 0-4 months old), an infant (e.g., 0-5 months old), a toddler (e.g., 6-12 months old), a child aged 1-3 years, a child aged 3-5 years, a child aged 6-10 years, an adolescent (e.g., 11-14 years old), or an adult (e.g., 15+ years old (e.g., 16+, 17+, 18+, 19+, 20+, 21+, 22+, 23+, 24+, 25+, 26+, 27+, 28+, 29+, 30+, 40+, 50+, 60+, 70+, 80+, or 90+ years old)).

[0197] In some embodiments, the patient is a newborn (e.g., 0-4 months old) and the patient's heart rate is measured by the methods described herein or other methods and is considered to be within the age-adjusted range when it falls within the range of about 100 to about 160 heart rate per minute (bpm) (e.g., about 105 to about 155 bpm, about 110 to about 150 bpm, about 120 to about 150 bpm, about 130 to about 140 bpm or about 135 bpm).

[0198] In some embodiments, the patient is an infant (e.g., 0–5 months old) and the patient’s heart rate is measured by the methods described herein or other methods and is considered to be within the age-adjusted range when it falls within about 90 to about 150 bpm (e.g., about 95 to about 145 bpm, about 100 to about 140 bpm, about 110 to about 130 bpm or about 120 bpm).

[0199] In some embodiments, the patient is a toddler (e.g., 6–12 months old), and the patient’s heart rate is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 80 to about 140 bpm (e.g., about 85 to about 135 bpm, about 90 to about 130 bpm, about 100 to about 120 bpm or about 110 bpm).

[0200] In some embodiments, the patient is a child aged 1–3 years, and the patient’s heart rate is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 80 to about 130 bpm (e.g., about 85 to about 125 bpm, about 90 to about 120 bpm, about 100 to about 110 bpm or about 115 bpm).

[0201] In some embodiments, the patient is a child aged 3–5 years, and the patient’s heart rate is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 80 to about 120 bpm (e.g., about 85 to about 115 bpm, about 90 to about 110 bpm or about 100 bpm).

[0202] In some embodiments, the patient is a child aged 6–10 years, and the patient’s heart rate is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within about 70 to about 110 bpm (e.g., about 75 to about 105 bpm, about 80 to about 100 bpm or about 90 bpm).

[0203] In some embodiments, the patient is an adolescent (e.g., 11–14 years old) and the patient’s heart rate is measured by the methods described herein or other methods and is considered to be within the age-adjusted range when it falls within the range of about 60 to about 105 bpm (e.g., about 65 to about 100 bpm, about 70 to about 95 bpm, about 75 to about 90 bpm or about 80 bpm to about 85 bpm).

[0204] In some embodiments, the patient is an adult (e.g., 15+ years of age (e.g., 16+, 17+, 18+, 19+, 20+, 21+, 22+, 23+, 24+, 25+, 26+, 27+, 28+, 29+, 30+, 40+, 50+, 60+, 70+, 80+, or 90+ years of age)), and the patient's heart rate is measured by the methods described herein or other methods, and a heart rate falling within the range of approximately 60 to approximately 100 bpm (e.g., approximately 65 to approximately 95 bpm, approximately 70 to approximately 90 bpm, or approximately 80 bpm) is considered to be within the age-adjusted range. Ic. Respiratory Rate

[0205] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when the patient’s RR is within the age-adjusted criteria as described herein.

[0206] In some embodiments, a patient’s RR can be measured using a stethoscope or by methods including but not limited to impedance respiration and carbon dioxide mapping.

[0207] In some embodiments, the patient is a newborn (e.g., 0-6 weeks old), an infant aged 6 weeks to 6 months, a child aged 6 months to 3 years, a child aged 3-6 years, a child aged 6-10 years, an adult aged 10-65 years, an elderly person aged 65-80 years, or an elderly person aged 80+ years.

[0208] In some embodiments, the patient is a newborn (e.g., 0–6 weeks old), and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 30 to about 40 breaths per minute (e.g., about 31 to about 39 breaths, about 32 to about 38 breaths, about 33 to about 37 breaths, about 34 to about 36 breaths, or about 35 breaths).

[0209] In some embodiments, the patient is an infant aged 6 weeks to 6 months, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 25 to about 40 breaths per minute (e.g., about 26 to about 39 breaths, about 27 to about 38 breaths, about 28 to about 37 breaths, about 29 to about 36 breaths, about 30 to about 35 breaths, about 31 to about 34 breaths or about 32 to about 33 breaths).

[0210] In some embodiments, the patient is a child aged 6 months to 3 years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 20 to about 30 breaths per minute (e.g., about 21 to about 29 breaths, about 22 to about 28 breaths, about 23 to about 27 breaths, about 29 to about 26 breaths or about 25 breaths).

[0211] In some embodiments, the patient is a child aged 3–6 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 18 to about 25 breaths per minute (e.g., about 19 to about 24 breaths, about 20 to about 23 breaths, about 21 to about 22 breaths).

[0212] In some embodiments, the patient is a child aged 6–10 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 17 to about 23 breaths per minute (e.g., about 18 to about 22 breaths, about 19 to about 21 breaths or about 20 breaths).

[0213] In some embodiments, the patient is an adult aged 10–65 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 15 to about 18 breaths (e.g., about 16 to about 17 breaths) per minute.

[0214] In some embodiments, the patient is an adult aged 65+ (e.g., 66+, 67+, 68+, 69+, 70+, 75+, 80+, 90+) years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of approximately 12 to approximately 28 breaths per minute (e.g., approximately 13 to approximately 27 breaths, approximately 14 to approximately 26 breaths, approximately 15 to approximately 25 breaths, approximately 16 to approximately 24 breaths, approximately 17 to approximately 23 breaths, approximately 18 to approximately 22 breaths, approximately 19 to approximately 21 breaths, or approximately 20 breaths). Id. Blood Pressure

[0215] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when the patient’s blood pressure is within the age-adjusted criteria as described herein.

[0216] In some embodiments, a patient’s blood pressure may be measured using a blood pressure monitor, an oscilloscope or other means.

[0217] In some embodiments, the patient is a newborn (e.g., 0-1 month old), an infant (e.g., 1-12 months old), a toddler (e.g., 1-5 years old), an older child (e.g., 5+-13 years old), an adolescent (e.g., 13+-18 years old), an adult aged 18+-40, an adult aged 40+-60, or an elderly person (e.g., 60+ years old (e.g., 61+, 62+, 63+, 64+, 65+, 70+, 75+, 80+, 90+) years old).

[0218] In some embodiments, the patient is a newborn (e.g., 0-1 month old), and the patient's blood pressure is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 40 to about 80 mmHg (e.g., about 41 to about 79 mmHg, about 42 to about 78 mmHg, about 44 to about 77 mmHg, about 44 to about 76 mmHg, about 45 to about 75 mmHg, about 50 to about 70 mmHg, about 55 to about 65 mmHg, or about 60 mmHg).

[0219] In some embodiments, the patient is an infant (e.g., 1-12 months old), and the patient's blood pressure is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 65 to about 100 mmHg (e.g., about 66 to about 99 mmHg, about 67 to about 98 mmHg, about 68 to about 97 mmHg, about 69 to about 96 mmHg, about 70 to about 95 mmHg, about 75 to about 90 mmHg, or about 80 to about 85 mmHg).

[0220] In some embodiments, the patient is a young child (e.g., 1-5 years old), and the patient's blood pressure is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within about 80 to about 115 mmHg (e.g., about 81 to about 114 mmHg, about 82 to about 113 mmHg, about 83 to about 112 mmHg, about 84 to about 111 mmHg, about 85 to about 110 mmHg, about 90 to about 105 mmHg, or about 95 to about 100 mmHg).

[0221] In some embodiments, the patient is an older child (e.g., 5+-13 years old) and the patient’s blood pressure is measured by the methods described herein or other methods and is considered to be within the age-adjusted range when it falls within the range of about 80 to about 120 mmHg (e.g., about 81 to about 119 mmHg, about 82 to about 118 mmHg, about 83 to about 117 mmHg, about 84 to about 116 mmHg, about 85 to about 115 mmHg, about 90 to about 110 mmHg, about 95 to about 105 mmHg or about 100 mmHg).

[0222] In some embodiments, the patient is an adolescent (e.g., 13+-18 years old) and the patient's blood pressure is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within about 90 to about 120 mmHg (e.g., about 91 to about 119 mmHg, about 92 to about 118 mmHg, about 93 to about 117 mmHg, about 94 to about 116 mmHg, about 95 to about 115 mmHg, about 100 to about 110 mmHg or about 105 mmHg).

[0223] In some embodiments, the patient is an adult aged 18+-40 years, and the patient's blood pressure is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within about 95 to about 135 mmHg (e.g., about 96 to about 134 mmHg, about 97 to about 133 mmHg, about 98 to about 132 mmHg, about 99 to about 131 mmHg, about 100 to about 130 mmHg, about 105 to about 125 mmHg, about 110 to about 120 mmHg, or about 115 mmHg).

[0224] In some embodiments, the patient is an adult aged 40+-60 years, and the patient's blood pressure is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 110 to about 145 mmHg (e.g., about 111 to about 144 mmHg, about 112 to about 143 mmHg, about 113 to about 142 mmHg, about 114 to about 141 mmHg, about 115 to about 140 mmHg, about 120 to about 135 mmHg, or about 125 to about 130 mmHg).

[0225] In some embodiments, the patient is considered to be elderly (e.g., 60+ (e.g., 61+, 62+, 63+, 64+, 65+, 70+, 75+, 80+, 90+) years old), and the patient's blood pressure is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within about 95 to about 145 mmHg (e.g., about 96 to about 144 mmHg, about 97 to about 143 mmHg, about 98 to about 142 mmHg, about 99 to about 141 mmHg, about 100 to about 140 mmHg, about 105 to about 135 mmHg, about 110 to about 130 mmHg, about 115 to about 125 mmHg, or about 120 mmHg). Ie. Weight

[0226] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when their weight is within the age-adjusted criteria as described herein.

[0227] In some embodiments, male patients are considered ready to begin daytime weaning from mechanical ventilation when their weight falls within the range listed in Table 3. Table 3. Age-Adjusted Standard Weight Ranges for Men Age (months / years) Age-adjusted standard weight range (pounds) 0-1 month From approximately 5.5 to approximately 9.5 1-2 months Approximately 7.5 to approximately 12.5 2-3 months From approximately 9.7 to approximately 15.4 3-4 months From approximately 11.2 to approximately 17.4 4-5 months From approximately 12.3 to approximately 18.9 5-6 months From approximately 13.4 to approximately 20.3 6-7 months From approximately 14.1 to approximately 21.4 7-8 months Approximately 14.7 to approximately 22.5 8-9 months Approximately 15.4 to approximately 23.1 9-10 months From approximately 15.9 to approximately 24.0 10-11 months Approximately 16.5 to approximately 24.7 11-12 months From approximately 16.3 to approximately 25.4 1-2 years old From about 17 to about 21 2-3 years old Approximately 24 to approximately 34 3-4 years old Approximately 26 to approximately 38 4-6 years old Approximately 30 to approximately 44 6-8 years old Approximately 36 to approximately 60 8-10 years old Approximately 46 to approximately 78 10-12 years old Approximately 54 to approximately 102 12-14 years old Approximately 66 to approximately 130 14-16 years old Approximately 84 to approximately 160 16-18 years old Approximately 104 to approximately 186 18+ years old Approximately 116 to approximately 202

[0228] In some embodiments, female patients are considered ready to begin daytime weaning from mechanical ventilation when their weight falls within the range listed in Table 4. Table 4. Age-Adjusted Standard Weight Ranges for Women Age (months / years) Age-adjusted standard weight range (lbs) 0-1 month From approximately 5.3 to approximately 9.3 1-2 months From approximately 7.0 to approximately 11.9 2-3 months From approximately 8.8 to approximately 14.3 3-4 months From approximately 10.1 to approximately 16.3 4-5 months From approximately 11.2 to approximately 17.9 5-6 months From approximately 12.1 to approximately 19.1 6-7 months From approximately 12.8 to approximately 20.3 7-8 months From approximately 13.4 to approximately 21.1 8-9 months From approximately 13.8 to approximately 22.0 9-10 months From approximately 14.5 to approximately 22.9 10-11 months From approximately 15.0 to approximately 23.6 11-12 months Approximately 15.4 to approximately 24.3 1-2 years old Approximately 15 to approximately 20 2-3 years old Approximately 22 to approximately 32 3-4 years old Approximately 26 to approximately 38 4-6 years old Approximately 28 to approximately 44 6-8 years old Approximately 36 to approximately 60 8-10 years old Approximately 44 to approximately 80 10-12 years old Approximately 54 to approximately 106 12-14 years old Approximately 68 to approximately 136 14-16 years old Approximately 84 to approximately 160 16-18 years old Approximately 94 to approximately 172 18+ years old Approximately 100 to approximately 178 II. Respiratory function

[0229] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when one or more respiratory function indicators (e.g., MIP, MEP, PEEP, SpO2, TcCO2, or ETCO2) are within the ranges described herein. IIa. Inspiratory pressure

[0230] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilator when the patient's MIP requirement for the ventilator is greater than -50 cmH2O (e.g., greater than -49 cmH2O, greater than -48 cmH2O, greater than -47 cmH2O, greater than -46 cmH2O, greater than -45 cmH2O, greater than -40 cmH2O, greater than -35 cmH2O, greater than -30 cmH2O, greater than -20 cmH2O, greater than -10 cmH2O, or greater than 0.0 cmH2O). IIb. Expiratory Pressure

[0231] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when the patient's MEP requirement for the ventilator is greater than 40 cmH2O (e.g., greater than 41 cmH2O, greater than 42 cmH2O, greater than 43 cmH2O, greater than 44 cmH2O, greater than 45 cmH2O, greater than 50 cmH2O, greater than 55 cmH2O, greater than 60 cmH2O, greater than 70 cmH2O, or greater than 80 cmH2O). IIc. Positive End-Expiratory Pressure

[0232] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when the patient's PEEP requirement for the ventilator is less than or equal to 5 cmH2O (e.g., less than or equal to 5 cmH2O, less than or equal to 4 cmH2O, less than or equal to 3 cmH2O, less than or equal to 2 cmH2O, less than or equal to 1 cmH2O, or less than or equal to 0 cmH2O). IId. Indoor air oxygen saturation

[0233] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when their SpO2 is greater than 94% (e.g., greater than 95%, greater than 96%, greater than 97%, greater than 98%, or greater than 99%). IIe. Transcutaneous CO2

[0234] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when their TcCO2 is about 35 to about 45 mmHg (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg).

[0235] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when their ETCO2 is about 35 to about 45 mmHg (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg). III. Indirect Gas Exchange

[0236] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when one or more indirect gas exchange markers (e.g., serum bicarbonate) are within the measurement ranges described herein. IIIa. Serum bicarbonate

[0237] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when their serum bicarbonate level is about 22 to about 27 mEq / L (e.g., about 23 to about 26 mEq / L or about 24 to about 25 mEq / L). VI. Other considerations: Clinical judgment

[0238] In some embodiments, a patient is considered ready to begin daytime weaning from mechanical ventilation when considering one or more clinical parameters, including motor milestones (e.g., head control, sitting, voluntary grasping, supine, rolling, crawling or hip movement ability, standing and walking), phonation, coughing, secretions, or motor function scores on CHOP INTEND. Recommended clinical parameters for continuing daytime weaning from mechanical ventilation.

[0239] In some embodiments, when one or more of the patient's vital signs (e.g., RR), respiratory function indicators (e.g., SpO2, TcCO2), and clinical parameters (e.g., intercostal contractions, respiratory tachycardia, respiratory paradox, or phase delay) are within the measurement ranges described herein during video recording of the assessment of a respiratory sprint test; when one or more of the patient's vital signs (e.g., RR) or respiratory function indicators (e.g., TcCO2, ETCO2, or SpO2) are monitored during nighttime respiratory monitoring When the patient's vital signs (e.g., RR), respiratory function indicators (e.g., TcCO2, petCO2, ptcCO2, PO2, or SpO2), or apnea-hypopnea index (AHI) are within the ranges described herein, the patient is considered ready to continue daytime weaning from mechanical ventilation. I. Breathing Sprint Test

[0240] In some embodiments, a patient is considered ready to continue daytime weaning from mechanical ventilation when one or more of the respiratory function indicators (e.g., SpO2, TcCO2) are within the range of measurements described herein during the assessment of the video recording of the respiratory sprint test or when no clinical parameters (e.g., intercostal retraction, respiratory tachycardia, respiratory paradox, or phase delay) are observed during the assessment of the video recording of the respiratory sprint test.

[0241] In some embodiments, the duration of the breathing sprint test is about 15 to about 30 minutes (e.g., about 16 to about 29 minutes, about 17 to about 28 minutes, about 18 to about 27 minutes, about 19 to about 26 minutes, about 20 to about 25 minutes or about 20 minutes).

[0242] In some embodiments, the duration of the respiratory sprint test is gradually increased, for example, from 24 to 25 minutes every 3 to 4 days. Ia. Respiratory function

[0243] In some embodiments, a patient is considered ready to continue daytime weaning from mechanical ventilation when one or more respiratory function indicators (e.g., SpO2 or TcCO2) are within the measurement ranges described herein.

[0244] In some embodiments, when a patient’s SpO2 is observed to be greater than 94% (e.g., greater than 95%, greater than 96%, greater than 97%, greater than 98%, or greater than 99%) during video recording of a respiratory sprint test, the patient is considered ready to continue weaning from mechanical ventilator during the day.

[0245] In some embodiments, when a patient's SpO2 differs from a conscious baseline by no more than 3% (e.g., no more than 4%, 5%, 6%, 7%, 8%, 9%, 10%, 15%, 20%, or 30%) during video recording of a respiratory sprint test, the patient is considered ready to continue daytime weaning from mechanical ventilation.

[0246] In some embodiments, when a patient’s TcCO2 is less than 45 mmHg (e.g., less than 44 mmHg, less than 43 mmHg, less than 42 mmHg, less than 41 mmHg, or less than 40 mmHg) during video recording of a respiratory sprint test, the patient is considered ready to continue weaning from mechanical ventilator during the day.

[0247] In some embodiments, a patient is considered ready to continue daytime weaning from mechanical ventilation when their TcCO2 does not increase by 10 mmHg or more relative to waking baseline during video recording of a respiratory sprint test (e.g., not increasing by 11 mmHg or more, not increasing by 12 mmHg or more, not increasing by 13 mmHg or more, not increasing by 14 mmHg or more, not increasing by 15 mmHg or more, not increasing by 20 mmHg or more, not increasing by 25 mmHg or more, or not increasing by 30 mmHg or more). Ib. Clinical Judgment

[0248] In some embodiments, when no distress is observed during video recording of a respiratory sprint test, the patient is considered ready to continue weaning from mechanical ventilator during the day.

[0249] In some embodiments, when no intercostal retraction is observed during video recording of a respiratory sprint test, the patient is considered ready to continue weaning from mechanical ventilator during the day.

[0250] In some embodiments, when no respiratory tachycardia is observed during video recording of a respiratory sprint test, the patient is considered ready to continue weaning from mechanical ventilator during the day.

[0251] In some embodiments, when no respiratory abnormalities are observed during video recording of a respiratory sprint test, the patient is considered ready to continue weaning from mechanical ventilator during the day.

[0252] In some embodiments, when no phase delay is observed during video recording of the respiratory sprint test, the patient is considered ready to continue daytime weaning from mechanical ventilation. II. Nighttime Respiratory Monitoring

[0253] In some embodiments, a patient is considered ready to continue daytime weaning from mechanical ventilation when one or more of the patient's vital signs (e.g., RR) or respiratory function indicators (e.g., TcCO2, ETCO2, SpO2) are within the measurement ranges described herein during nighttime monitoring assessment. IIa. Vital Signs

[0254] In some embodiments, a patient is considered ready to continue daytime weaning from mechanical ventilation when one or more of the patient's vital signs (e.g., RR) are within the measurement range as described herein during an assessment of nighttime monitoring. IIai. Respiratory rate

[0255] In some embodiments, a patient’s RR can be measured using a stethoscope or by methods including but not limited to impedance respiration and carbon dioxide mapping.

[0256] In some embodiments, the patient is a newborn (e.g., 0-6 weeks old), an infant aged 6 weeks to 6 months, a child aged 6 months to 3 years, a child aged 3-6 years, a child aged 6-10 years, an adult aged 10-65 years, an elderly person aged 65-80 years, or an elderly person aged 80+ years.

[0257] In some embodiments, the patient is a newborn (e.g., 0–6 weeks old), and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 30 to about 40 breaths per minute (e.g., about 31 to about 39 breaths, about 32 to about 38 breaths, about 33 to about 37 breaths, about 34 to about 36 breaths or about 35 breaths).

[0258] In some embodiments, the patient is an infant aged 6 weeks to 6 months, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 25 to about 40 breaths per minute (e.g., about 26 to about 39 breaths, about 27 to about 38 breaths, about 28 to about 37 breaths, about 29 to about 36 breaths, about 30 to about 35 breaths, about 31 to about 34 breaths or about 32 to about 33 breaths).

[0259] In some embodiments, the patient is a child aged 6 months to 3 years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 20 to about 30 breaths per minute (e.g., about 21 to about 29 breaths, about 22 to about 28 breaths, about 23 to about 27 breaths, about 29 to about 26 breaths or about 25 breaths).

[0260] In some embodiments, the patient is a child aged 3–6 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 18 to about 25 breaths (e.g., about 19 to about 24 breaths, about 20 to about 23 breaths, about 21 to about 22 breaths) per minute.

[0261] In some embodiments, the patient is a child aged 6–10 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 17 to about 23 breaths per minute (e.g., about 18 to about 22 breaths, about 19 to about 21 breaths or about 20 breaths).

[0262] In some embodiments, the patient is an adult aged 10–65 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 15 to about 18 breaths (e.g., about 16 to about 17 breaths) per minute.

[0263] In some embodiments, the patient is an adult aged 65+ (e.g., 66+, 67+, 68+, 69+, 70+, 75+, 80+, 90+) years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of approximately 12 to approximately 28 breaths per minute (e.g., approximately 13 to approximately 27 breaths, approximately 14 to approximately 26 breaths, approximately 15 to approximately 25 breaths, approximately 16 to approximately 24 breaths, approximately 17 to approximately 23 breaths, approximately 18 to approximately 22 breaths, approximately 19 to approximately 21 breaths, or approximately 20 breaths). IIb. Respiratory Function

[0264] In some embodiments, a patient is considered ready to continue daytime weaning from mechanical ventilation when one or more respiratory function parameters (e.g., SpO2, TcCO2, or ETCO2) are within the measurement ranges described herein during nocturnal respiratory monitoring. IIbi. Transcutaneous CO2

[0265] In some embodiments, when a patient's TcCO2 is about 35 to about 45 mmHg during nighttime respiratory monitoring (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg), the patient is considered ready to continue daytime weaning from mechanical ventilation. IIbii. End-tidal CO2

[0266] In some embodiments, when a patient's ETCO2 is about 35 to about 45 mmHg during nighttime respiratory monitoring (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg), the patient is considered ready to continue daytime weaning from mechanical ventilation. IIbiii. Oxygen saturation

[0267] In some embodiments, when a patient's SpO2 is greater than 94% (e.g., greater than 95%, greater than 96%, greater than 97%, greater than 98%, or greater than 99%) during nocturnal respiratory monitoring, the patient is considered ready to continue daytime weaning from mechanical ventilation. III. Polysomnography

[0268] In some embodiments, polysomnography (PSG) of respiration is performed when the patient is weaned from a mechanical ventilator. In some embodiments, the patient is a patient on invasive ventilation, wherein PSG is performed through a tracheostomy opening when the patient is weaned from a mechanical ventilator. In some embodiments, the patient is a patient on non-invasive ventilation, wherein PSG is performed when the patient is weaned from a mechanical ventilator and nighttime monitoring is conducted.

[0269] In some embodiments, a patient is considered ready to continue daytime weaning from mechanical ventilation when one or more of the patient’s vital signs (e.g., respiratory rate), respiratory function indicators (e.g., TcCO2, petCO2, ptcCO2, PO2, or SpO2), or AHI are within the range of measurements as described herein during PSG.

[0270] In some embodiments, TcCO2 is measured instead of PSG during nighttime respiratory monitoring (i.e., using a digital monitoring system). In some embodiments, when a patient's TcCO2 has been monitored nighttime for about 2-3 nights (e.g., about 2 or about 3 nights) and the TcCO2 is about 35 to about 45 mmHg (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg), the patient is considered ready to continue daytime weaning from mechanical ventilation. IIIa. Vital Signs

[0271] In some embodiments, a patient is considered ready to continue daytime weaning from mechanical ventilation when one or more of the patient's vital signs (e.g., RR) are within the range of measurements as described herein during PSG. IIIai. Respiratory rate

[0272] In some embodiments, a patient’s RR can be measured using a stethoscope or by methods including but not limited to impedance respiration and carbon dioxide mapping.

[0273] In some embodiments, the patient is a newborn (e.g., 0-6 weeks old), an infant 6 weeks to 6 months old, a child 6 months to 3 years old, a child 3-6 years old, a child 6-10 years old, an adult 10-65 years old, an elderly person 65-80 years old, or an elderly person 80+ years old.

[0274] In some embodiments, the patient is a newborn (e.g., 0–6 weeks old), and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 30 to about 40 breaths per minute (e.g., about 31 to about 39 breaths, about 32 to about 38 breaths, about 33 to about 37 breaths, about 34 to about 36 breaths or about 35 breaths).

[0275] In some embodiments, the patient is an infant aged 6 weeks to 6 months, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 25 to about 40 breaths per minute (e.g., about 26 to about 39 breaths, about 27 to about 38 breaths, about 28 to about 37 breaths, about 29 to about 36 breaths, about 30 to about 35 breaths, about 31 to about 34 breaths or about 32 to about 33 breaths).

[0276] In some embodiments, the patient is a child aged 6 months to 3 years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 20 to about 30 breaths per minute (e.g., about 21 to about 29 breaths, about 22 to about 28 breaths, about 23 to about 27 breaths, about 29 to about 26 breaths, or about 25 breaths).

[0277] In some embodiments, the patient is a child aged 3–6 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 18 to about 25 breaths per minute (e.g., about 19 to about 24 breaths, about 20 to about 23 breaths, about 21 to about 22 breaths).

[0278] In some embodiments, the patient is a child aged 6–10 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 17 to about 23 breaths per minute (e.g., about 18 to about 22 breaths, about 19 to about 21 breaths or about 20 breaths).

[0279] In some embodiments, the patient is an adult aged 10–65 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 15 to about 18 breaths (e.g., about 16 to about 17 breaths) per minute.

[0280] In some embodiments, the patient is an adult aged 65+ (e.g., 66+, 67+, 68+, 69+, 70+, 75+, 80+, 90+) years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of approximately 12 to approximately 28 breaths per minute (e.g., approximately 13 to approximately 27 breaths, approximately 14 to approximately 26 breaths, approximately 15 to approximately 25 breaths, approximately 16 to approximately 24 breaths, approximately 17 to approximately 23 breaths, approximately 18 to approximately 22 breaths, approximately 19 to approximately 21 breaths, or approximately 20 breaths). IIIb. Apnea-Hypopnea Index

[0281] In some embodiments, when a tracheostomy is performed on a patient on invasive ventilation or when a mask is removed from a patient on non-invasive ventilation for PSG, the patient is considered ready to continue daytime weaning from mechanical ventilation when the AHI is less than 5 events / hour (e.g., less than 4 events / hour, less than 3 events / hour, less than 2 events / hour, or less than 1 event / hour). IIIc. Respiratory Function

[0282] In some embodiments, when a tracheostomy is performed on a patient on invasive ventilation or when a mask is removed from a patient on non-invasive ventilation for PSG, the patient is considered ready to continue daytime weaning from mechanical ventilation when one or more respiratory function parameters (e.g., TcCO2, petCO2, or ptcCO2 or ETCO2) are within the ranges described herein. IIIci. Transcutaneous CO2

[0283] In some embodiments, when a tracheostomy is performed on a patient undergoing invasive ventilation or when a mask is removed from a patient undergoing PSG on a patient undergoing non-invasive ventilation, the patient is considered ready to continue weaning from mechanical ventilation during the day when the patient's TcCO2 is about 35 to about 45 mmHg (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg).

[0284] In some embodiments, when a tracheostomy is performed on a patient undergoing invasive ventilation or when a mask is removed from a patient undergoing PSG on a non-invasively ventilated patient, the patient is considered ready to continue daytime weaning from mechanical ventilation when their TcCO2 does not increase by 10 mmHg or more relative to their awake baseline (e.g., not increasing by 11 mmHg or more, not increasing by 12 mmHg or more, not increasing by 13 mmHg or more, not increasing by 14 mmHg or more, not increasing by 15 mmHg or more, not increasing by 20 mmHg or more, not increasing by 25 mmHg or more, or not increasing by 30 mmHg or more). IIIcii. End-tidal CO2 or CO2 partial pressure

[0285] In some embodiments, when a patient’s petCO2 or ptcCO2 is within the measurement range as described herein during PSG, the patient is considered ready to continue weaning from mechanical ventilator during the day.

[0286] In some embodiments, when a patient on invasive ventilation is opened via tracheostomy or when a patient on non-invasive ventilation is removed from their mask for PSG, the patient is considered ready to continue weaning from mechanical ventilation during the day when their petCO2 or ptcCO2 is less than 50 mmHg (e.g., less than 49 mmHg, less than 48 mmHg, less than 47 mmHg, less than 46 mmHg, less than 45 mmHg, less than 40 mmHg, less than 35 mmHg, less than 30 mmHg, less than 20 mmHg, or less than 10 mmHg).

[0287] In some embodiments, when a tracheostomy is performed on a patient undergoing invasive ventilation or when a mask is removed from a patient undergoing PSG on a non-invasively ventilated patient, the patient is considered ready to continue daytime weaning from mechanical ventilation when the patient's petCO2 or ptcCO2 does not increase by more than 10 mmHg relative to the awake baseline (e.g., not more than 11 mmHg, not more than 11 mmHg during sleep, not more than 11 mmHg, not more than 11 mmHg, not more than 11 mmHg, not more than 11 mmHg, or not more than 11 mmHg). IIIciii. Oxygen saturation

[0288] In some embodiments, when a tracheostomy is performed on a patient on invasive ventilation or when a mask is removed from a patient on non-invasive ventilation for PSG, the patient is considered ready to continue weaning from mechanical ventilation during the day when their SpO2 is greater than 94% (e.g., greater than 95%, greater than 96%, greater than 97%, greater than 98%, or greater than 99%). (Weaning from mechanical ventilation during nap time)

[0289] In some embodiments, when a patient successfully discontinues ventilator support during the daytime waking hours, a physician familiar with this technique may consider initiating the process of weaning the patient off the mechanical ventilator during nap time.

[0290] In some embodiments, a pulse oximeter is used during naps to monitor a decrease in the patient’s oxygen saturation and an increase in heart rate.

[0291] In some embodiments, a physician skilled in this technique may consider monitoring the patient’s TcCO2 at home when determining whether the patient is ready to begin the process of weaning from mechanical ventilator during nap time.

[0292] In some embodiments, when respiratory tachycardia is observed in a patient during weaning from mechanical ventilation during a nap, the patient is considered not ready to continue napping and be weaned from mechanical ventilation.

[0293] In some embodiments, when a patient’s respiratory tachycardia is observed during weaning from mechanical ventilation during a nap, the patient is considered not ready to continue napping and be weaned from mechanical ventilation.

[0294] In some embodiments, when a patient’s SpO2 is less than 95% (e.g., less than 94%, less than 93%, less than 92%, less than 91%, less than 90%, less than 85%, less than 80%, less than 70%, or less than 60%) during nap weaning, the patient is considered not ready to continue napping and wean off the mechanical ventilator.

[0295] In some embodiments, when a patient’s heart rate increases by more than 20 bpm relative to the awake baseline during nap weaning (e.g., more than 21 bpm, more than 22 bpm, more than 23 bpm, more than 24 bpm, more than 25 bpm, more than 30 bpm or more than 40 bpm), the patient is considered not ready to continue napping and wean off the mechanical ventilator.

[0296] In some embodiments, when a patient’s TcCO2 is greater than 50 mmHg (e.g., greater than 51 mmHg, greater than 52 mmHg, greater than 53 mmHg, greater than 54 mmHg, greater than 55 mmHg, greater than 60 mmHg, greater than 65 mmHg, greater than 70 mmHg, or greater than 80 mmHg) during nap weaning, the patient is considered not ready to continue napping and be weaned from mechanical ventilator.

[0297] In some embodiments, when a patient's TcCO2 increases by 10 mmHg or more relative to waking baseline during nap weaning (e.g., an increase of 11 mmHg or more, 12 mmHg or more, 13 mmHg or more, 14 mmHg or more, 15 mmHg or more, 20 mmHg or more, 25 mmHg or more, or 30 mmHg or more), the patient is considered not ready to continue napping for weaning from mechanical ventilation. Nighttime weaning from mechanical ventilation

[0298] In some embodiments, when a patient successfully discontinues ventilator support during daytime wakefulness and nap time, a physician familiar with this technique may consider initiating the process of weaning the patient off the mechanical ventilator during the night.

[0299] In some embodiments, a patient is considered ready to continue nighttime weaning from mechanical ventilation when one or more of the patient's vital signs (e.g., RR) or respiratory function indicators (e.g., TcCO2, ETCO2, or SpO2) are within the ranges described herein during nocturnal respiratory monitoring; or when a tracheostomy is performed on an invasively ventilated patient or a polysomnography (PSG) is performed on a non-invasively ventilated patient after mask removal, and one or more of the patient's vital signs (e.g., RR), respiratory function indicators (e.g., TcCO2, end-tidal CO2 (petCO2), partial pressure of CO2 (ptcCO2), PO2, or SpO2), or AHI are within the ranges described herein. Recommended clinical parameters for continuing daytime weaning from mechanical ventilation.

[0300] In some embodiments, a patient is considered ready to continue nighttime weaning from mechanical ventilation when one or more of the patient's vital signs (e.g., RR) or respiratory function indicators (e.g., TcCO2, ETCO2, or SpO2) are within the ranges described herein during video recording of a respiratory sprint assessment; or when a tracheostomy is performed on an invasively ventilated patient or a mask is removed from a non-invasively ventilated patient for PSG, and one or more of the patient's vital signs (e.g., RR), respiratory function indicators (e.g., TcCO2, petCO2, ptcCO2, PO2, or SpO2), or AHI are within the ranges described herein. I. Nighttime Respiratory Monitoring

[0301] In some embodiments, a patient is considered ready to continue nighttime weaning from mechanical ventilation when one or more of the patient's vital signs (e.g., RR) or respiratory function indicators (e.g., TcCO2, ETCO2, SpO2) are within the measurement ranges described herein during an assessment of nighttime monitoring. Ia. Vital Signs

[0302] In some embodiments, a patient is considered ready to continue nighttime weaning from mechanical ventilation when one or more of the patient's vital signs (e.g., respiratory rate) are within the range of measurements as described herein during an assessment of nighttime monitoring.

[0303] In some embodiments, a patient’s RR can be measured using a stethoscope or by methods including but not limited to impedance respiration and carbon dioxide mapping.

[0304] In some embodiments, the patient is a newborn (e.g., 0-6 weeks old), an infant aged 6 weeks to 6 months, a child aged 6 months to 3 years, a child aged 3-6 years, a child aged 6-10 years, an adult aged 10-65 years, an elderly person aged 65-80 years, or an elderly person aged 80+ years.

[0305] In some embodiments, the patient is a newborn (e.g., 0–6 weeks old), and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 30 to about 40 breaths per minute (e.g., about 31 to about 39 breaths, about 32 to about 38 breaths, about 33 to about 37 breaths, about 34 to about 36 breaths or about 35 breaths).

[0306] In some embodiments, the patient is an infant aged 6 weeks to 6 months, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 25 to about 40 breaths per minute (e.g., about 26 to about 39 breaths, about 27 to about 38 breaths, about 28 to about 37 breaths, about 29 to about 36 breaths, about 30 to about 35 breaths, about 31 to about 34 breaths or about 32 to about 33 breaths).

[0307] In some embodiments, the patient is a child aged 6 months to 3 years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 20 to about 30 breaths per minute (e.g., about 21 to about 29 breaths, about 22 to about 28 breaths, about 23 to about 27 breaths, about 29 to about 26 breaths, or about 25 breaths).

[0308] In some embodiments, the patient is a child aged 3–6 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 18 to about 25 breaths per minute (e.g., about 19 to about 24 breaths, about 20 to about 23 breaths, about 21 to about 22 breaths).

[0309] In some embodiments, the patient is a child aged 6–10 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 17 to about 23 breaths per minute (e.g., about 18 to about 22 breaths, about 19 to about 21 breaths or about 20 breaths).

[0310] In some embodiments, the patient is an adult aged 10–65 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 15 to about 18 breaths (e.g., about 16 to about 17 breaths) per minute.

[0311] In some embodiments, the patient is an adult aged 65+ (e.g., 66+, 67+, 68+, 69+, 70+, 75+, 80+, 90+) years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of approximately 12 to approximately 28 breaths per minute (e.g., approximately 13 to approximately 27 breaths, approximately 14 to approximately 26 breaths, approximately 15 to approximately 25 breaths, approximately 16 to approximately 24 breaths, approximately 17 to approximately 23 breaths, approximately 18 to approximately 22 breaths, approximately 19 to approximately 21 breaths, or approximately 20 breaths). Ib. Respiratory Function

[0312] In some embodiments, a patient is considered ready to continue nighttime weaning from mechanical ventilation when one or more respiratory function parameters (e.g., SpO2, TcCO2, or ETCO2) are within the measurement ranges described herein during nocturnal respiratory monitoring. Ibi. Transcutaneous CO2

[0313] In some embodiments, when a patient's TcCO2 is about 35 to about 45 mmHg during nocturnal respiratory monitoring (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg), the patient is considered ready to continue nighttime weaning from mechanical ventilation. (Ibii. end-tidal CO2)

[0314] In some embodiments, when a patient's ETCO2 is about 35 to about 45 mmHg during nighttime respiratory monitoring (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg), the patient is considered ready to continue nighttime weaning from mechanical ventilation. Ibiii. Oxygen saturation

[0315] In some embodiments, when a patient's SpO2 is greater than 94% (e.g., greater than 95%, greater than 96%, greater than 97%, greater than 98%, or greater than 99%) during nocturnal respiratory monitoring, the patient is considered ready to continue weaning from mechanical ventilation at night. II. Polysomnography

[0316] In some embodiments, PSG is performed during patient weaning from mechanical ventilation. In some embodiments, the patient is on invasive ventilation, wherein PSG is performed through a tracheostomy opening during patient weaning from mechanical ventilation. In some embodiments, the patient is on non-invasive ventilation, wherein PSG is performed during patient weaning from mechanical ventilation and nighttime monitoring is conducted.

[0317] In some embodiments, a patient is considered ready to continue nighttime weaning from mechanical ventilation when one or more of the patient’s vital signs (e.g., RR), respiratory function indicators (e.g., TcCO2, petCO2, ptcCO2, PO2, or SpO2) or AHI are within the range of measurements as described herein during PSG.

[0318] In some embodiments, TcCO2 is measured instead of PSG during nighttime respiratory monitoring (i.e., using a digital monitoring system). In some embodiments, when a patient's TcCO2 has been monitored nighttime for about 2-3 nights (e.g., about 2 or about 3 nights) and the TcCO2 is about 35 to about 45 mmHg (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg), the patient is considered ready to continue nighttime weaning from mechanical ventilation. IIa. Vital Signs

[0319] In some embodiments, a patient is considered ready to continue overnight weaning from mechanical ventilation when one or more of the patient's vital signs (e.g., respiratory rate) are within the ranges described herein during PSG.

[0320] In some embodiments, a patient’s RR can be measured using a stethoscope or by methods including but not limited to impedance respiration and carbon dioxide mapping.

[0321] In some embodiments, the patient is a newborn (e.g., 0-6 weeks old), an infant aged 6 weeks to 6 months, a child aged 6 months to 3 years, a child aged 3-6 years, a child aged 6-10 years, an adult aged 10-65 years, an elderly person aged 65-80 years, or an elderly person aged 80+ years.

[0322] In some embodiments, the patient is a newborn (e.g., 0–6 weeks old), and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 30 to about 40 breaths per minute (e.g., about 31 to about 39 breaths, about 32 to about 38 breaths, about 33 to about 37 breaths, about 34 to about 36 breaths or about 35 breaths).

[0323] In some embodiments, the patient is an infant aged 6 weeks to 6 months, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 25 to about 40 breaths per minute (e.g., about 26 to about 39 breaths, about 27 to about 38 breaths, about 28 to about 37 breaths, about 29 to about 36 breaths, about 30 to about 35 breaths, about 31 to about 34 breaths or about 32 to about 33 breaths).

[0324] In some embodiments, the patient is a child aged 6 months to 3 years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 20 to about 30 breaths per minute (e.g., about 21 to about 29 breaths, about 22 to about 28 breaths, about 23 to about 27 breaths, about 29 to about 26 breaths or about 25 breaths).

[0325] In some embodiments, the patient is a child aged 3–6 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 18 to about 25 breaths per minute (e.g., about 19 to about 24 breaths, about 20 to about 23 breaths, about 21 to about 22 breaths).

[0326] In some embodiments, the patient is a child aged 6–10 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 17 to about 23 breaths per minute (e.g., about 18 to about 22 breaths, about 19 to about 21 breaths or about 20 breaths).

[0327] In some embodiments, the patient is an adult aged 10–65 years, and the patient’s RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of about 15 to about 18 breaths (e.g., about 16 to about 17 breaths) per minute.

[0328] In some embodiments, the patient is an adult aged 65+ (e.g., 66+, 67+, 68+, 69+, 70+, 75+, 80+, 90+) years, and the patient's RR is measured by the methods described herein or other methods, and is considered to be within the age-adjusted range when it falls within the range of approximately 12 to approximately 28 breaths per minute (e.g., approximately 13 to approximately 27 breaths, approximately 14 to approximately 26 breaths, approximately 15 to approximately 25 breaths, approximately 16 to approximately 24 breaths, approximately 17 to approximately 23 breaths, approximately 18 to approximately 22 breaths, approximately 19 to approximately 21 breaths, or approximately 20 breaths). IIb. Apnea-Hypopnea Index

[0329] In some embodiments, when a tracheostomy is performed on a patient on invasive ventilation or when a mask is removed from a patient on non-invasive ventilation for PSG, the patient is considered ready to continue nighttime weaning from mechanical ventilation when the AHI is less than 5 events / hour (e.g., less than 4 events / hour, less than 3 events / hour, less than 2 events / hour, or less than 1 event / hour). IIc. Respiratory Function

[0330] In some embodiments, when a tracheostomy is performed on a patient on invasive ventilation or when a mask is removed from a patient on non-invasive ventilation for PSG, the patient is considered ready to continue nighttime weaning from mechanical ventilation when one or more respiratory function parameters (e.g., TcCO2, petCO2, or ptcCO2 or ETCO2) are within the ranges described herein. IIci. Transcutaneous CO2

[0331] In some embodiments, when a patient with invasive ventilation is opened via tracheostomy or when a patient with non-invasive ventilation is removed from their mask for PSG, the patient is considered ready to continue weaning from mechanical ventilation at night when their TcCO2 is about 35 to about 45 mmHg (e.g., about 36 to about 44 mmHg, about 37 to about 43 mmHg, about 38 to about 42 mmHg, about 39 to about 41 mmHg, or about 40 mmHg).

[0332] In some embodiments, when a tracheostomy is performed on a patient undergoing invasive ventilation or when a mask is removed from a patient undergoing PSG on a non-invasively ventilated patient, the patient is considered ready to continue nighttime weaning from mechanical ventilation when their TcCO2 does not increase by 10 mmHg or more relative to waking baseline (e.g., not increasing by 11 mmHg or more, not increasing by 12 mmHg or more, not increasing by 13 mmHg or more, not increasing by 14 mmHg or more, not increasing by 15 mmHg or more, not increasing by 20 mmHg or more, not increasing by 25 mmHg or more, or not increasing by 30 mmHg or more). IIcii. End-tidal CO2 or partial pressure of CO2

[0333] In some embodiments, when a patient’s petCO2 or ptcCO2 is within the measurement range as described herein during PSG, the patient is considered ready to continue nighttime weaning from mechanical ventilator.

[0334] In some embodiments, when a patient on invasive ventilation is opened via tracheostomy or when a patient on non-invasive ventilation is removed from their mask for PSG, the patient is considered ready to continue weaning from mechanical ventilation at night when their petCO2 or ptcCO2 is less than 50 mmHg (e.g., less than 49 mmHg, less than 48 mmHg, less than 47 mmHg, less than 46 mmHg, less than 45 mmHg, less than 40 mmHg, less than 35 mmHg, less than 30 mmHg, less than 20 mmHg, or less than 10 mmHg).

[0335] In some embodiments, when a tracheostomy is performed on a patient on invasive ventilation or when a mask is removed from a patient on non-invasive ventilation for PSG, the patient is considered ready to continue nighttime weaning from mechanical ventilation when the patient's petCO2 or ptcCO2 does not increase by more than 10 mmHg relative to the awake baseline (e.g., not more than 11 mmHg, not more than 11 mmHg during sleep, not more than 11 mmHg, not more than 11 mmHg, not more than 11 mmHg, not more than 11 mmHg, or not more than 11 mmHg). IIciii. Oxygen saturation

[0336] In some embodiments, when a patient on invasive ventilation is opened via tracheostomy or when a patient on non-invasive ventilation is removed from their mask for PSG, the patient is considered ready to continue weaning from mechanical ventilation overnight when their SpO2 is greater than 94% (e.g., greater than 95%, greater than 96%, greater than 97%, greater than 98%, or greater than 99%). Example

[0337] The following examples are provided to provide those skilled in the art with a description of how the components and methods described herein can be used and evaluated, and are intended only as examples of the invention, but not to limit the scope of what the inventors consider to be their invention. Example 1. Summary of an algorithm for discontinuing mechanical ventilation in pediatric patients with X-linked myofascitis.

[0338] X-linked microtubule myopathy (XLMTM) is a rare, life-threatening congenital myopathy characterized by severe muscle weakness and hypotonia at birth in most patients, leading to severe respiratory failure, inability to sit, stand, or walk, and early death. At birth, 85-90% of XLMTM patients require mechanical ventilation, and more than half require invasive mechanical ventilation. Therefore, prior expectations for improvement in neuromuscular respiratory failure and respiratory-digestive risks in these ventilator-dependent children are low. However, in the recent ASPIRO trial, administration of novel gene therapy to children with XLMTM exceeded expectations, resulting in unprecedentedly rapid improvements in respiratory and neuromuscular function, including ventilator-free independence, unsupported sitting, standing, and walking. Therefore, the study protocol combines robust outcome assessment with a rigorous weaning algorithm to match observed clinical efficacy, minimize potential morbidity, and help clinicians and families meet patients' emerging abilities and needs (e.g., increased muscle strength, vocalization). However, there is no precedent for weaning long-term ventilated patients with congenital neuromuscular diseases from mechanical ventilation. Without publicly available guidelines, an algorithm was developed to assist clinicians in treating XLMTM patients, enabling pediatric patients to safely wean from mechanical ventilation by responding to improved respiratory muscle strength in ASPIRO. This algorithm provides recommendations for assessing weaning preparation, tiered weaning methods, and monitoring patients during and after weaning. Introduction

[0339] X-linked myotubular myopathy (XLMTM) is a rare, life-threatening congenital myopathy caused by mutations in the MTM1 gene, leading to the absence or dysfunction of myotubularin protein. XLMTM is characterized in most patients by severe muscle weakness and hypotonia at birth, resulting in severe respiratory failure; absent or transient achievement of motor milestones, including sitting, standing, or walking; and premature death. Most patients with XLMTM require mechanical ventilation at birth (85–90%), with approximately two-thirds requiring ventilation >16 hours / day, some requiring 24-hour ventilation, and more than half requiring invasive respiratory support. Most patients with XLMTM require permanent invasive respiratory support.

[0340] In the recently reported ASPIRO trial, a single infusion of resamirigene bilparvovec gene therapy resulted in unprecedented improvements in respiratory and neuromuscular function in children with XLMTM, all of whom required at least 12 hours of mechanical ventilation daily prior to treatment. Other improvements following treatment included ventilator independence, spontaneous secretion management, unsupported sitting, standing, and walking. Similar to XLMTM, long-term ventilated patients with congenital neuromuscular diseases (NMD) are never weaned from mechanical ventilation. Due to neuromuscular insufficiency, restrictive lung disease (e.g., diaphragmatic atrophy and pulmonary scarring due to aspiration pneumonia or recurrent pneumonia), impaired secretion clearance, scoliosis, these patients typically require near-24-hour permanent mechanical ventilation. Nevertheless, in ASPIRO, evidence of readiness to wean from mechanical ventilation emerged almost immediately after gene transfer.

[0341] In the absence of existing clinical guidelines for weaning and / or discontinuing mechanical ventilation in this population, guidelines for clinicians to treat XLMTM patients were developed in the ASPIRO trial to safely wean children from mechanical ventilation and to potentially extubate children with invasive support, based on their response to gene therapy.

[0342] In April 2018, an international panel of pulmonologists and respiratory physiologists (RJG, ND, LE, EKF, CL, VM, GFR, CS, BKS, FS, SP, SR, GFP) convened in Boston to design an algorithm for safe weaning (reducing) ventilation hours. The algorithm was based on XLMTM patient profiles and a summary of studies on ventilator dependence, respiratory pressure, secretion management, carbon dioxide mapping, and polysomnography. The initial draft algorithm was based on the expert consensus reached at this meeting, improved upon with input from other experts in pediatric pulmonology, sleep medicine, respiratory physiology, and neuromuscular disorders (RA, HS, WM), and supplemented with comments from recently available literature.

[0343] provides recommendations for: 1) assessing weaning preparation, 2) phased weaning methods, and 3) a multidisciplinary monitoring framework for patients during and after weaning. It should be understood that clinical care for children with NMD varies across providers and institutions worldwide, and interpretations and adherence to established respiratory care guidelines differ. In the absence of prior weaning experience, greater variability, potentially inappropriate but unavoidable, inferences from practice and inferences based on irrelevant circumstances can be expected. Therefore, the guidelines outlined here acknowledge the differences in existing care protocols while emphasizing appropriate developmental pathways and creating guidance that may limit the clinical boundaries of weaning. This aims to wean patients off prolonged mechanical ventilation.

[0344] Clinical experience in weaning pediatric patients with NMD from mechanical ventilation is limited and primarily confined to extubation in the intensive care unit (i.e., non-long-term ventilated patients). The vast majority of experience in weaning pediatric patients from long-term invasive or non-invasive respiratory support comes from children with congenital malformations (i.e., tracheomalacia, congenital heart disease); self-limiting, acquired neuromuscular disorders (such as Guillain-Barré syndrome or spinal cord injury); and children with chronic lung disease in premature infants. The term "weaning" is appropriate in patients with long-term respiratory failure because it describes the gradual process of improving the load-to-capacity ratio of the respiratory system's mechanical and gas exchange capabilities to achieve spontaneous and sustained breathing.

[0345] In summary, fewer studies have been conducted on ventilator-induced neuromuscular (especially diaphragmatic) weakness in children than in adults. Ventilator-induced neuromuscular (especially diaphragmatic) weakness is common in mechanically ventilated adults in intensive care settings and leads to prolonged weaning time, extubation failure, and higher mortality. In children, studies have shown that diaphragmatic atrophy is associated with prolonged recovery and the use of non-invasive ventilation in acute care settings. It is believed that changes in respiratory mechanics and diaphragmatic histology throughout infancy may be a contributing factor. As children grow, the mechanisms change and their anabolistic requirements differ significantly from those of adults. Risk factors for reintubation in pediatric emergency care settings include acute neurological disorders, lower pre-extubation MIP, impaired spontaneous secretion clearance, post-extubation upper airway obstruction, higher pre-extubation positive end-expiratory pressure (PEEP) setting, higher post-extubation pressure-heart rate product, and higher post-extubation phase angle.

[0346] Due to the static or progressive nature of most NMD, there is limited publicly available experience in weaning NMD patients off mechanical ventilation. Weaning from tracheal support is often not considered, or a transition to noninvasive supportive ventilation is frequently required. This necessitates that parents (or adult patients) accept different risks and monitoring, demonstrate developmental capacity and willingness to tolerate noninvasive ventilation, and adjust care accordingly.

[0347] Weaning from prolonged invasive mechanical ventilation is a slow process. In children with preterm chronic lung disease (NMD), the median age of release from respiratory support is 24 months. Patients with NMD typically do not show rapid improvement (or any improvement) in respiratory muscle function, especially those dependent on invasive ventilation. Determine if the patient is ready to be weaned from mechanical ventilation.

[0348] Before considering weaning any mechanically ventilated patient, baselines can be established for airway patency, oxygenation and ventilation capacity, nutritional status, and tolerance to rehabilitation therapy, and broader patient and environmental factors can be considered (Table 2). A multidisciplinary approach is recommended. For XLMTM patients in the ASPIRO trial, some treatment-emergent adverse events require enhanced immunosuppression, thereby increasing the risk of respiratory infections in already at-risk individuals. Similar considerations are expected to apply to future gene therapies for other NMD conditions.

[0349] Parameters and values ​​indicating readiness to reduce mechanical ventilation support are shown in Figure 2. These parameters and values ​​include respiratory function tests, gas exchange markers, airway patency indicators, nocturnal respiratory parameters, polysomnography results, and clinical judgment. Figure 2 also provides guidelines for monitoring patients during weaning and after successful cessation of mechanical ventilation. Recommendations for weaning patients from mechanical ventilation.

[0350] Weaning is the process of reducing the amount of support a patient receives from mechanical ventilation in order to allow the patient to undertake a greater proportion of ventilatory effort. The goal is to assess the likelihood that mechanical ventilation can be successfully discontinued.

[0351] Multiple respiratory assessments can be performed before attempting weaning assessment. Based on the rapid clinical response of the first patients treated with resamirigene bilparvovec gene therapy, weaning assessment can be attempted after week 12. Discontinuation of mechanical ventilation is a multi-step process consisting of preparation testing, weaning, and reassessment. Unlike other methods of weaning from chronic lung disease or acute care, this guideline supports continuous weaning from tracheal support and transition to spontaneous breathing without requiring the anticipated transition to noninvasive ventilation as an intermediate step. The reasoning is multifactorial. The mask interface required for noninvasive ventilation (NIV) may not be acceptable to infants and young children who are not accustomed to masks. NIV carries the potential risks of compromising skin integrity, aspiration, and other respiratory and digestive considerations, and can lead to long-term tracheocutaneous fistulas / tubes in patients requiring surgical intervention for tracheostomy. Most importantly, the need for NIV implies persistent respiratory failure, which supports more conditioning, time, and assessment of tolerance to other stressors (e.g., respiratory infections).

[0352] The algorithm in Figure 3 illustrates a step-by-step weaning method that involves assessing respiratory function and readiness at each step during the weaning process.

[0353] Patients meeting the preparation criteria outlined in Figure 2 can proceed with daytime weaning. These recommendations are made in the context of the ASPIRO clinical trial. They aim to be more conservative, recognizing the uncertainties and intuitive needs of clinical trials, to optimize respiratory support in response to the dynamic metabolic and catabolic demands of gene therapy. Weaning typically involves gradually reducing ventilator support (i.e., pressure / volume / rate) for patients on higher settings and continuous support, followed by a gradual sprint to wean them off the ventilator.

[0354] Throughout the weaning process, providers and parents should monitor for signs of respiratory work, compensatory tachypnea, compensatory tachycardia, and other clinical evidence of distress. Assessment of spontaneous secretion clearance or, conversely, the need for additional coughing or suctioning can also guide the process. Pulse oximetry can be used to monitor oxygen saturation and heart rate. If oxygen saturation decreases to <95% or decreases by 3-4% relative to baseline; or if heart rate increases by more than 20 bpm relative to baseline, daytime weaning may be considered. (Baseline is defined as the time between weaning assessment and reassessment in subsequent trial encounters.) Increased heart rate can be an indicator of cardiac compensation in respiratory failure, carbon dioxide retention, or pre-desaturated inert hypercapnia. It is important to note that patients with neuromuscular weakness may not exhibit typical signs of respiratory failure, such as retraction and compensatory tachypnea; therefore, other signs, including tachycardia and apparent anxiety, may prompt clinicians to discontinue the weaning process. Ventilator settings during weaning.

[0355] The reduction of ventilator settings will depend on the mode of mechanical ventilation support. The basic concept is to gradually reduce the settings while monitoring adequate gas exchange and vital signs. Weaning can be achieved by reducing peak inspiratory pressure (PIP), tidal volume (TV), or rate. Generally, one parameter can be weaned at a time to avoid weaning failure due to excessive respiratory muscle overload. This will also help explain the response of different parameters to the weaning process.

[0356] Adjustments to ventilator settings during weaning can be tailored to each patient, allowing for careful assessment of the child's overall health in response to ventilator changes. First, the level of ventilator support over the past 24 hours can be considered. Depending on the patient's recent support needs, the time spent on the ventilator or the ventilator pressure over time may decrease. Generally, during daytime weaning, the nighttime ventilator settings can be maintained to provide effective recruitment and gas exchange for recovery, thereby maximizing respiratory muscle performance throughout the day.

[0357] A patient's baseline tolerance to spontaneous breathing can be determined by testing the duration of sprints in the clinic and gradually increasing the time between ventilator shutdowns in 30-60 minute increments (e.g., 1 hour, 2 hours, 3 hours, etc.). Providers can help families determine which daytime weaning strategy is better: a longer single weaning or shorter multiple "sprints" until these weaning periods are combined. From a neuromuscular perspective, the latter has implicit benefits for muscle regulation and intermittent rest.

[0358] Before a daytime "sprint," caution should be exercised with the lowest ventilator settings: PIP in the range of 10-15 cmH2O and PEEP in the range of 4-5 cmH2O. The resulting tidal volume may tend to avoid atelectasis. Spontaneous mode is preferred in the absence of other central nervous system problems. Some providers may prefer a low forced rate of 5-10 bpm for mixed support (e.g., average volume-assured pressure support) and complete daytime release, which is also appropriate. Naps and nighttime weaning are also recommended.

[0359] When a patient is successfully weaned off ventilator support during the daytime waking hours, the weaning process can be considered to begin during nap time to assess respiratory efficiency during sleep. A pulse oximeter can also be used during nap time to monitor decreased oxygen saturation and increased heart rate; the latter may be a substitute symptom for pre-desaturation cardiopulmonary compensation or sluggish hypercapnia. If available, a home TcCO2 monitor may be beneficial, although experience with such monitors may be challenging. Weaning from nap time can be considered if tachypnea, oxygen saturation drops to <95%, heart rate increases by more than 20 bpm relative to baseline, or TcCO2 exceeds 50 mmHg or increases by 10 mmHg relative to waking baseline.

[0360] Once the patient has successfully discontinued mechanical ventilation support during daytime wakefulness and naps, the process of discontinuing nighttime mechanical ventilation support can begin. Polysomnography, which monitors gas exchange adequacy and assesses sleep sufficiency (i.e., wakefulness) before discontinuing nighttime mechanical ventilation support, is the gold standard for assessing sleep-disordered breathing.

[0361] Nighttime weaning can be achieved by periodically reducing the number of nighttime ventilator support hours or by completely eliminating nighttime support. Most clinicians prefer to eliminate nighttime support all at once, as weaning in hourly increments can place a significant sleep burden on patients and their families / caregivers. The need for "nighttime conditioning" also indicates that children may not be ready for weaning and may require the reinstatement of support for any stressors. Recommended nighttime respiratory monitoring and polysomnography parameters for cessation of mechanical ventilation are shown in Figure 4. Polysomnography can be performed to wean patients off the ventilator, either through a tracheostomy in invasively ventilated patients or by removing the mask in non-invasively ventilated patients. If polysomnography is not feasible, the best alternative in patients using this technique is nighttime TcCO2 monitoring (i.e., using a digital monitoring system), with the ventilator turned off for 2-3 nights before complete cessation. In any case, after discontinuing nighttime ventilator support within the first 6-8 weeks following the study, nighttime monitoring of oxygen saturation, heart rate, estimated respiratory rate, and home EtCO2 monitoring (if available) can continue. Alternatively, patients can be admitted for close nighttime monitoring and morning blood gas analysis. Polysomnography is recommended for patients experiencing changes in clinical course (including mild desaturation, poor weight gain, or mood changes). Subsequently, the achievement of gross motor trajectories and standardized neuromuscular measurements (e.g., CHOP INTEND or Bayley Scales of Infant and Toddler Development, 3rd edition, gross motor domain) or tracking of major motor milestones (e.g., unassisted sitting >30 seconds, standing, walking with or without support) and general clinical status can indicate whether polysomnography follow-up is necessary. Assess weaning outcomes.

[0362] For any weaning strategy, clinicians can determine whether weaning was successful or unsuccessful. Objective criteria indicating weaning failure include respiratory tachycardia, respiratory distress (use of accessory muscles, chest and abdominal paradoxes, and sweating), hemodynamic changes (tachycardia, hypertension), desaturation of oxyhemoglobin, hypercapnia, developmental delay (weight loss or slowed growth), and changes in mental status (drowsiness, agitation, or more subtle behavioral changes). In addition, parents and providers may continue to monitor and report daytime symptoms such as fatigue and headache or intolerance to activity and treatment. Other care considerations

[0363] During weaning from ventilator support, a multidisciplinary approach can be adopted, enabling close collaboration and regular data and care information sharing among the clinical team, research team, principal investigator, and pulmonary / respiratory rehabilitation team. It is also crucial to communicate with the patient's other healthcare providers (including physiotherapists, speech-language pathologists, and nutritionists) to determine treatment modifications based on the patient's improvement. Management of secretions and / or intermittent illnesses or infections.

[0364] Improved secretion clearance can aid in weaning and the sprint. Chest physiotherapy, mechanical cough assist, endotracheal suctioning, and / or manual bag ventilation may be recommended before the sprint to minimize initial airway obstruction and atelectasis. However, increased intervention requirements during the sprint may indicate a need to reinstate mechanical support, as this is an indicator of volume depletion.

[0365] Weaning may be paused during illness (infectious or unrelated reactive airway disease episodes) and volume may be reassessed after recovery. If a child is weaned from a ventilator but still has a tracheostomy, the provider may consider resuming support; that is, resuming ventilator support may be a first-line treatment if supplemental oxygen is needed or the child is in distress. An increase in the frequency or severity of illness during weaning may indicate an increased need for respiratory support.

[0366] It is also recognized that patients with lung injury due to prolonged inhalation or recurrent pneumonia may be unable to wean off support. It may be necessary to initiate a parallel approach for chronic parenchymal lung disease in accordance with NMD guidelines. In this case, prolonged ventilation may not be necessary, and only supplemental oxygen may be required. However, clinicians may notice warning signs of hypoxia, as it can reflect ventilation-perfusion mismatch, and supplemental oxygen can mask inadequate ventilation. Weight maintenance

[0367] In the absence of other contributing factors, developmental delays during weaning may indicate that the caloric requirements for weaning and spontaneous breathing exceed caloric intake. The answer may not be an empirical increase in calories, as this could increase CO2 burden and thus require more breathing. Close monitoring by an experienced team is essential. Daytime activities

[0368] Close monitoring of fatigue and ensuring adequate rest are important. If activity decreases during weaning, a ventilator may be used to help restore or return to previous support levels. Signs of fatigue (which may manifest as intolerance of routine physical therapy) may indicate that weaning is proceeding too quickly. Ideally, children may be able to maintain their previous activity levels during weaning. Interventions in the presence of fixed restrictive lung disease

[0369] Spinal devices required to correct neuromuscular scoliosis (growth rods, vertically expandable prosthetic titanium ribs, etc.) may require prolonged postoperative respiratory support, facilitated by tracheostomy and mechanical or non-invasive ventilation. For patients with fixed and restrictive thoracic structures, a degree of persistent respiratory insufficiency may exist, which cannot be recovered without muscle strength. As mentioned above, this may raise discussions about long-term options, and information will be obtained through polysomnography and other clinical indicators. Conclusion

[0370] Using this weaning protocol, seven out of ten children with XLMTM who had previously received gene therapy in the ongoing ASPIRO trial safely discontinued mechanical ventilation support. Given the unknown trajectory and persistence of respiratory outcomes after cessation of mechanical ventilation in these patients, close follow-up and regular respiratory assessments are necessary. This algorithm has only been evaluated in the XLMTM population receiving resamirigene bilparvovec gene therapy. However, considering the similarity of the pathophysiology and recovery of respiratory failure in NMD, its applicability is considered to be extrapolable to other congenital NMDs. The guidelines presented in this manuscript can serve as a valuable tool for pediatric NMD patients receiving investigational therapies. Example 2. Treatment of human patients with their condition by administering a pseudotyped AAV2 / 8 vector containing a nucleic acid sequence encoding the tubulin 1 gene operatively linked to the desmin promoter and by using a mechanical ventilation weaning protocol according to this disclosure.

[0371] Using the compositions and methods disclosed herein, a pseudo-AAV2 / 8 vector comprising a nucleic acid sequence encoding a tubulin 1 (MTM1) gene operatively linked to a desmin promoter can be administered to a patient with a condition (e.g., X-linked myotubular myopathy (XLMTM)) (Figure 1).

[0372] To assess whether a patient is ready to be weaned from mechanical ventilation during the day after administration of the above-mentioned treatment, a physician familiar with this technique may analyze one or more of the following parameters: (1) Determine that the patient exhibits vital signs and weight within the age-adjusted range; (2) Determine that the patient has a motor function score >45 or reaches a neuromuscular developmental milestone on the Children's Hospital of Philadelphia Neuromuscular Infant Test (CHOP INTEND); (3) Determine that the patient exhibits a maximum inspiratory pressure >-50 cmH2O on the ventilator; (4) Determine that the patient exhibits a maximum expiratory pressure >40 cmH2O on the ventilator; (5) Determine that the patient exhibits a positive end-expiratory pressure ≤5 cmH2O on the ventilator; (6) Determine that the patient exhibits an indoor air oxygen saturation (SpO2) >94%; (7) Determine that the patient exhibits a transcutaneous CO2 (TcCO2) within 35-45 mmHg; (8) Determine that the patient exhibits a transcutaneous CO2 (TcCO2) within 35-45 mmHg. End-tidal CO2 (ETCO2) within mmHg; or (9) determine the patient's serum bicarbonate level within 22-27 mEq / L (Figure 2). Readiness for daytime weaning from mechanical ventilation can be assessed, for example, by determining the following: the patient exhibits vital signs and weight within age-adjusted ranges; the patient exhibits a CHOP INTEND score >45 or has reached a neuromuscular developmental milestone; and the patient exhibits a maximum inspiratory pressure >-50 cmH2O on a ventilator.

[0373] If, after assessing the above parameters, a physician skilled in this technique determines that the patient is ready to be weaned off mechanical ventilation during the day, then after weaning off mechanical ventilation during the day, the physician skilled in this technique may analyze one or more of the following parameters to assess whether the patient is ready to continue daytime weaning off mechanical ventilation: (1) Determining that the patient's respiratory rate (RR) is within the age-adjusted range when monitoring respiration at night; (2) Determining that the patient does not show distress in the video recording of the respiratory sprint test; (3) Determining that the patient's RR is within the age-adjusted range when polysomnography is performed with a tracheostomy opening; (4) Determining that the patient's TcCO2 is within 35-45 mmHg when monitoring respiration at night; (5) Determining that the patient's TcCO2 is within 35-45 mmHg when monitoring respiration at night. (6) ETCO2 within mmHg; (7) SpO2 >94 when monitoring respiration at night; (8) TcCO2 within 35-45 mmHg or not increased by 10 mmHg or more from the awake baseline when polysomnography is performed with a tracheostomy opening; (9) TcCO2 within 50 mmHg or not increased by more than 10 mmHg from the awake baseline when polysomnography is performed with a tracheostomy opening. (10) Determine that the patient does not exhibit intercostal retraction in the video recording of the respiratory sprint test; (11) Determine that the patient does not exhibit respiratory tachycardia in the video recording of the respiratory sprint test; (12) Determine that the patient does not exhibit respiratory paradox in the video recording of the respiratory sprint test; (13) Determine that the patient does not exhibit phase delay in the video recording of the respiratory sprint test; (14) Determine that the patient exhibits SpO2 <94% or less than 3% relative to baseline in the video recording of the respiratory sprint test; or (15) Determine that the patient exhibits TcCO2 >45 mmHg or less than 10 mmHg or more relative to awake baseline in the video recording of the respiratory sprint test (Figure 4). Readiness to continue daytime weaning from mechanical ventilation can be assessed, for example, by determining the following: the patient exhibits RR within age-adjusted ranges during nighttime respiratory monitoring; the patient does not exhibit distress during video recordings of a respiratory sprint test; and the patient exhibits TcCO2 within 35-45 mmHg during nighttime respiratory monitoring. Example 3. Treatment of X-linked myotubular microtubule myopathy in human patients by administering a pseudotyped AAV2 / 8 vector containing a nucleic acid sequence encoding the MTM1 gene operatively linked to the desmin promoter, and by using a mechanical ventilation weaning protocol according to this disclosure.

[0374] Using the compositions and methods disclosed herein, a pseudotyped AAV2 / 8 vector comprising a nucleic acid sequence encoding an MTM1 gene operatively linked to a desmin promoter can be administered to a patient suffering from a neuromuscular disorder (e.g., XLMTM).

[0375] To assess whether a patient is ready to be weaned off mechanical ventilation during the day after administration of the above-mentioned treatments, a physician familiar with this technique may analyze one or more of the following parameters: (1) Determine that the patient exhibits vital signs and weight within the age-adjusted range; (2) Determine that the patient has a motor function score >45 on the CHOP INTEND or reaches a neuromuscular development milestone; (3) Determine that the patient exhibits a maximum inspiratory pressure >-50 cmH2O on the ventilator; (4) Determine that the patient exhibits a maximum expiratory pressure >40 cmH2O on the ventilator; (5) Determine that the patient exhibits a positive end-expiratory pressure ≤5 cmH2O on the ventilator; (6) Determine that the patient exhibits >94% SpO2; (7) Determine that the patient exhibits TcCO2 within 35-45 mmHg; (8) Determine that the patient exhibits ETCO2 within 35-45 mmHg; or (9) Determine that the patient's serum bicarbonate level is within 22-27 mEq / L. Readiness to wean off mechanical ventilation during the day can be assessed, for example, by determining the following: when monitoring breathing at night, the patient exhibits vital signs and weight within age-adjusted ranges; the patient has a motor function score >45 on the CHOP INTEND or has reached a neuromuscular developmental milestone; and the patient exhibits a maximum inspiratory pressure >-50 cmH2O on the ventilator.

[0376] If, after assessing the above parameters, a physician skilled in this technique determines that the patient is ready to be weaned off mechanical ventilation during the day, then after weaning off mechanical ventilation during the day, the physician skilled in this technique may analyze one or more of the following parameters to assess whether the patient is ready to continue daytime weaning off mechanical ventilation: (1) Determining that the patient's respiratory rate (RR) is within the age-adjusted range when monitoring respiration at night; (2) Determining that the patient does not show distress in the video recording of the respiratory sprint test; (3) Determining that the patient's RR is within the age-adjusted range when performing polysomnography with a tracheostomy opening; (4) Determining that the patient's TcCO2 is within 35-45 mmHg when monitoring respiration at night; (5) Determining that the patient's TcCO2 is within 35-45 mmHg when monitoring respiration at night. (6) ETCO2 within mmHg; (7) SpO2 >94 when monitoring respiration at night; (8) AHI <5 events / hour when the patient is on polysomnography with a tracheostomy opening; (9) TcCO2 within 35-45 mmHg or not increased by 10 mmHg or more relative to the awake baseline when the patient is on polysomnography with a tracheostomy opening; (10) TcCO2 <50 mmHg or not increased by more than 10 mmHg relative to the awake baseline when the patient is on polysomnography with a tracheostomy opening. (10) Determine that the patient does not exhibit intercostal retraction in the video recording of the respiratory sprint test; (11) Determine that the patient does not exhibit respiratory tachycardia in the video recording of the respiratory sprint test; (12) Determine that the patient does not exhibit respiratory paradox in the video recording of the respiratory sprint test; (13) Determine that the patient does not exhibit phase delay in the video recording of the respiratory sprint test; (14) Determine that the patient exhibits SpO2 <94% or less than 3% relative to baseline in the video recording of the respiratory sprint test; or (15) Determine that the patient exhibits TcCO2 >45 mmHg or less than 10 mmHg or more relative to awake baseline in the video recording of the respiratory sprint test. Readiness to continue daytime weaning from mechanical ventilation can be assessed, for example, by determining the following: the patient exhibits RR within age-adjusted ranges during nighttime respiratory monitoring; the patient does not exhibit distress during video recordings of the respiratory sprint test; and the patient exhibits TcCO2 within 35-45 mmHg during nighttime respiratory monitoring. Example 4. Treatment of X-linked myotubular myopathy in human patients by administration of resamirigene bilparvovec and by weaning from mechanical ventilation according to the protocol disclosed herein.

[0377] Using the composition and method disclosed herein, resamirigene bilparvovec can be administered to patients suffering from neuromuscular disorders (e.g., XLMTM).

[0378] To assess whether a patient is ready to be weaned off mechanical ventilation during the day after administration of the above-mentioned treatments, a physician familiar with this technique may analyze one or more of the following parameters: (1) Determine that the patient exhibits vital signs and weight within the age-adjusted range; (2) Determine that the patient has a motor function score >45 on the CHOP INTEND or reaches a neuromuscular development milestone; (3) Determine that the patient exhibits a maximum inspiratory pressure >-50 cmH2O on the ventilator; (4) Determine that the patient exhibits a maximum expiratory pressure >40 cmH2O on the ventilator; (5) Determine that the patient exhibits a positive end-expiratory pressure ≤5 cmH2O on the ventilator; (6) Determine that the patient exhibits >94% SpO2; (7) Determine that the patient exhibits TcCO2 within 35-45 mmHg; (8) Determine that the patient exhibits ETCO2 within 35-45 mmHg; or (9) Determine that the patient's serum bicarbonate level is within 22-27 mEq / L. Readiness to wean off mechanical ventilation during the day can be assessed, for example, by determining the following: the patient exhibits vital signs and weight within age-adjusted ranges; the patient exhibits a CHOP INTEND score >45 or has reached a neuromuscular developmental milestone; and the patient exhibits a maximum inspiratory pressure >-50 cmH2O on a ventilator.

[0379] If, after assessing the above parameters, a physician skilled in this technique determines that the patient is ready to be weaned off mechanical ventilation during the day, then after weaning off mechanical ventilation during the day, the physician skilled in this technique may analyze one or more of the following parameters to assess whether the patient is ready to continue daytime weaning off mechanical ventilation: (1) Determining that the patient's respiratory rate (RR) is within the age-adjusted range when monitoring respiration at night; (2) Determining that the patient does not show distress in the video recording of the respiratory sprint test; (3) Determining that the patient's RR is within the age-adjusted range when performing polysomnography with a tracheostomy opening; (4) Determining that the patient's TcCO2 is within 35-45 mmHg when monitoring respiration at night; (5) Determining that the patient's TcCO2 is within 35-45 mmHg when monitoring respiration at night. (6) ETCO2 within mmHg; (7) SpO2 >94 when monitoring respiration at night; (8) AHI <5 events / hour when the patient is on polysomnography with a tracheostomy opening; (9) TcCO2 within 35-45 mmHg or not increased by 10 mmHg or more relative to the awake baseline when the patient is on polysomnography with a tracheostomy opening; (10) TcCO2 <50 mmHg or not increased by more than 10 mmHg relative to the awake baseline when the patient is on polysomnography with a tracheostomy opening. (10) Determine that the patient does not exhibit intercostal retraction in the video recording of the respiratory sprint test; (11) Determine that the patient does not exhibit respiratory tachycardia in the video recording of the respiratory sprint test; (12) Determine that the patient does not exhibit respiratory paradox in the video recording of the respiratory sprint test; (13) Determine that the patient does not exhibit phase delay in the video recording of the respiratory sprint test; (14) Determine that the patient exhibits SpO2 <94% or less than 3% relative to baseline in the video recording of the respiratory sprint test; or (15) Determine that the patient exhibits TcCO2 >45 mmHg or less than 10 mmHg or more relative to awake baseline in the video recording of the respiratory sprint test. Readiness to continue daytime weaning from mechanical ventilation can be assessed, for example, by determining the following: the patient exhibits RR within the age-adjusted range when breathing is monitored at night; the patient does not exhibit distress in the video recording of the respiratory sprint test; and the patient exhibits TcCO2 within 35-45 mmHg when breathing is monitored at night.

[0380] Alternatively, to assess whether a patient is ready to be weaned from mechanical ventilation during the day after administration of the above-mentioned treatments, a physician skilled in this technique may analyze all of the following parameters: (1) confirming that the patient exhibits vital signs and weight within age-adjusted ranges; (2) confirming that the patient has a motor function score >45 or reaches a neuromuscular developmental milestone on the Children's Hospital of Philadelphia Neuromuscular Infant Test (CHOP INTEND); (3) confirming that the patient exhibits a maximum inspiratory pressure >-50 cmH2O on the ventilator; (4) confirming that the patient exhibits a maximum expiratory pressure >40 cmH2O on the ventilator; (5) confirming that the patient exhibits a positive end-expiratory pressure ≤5 cmH2O on the ventilator; (6) confirming that the patient exhibits >94% SpO2; (7) confirming that the patient exhibits a TcCO2 within 35-45 mmHg; (8) confirming that the patient exhibits an ETCO2 within 35-45 mmHg; or (9) confirming that the patient exhibits a TcCO2 within 22-27 mmHg. Serum bicarbonate levels within mEq / L (Figure 3; boxes with solid thick lines). Readiness for daytime weaning from mechanical ventilation can be assessed by determining the following: patient exhibiting vital signs and weight within age-adjusted ranges; patient demonstrating a motor function score >45 on the CHOP INTEND or reaching a neuromuscular developmental milestone; patient demonstrating a maximum inspiratory pressure >-50 cmH2O on the ventilator; patient demonstrating a maximum expiratory pressure >40 cmH2O on the ventilator; patient demonstrating a positive end-expiratory pressure ≤5 cmH2O on the ventilator; patient demonstrating >94% SpO2; patient demonstrating a TcCO2 within 35-45 mmHg; patient demonstrating an ETCO2 within 35-45 mmHg; and patient having a serum bicarbonate level within 22-27 mEq / L.

[0381] If, after assessing the above parameters, a physician skilled in this technique determines that the patient is ready to be weaned off mechanical ventilation during the day, then after weaning off mechanical ventilation during the day, the physician skilled in this technique may analyze all of the following parameters to assess whether the patient is ready to continue daytime weaning off mechanical ventilation: (1) Determining that the patient's respiratory rate (RR) is within the age-adjusted range when monitored at night; (2) Determining that the patient does not show distress in the video recording of the respiratory sprint test; (3) Determining that the patient's RR is within the age-adjusted range when polysomnography is performed with a tracheostomy opening; (4) Determining that the patient's TcCO2 is within 35-45 mmHg when monitored at night; (5) Determining that the patient's TcCO2 is within 35-45 mmHg when monitored at night. (6) ETCO2 within mmHg; (7) SpO2 >94 when monitoring respiration at night; (8) AHI <5 events / hour when the patient is on polysomnography with a tracheostomy opening; (9) TcCO2 within 35-45 mmHg or not increased by 10 mmHg or more relative to the awake baseline when the patient is on polysomnography with a tracheostomy opening; (10) TcCO2 <50 mmHg or not increased by more than 10 mmHg relative to the awake baseline when the patient is on polysomnography with a tracheostomy opening. (10) Determine that the patient does not exhibit intercostal retraction in the video recording of the respiratory sprint test; (11) Determine that the patient does not exhibit respiratory tachycardia in the video recording of the respiratory sprint test; (12) Determine that the patient does not exhibit respiratory paradox in the video recording of the respiratory sprint test; (13) Determine that the patient does not exhibit phase delay in the video recording of the respiratory sprint test; (14) Determine that the patient exhibits SpO2 <94% or less than 3% relative to the conscious baseline in the video recording of the respiratory sprint test; and (15) Determine that the patient exhibits TcCO2 >45 mmHg or less than 10 mmHg or more relative to the conscious baseline in the video recording of the respiratory sprint test (Figure 3; boxed with a thick dashed line).Readiness to continue daytime weaning from mechanical ventilation can be assessed, for example, by determining the following: RR within age-adjusted range during nighttime respiratory monitoring; no distress observed in the video recording of the respiratory sprint test; TcCO2 within 35-45 mmHg during nighttime respiratory monitoring; ETCO2 within 35-45 mmHg during nighttime respiratory monitoring; SpO2 >94% during nighttime respiratory monitoring; no intercostal retractions observed in the video recording of the respiratory sprint test; no tachypnea observed in the video recording of the respiratory sprint test; no respiratory paradoxes observed in the video recording of the respiratory sprint test; no phase delay observed in the video recording of the respiratory sprint test; SpO2 <94% or less than 3% from waking baseline in the video recording of the respiratory sprint test; and TcCO2 >45 mmHg or less than 10 mmHg or greater increase from waking baseline in the video recording of the respiratory sprint test. If polysomnography is performed with a tracheostomy opening, readiness to continue daytime mechanical ventilation can be assessed, for example, by additionally determining the following: a patient exhibiting an age-adjusted response rate (RR) with a tracheostomy opening; an acute airway index (AHI) of <5 events / hour with a tracheostomy opening; a total chorionic purpura (TcCO2) of 35-45 mmHg or no increase of 10 mmHg or more relative to the waking baseline with a tracheostomy opening; and a petCO2 or ptcCO2 of <50 mmHg or no increase of more than 10 mmHg relative to the waking baseline during sleep with a tracheostomy opening. Other embodiments.

[0382] All publications, patents and patent applications mentioned in this specification are incorporated herein by reference as if each separate publication or patent application were expressly and individually indicated to be incorporated herein by reference.

[0383] Although the present invention has been described in conjunction with specific embodiments thereof, it should be understood that further modifications can be made thereto, and this application is intended to cover any variations, applications or adaptations of the invention that generally follow the principles of the invention and include the known or conventional practice within the art to which the invention pertains, and may be applied to deviations from the basic features set forth above and within the scope of the claims.

[0384] Other embodiments are within the scope of the patent application. [Simplified Explanation of the Diagram]

[0107] Figure 1 is a schematic diagram of an exemplary pseudotyped adeno-associated virus (AAV) 2 / 8 (AAV2 / 8) viral vector used to represent the human tubulin 1 (hMTM1) gene. From left to right, the shaded arrows and rectangles represent the nucleic acid sequences encoding the human desmin (hDes) promoter (SEQ ID NO: 3), the hMTM1 gene (SEQ ID NO: 4), the β-globin polyadenylation signal (β-globin_pA), and the flanking AAV2 inverted terminal repeat (ITR) sequence that are operatively linked to the β-globin intron. Abbreviations: AAV2_ITR, adeno-associated virus 2 inverted terminal repeat; β-globin_pA, human β-globin polyadenylation signal; hDes, human desmin promoter; hMTM1, human tubulin complementary DNA. Figure 2 is a diagram of parameters recommended for assessing patients by physicians familiar with this technique before initiating daytime weaning from mechanical ventilator. Figure 3 is a flowchart illustrating the step-by-step criteria for determining whether a patient is ready to begin daytime, naptime, or nighttime weaning from mechanical ventilation, and whether the patient is ready to continue daytime, naptime, or nighttime weaning from mechanical ventilation, respectively. Boxes with solid thick lines represent recommended steps for determining whether a patient is ready to begin daytime weaning from mechanical ventilation. Boxes with dashed thick lines represent recommended steps for determining whether a patient is ready to continue daytime weaning from mechanical ventilation. Abbreviations: CHOP INTEND, Children's Hospital of Philadelphia Neuromuscular Disorders Infant Test; MIP, Maximum Inspiratory Pressure; ORL, Otolaryngology; PEEP, Positive End-Expiratory Pressure; PIP, Peak Inspiratory Pressure; PSG, Polysomnography. Figure 4 is a diagram illustrating the parameters recommended for assessing patients by physicians familiar with this technique before initiating daytime weaning from mechanical ventilation. Definitions

[0108] As used herein, the term "about" means a value that is greater than or less than 5% of the value described. For example, "100 pounds" as used in the context of weight described herein includes a quantity that is 5% greater than or less than 100 pounds. Furthermore, when used in the context of a list of numerical quantities, it should be understood that when the term "about" precedes the list of numerical quantities, it applies to each individual quantity listed in the list.

[0109] As used herein, the terms "administering" and "administration" refer to the direct administration of a therapeutic agent to a patient via any effective route (e.g., pharmaceutical compositions including viral vectors comprising a nucleic acid sequence encoding a myotubulin 1 (MTM1) gene operatively linked to a muscle-specific promoter). Exemplary administration routes are described herein and include systemic administration routes, such as intravenous injection, and direct administration to the patient's central nervous system, such as intrathecal or intraventricular injection.

[0110] As used herein, the term “age-adjusted standard” refers to the process of standardizing data by age, which is a technique used to allow comparisons of individual groups when the age profiles of the groups differ.

[0111] As used herein, the term "awake baseline" refers to a comparative basis obtained during the patient's daytime awake time and is defined in weaning assessments and reassessments in subsequent trial encounters. As used herein, the term "daytime awake time" refers to the period from 7:00 AM to 7:00 PM, such as 8:00 AM, 9:00 AM, 10:00 AM, 11:00 AM, 12:00 PM, 1:00 PM, 2:00 PM, 3:00 PM, 4:00 PM, 5:00 PM, or 6:00 PM. The duration of the awake baseline is not an absolute duration and will vary depending on the patient and outcome. Furthermore, the duration of an "awake baseline trial" will vary from trial to trial and may consist of the following: the time gradually increases in 15-minute increments (e.g., a 15-minute awake baseline trial, a 30-minute awake baseline trial, a 45-minute awake baseline trial). In some embodiments, the time for obtaining a conscious baseline test is between 7 a.m. and 7 p.m., such as 8 a.m., 9 a.m., 10 a.m., 11 a.m., 12 p.m., 1 p.m., 2 p.m., 3 p.m., 4 p.m., 5 p.m., or 6 p.m.

[0112] As used herein, the term "apnea-hypopnea index" or "AHI" refers to the number of apneas or hypopneas recorded per hour of sleep during the study period. As used herein, the term "apnea" is defined as an event lasting 10 seconds or more during sleep in which a reduction in airflow relative to baseline is observed to be 90% or more, where baseline is defined as moderate stable breathing and ventilation in the last 2 minutes before the event for patients with a fixed breathing pattern, or moderate of the three longest breaths in the last 2 minutes before the event for patients with a variable breathing pattern, where the reduction in airflow is defined as an apnea event occurring in 90% or more of the time. As used herein, the term "hypopnea" is defined as an event lasting 10 seconds or more during sleep in which a reduction in respiratory rate relative to baseline is observed to be 50% or more, where baseline is defined as moderate stable breathing and ventilation in the last 2 minutes before the event for patients with a fixed breathing pattern, or moderate of the three longest breaths in the last 2 minutes before the event for patients with a variable breathing pattern.

[0113] As used herein, the terms "Children's Hospital of Philadelphia Neuromuscular Disorder Infant Test" or "CHOP INTEND" refer to a validated measure of motor outcomes developed to assess infants with disabilities (e.g., infants with skeletal muscle disorders, such as X-linked myomicrotubule myopathy (XLMTM)). CHOP INTEND uses a 0-64 subscale, where higher scores indicate better motor function. As used herein, the term "motor function score" refers to the 0-64 subscale score of CHOP INTEND (e.g., a score >45 on CHOP INTEND).

[0114] As used herein, the term “discomfort” means, as defined in the medical sense, any situation in which there is an emotional or physical state of pain, grief, misery, suffering, or discomfort.

[0115] As used herein, the term "dosage" refers to a therapeutic agent, such as the amount of a viral vector described herein, administered to an individual at a specific time to treat a condition, such as treating or improving one or more symptoms of a neuromuscular condition (e.g., XLMTM) described herein. The therapeutic agent described herein may be administered in single or multiple doses during the course of treatment, as defined herein. In each case, one or more unit dosage forms of the therapeutic agent may be used to administer the therapeutic agent; this term refers to one or more discrete compositions containing the therapeutic agent that together constitute a single dose.

[0116] As used herein, the terms "effective amount," "therapeutic effective amount," etc., when used with reference to a therapeutic composition such as a carrier construct described herein, refer to an amount sufficient to produce a beneficial or desired outcome (e.g., clinical outcome) when administered to an individual (including mammals, such as humans). For example, in the context of treating neuromuscular diseases such as XLMTM, these terms refer to an amount of composition sufficient to achieve a therapeutic response compared to a response obtained without administration of the composition of interest. The "effective amount," "therapeutic effective amount," etc., of the compositions of this disclosure, such as carrier constructs, also include an amount that produces a beneficial or desired outcome in an individual compared to a control.

[0117] As used herein, the terms “end-tidal CO2”, “ETCO2” and “petCO2” refer to the volume of CO2 entering a patient’s lungs during inspiration (e.g., 35-45 mmHg of CO2 entering a patient’s lungs during inspiration).

[0118] As used herein, the term “maximum expiratory pressure” or “MEP” refers to variables in mechanical ventilation, including the strength of the respiratory muscles obtained by having the patient exhale as forcefully as possible through the mouthpiece; the maximum value is close to the total vital capacity.

[0119] As used herein, the term “intercostal retraction” refers to a clinically observable medical phenomenon that occurs when the muscles between the ribs are pulled inward.

[0120] As used herein, the terms "maximum inspiratory pressure" or "MIP" refer to variables in mechanical ventilation, including the total airway pressure delivered, typically used to overcome respiratory compliance and airway resistance. In pressure control mode, MIP includes the sum of positive end-expiratory pressure and "Δ pressure." As used herein, the term "Δ pressure" refers to variables in mechanical ventilation, including the difference between MIP and positive end-expiratory pressure.

[0121] As used herein, the term “mechanical ventilation” is the medical term for artificial ventilation, in which a mechanical device is used to assist or replace spontaneous breathing.

[0122] As used herein, the terms "monitored nocturnally," "nocturnal monitoring," "nocturnal respiration monitoring," and "respiration is monitored nocturnally" refer to monitoring patients during nighttime hours. As used herein, the term "nighttime" refers to the period from 7 p.m. to 7 a.m., such as 8 p.m., 9 p.m., 10 p.m., 11 p.m., 12 p.m., 1 p.m., 2 p.m., 3 p.m., 4 p.m., 5 p.m., or 6 a.m. The duration of nighttime monitoring is not an absolute duration and will vary depending on the patient and outcome. Furthermore, the duration of nighttime monitoring will vary from trial to trial and may include gradually decreasing or increasing time in 1-second increments (e.g., nighttime monitoring lasting up to 12 hours, nighttime monitoring lasting up to 11 hours, and nighttime monitoring lasting up to 11 hours and 15 minutes).

[0123] As used herein, the term "neuromuscular developmental milestone" refers to the behaviors or physical skills observed in infants and children during their growth and development, including head control, sitting, independent grasping, supine position, rolling over, crawling or hip movement, standing, and walking. Milestones vary at different ages; for example, it is normal to sit on hip support at 4 months of age, to sit with props at 6 months of age, to sit steadily at 7-8 months of age, and to sit and rotate at 9 months of age, see De Sanctis et al., Neuromuscular Disorders 26:754 (2016).

[0124] As used herein, the term "operably linked" means that a first molecule is linked to a second molecule, wherein the molecules are arranged such that the first molecule influences the function of the second molecule. The two molecules may or may not be part of a single adjacent molecule and may or may not be adjacent. For example, if a promoter regulates the transcription of a polynucleotide molecule of interest in a cell, then the promoter is operably linked to the polynucleotide molecule. Additionally, if two parts of a transcriptional regulatory element are linked such that the transcriptional activation of one part is not adversely affected by the presence of the other part, then the two parts are operably linked to each other. Two transcriptional regulatory elements may be operably linked to each other via a linker nucleic acid (e.g., an intercalated non-coding nucleic acid) or may be operably linked to each other in the absence of an intercalated nucleotide.

[0125] As used herein, the terms "oxygen saturation" or "SpO2" refer to a measure of the level of hemoglobin in a patient's body that is bound to molecular oxygen. As used herein, the term "room air oxygen saturation" refers to the amount of oxygen in a patient's bloodstream, determined by the degree to which hemoglobin in a patient's red blood cells is bound to oxygen molecules. Oxygen in the blood comes from the lungs and from inhalation.

[0126] As used herein, the term "medical composition" means a mixture containing a therapeutic compound administered to a patient (such as a mammal, for example, a human) to prevent, treat or control a particular disease or condition that affects or may affect an individual.

[0127] As used herein, the term “medically acceptable” means that such compounds, materials, compositions and / or dosage forms are suitable for contact with individual tissues such as mammals (e.g., humans) without excessive toxicity, irritation, allergic reactions and other problematic complications commensurate with a reasonable benefit / risk ratio.

[0128] As used herein, the term "phase delay" refers to a time delay, which includes the time it takes for the mechanical ventilator to first sense the trigger (e.g., a pressure trigger) and the time it takes for the ventilator to respond by delivering airflow. For example, in a diaphragmatic pressure (Pdi) driven servo ventilation system, ventilatory pressure breathing is adjusted in response to the patient's Pdi so that triggering occurs when the patient begins to breathe, or a preset flow threshold is set, depending on which is generated first. Subsequently, the ventilator algorithm generates a new flow signal that differs from the patient's actual flow by 0.25 L / s and is delayed (e.g., delayed by 300 milliseconds), thereby allowing the signal to lag behind the patient's actual flow rate so that once the patient begins to breathe, a sudden decrease in expiratory flow will initiate ventilatory breathing.

[0129] As used herein, the terms “positive end-expiratory pressure” or “PEEP” refer to variables in mechanical ventilation, including the pressure maintained in the airway at the end of expiration (e.g., the pressure applied to the lungs on a ventilator never exceeds 5 cmH2O).

[0130] As used herein, the term "promoter" refers to a recognition site on DNA that is bound by RNA polymerase. Polymerase drives transcription of transfected genes. Exemplary promoters suitable for the compositions and methods described herein are described, for example, in Sandelin et al., Nature Reviews Genetics 8:424 (2007), the disclosure of which is incorporated herein by reference as it relates to nucleic acid regulatory elements. Furthermore, the term "promoter" may refer to a synthetic...

[0131] A promoter is a regulatory DNA sequence that does not naturally exist in a biological system. Synthetic promoters contain a combination of a portion of a naturally occurring promoter and a polynucleotide sequence that does not exist in nature, and can be optimized to express recombinant DNA using various transgenic genes, vectors and target cell types.

[0132] As used herein, a therapeutic agent is considered to be "provided" to a patient if it is administered directly to the patient, or if it is administered to the patient a substance that is processed or metabolized in the body to produce the therapeutic agent endogenously. For example, a nucleic acid molecule (e.g., MTM1) encoding a therapeutic protein can be provided to a patient, such as one suffering from a neuromuscular disease described herein, by administering a nucleic acid molecule directly or by administering a substance that is processed in the body to produce the desired nucleic acid molecule (e.g., a viral vector or cells).

[0133] As used herein, the terms “respiration rate” or “RR” refer to the rate at which a patient breathes.

[0134] As used herein, the term “paradoxical breathing” refers to respiratory distress in patients that is associated with damage to the structures involved in breathing, in which the patient’s chest or abdominal wall does not move outward during breathing but moves inward.

[0135] As used herein, the terms "breathing sprint test" or "sprint" refer to a formal test of spontaneous breathing to assess whether mechanical ventilation release may be successful or unsuccessful. The duration of a breathing sprint test is not an absolute duration and will vary depending on the patient and outcome. Furthermore, a "breathing sprint test" can vary in time and may consist of the following: the time is gradually increased in one-minute increments (e.g., a breathing sprint test with a duration of 15 minutes, a breathing sprint test with a duration of 16 minutes, a breathing sprint test with a duration of 17 minutes).

[0136] As used herein, the term “serum bicarbonate level” refers to the CO2 level in a patient’s blood (e.g., 22-27 mEq / L CO2 in the patient’s blood).

[0137] As used herein, the terms "individual" and "patient" refer to an organism receiving treatment as described herein for a particular disease or condition (e.g., neuromuscular disease, such as XLMTM). Examples of individuals and patients include mammals, such as humans, receiving treatment for the diseases or conditions described herein.

[0138] As used herein, the term “rapid breathing” refers to a condition of abnormally rapid respiratory rate. As used herein, “rapid breathing” is defined as a respiratory rate >60 breaths / minute in children under 2 months of age, >50 breaths / minute in children between 2 and 12 months of age, >40 breaths / minute in children between approximately 1 and 5 years of age, and >20 breaths / minute in children over 5 years of age.

[0139] As used herein, the terms “tracheostomy opening” and “open tracheostomy” refer to a surgical procedure consisting of an incision made in the front of the patient’s neck and an opening of a direct airway through the incision in the trachea. The resulting stoma can be used independently as an airway or as a site for inserting an endotracheal tube or tracheostomy tube that allows an individual to breathe without using a nose or mouth.

[0140] As used herein, the terms “transcutaneous CO2” or “TcCO2” refer to the CO2 level beneath the patient’s skin.

[0141] As used herein, the term "transgenic gene" refers to a recombinant nucleic acid (e.g., DNA or cDNA) encoding a gene product (e.g., the gene product described herein). The gene product may be RNA, a peptide, or a protein. In addition to the coding region of the gene product, the transgenic gene may include or be operatively linked to one or more elements to promote or enhance expression, such as promoters, enhancers, destabilizing regions, reactive elements, reporter elements, insulator elements, polyadenylation signaling elements, and / or other functional elements. Embodiments of this disclosure may utilize any known suitable promoters, enhancers, destabilizing regions, reactive elements, reporter elements, insulator elements, polyadenylation signaling elements, and / or other functional elements.

[0142] As used herein, the term "treat / treatment" refers to therapeutic treatment aimed at preventing or slowing (alleviating) unwanted physiological changes or conditions, such as the progression of neuromuscular disorders like XLMTM. Beneficial or desired clinical outcomes include, but are not limited to, symptom relief, disease severity reduction, disease stabilization (i.e., no worsening), delay or slowing of disease progression, improvement or mitigation of disease status, and remission (partial or complete), whether detectable or undetectable. In the context of neuromuscular disorders such as XLMTM, treatment of patients may manifest as one or more detectable alterations, such as increased concentrations of MTM1 protein or nucleic acids encoding MTM1 (e.g., DNA or RNA, e.g., mRNA), or increased MTM1 activity (e.g., increases of 1%, 2%, 3%, 4%, 5%, 6%, 7%, 8%, 9%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75%, 80%, 85%, 90%, 95%, 100%, 200%, 300%, 400%, 500%, 600%, 700%, 800%, 900%, or more). The concentration of MTM1 protein can be determined using protein detection assays known in this art, including the ELISA assay described herein. The concentration of nucleic acids encoding MTM1 can be determined using nucleic acid detection assays described herein (e.g., RNA, mRNA ... The Seq test is used to determine this. Furthermore, treatment for patients with neuromuscular disorders (such as XLMTM) can manifest as improvements in muscle function (e.g., skeletal muscle function) and muscle coordination.

[0143] As used herein, the term "X-linked myotubular myopathy" or "XLMTM" refers to a hereditary neuromuscular disorder caused by mutations in the MTM1 gene, characterized by symptoms including mild to severe muscle weakness, hypotonia (weakened muscle tone), feeding difficulties, and / or severe respiratory complications. Human MTM1 has NCBI gene ID NO 4534. An exemplary wild-type human MTM1 nucleic acid sequence is provided in NCBI RefSeq accession number NM_000252.3 (SEQ ID NO: 1), and an exemplary wild-type tubulin 1 amino acid sequence is provided in NCBI RefSeq accession number NP_000243.1 (SEQ ID NO: 2).

[0144] As used herein, the term "vector" refers to a nucleic acid, such as DNA or RNA, that can be used as a carrier for, for example, for the purpose of replication and / or expression, to deliver a gene of interest into a cell (e.g., a mammalian cell, such as a human cell). It can be used with...

[0145] Exemplary vectors used in the compositions and methods described herein are plastids, DNA vectors, RNA vectors, virions, or other suitable replicons (e.g., viral vectors). Various vectors have been developed for delivering polynucleotides encoding exogenous proteins into prokaryotic or eukaryotic cells. Examples of such expression vectors are disclosed, for example, in WO 1994 / 11026, the disclosure of which is incorporated herein by reference. The expression vectors described herein contain polynucleotide sequences and additional sequence elements, for example, for expressing proteins and / or integrating such polynucleotide sequences into the genome of mammalian cells. Some vectors that can be used to express transgenic genes as described herein include vectors containing regulatory sequences (e.g., promoter and enhancer regions) that guide gene transcription. Other vectors that can be used to express transgenic genes contain polynucleotide sequences that enhance the translation rate of such genes or improve the stability of mRNA produced by gene transcription or nuclear export. These sequence elements include, for example, 5' and 3' untranslated regions, internal ribosome entry sites (IRES), and polyadenylation signaling sites that guide the effective transcription of genes carried on the expression vector. The expression vectors described herein may also contain polynucleotides encoding markers for selecting cells containing the vector. Examples of suitable markers include genes encoding antibiotic resistance (e.g., ampicillin, chloramphenicol, conomycin, or nourseothricin).

[0146] As used herein, the term "vital signs" refers to a group of four of the most important medical signs that indicate the state of bodily life functions. The four main vital signs that medical professionals and healthcare providers regularly monitor include body temperature, pulse rate, respiratory rate, and blood pressure.

[0147] As used herein, the term "weaning" refers to the cessation of mechanical ventilation, including the gradual process of increasing the mechanical and gas exchange capacity of the respiratory system to achieve spontaneous and sustainable breathing. Weaning typically involves gradually reducing ventilator support (i.e., pressure, volume, and / or rate) for patients on higher settings and continuous support, followed by a gradual sprint to wean them off the ventilator while changing no more than one ventilator support parameter. As used herein, the term "daytime weaning" refers to weaning during the daytime when the patient is awake. The duration of daytime weaning is not an absolute duration and will vary depending on the patient and outcome. Furthermore, "daytime weaning trials" will vary by time and may consist of the following: the duration gradually increases in 15-minute increments (e.g., a daytime weaning trial lasting 15 minutes, a daytime weaning trial lasting 30 minutes, a daytime weaning trial lasting 45 minutes). As used herein, the term "nap weaning" refers to weaning during the daytime when the patient is awake and asleep. The duration of weaning during naps is not an absolute duration and varies depending on the patient and outcome. Furthermore, the duration of a "nap weaning trial" can vary over time and may consist of increments of 1 second (e.g., a 15-minute nap weaning trial, a 16-minute nap weaning trial, a 17-minute nap weaning trial). As used herein, the term "nighttime weaning" refers to weaning during the night. The duration of nighttime weaning is not an absolute duration and varies depending on the patient and outcome. Furthermore, the duration of a "nighttime weaning trial" can vary over time and may consist of increments of 1 second (e.g., a 15-minute nighttime weaning trial, a 16-minute nighttime weaning trial, a 17-minute nighttime weaning trial). [Sequence List]

[0385] <![CDATA[ <110> Audentes Therapeutics, Inc. (USA) <![CDATA[ <120> Compositions and methods for treating X-linked microtubule myopathy <![CDATA[ <130> 51037-056TW2]]> <![CDATA[ <150> US 63 / 159,898 <![CDATA[ <151> 2021-03-11 <![CDATA[ <160> 5 ]]> <![CDATA[ <170> PatentIn version 3.5]]> <![CDATA[ <210> 1]]> <![CDATA[ <211> 3412]]> <![CDATA[ <212> DNA <![CDATA[ <213> Homo sapiens <![CDATA[ <400> 1]]> agccgagcag cctggcaacg gcggtggcgc ccggagcccg agagtttcca ggatggcttc 60 tgcatcaact tctaaatata attcacactc cttggagaat gagtctatta agaggacgtc 120 tcgagatgga gtcaatcgag atctcactga ggctgttcct cgacttccag gagaaacact 180 aatcactgac aaagaagtta tttacatatg tcctttcaat ggccccatta agggaagagt 240 ttacatcaca aattatcgtc tttatttaag aagtttggaa acggattctt ctctaatact 300 tgatgttcct ctgggtgtga tctcgagaat tgaaaaaatg ggaggcgcga caagtagagg 360 agaaaattcc tatggtctag atattacttg taaagacatg agaaacctga ggttcgcttt 420 gaaacaggaa ggccacagca gaagagatat gtttgagatc ctcacgagat acgcgtttcc 480 cctggctcac agtctgccattatttgcatttttaaatgaa gaaaagtttaacgtggatgg 540 atggacagtt tacaatccag tggaagaata caggaggcag ggcttgccca atcaccattg 600 gagaataact tttattaata agtgctatga gctctgtgac acttaccctg ctcttttggt 660 ggttccgtat cgtgcctcag atgatgacct ccggagagtt gcaactttta ggtcccgaaa 720 tcgaattcca gtgctgtcat ggattcatcc agaaaataag acggtcattg tgcgttgcag 780 tcagcctctt gtcggtatga gtgggaaacg aaataaagat gatgagaaat atctcgatgt 840 tatcagggag actaataaac aaatttctaa actcaccatt 900 aatgcagtg gccaacaagg caacaggagg aggatga attgatgatg catatcataa 960 cgccgaactt ttcttcttag acattcataa tattcatgtt atgcgggaat ctttaaaaaa 1020 aaatggac attgtttatc ctaatgtaga agaatctcat tggttgtcca gtttggagtc 1080 tactcattgg ttagaacata tcaagctcgt tttgacagga gccattcaag tagcagacaa 1140 agtttcttca gggaagagtt cagtgcttgt gcattgcagt gacggatggg acaggactgc 1200 tcagctgaca tccttggcca tgctgatgtt ggatagcttc tataggagca ttgaagggtt 1260 cgaaatactg gtacaaaaag aatggataag ttttggacat aaatttgcat ctcgaatagg 1320 tcatggtgat aaaaaccaca ccgatgctga ccgttctcct atttttctcc agtttattga1380 ttgtgtgtgg caatgtcaa aacagttccc tacagcttt gattcaatg aacaatttt 1440 gattataatt ttggatcatc tgtatagttg ccgatttgt acttctt tcaactgtga 1500 atctgctcga gaacagacactaga aaggattaga aggtta 1560 cagtataaa gaaaaattca aaaacccctt ctatactaaa gaatcaatc gagttttata 1620 tccagttgcc agtatgcgtc acttggact ctggtgaat tactacatta gatggaaccc 1680 caggatcaag cacaacagcgc taggacaccacc taggacaatcc tcttagcctt 1740 acgcgacgaa tacataaagc ggcttgagga actgcagctc gccactctg ccaagcttc 1800 tgatccccca acttcacctt ccagctctc gcaatgatg cccatgtgc aaactcactt 18cagggagcggg accgactgc aggcgatagc tgactttcat 1920 ttggggcatt tgtaaaagt agattaaaat atttgcctcc atgtagaact tgaactaca 1980 taatcttaa ctctgaata tgtgccttct agaatacagata ttacaggagaa actacagccattca atgattcagt 2040 ggaaaaccct gandaccttta 2100 aaaagcagtt tttgaagac aaaatttaga tttaatttac gtcttgagaa atactata 2160 tacaatatat atttgtggg cttaattgaa acaacattat tttaaaatca aagggatat 2220atgtttgtgg aatggatttt cctgaagctg cttaacagtt gctttggatt ctctaagatg 2280 aatccaaatg tgaaagatgc atgttactgc caaaaccaaa ttgagctcag cttcctaggc 2340 attacccaaa agcaaggtgt ttaagtaatt gccagctttt atacatcat gagtggtgac 2400 ttaaggagaa atagcttat agatgagttt ttcattattt ggaaatttag gggtagaaaa 2460 tgttttcccc taattttcca gagaagccta tttttatatt tttaaaaaac tgacagggcc 2520 cagttaaata tgatttgcat tttttaaatt tgccagtttt attttctaaa ttctttcatg 2580 agcttgccta aaattcggaa tggttttcgg gttgtggcaa accccaaaga gagcactgtc 2640 caaggatgtc gggagcatcc tgctgcttag gggaatgttt tcgcaaatgt tgctctagtc 2700 agtccagctc atctgccaaa atgtagggct accgtcttgg atgcatgagc tattgctaga 2760 gcatcatcct tagaaatcag tgccccagat gtacatgtgt tgagcgtatt cttgaaagta 2820 ttgtgtttat gcatttcaat ttcaatggtg ttggcttcc ctccccaccc cacgcgtgca 2880 taaaaactgg ttctacaaat ttttacttga agtaccaggc cgtttgcttt ttcaggttgt 2940 tttgttttat agtattaagt gaaattttaa atgcacagtt ctatttgcta tctgaactaa 3000 ttcatttatt aagtatattt gtaaaagcta aggctcgagt taaaacaatg aagtgtttta 3060caatgatttg taaaggacta tttataacta atatggtttt gttttcaatg aattaagaaa 3120 gattaaatat atctttgtaa attattttat gtcatagttt aattggtcta ccaagtaaga 3180 catctcaaat acagtagtat aatgtatgaa ttttgtaagt ataagaaatt ttattagaca 3240 ttctcttact ttttgtaaat gctgtaaata tttcataaat taacaaagtg tcactccata 3300 aaaagaaagc taatactaat agcctaaaag attttgtgaa atttcatgaa aactttttaa 3360 tggcaataat gactaaagac ctgctgtaat aaatgtatta actgaaacct aa 3412 <![CDATA[<210> 2]]> <![CDATA[<211> 603]]> <![CDATA[<212> PRT]]> <![CDATA[<213> Homo sapiens]]> <![CDATA[<400> 2]]> Met Ala Ser Ala Ser Thr Ser Lys Tyr Asn Ser His Ser Leu Glu Asn 1 5 10 15 Glu Ser Ile Lys Arg Thr Ser Arg Asp Gly Val Asn Arg Asp Leu Thr 20 25 30 Glu Ala Val Pro Arg Leu Pro Gly Glu Thr Leu Ile Thr Asp Lys Glu 35 40 45 Val Ile Tyr Ile Cys Pro Phe Asn Gly Pro Ile Lys Gly Arg Val Tyr 50 55 60 Ile Thr Asn Tyr Arg Leu Tyr Leu Arg Ser Leu Glu Thr Asp Ser Ser 65 7,0 75 80 Leu Ile Leu Asp Val Pro Leu Gly Val Ile Ser Arg Ile Glu Lys Met 85 90 95 Gly Gly Ala Thr SerArg Gly Glu Asn Ser Tyr Gly Leu Asp Ile Thr 100 105 110 Cys Lys Asp Met Arg Asn Leu Arg Phe Ala Leu Lys Gln Glu Gly His 115 120 125 Ser Arg Arg Asp Met Phe Glu Ile Leu Thr Arg Tyr Ala Phe Pro Leu 130 135 140 Ala His Ser Leu Pro Leu Phe Ala Phe Leu Asn Glu Glu Lys Phe Asn 145 150 155 160 Val Asp Gly Trp Thr Val Tyr Asn Pro Val Glu Glu Tyr Arg Arg Gln 165 170 175 Gly Leu Pro Asn His His Trp Arg Ile Thr Phe Ile Asn Lys Cys Tyr 180 185 190 Glu Leu Cys Asp Thr Tyr Pro Ala Leu Leu Val Val Pro Tyr Arg Ala 195 200 205 Ser Asp Asp Asp Leu Arg Arg Val Ala Thr Phe Arg Ser Arg Asn Arg 210 215 220 Ile Pro Val Leu Ser Trp Ile His Pro Glu Asn Lys Thr Val Ile Val 225 230 235 240 Arg Cys Ser Gln Pro Leu Val Gly Met Ser Gly Lys Arg Asn Lys Asp 245 250 255 Asp Glu Lys Tyr Leu Asp Val Ile Arg Glu Thr Asn Lys Gln Ile Ser 260 265 270 Lys Leu Thr Ile Tyr Asp Ala Arg Pro Ser Val Asn Ala Val Ala Asn 275 280 285 Lys Ala Thr Gly Gly Gly Tyr Glu Ser Asp Asp Ala Tyr His Asn Ala 290 295 300 Glu Leu Phe Phe Leu AspIle His Asn Ile His Val Met Arg Glu Ser 305 310 315 320 Leu Lys Lys Val Lys Asp Ile Val Tyr Pro Asn Val Glu Glu Ser His 325 330 335 Trp Leu Ser Ser Leu Glu Ser Thr His Trp Leu Glu His Ile Lys Leu 340 345 350 Val Leu Thr Gly Ala Ile Gln Val Ala Asp Lys Val Ser Ser Gly Lys 355 360 365 Ser Ser Val Leu Val His Cys Ser Asp Gly Trp Asp Arg Thr Ala Gln 370 375 380 Leu Thr Ser Leu Ala Met Leu Met Leu Asp Ser Phe Tyr Arg Ser Ile 385 390 395 400 Glu Gly Phe Glu Ile Leu Val Gln Lys Glu Trp Ile Ser Phe Gly His 405 410 415 Lys Phe Ala Ser Arg Ile Gly His Gly Asp Lys Asn His Thr Asp Ala 420 425 430 Asp Arg Ser Pro Ile Phe Leu Gln Phe Ile Asp Cys Val Trp Gln Met 435 440 445 Ser Lys Gln Phe Pro Thr Ala Phe Glu Phe Asn Glu Gln Phe Leu Ile 450 455 460 Ile Ile Leu Asp His Leu Tyr Ser Cys Arg Phe Gly Thr Phe Leu Phe 465 470 475 480 Asn Cys Glu Ser Ala Arg Glu Arg Gln Lys Val Thr Glu Arg Thr Val 485 490 495 Ser Leu Trp Ser Leu Ile Asn Ser Asn Lys Glu Lys Phe Lys Asn Pro 500 505 510 Phe Tyr Thr Lys Glu IleAsn Arg Val Leu Tyr Pro Val Ala Ser Met 515 520 525 Arg His Leu Glu Leu Trp Val Asn Tyr Tyr Ile Arg Trp Asn Pro Arg 530 535 540 Ile Lys Gln Gln Gln Pro Asn Pro Val Glu Gln Arg Tyr Met Glu Leu 545 550 555 560 Leu Ala Leu Arg Asp Glu Tyr Ile Lys Arg Leu Glu Glu Leu Gln Leu 565 570 575 Ala Asn Ser Ala Lys Leu Ser Asp Pro Pro Thr Ser Pro Ser Ser Pro 580 585 590 Ser Gln Met Met Pro His Val Gln Thr His Phe 595 600 <![CDATA[<210> 3]]> <![CDATA[<211> 1060]]> <![CDATA[<212> DNA]]> <![CDATA[<213> Artificial Sequence]]> <![CDATA[<220>]]> <![CDATA[<223> Synthetic construct]]> <![CDATA[<400> 3]]> taccccctgc cccccacagc tcctctcctg tgccttgttt cccagccatg cgttctcctc 60 tataaatacc cgctctggta tttggggttg gcagctgttg ctgccaggga gatggttggg 120 ttgacatgcg gctcctgaca aaacacaaac ccctggtgtg tgtgggcgtg ggtggtgtga 180 gtagggggat gaatcaggga gggggcgggg gacccagggg gcaggagcca cacaaagtct 240 gtgcgggggt gggagcgcac atagcaattg gaaactgaaa gcttatcaga ccctttctgg 300 aaatcagccc actgtttata aacttgaggc cccaccctcg acagtaccgg ggaggaagag360 ggcctgcact agtccagagg gaaactgagg ctcagggcca gctcgcccat agacatacat 420 ggcaggcagg ctttggccag gatccctccg cctgccaggc gtctccctgc cctcccttcc 480 tgcctagaga cccccaccct caagcctggc tggtctttgc ctgagaccca aacctcttcg 540 acttcaagag aatatttagg aacaaggtgg tttagggcct ttcctgggaa caggccttga 600 ccctttaaga aatgacccaa agtctctcct tgaccaaaaa ggggaccctc aaactaaagg 660 gaagcctctc ttctgctgtc tcccctgacc ccactccccc ccaccccagg acgaggagat 720 aaccagggct gaaagaggcc cgcctggggg ctgcagacat gcttgctgcc tgccctggcg 780 aaggattggt aggcttgccc gtcacaggac ccccgctggc tgactcaggg gcgcaggcct 840 cttgcggggg agctggcctc cccgccccca cggccacggg ccgccctttc ctggcaggac 900 agcgggatct tgcagctgtc aggggagggg aggcgggggc tgatgtcagg agggatacaa 960 atagtgccga cggctggggg ccctgtctcc cctcgccgca tccactctcc ggccggccgc 1020 ctgcccgccg cctcctccgt gcgcccgcca gcctcgcccg 1060 <![CDATA[<210> 4]]> <![CDATA[<211> 1822]]> <![CDATA[<212> DNA]]> <![CDATA[<213> Artificial Sequence]]> <![CDATA[<220>]]> <![CDATA[<223> Synthetic construct]]> <![CDATA[<400> 4]]>agtttccagg atggctctg catcaacttc taaatataat tcacactcct tggagaatga 60 gtctattaag aggacctc gagatggagt caatcgagat ctcactgagg ctgttcctcg 120 acttccagga gaacactaa tcactgaca80acatttc ccccattaag ggaagagttt acatcacaaa ttatcgtctt tattaagaa gttggaaac 240 ggattctct ctaatacttg atgttcctct gggtgtgatc tcgagaattg aaaaaatggg 300 aggcgacgaca acagaccgatag aattagagtag aattagagtag 360 aaacctgagg ttcgctttga aacaggaagg ccacagcaga agagatatgt ttgagatcct 420 cacgagatac gcgttccc tggctcacag tctgccatta tttgcatttt taaatgaga 480 aaagtttaac gtggatggat ggacacagt4gaggagttta cacaattta cttgcccaat caccattgga gaataacttt tattaatag tgctatgagc tctgtgacac 600 ttaccctgct cttttggtgg ttccgtacg tgcctcagat gatgacctcc ggagagttgc 660 aacttttagg tcccgaaatc gattcaccagtgg aataact7aataatt ggtcattgtg cgttgcagtc agcctcttgt cggtatgagt gggaaacgaa ataagatga 780 tgagaaatat ctcgatgtta tcagggac tataaacaa atttctaaac tcaccatta 840 tgatgcaaga cccaccgtaaatgcagtggc caacaaggca acaggaggag gatatgaaag 900 tgatgatgca tatcataacg ccgaactttt cttcttagac attcataata ttcatgttat 960 gcgggaatct ttaaaaaaag tgaaggacat tgtttatcct aatgtagaag aatctcattg 1020 gttgtccagt ttggagtcta ctcattggtt agaacatatc aagctcgttt tgacaggagc 1080 cattcaagta gcagacaaag tttcttcagg gaagagttca gtgcttgtgc attgcagtga 1140 cggatgggac aggactgctc agctgacatc cttggccatg ctgatgttgg atagcttcta 1200 taggagcatt gaagggttcg aaatactggt acaaaaagaa tggataagtt ttggacataa 1260 atttgcatct cgaataggtc atggtgataa aaaccacacc gatgctgacc gttctcctat 1320 ttttctccag tttattgatt gtgtgtggca aatgtcaaaa cagttcccta cagcttttga 1380 attcaatgaa caatttttga ttataatttt ggatcatctg tatagttgcc gatttggtac 1440 tttcttattc aactgtgaat ctgctcgaga aagacagaag gttacagaaa ggactgtttc 1500 tttatggtca ctgataaaca gtaataaaga aaaattcaaa aaccccttct atactaaaga 1560 aatcaatcga gttttatatc cagttgccag tatgcgtcac ttggaactct gggtgaatta 1620 ctacattaga tggaacccca ggatcaagca acaacagccg aatccagtgg agcagcgtta 1680 catggagctc ttagccttacgcgacgaata cataaagcgg cttgaggaac tgcagctcgc 1740 caactctgcc aagctttctg atcccccaac ttcaccttcc agtccttcgc aaatgatgcc 1800 ccatgtgcaa actcacttct ga 1822 <![CDATA[<210> 5]]> <![CDATA[<211> 12471]]> <![CDATA[<212> DNA]]> <![CDATA[<213> Artificial Sequence]]> <![CDATA[<220>]]> <![CDATA[<223> Synthetic construct]]> <![CDATA[<400> 5]]> tcgcgcgttt cggtgatgac ggtgaaaacc tctgacacat gcagctcccg gacgtcattg 60 tcgatcctgc aggcgtacgg taaaaaaagg catagctaac aaggtgtgga aaaagaattaattcataaat cttaaggaaa 600 tccattgtga gttttcatta tgagtgcatc caatgtataa tttccatgac cctcccatgc 660 aagtgagcat gtgaatcagg aaacgttaca agaacccaac aaactcaacc actactagac 720 aggcgatcac ttccagttag tatgcaactt tctgtgtaat tttagttacc attaaaatct 780 ggatgacctt agtgtaagga aaaaatacct tgaatagtgt taaagatgta cacttggtgt 840 caggcattgt aacattgata aatctgtgta aggtgctttt tgaaaacttc aaagctgcat 900 caagtcaagt acaagaaagg ccatggctgc taaagctgtt gaagatgtgg gatggaactg 960 ggtcacattg gtgttaacag cgttgtg agccggcagg atcttggtgt gagcgaacat 1020 tagtctattt aataaagctg tgtgaatgtt gtagaggtga ggatgctcac ttgaaaaactc 1080 actgaagaac acttggcccc ttgaactaaa gtgcttctat caagttcagt gagaaattcc 1140 gaattacaag cataggtact agaaaagttt tgaaaagcag tatagagcaa cataagcaca 1200 ttcataaaat tagtgatgta gaaagtgaaa tttccacgta tggtcactcc cagagaaaaa 1260 aaatacgtt atttaccttt tttaaaaata gggatttca ggccgggtga ggtggctcac 1320 gcctgtaatc ccagcacttt gggaggccca ggtgggcgga tcacctgagg tcaggaggttg 1380 gagggatggc aaatcccatc tctacaaaaat atacaaaaa atagctgggtgtgttggcag 1440 gcgcctgtaa tcccagctac tcggaaggct gaggcaggag aatccctgga accagggatg 1500 tggaggttgc agtgagccga gattgtgtaa ctgcattcca gcctgggcaa caagagcaag 1560 actccgtatc aggaagg ttggatttcg cttgttgcat aggttggtct 1620 caaactcctg gcctcaagtg attctcctgc ctctgcctcc caaagtgctg agattacagg 1680 tgtgaggcac catgccaggt ctcttactgt ttgtaattaa atacatacag atttgttc70 ttgttcag cctttataaa gtcaaaggtg atagtaaccc atttaagttc ctactcaatt 1800 ttactttcca gggataacta actacttttt ctttttgaga tggagtctcg ctgtgtagcc 1860 caggctggag tgcagtggca ccatctcggc tcactgcaagc cctcctcg cctcgc1920 ctattctcct gcctcagcct ccccaacaac taggactaca ggctcacctc gccatacctg 1980 gctaattttt tgtattttta gtagagacag ggtttcactg tgttagccag gatggtctcg 2040 atctcctgac cttgtgatcc gcctgccctgc 2100 agcaacctca cccagctggg ataactactt tttacaggtt gatattcttt tggacttttc 2160 ccctgtgtaa aatatacta tatttgttat gtacatatta tgtacataca gacacaaatt 2220 ggaccattct cagtataatg attctcaggtt ttttgaggttggggaactag 2280 ataattatgg acatctttcc atactagcat atcaatatct acctcattct ttttaatatt 2340 tttgctagta ttccattgta tgaatgtcct atgatttact taacctgtcc atcaatattt 2400 gtttccaggt ttttgctatt ataatgctgc tgcaaagtac atcctcacac atctttattt 2460 tgtctattca tatttctgta agataggtta ctaaagttgg aactgccaaa ttaacactat 2520 catactattt tgttttttaa ttttaatttt ttaaaaaatg taaaatgtgc aatttcaaga 2580 ggagaaactt gaacacaagg agcaaaatct atttttataa catcctatta aaagcttgct 2640 ttacataaag attttgaaag aatagcataa atacaagatt tctattttaa ttggattctt 2700 agggctaata aaataatcag ccttagcact tatttattta ttttttttga gagggagtct 2760 cgctctgttg tccatgctgg agtgcagtgg cgtgatctcg gctcactgca agctccacct 2820 catgagttca caccattctc ctgcctcagt ctcccgagta gctgggactc caggcgccct 2880 ctacaaagcc cgtctaattt tttttgtatt tttagtagag acagggtttc actgtgttag 2940 ccaggatggt cttgatctcc tgaccttgtg atctgcccgc ctcggcctcc caaagtgctg 3000 ggattatagg cttgagccac tgctcccggc cagcacttat ttttataatt cttcatgatt 3060 actgtgttac tgtcccatgg gccgccaggg ccagctaggt tggccactccctctctgcgc 3120 gctcgctcgc tcactgaggc cgggcgacca aaggtcgccc gacgcccggg ctttgcccgg 3180 gcggcctcag tgagcgagcg agcgcgcaga gagggagtgg ccaactccat cactagggcgt t32tcgcgc ccctgccccc cacagctcct ctcctgtgcc ttgtttccca 3300 gccatgcgtt ctcctctata aatacccgct ctggtatttg gggttggcag ctgttgctgc 3360 cagggagatg gttgggttga catgcggctc ctgacaacacct gttgtacgcgt344 ggcgtgggtg gtgtgagtag ggggatgaat cagggagggg gcgggggacc cagggggcag 3480 gagccacaca aagtctgtgc gggggtggga gcgcacatag caattggaaa ctgaaagctt 3540 atcagaccct ttctggaaat cagcccactg ttcgacct tggtataacccagc 3600 taccggggag gaagagggcc tgcactagtc cagagggaaa ctgaggctca gggccagctc 3660 gcccatagac atacatggca ggcaggcttt ggccaggatc cctccgcctg ccaggcgtct 3720 ccctgccctc ccttccctgcc tagagcct cggcctc ctttgcctga 3780 gacccaaacc tcttcgactt caagagaata tttaggaaca aggtggttta gggcctttcc 3840 tgggaacagg ccttgaccct ttaagaaatg acccaaagtc tctccttgac caaaaagggg 3900 accctcaacct ccggact gccctcct ctgaccccactccccccac 3960 cccaggacga ggataacc agggctgaaa gaggcccgcc tgggggctgc agacatgctt 4020 gctgcctgcc ctggcgaagg attggtaggc ttgcccgtca caggaccccc gctggctgac 4080 tcaggcccgct aggggc ggcctccccg cccccacggc cacgggcgc 4140 cctttcctgg caggacagcg ggatcttgca gctgtcaggg gaggggaggc gggggctgat 4200 gtcaggaggg attacaatag tgccgacggc tgggggccct gctctccctc gccgcccccgcgcgcgc ccgccgcctc ctccgtgcgc ccgccagcct cgcccggact 4320 ctagaggatc cagatctaag cttctctggt caccgatcct gagaacttca gggtgagtct 4380 atgggaccct tgatgttttc tttccccttc ttttcttgg ttaagttagg gcattag40 aacagggtac acatattgac caaatcaggg taattttgca tttgtaattt 4500 taaaaaatgc tttcttcttt tatatacttt ttttgtttat cttatttcta atactttccc 4560 taatctcttt ctttcagggc aataatgata caatgtatca tgcctcttgtta caccatcta caattcta caatgtatca tgcctcttgcta caattcta caattc ctgggttaag gcaatagcaa tatttctgca tataaatatt 4680 tctgcatata aattgtaact gatgtaagag gtttcatatt gctaatagca gctacaatcc 4740 agctaccatt ctgcttttat tttatggttg ggataaggct ggattattctgagtccaagc 4800 taggcccttt tgctaatcat gttcatacct cttatcttcc tcccacagct cctgggcaac 4860 gtgctggtct gtgtgctggc ccatcacttt ggcaaagaat tccgcgggcg gccgcaagtt 4920 tccaggatgg cttctgcatc aacttctaaa tataattcac actccttgga gaatgagtct 4980 attaagagga cgtctcgaga tggagtcaat cgagatctca ctgaggctgt tcctcgactt 5040 ccaggagaaa cactaatcac tgacaaagaa gttatttaca tatgtccttt caatggcccc 5100 attaagggaa gagtttacat cacaaattat cgtctttatt taagaagtt ggaaacggat 5160 tcttctaa tacttgatgt tcctctgggt gtgatctcga gaattgaaaa aatgggaggc 5220 gcgacaagga gaggaaaa ttcctatggt ctagatatta cttgtaaaaga catgagaaac 5280 ctgaggttcg ctttgaaaca ggaaggccac agcagaagag atatgtttga gatcctcacg 5340 agatacgcgt ttcccctggc tcacagtctg ccattattg catttttaaa tgaagaaaag 5400 tttaacgtgg atggatggac agtttacaat ccagtggaag aatacaggag gcagggcttg 5460 cccaatcacc attggagaat aacttttat aataagtgct atgagctctg tgacacttac 5520 cctgctcttt tggtggttcc gtatcgtgcc tcagatgatg acctccggag agttgcaact 5580 tttaggtccc gaaatcgaat tccagtgctg tcatggattc atccagaaaataagacggtc 5640 attgtgcgtt gcagtcagcc tcttgtcggt atgagtggga aacgaaataa agatgatgag 5700 aaatatctcg atgttatcag ggagactaat aaacaaattt ctaaactcac catttatgat 5760 gcaagaccca gcgtaaatgc agtggccaac aaggcaacag gaggaggata tgaaagtgat 5820 gatgcatatc ataacgccga acttttcttc ttagacattc ataataattca tgttatgcgg 5880 gaatctttaa aaaaagtgaa ggacattgtt tatcctaatg tagagaaatc tcattggttg 5940 tccagtttgg agtctactca ttggttagaa catatcaagc tcgtttgac aggagccatt 6000 caagtagcag acaaagtttc ttcagggaag agttcagtgc ttgtgcattg cagtgacgga 6060 tgggacagga ctgctcagct gacatccttg gccatgctga tgttgtag cttctatagg 6120 agcattgaag ggttcgaaat actggtacaa aaagaatgga taagttttgg acataaattt 6180 gcatctcgaa taggtcatgg tgataaaaac cacaccgatg ctgaccgttc tcctattttt 6240 ctccagttta ttgattgtgt gtggcaaatg tcaaaacagt tccctacagc ttttgaattc 6300 aatgaacaat ttttgattat aattttggat catctgtata gttgccgatt tggtactttc 6360 ttattcaact gtgaatctgc tcgagaaaga cagaaggtta cagaaaggac tgtttcttta 6420 tggtcactga taaacagtaa taaagaaaaa ttcaaaaacc ccttttatactaaagaaatc 6480 aatcgagttt tatatccagt tgccagtatg cgtcacttgg aactctgggt gaattactac 6540 attagatgga accccaggat caagcaacaa cagccgaatc cagtggagca gcgttacatg 6600 gagctcttag ccttacgcga cgaatacata aagcggcttg aggaactgca gctcgccaac 6660 tctgccaagc tttctgatcc cccaacttca ccttccagtc cttcgcaaat gatgccccat 6720 gtgcaaactc acttctgacc ggtccgaggg cccagatcta attcacccca ccagtgcagg 6780 ctgcctatca gaaagtggtg gctggtgtgg ctaatgccct ggcccacaag tatcactaag 6840 ctcgctttct tgctgtccaa tttctattaa aggttccttt gttccctaag tccaactact 6900 aaactgggg atattatgaa gggccttgag catctggatt ctgcctaata aaaaacattt 6960 attttcattg caatgatgta tttaaattat ttctgaatat tttactaaaa agggaatgtg 7020 ggaggtcagt gcatttaaaa cataaagaaa tgaagagcta gttcaaacct tgggaaaata 7080 cactatatct taaactccat gaaagaaggt gaggctgcaa acagctaatg cacattggca 7140 acagcccctg atgcctatgc cttatcatc cctcagaaaa ggattcaagt agaggcttga 7200 tttggaggtt aaaggttttgc tatgctgtat tttacattac ttatgtttt agctgtcctc 7260 atgaatgtct tttcactacc catttgctta tcctgcatct ctcagccttgactccactca 7320 gttctcttgc ttagagatac caccttccc ctgaagtgtt ccttccatgt tttacggcga 7380 gatggttct cctcgcctgg ccactcagcc ttagttgtct ctgttgctt atagaggtct gggagaggt 7440 ttgactgtcc tgtgagccct tcttccctgc 7500 ctccccact cacagtgacc ggccgctta ggaggaaccc ctagtgatgg agttggccac 7560 tccctctg cgcgctcgct cgctcactga ggccggtccg ccagggaggcc ccaccaggcc cgggcggcct cagtgagcga gcgagcgcgc aggagggag tggccaacct 7680 agaggccgcc agggccatat ttcaattt ttaaatttt caaaaaatt aatccttaat 7740 gtgcatatttttgaattgtt ataatactcat tgtt8cttgattga acttaaaaac ttttaaacag tatatataa aaaatcttcc aggccactca cacctgtaat 7860 cccagcactt tgggaggctg aggtggcag atcacctgag ggcaggagtt cgagaccagc 7920 ctggccaata tatattat catatattca tatatattca tatatatcatta9 tatatatcattc tatatatata tagcaaaacc tcatctctaa 8040 taaaatacaa aaattagctg agcgtggtga tggatgcctg tagtcccagc tactcgggag 8100 gctgaggcag gagaatctct tgaacctggg aggtggaggt tgcagtgagctgagatggtg 8160 ccactgccct ccagcctgag tgacagagcg agactcggtc tccaaaaaaaaacaaaa 8220 aaatctcca tccttgctc ccatccaccc cttccccca gcatgtactt gcagactatatatatacatacatta 8 atagacatacataca80 aaatcatata tataatatat 8340 gtaattcccc tttacatgaa aggtagcaca ctggtctgta cagtctgtct gcactgtgct 8400 atttcactt atattttat agttgacag agttctaca tttcttttttttttta 8460 aacattcttttt gttacatttgactt aaagtttggt ttcacacttg 8520 aatgaatacc atgtaggat tcacttacat agatgtggtt gcctgaatct taagataaa 8580 atacattgt ttgtatttat ttaaattagt gttccttat tggtttgcct gaagcacaa 86accactatta acaaccacaatcct aggtaactg tttagagatt 8700 ggcaagcacc ttttaatgaa aggagtcagc cagcttagtg tgcagtattt atttctgccg 8760 gaagagggag cttcagggac agactttgt ttagtcatga agcctccagc actcacctag0 gaccagttc 8700 tacctttcta cttccagagg cttgtttact 8880 tatcagtaag cattaattta gtgtcccctc agatgccttt tacttctc ttttctgcct 8940 agaataagct gctcttccaa tttgcagct acatgttcc acccagttggatttctcc 9000 atacatcca ttgtagctat ccttcaatct acagccta ttcctcta tagctgtca 9060 gtctaatcc ctcaaatac tctgccct gctcctctta tctgctggcc acctttcc 9120 tgccagccattca gttccctgcc acctcaacaa 9180 atttaagtcc attaaataga gtaagtgttc ctgactgtta aattttaaag catcccaaag 9240 tctgatttca cactcgaatg atactgt acggattcat ttacatagat gcggttgcat 9300 aattattagattacattaac agtactgtca agatataatg 9360 tcaagaccta attcaaggt tccacaagc cttccttgac tgccccaac gaagattatc 9420 cattttccct gaatcccat tgacttct atttgtaag gaggctcgtg agactgtca aaaacaaaga taaaacaaaga 9480 caaacggctt gcttctgttc tttgatctgc 9540 tagtaagcaa aattacaca tggtgacagg agctatgtga ggctgtcagg tgaatggga 9600 ggagttgggg atcctgcttg tggatggttg gagaggctt tcgggaat aga gga6gtta0 cttagctttg cagaaggtgg agaggcagga atagcacgg 9720 gggccctggg gctggaagac ttggcatat tgaggaaca gaaggagac cagcatact 9780 gaggtgggaa aagcatgtga agagatgggg ctggaggagg ccgggagtggtggctcacgc 9840 ctgtaatccc agcactttgg gaggccaagg caggcggatc atgagctcag gagattgaga 9900 ccatcctggc taacacggtg aaaccccctc tctactaaaa atacaaaaaa aaaaaaaaaa 9960 aaaattagct gggcgtggtg gcaggagcct gtagtcccag ctacctggga ggctgaggca 10020 ggagaatggc gtgaacctgg aaggctgagc ttgcagtgag ccgagattgc accactgcac 10080 tccagcctgg gagacagaga gagactccct ctcaaaaaaa caaacaaacg aaacaaaaca 10140 aaacaaaaat tagccaggcg tggtggtatg cacctgtaat cccagctact cgggaggttg 10200 aggcaggaga aacgcttgaa ctcaggaggc ggaggttgca gtgagccgag actgcgccac 10260 tgcactccag cctgggtgac agagggagac tccatctcaa aaaaaaaaat tttttttttt 10320 ttacaaacgg tgtctccctc tgtcgcccag gctggagtgc agtggtgtga tcacagctca 10380 ctccagcctc aacctcccca gctgaagcca tcctcttgcc tcagcctcct aagtagctgg 10440 gactacaggc gcgcacctcc aggcttggct cttattcttt ttattgtttt tgaaactata 10500 gaacctattt ttaaaaaatg ttttggttgt ttttattgct gcttttcctt ttggggttag 10560 aacacaagtt ttgatgggaa acaggttaga acacattcat ctcttcccat agcgatggtc 10620 atagaaaaac ggggcatatt tataaactct cagttgatcttaaaatgtgc aaaagctgcc 10680 gaactcctgg gagtgagctc gagccctgca ggatcattgt cacatgtgag caaaaggcca 10740 gcaaaaggcc aggaaccgta aaaaggccgc gttgctggcg tttttccata ggctccgccc 10800 ccctgacgag catcacaaaa atcgacgctc aagtcagagg tggcgaaacc cgacaggact 10860 ataaagatac caggcgtttc cccctggaag ctccctcgtg cgctctcctg ttccgaccct 10920 gccgcttacc ggatacctgt ccgcctttct cccttcggga agcgtggcgc tttctcatag 10980 ctcacgctgt aggtatctca gttcggtgta ggtcgttcgc tccaagctgg gctgtgtgca 11040 cgaacccccc gttcagcccg accgctgcgc cttatccggt aactatcgtc ttgagtccaa 11100 cccggtaaga cacgacttat cgccactggc agcagccact ggtaacagga ttagcagagc 11160 gaggtatgta ggcggtgcta cagagttctt gaagtggtgg cctaactacg gctacactag 11220 aagaacagta tttggtatct gcgctctgct gaagccagtt accttcggaa aaagagttgg 11280 tagctcttga tccggcaaac aaaccaccgc tggtagcggt ggtttttttg tttgcaagca 11340 gcagattacg cgcagaaaaa aaggatctca agaagatcct ttgatctttt ctacggggtc 11400 tgacgctcag tggaacgaaa actcacgtta agggattttg gtcatgagat tatcaaaaag 11460 gatcttcacc tagatccttt taaattaaaaatgaagtttt aaatcaagcc caatctgaat 11520 aatgttacaa ccaattaacc aattctgatt agaaaaaactc atcgagcatc aaatgaaact 11580 gcaatttatt catatcagga ttatcaatac catattttg aaaaagccgt ttctgtaatg 11640 aaggagaaaa ctcaccgagg cagttccata ggatggcaag atcctggtat cggtctgcga 11700 ttccgactcg tccaacatca atacaaaccta ttaatttccc ctcgtcaaaa ataaggttat 11760 caagtgagaa atcaccatga gtgacgactg aatccggtga gaatggcaaa agtttatgca 11820 tttctttcca gacttgttca acaggccagc cattacgctc gtcatcaaaa tcactcgcat 11880 caaccaaacc gttattcatt cgtgattgcg cctgagcgag acgaaatacg cgatcgctgt 11940 taaagca attacaaaca ggaatcgaat gcaaccggcg caggaacact gccagcgcat 12000 caacaatatt ttcacctgaa tcaggatatt cttttaatac ctggaatgct gtttttccgg 12060 ggatcgcagt ggtgagtaac catgcatcat caggagatcg gataaaatgc ttgatggtcg 12120 gaagaggcat aaattccgtc agccagttta gtctgaccat ctcatctgta acatcattgg 12180 caacgctacc tttgccatgt ttcagaaaca actctggcgc atcgggcttc ccatacaagc 12240 gatagattgt cgcacctgat tgcccgacat tatcgcgagc ccatttatac ccatataaat 12300 cagcatccat gttggaatttaatcgcggcc tcgacgtttc ccgttgaata tggctcataa 12360 caccccttgt attactgttt atgtaagcag acagttttat tgttcatgat gatatatttt 12420 tatcttgtgc aatgtaacat cagagatttt gagacacggg ccagagctgc a

Claims

1. A method for weaning a human patient undergoing mechanical ventilation who has X-linked myotubular myopathy (XLMTM), wherein the patient has previously been administered a therapeutically effective amount of a viral vector containing a transgenic gene encoding tubulin 1 (MTM1), the method comprising: a. determining that the patient exhibits one or more of the following: (i) a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator, (iii) a positive end-expiratory pressure of about 5 cmH2O or lower on a ventilator, (iv) an indoor air oxygen saturation (SpO2) of about 94% or higher, (v) a transcutaneous CO2 (TcCO2) of about 35 mmHg to about 45 mmHg, (vi) an end-tidal CO2 (petCO2) of about 35 mmHg to about 45 mmHg, and (vii) a TcCO2 of about 22 mEq / L to about 27 mEq / L. a. Serum bicarbonate level of mEq / L; and b. Wean the patient off mechanical ventilation during the daytime.

2. The method of claim 1, wherein the method comprises determining that the patient exhibits a maximum inspiratory pressure of approximately 50 cmH2O or higher on a ventilator.

3. The method of claim 1 or 2, wherein the method comprises determining that the patient exhibits a maximum expiratory pressure of approximately 40 cmH2O or higher on a ventilator.

4. The method of any one of claims 1-3, wherein the method comprises determining that the patient exhibits a positive end-expiratory pressure of about 5 cmH2O or less on a ventilator.

5. The method of any one of claims 1-4, wherein the method comprises determining that the patient exhibits approximately 94% or higher SpO2.

6. The method of any one of claims 1-5, wherein the method comprises determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg.

7. The method of any one of claims 1-6, wherein the method comprises determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg.

8. The method of any one of claims 1-7, wherein the method comprises determining that the patient exhibits a serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

9. The method of any one of claims 1-8, wherein the method further comprises determining that the patient exhibits vital signs and weight within age-adjusted criteria.

10. The method of any one of claims 1-9, wherein the method further comprises determining that the patient has a motor function score greater than 45 or has reached a neuromuscular developmental milestone on the Children's Hospital of Philadelphia Infant Test of Neuromuscular Disorders (CHOP INTEND).

11. The method of any one of claims 1-10, wherein the method further comprises: c. determining that the patient exhibits one or more of the following: (i) a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of about 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) an apnea-hypopnea index (AHI) of less than 5 events / hour, as assessed by polysomnography (PSG) performed with an open tracheostomy; (v) a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by PSG performed with an open tracheostomy; (vi) a TcCO2 that has not increased by 10 mmHg or more relative to the patient's awake baseline, as assessed by PSG performed with an open tracheostomy; (vii) a TcCO2 of less than 50 mmHg. (viii) PetCO2 or partial pressure of CO2 (ptcCO2) of mmHg, as assessed by PSG with open tracheostomy, does not increase by 10 mmHg or more during sleep relative to the patient's awake baseline. (ix) No intercostal contractions are observed in the video recording of the breathing sprint test, (x) No respiratory tachycardia is observed in the video recording of the breathing sprint test, (xi) No respiratory paradoxes are observed in the video recording of the breathing sprint test, (xii) No phase delay is observed in the video recording of the breathing sprint test, (xiii) SpO2 is less than 94% of the target value, as assessed by video recording of the breathing sprint test, (xiv) SpO2 is not more than 3% of the target value relative to the patient's awake baseline. (xv) TcCO2 is greater than 45 mmHg, as assessed by video recording of the breathing sprint test, and (xvi) TCO2 does not increase by 10 mmHg or more relative to the patient's awake baseline. mmHg or higher, as assessed by video recording of a respiratory sprint test; and d. Continue to wean the patient off mechanical ventilation during the daytime.

12. The method of claim 11, wherein the method comprises determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg, such as by nighttime respiratory monitoring.

13. The method of claim 11 or 12, wherein the method comprises determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg, such as by assessment via nocturnal respiratory monitoring.

14. The method of any one of claims 11-13, wherein the method comprises determining that the patient exhibits approximately 94% or higher SpO2, such as by assessment via nocturnal respiratory monitoring.

15. The method of any one of claims 11-14, wherein the method includes determining that the patient exhibits an AHI of less than 5 events / hour, such as by PSG assessment performed with an open tracheostomy.

16. The method of any one of claims 11-15, wherein the method comprises determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg, such as by PSG assessment performed with an open tracheostomy.

17. The method of any one of claims 11-16, wherein the method comprises determining that the patient demonstrates that TcCO2 has not increased by 10 mmHg or more relative to the patient’s waking baseline, such as by PSG assessment performed with an open tracheostomy.

18. The method of any one of claims 11-17, wherein the method comprises determining that the patient exhibits a petCO2 or ptcCO2 of less than 50 mmHg, such as by PSG assessment performed with an open tracheostomy.

19. The method of any one of claims 11-18, wherein the method comprises determining that the patient demonstrates no increase of 10 mmHg or more in petCO2 or ptcCO2 relative to the patient’s awake baseline during sleep, such as by PSG assessment performed with tracheostomy.

20. The method of any one of claims 11-19, wherein the method comprises determining that the patient does not exhibit intercostal contractions in a video recording of a respiratory sprint test.

21. The method of any one of claims 11-20, wherein the method comprises determining that the patient does not exhibit respiratory tachycardia in a video recording of a respiratory sprint test.

22. The method of any one of claims 11-21, wherein the method comprises determining that the patient does not exhibit respiratory abnormalities in a video recording of a respiratory sprint test.

23. The method of any one of claims 11-22, wherein the method comprises determining that the patient does not exhibit phase delay in the video recording of the respiratory sprint test.

24. The method of any one of claims 11-23, wherein the method comprises determining that the patient exhibits SpO2 of less than 94%, such as by assessment via video recording of a breathing sprint test.

25. The method of any one of claims 11-24, wherein the method comprises determining that the patient exhibits an SpO2 difference of no more than 3% relative to the patient’s awake baseline, such as by video recording of a breathing sprint test.

26. The method of any one of claims 11-25, wherein the method comprises determining that the patient exhibits a TCO2 greater than 45 mmHg, such as by assessing via video recording of a breathing sprint test.

27. The method of any one of claims 11-26, wherein the method comprises determining that the patient demonstrates that the TCO2 has not increased by 10 mmHg or more relative to the patient’s awake baseline, such as by video recording of a breathing sprint test.

28. The method of any one of claims 11-27, wherein the method further comprises determining that the patient exhibits a respiratory rate within age-adjusted criteria, such as by assessment via nocturnal respiratory monitoring.

29. The method of any one of claims 11-28, wherein the method further comprises determining that the patient did not exhibit distress in the video recording of the breathing sprint test.

30. The method of any one of claims 11-29, wherein the method further comprises determining that the patient exhibits a respiratory rate within age-adjusted criteria, such as by PSG assessment performed with an open tracheostomy.

31. A method for weaning a human patient undergoing mechanical ventilation who has XLMTM, wherein the patient has previously been administered a therapeutically effective amount of a viral vector containing the transgenic gene of MTM1, the method comprising: a. measuring one or more of the following in the patient: (i) maximum inspiratory pressure on the ventilator, (ii) maximum expiratory pressure on the ventilator, (iii) positive end-expiratory pressure on the ventilator, (iv) SpO2 level, (v) TcCO2 level, (vi) petCO2 level, and (vii) serum bicarbonate level; and b. weaning the patient from mechanical ventilation during the daytime if the patient exhibits one or more of the following: (i) a maximum inspiratory pressure of about 50 cmH2O or higher on the ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on the ventilator, (iii) a maximum expiratory pressure of about 5 cmH2O or higher on the ventilator. (iv) positive end-expiratory pressure of cmH2O or lower, (v) SpO2 of about 94% or higher, (v) TcCO2 of about 35 mmHg to about 45 mmHg, (vi) petCO2 of about 35 mmHg to about 45 mmHg, and (vii) serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

32. The method of claim 31, wherein the method comprises determining that the patient exhibits a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator.

33. The method of claim 31 or 32, wherein the method comprises determining that the patient exhibits a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator.

34. The method of any one of claims 31-33, wherein the method comprises determining that the patient exhibits a positive end-expiratory pressure of about 5 cmH2O or less on a ventilator.

35. The method of any one of claims 31-34, wherein the method comprises determining that the patient exhibits approximately 94% or higher SpO2.

36. The method of any one of claims 31-35, wherein the method comprises determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg.

37. The method of any one of claims 31-36, wherein the method comprises determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg.

38. The method of any one of claims 31-37, wherein the method comprises determining that the patient exhibits a serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

39. The method of any one of claims 31-38, wherein the method further comprises determining that the patient exhibits vital signs and weight within age-adjusted criteria.

40. The method of any one of claims 31-39, wherein the method further comprises determining that the patient has a motor function score greater than 45 on CHOP INTEND or has reached a neuromuscular developmental milestone.

41. A method for treating a human patient with X-linked myotubular myopathy (XLMTM) who is undergoing mechanical ventilation, the method comprising: a. administering to the patient a therapeutically effective amount of a viral vector containing a transgenic gene encoding tubulin 1 (MTM1); b. determining that the patient exhibits one or more of the following: (i) a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator, (iii) a positive end-expiratory pressure of about 5 cmH2O or lower on a ventilator, (iv) an indoor air oxygen saturation (SpO2) of about 94% or higher, (v) a transcutaneous CO2 (TcCO2) of about 35 mmHg to about 45 mmHg, (vi) an end-tidal CO2 (petCO2) of about 35 mmHg to about 45 mmHg, and (vii) a temperature of about 22 mEq / L to about 27 mEq / L. The serum bicarbonate level was measured at mEq / L; and c. the patient was weaned off mechanical ventilation during the daytime.

42. The method of claim 41, wherein the method comprises determining that the patient exhibits a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator.

43. The method of claim 41 or 42, wherein the method comprises determining that the patient exhibits a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator.

44. The method of any one of claims 41-43, wherein the method comprises determining that the patient exhibits a positive end-expiratory pressure of about 5 cmH2O or less on a ventilator.

45. The method of any one of claims 41-44, wherein the method comprises determining that the patient exhibits approximately 94% or higher SpO2.

46. ​​The method of any one of claims 41-45, wherein the method comprises determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg.

47. The method of any one of claims 41-46, wherein the method comprises determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg.

48. The method of any one of claims 41-47, wherein the method comprises determining that the patient exhibits a serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

49. The method of any one of claims 41-48, wherein the method further comprises determining that the patient exhibits vital signs and weight within age-adjusted criteria.

50. The method of any one of claims 41-49, wherein the method further comprises determining that the patient has a motor function score greater than 45 or has reached a neuromuscular developmental milestone on the Children's Hospital of Philadelphia Neuromuscular Disorder Infant Test (CHOP INTEND).

51. The method of any one of claims 41-50, wherein the method further comprises: d. determining that the patient exhibits one or more of the following: (i) a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of about 35 mmHg to about 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of about 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) an apnea-hypopnea index (AHI) of less than 5 events / hour, as assessed by polysomnography (PSG) performed with an open tracheostomy; (v) a TcCO2 of about 35 mmHg to about 45 mmHg, as assessed by PSG performed with an open tracheostomy; (vi) a TcCO2 that has not increased by 10 mmHg or more relative to the patient's awake baseline, as assessed by PSG performed with an open tracheostomy; (vii) a TcCO2 of less than 50 mmHg. PetCO2 or partial pressure of CO2 (ptcCO2) of mmHg, as assessed by PSG with open tracheostomy, (viii) no increase of 10 mmHg or more in petCO2 or ptcCO2 during sleep relative to the patient's awake baseline, as assessed by PSG with tracheostomy, (ix) no intercostal contractions in the video recording of the breathing sprint, (x) no respiratory tachycardia in the video recording of the breathing sprint, (xi) no respiratory paradoxes in the video recording of the breathing sprint, (xii) no phase delay in the video recording of the breathing sprint, (xiii) SpO2 less than 94%, as assessed by video recording of the breathing sprint, (xiv) SpO2 no greater than 3% difference from the patient's awake baseline, as assessed by video recording of the breathing sprint, (xv) TcCO2 greater than 45 mmHg, as assessed by video recording of the breathing sprint, and (xvi) TcCO2 no increase of 10 mmHg or more relative to the patient's awake baseline. mmHg or higher, as assessed by video recording of a respiratory sprint test; and e. continue weaning the patient off mechanical ventilation during the daytime.

52. The method of claim 51, wherein the method comprises determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg, such as by nighttime respiratory monitoring.

53. The method of claim 51 or 52, wherein the method comprises determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg, such as by assessment via nocturnal respiratory monitoring.

54. The method of any one of the requests 51-53, wherein the method comprises determining that the patient exhibits approximately 94% or higher SpO2, such as by assessment via nocturnal respiratory monitoring.

55. The method of any one of claims 51-54, wherein the method comprises determining that the patient exhibits an AHI of less than 5 events / hour, such as by PSG assessment performed with an open tracheostomy.

56. The method of any one of claims 51-55, wherein the method comprises determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg, such as by PSG assessment performed with an open tracheostomy.

57. The method of any one of claims 51-56, wherein the method comprises determining that the patient demonstrates that TcCO2 has not increased by 10 mmHg or more relative to the patient’s waking baseline, such as by PSG assessment performed with an open tracheostomy.

58. The method of any one of claims 51-57, wherein the method comprises determining that the patient exhibits a petCO2 or ptcCO2 of less than 50 mmHg, such as by PSG assessment performed with an open tracheostomy.

59. The method of any one of claims 51-58, wherein the method comprises determining that the patient does not show an increase of 10 mmHg or more in petCO2 or ptcCO2 during sleep relative to the patient’s awake baseline, such as by PSG assessment performed with tracheostomy.

60. The method of any one of claims 51-59, wherein the method comprises determining that the patient does not exhibit intercostal contractions in a video recording of a respiratory sprint test.

61. The method of any one of claims 51-60, wherein the method comprises determining that the patient does not exhibit respiratory tachycardia in a video recording of a respiratory sprint test.

62. The method of any one of claims 51-61, wherein the method comprises determining that the patient does not exhibit respiratory abnormalities in the video recording of the respiratory sprint test.

63. The method of any one of claims 51-62, wherein the method comprises determining that the patient does not exhibit phase delay in the video recording of the respiratory sprint test.

64. The method of any one of claims 51-63, wherein the method comprises determining that the patient exhibits SpO2 of less than 94%, such as by assessment via video recording of a breathing sprint test.

65. The method of any one of claims 51-64, wherein the method comprises determining that the patient exhibits an SpO2 difference of no more than 3% relative to the patient’s awake baseline, such as by video recording of a breathing sprint test.

66. The method of any one of claims 51-65, wherein the method comprises determining that the patient exhibits a TcCO2 greater than 45 mmHg, such as by assessment via video recording of a breathing sprint test.

67. The method of any one of claims 51-66, wherein the method comprises determining that the patient demonstrates that TcCO2 has not increased by 10 mmHg or more relative to the patient’s awake baseline, such as by video recording of a breathing sprint test.

68. The method of any one of claims 51-67, wherein the method further comprises determining that the patient exhibits a respiratory rate within age-adjusted criteria, such as by assessment via nocturnal respiratory monitoring.

69. The method of any one of claims 51-68, wherein the method further comprises determining that the patient did not exhibit distress in the video recording of the breathing sprint test.

70. The method of any one of claims 51-69, wherein the method further comprises determining that the patient exhibits a respiratory rate within age-adjusted criteria, such as by PSG assessment performed with an open tracheostomy.

71. A method for treating a human patient with XLMTM who is undergoing mechanical ventilation, the method comprising: a. administering to the patient a therapeutically effective amount of a viral vector containing a transgenic gene encoding MTM1; b. measuring one or more of the following in the patient: (i) maximum inspiratory pressure on a ventilator, (ii) maximum expiratory pressure on a ventilator, (iii) positive end-expiratory pressure on a ventilator, (iv) SpO2 level, (v) TcCO2 level, (vi) petCO2 level, and (vii) serum bicarbonate level; and c. weaning the patient from mechanical ventilation during the daytime if the patient exhibits one or more of the following: (i) a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator, (ii) a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator, (iii) a maximum expiratory pressure of about 5 cmH2O or higher on a ventilator. (iv) positive end-expiratory pressure of cmH2O or lower, (v) SpO2 of about 94% or higher, (v) TcCO2 of about 35 mmHg to about 45 mmHg, (vi) petCO2 of about 35 mmHg to about 45 mmHg, and (vii) serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

72. The method of claim 71, wherein the method comprises determining that the patient exhibits a maximum inspiratory pressure of about 50 cmH2O or higher on a ventilator.

73. The method of claim 71 or 72, wherein the method comprises determining that the patient exhibits a maximum expiratory pressure of about 40 cmH2O or higher on a ventilator.

74. The method of any one of claims 71-73, wherein the method comprises determining that the patient exhibits a positive end-expiratory pressure of about 5 cmH2O or less on a ventilator.

75. The method of any one of claims 71-74, wherein the method comprises determining that the patient exhibits approximately 94% or higher SpO2.

76. The method of any one of claims 71-75, wherein the method comprises determining that the patient exhibits a TcCO2 of about 35 mmHg to about 45 mmHg.

77. The method of any one of claims 71-76, wherein the method comprises determining that the patient exhibits a petCO2 of about 35 mmHg to about 45 mmHg.

78. The method of any one of claims 71-77, wherein the method comprises determining that the patient exhibits a serum bicarbonate level of about 22 mEq / L to about 27 mEq / L.

79. The method of any one of claims 71-78, wherein the method further comprises determining that the patient exhibits vital signs and weight within age-adjusted criteria.

80. The method of any one of claims 71-79, wherein the method further comprises determining that the patient has a motor function score greater than 45 on CHOP INTEND or has reached a neuromuscular developmental milestone.

81. The method of any of claims 71-80, wherein the weaning from mechanical ventilation comprises gradually reducing one or more of the ventilator support parameters, including pressure, volume and rate, followed by a gradual sprint to wean from the ventilator, wherein, as appropriate, no more than one ventilator support parameter is changed at a time.

82. The method of any of claims 71-81, wherein after administration of the viral vector to the patient, the patient exhibits a change in ventilation support hours over time relative to baseline, wherein, where applicable, the patient exhibits a change in ventilation support hours over time relative to baseline up to approximately 24 weeks after administration of the viral vector to the patient.

83. The method of any of claims 71-82, wherein after administration of the viral vector to the patient, the patient achieves functionally independent sitting for at least 30 seconds, wherein, where appropriate, the patient achieves functionally independent sitting by approximately 24 weeks after administration of the viral vector to the patient.

84. The method of any of claims 71-83, wherein after administration of the viral vector to the patient, the patient exhibits a reduction in required ventilator support to about 16 hours or less per day, wherein, as appropriate, the patient exhibits a reduction in required ventilator support up to about 24 weeks after administration of the viral vector.

85. The method of any of claims 71-84, wherein after administration of the viral vector to the patient, the patient exhibits a change in CHOP INTEND relative to baseline, wherein, where applicable, the patient exhibits a change in CHOP INTEND relative to baseline up to approximately 24 weeks after administration of the viral vector to the patient.

86. The method of any of claims 71-85, wherein after administration of the viral vector to the patient, the patient exhibits a change in maximum inspiratory pressure relative to baseline, wherein, where applicable, the change in maximum inspiratory pressure relative to baseline occurs up to approximately 24 weeks after administration of the viral vector to the patient.

87. The method of any one of claims 71-86, wherein after administration of the viral vector to the patient, the patient exhibits a change in the quantitative analysis of tubulin expression in the muscle biopsy relative to baseline, wherein, where applicable, the patient exhibits a change in the quantitative analysis of tubulin expression in the muscle biopsy relative to baseline up to approximately 24 weeks after administration of the viral vector to the patient.

88. The method of any of claims 71-87, wherein the transgenic gene encoding MTM1 is operatively linked to a muscle-specific promoter.

89. The method of claim 88, wherein the muscle-specific promoter is a desmin promoter, a phosphoglycerate kinase (PGK) promoter, a muscle creatine kinase promoter, a myosin light chain promoter, a myosin heavy chain promoter, a cardiac troponin C promoter, a troponin I promoter, a myoD gene family promoter, an actin α promoter, an actin β promoter, an actin γ promoter, or a promoter within intron 1 of the eye pair-like homology domain 3 (PITX3).

90. The method of claim 89, wherein the muscle-specific promoter is a desmin promoter.

91. The method of any one of claims 1-90, wherein the viral vector is selected from the group consisting of: adeno-associated virus (AAV), adenovirus, lentivirus, retrovirus, poxvirus, baculovirus, herpes simplex virus, vaccinia virus, and synthetic virus.

92. The method of request item 91, wherein the virus vector is AAV.

93. The method of claim 92, wherein the AAV is serotype AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAVrh10 or AAVrh74.

94. The method of claim 91, wherein the virus vector is a pseudo-AAV.

95. The method of request 94, wherein the pseudotype AAV is AAV2 / 8 or AAV2 / 9, as appropriate, wherein the pseudotype AAV is AAV2 / 8.

96. The method of any one of claims 1-95, wherein the viral vector is resamirigene bilparvovec.

97. A method for treating a human patient with XLMTM who is undergoing mechanical ventilation, the method comprising: a. Administer a therapeutically effective dose of an AAV2 / 8 viral vector, which includes a transgenic gene encoding MTM1 operatively linked to the desmin promoter, to the patient; b. Determine that the patient exhibits: (i) a maximum inspiratory pressure of approximately 50 cmH2O or higher on a ventilator; (ii) a maximum expiratory pressure of approximately 40 cmH2O or higher on a ventilator; (iii) a positive end-expiratory pressure of approximately 5 cmH2O or lower on a ventilator; (iv) SpO2 of approximately 94% or higher; (v) TcCO2 of approximately 35 mmHg to approximately 45 mmHg; (vi) petCO2 of approximately 35 mmHg to approximately 45 mmHg; (vii) serum bicarbonate levels of approximately 22 mEq / L to approximately 27 mEq / L; (viii) vital signs and weight within age-adjusted range; and (ix) a motor function score on the CHOP INTEND scale greater than 45 or meeting neuromuscular developmental milestones; c. Wean the patient off mechanical ventilation during the daytime; d. Determine that the patient exhibits: (i) a maximum inspiratory pressure of approximately 35 mmH2O or higher on a ventilator; (ii) a maximum expiratory pressure of approximately 40 cmH2O or higher on a ventilator; (iii) a positive end-expiratory pressure of approximately 5 cmH2O or lower on a ventilator; (iv) SpO2 of approximately 94% or higher; (v) TcCO2 of approximately 35 mmHg to approximately 45 mmHg; (vi) petCO2 of approximately 35 mmHg to approximately 45 mmHg; (vii) serum bicarbonate levels of approximately 22 mEq / L to approximately 27 mEq / L; (viii) age-adjusted vital signs and weight; and (ix) a motor function score on the CHOP INTEND scale greater than 45 or meeting neuromuscular developmental milestones; (ii) TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) SpO2 of approximately 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) no intercostal contractions in the video recording of the respiratory sprint test; (v) no respiratory tachycardia in the video recording of the respiratory sprint test; (vi) no respiratory paradoxes in the video recording of the respiratory sprint test; (vii) no phase delay in the video recording of the respiratory sprint test; (viii) SpO2 less than 94%, as assessed by the video recording of the respiratory sprint test; (ix) SpO2 not exceeding 3% from the patient's waking baseline, as assessed by the video recording of the respiratory sprint test; (x) TCO2 greater than 45 mmHg, as assessed by the video recording of the respiratory sprint test; (xi) TCO2 not increasing by more than 10% from the patient's waking baseline. mmHg or higher, as assessed by video recording of a respiratory sprint test; (xii) respiratory rate within age-adjusted criteria, as assessed by nocturnal respiratory monitoring; (xiii) no distress in video recording of a respiratory sprint test; and (xiv) respiratory rate within age-adjusted criteria, as assessed by PSG performed with an open tracheostomy; and e. continue to wean the patient off mechanical ventilation during the daytime.

98. A method for treating a human patient with XLMTM who is undergoing mechanical ventilation, the method comprising: a. Administer a therapeutically effective dose of an AAV2 / 8 viral vector, which includes a transgenic gene encoding MTM1 operatively linked to the desmin promoter, to the patient; b. Determine that the patient exhibits: (i) a maximum inspiratory pressure of approximately 50 cmH2O or higher on a ventilator; (ii) a maximum expiratory pressure of approximately 40 cmH2O or higher on a ventilator; (iii) a positive end-expiratory pressure of approximately 5 cmH2O or lower on a ventilator; (iv) SpO2 of approximately 94% or higher; (v) TcCO2 of approximately 35 mmHg to approximately 45 mmHg; (vi) petCO2 of approximately 35 mmHg to approximately 45 mmHg; (vii) serum bicarbonate levels of approximately 22 mEq / L to approximately 27 mEq / L; (viii) vital signs and weight within age-adjusted range; and (ix) a motor function score on the CHOP INTEND scale greater than 45 or meeting neuromuscular developmental milestones; c. Wean the patient off mechanical ventilation during the daytime; d.The patient is identified as exhibiting (i) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of approximately 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) an AHI of less than 5 events / hour, as assessed by PSG with an open tracheostomy; (v) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by PSG with an open tracheostomy; (vi) a TcCO2 that has not increased by 10 mmHg or more relative to the patient's waking baseline, as assessed by PSG with an open tracheostomy; (vii) a petCO2 or ptcCO2 of less than 50 mmHg, as assessed by PSG with an open tracheostomy; (viii) During sleep, petCO2 or ptcCO2 did not increase by 10 mmHg or more relative to the patient's awake baseline, as assessed by PSG performed with tracheostomy; (ix) no intercostal contractions were observed in the video recording of the breathing sprint test; (x) no respiratory tachycardia was observed in the video recording of the breathing sprint test; (xi) no respiratory paradoxes were observed in the video recording of the breathing sprint test; (xii) no phase delay was observed in the video recording of the breathing sprint test; (xiii) SpO2 was less than 94%, as assessed by video recording of the breathing sprint test; (xiv) SpO2 was no more than 3% different from the patient's awake baseline, as assessed by video recording of the breathing sprint test; (xv) TCO2 was greater than 45 mmHg, as assessed by video recording of the breathing sprint test; (xvi) TCO2 did not increase by 10 mmHg or more relative to the patient's awake baseline. mmHg or higher, as assessed by video recording of a respiratory sprint test; (xvii) respiratory rate within age-adjusted criteria, as assessed by nocturnal respiratory monitoring; (xviii) no distress in video recording of a respiratory sprint test; and (xix) respiratory rate within age-adjusted criteria, as assessed by PSG performed with an open tracheostomy; and e. Continue to wean the patient off mechanical ventilation during the daytime.

99. A method for weaning a human patient undergoing mechanical ventilation who has XLMTM, wherein the patient has previously been administered a therapeutically effective amount of an AAV2 / 8 viral vector comprising a transgenic gene encoding MTM1 operatively linked to a desmin promoter, the method comprising: a. Determine that the patient exhibits: (i) a maximum inspiratory pressure of approximately 50 cmH2O or higher on a ventilator; (ii) a maximum expiratory pressure of approximately 40 cmH2O or higher on a ventilator; (iii) a positive end-expiratory pressure of approximately 5 cmH2O or lower on a ventilator; (iv) SpO2 of approximately 94% or higher; (v) TcCO2 of approximately 35 mmHg to approximately 45 mmHg; (vi) petCO2 of approximately 35 mmHg to approximately 45 mmHg; (vii) serum bicarbonate levels of approximately 22 mEq / L to approximately 27 mEq / L; (viii) vital signs and weight within age-adjusted range; and (ix) a motor function score on the CHOP INTEND scale greater than 45 or meeting neuromuscular developmental milestones; b. Wean the patient off mechanical ventilation during the daytime. c. Determine that the patient exhibits (i) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of approximately 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) no intercostal contractions in the video recording of the respiratory sprint test; (v) no respiratory tachycardia in the video recording of the respiratory sprint test; (vi) no respiratory paradoxes in the video recording of the respiratory sprint test; (vii) no phase delay in the video recording of the respiratory sprint test; (viii) a SpO2 of less than 94%, as assessed by the video recording of the respiratory sprint test; (ix) a SpO2 no greater than 3% from the patient's waking baseline, as assessed by the video recording of the respiratory sprint test; (x) a TCO2 greater than 45 mmHg, as assessed by the video recording of the respiratory sprint test; and (xi) a TCO2 no greater than 10% from the patient's waking baseline, as assessed by the video recording of the respiratory sprint test. mmHg or more, as assessed by video recording of a respiratory sprint test; (xii) respiratory rate within age-adjusted criteria, as assessed by nocturnal respiratory monitoring; (xiii) no distress in video recording of a respiratory sprint test; and (xiv) respiratory rate within age-adjusted criteria, as assessed by PSG performed with an open tracheostomy; and d. Continue to wean the patient off mechanical ventilation during the daytime.

100. A method for weaning a human patient undergoing mechanical ventilation who has XLMTM, wherein the patient has previously been administered a therapeutically effective amount of an AAV2 / 8 viral vector comprising a transgenic gene encoding MTM1 operatively linked to a desmin promoter, the method comprising: a. Determine that the patient exhibits: (i) a maximum inspiratory pressure of approximately 50 cmH2O or higher on a ventilator; (ii) a maximum expiratory pressure of approximately 40 cmH2O or higher on a ventilator; (iii) a positive end-expiratory pressure of approximately 5 cmH2O or lower on a ventilator; (iv) SpO2 of approximately 94% or higher; (v) TcCO2 of approximately 35 mmHg to approximately 45 mmHg; (vi) petCO2 of approximately 35 mmHg to approximately 45 mmHg; (vii) serum bicarbonate levels of approximately 22 mEq / L to approximately 27 mEq / L; (viii) vital signs and weight within age-adjusted range; and (ix) a motor function score on the CHOP INTEND scale greater than 45 or meeting neuromuscular developmental milestones; b. Wean the patient off mechanical ventilation during the daytime. c. Determine if the patient exhibits (i) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (ii) a petCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by nocturnal respiratory monitoring; (iii) a SpO2 of approximately 94% or higher, as assessed by nocturnal respiratory monitoring; (iv) an AHI of less than 5 events / hour, as assessed by PSG with an open tracheostomy; (v) a TcCO2 of approximately 35 mmHg to approximately 45 mmHg, as assessed by PSG with an open tracheostomy; (vi) a TcCO2 that has not increased by 10 mmHg or more relative to the patient's waking baseline, as assessed by PSG with an open tracheostomy; (vii) a petCO2 or ptcCO2 of less than 50 mmHg, as assessed by PSG with an open tracheostomy; (viii) During sleep, petCO2 or ptcCO2 did not increase by 10 mmHg or more relative to the patient's awake baseline, as assessed by PSG performed with tracheostomy; (ix) no intercostal contractions were observed in the video recording of the breathing sprint test; (x) no respiratory tachycardia was observed in the video recording of the breathing sprint test; (xi) no respiratory paradoxes were observed in the video recording of the breathing sprint test; (xii) no phase delay was observed in the video recording of the breathing sprint test; (xiii) SpO2 was less than 94%, as assessed by the video recording of the breathing sprint test; (xiv) SpO2 was no more than 3% different from the patient's awake baseline, as assessed by the video recording of the breathing sprint test; (xv) TCCO2 was greater than 45 mmHg, as assessed by the video recording of the breathing sprint test; (xvi) TcCO2 did not increase by 10 mmHg or more relative to the patient's awake baseline. mmHg or higher, as assessed by video recording of a respiratory sprint test; (xvii) respiratory rate within age-adjusted criteria, as assessed by nocturnal respiratory monitoring; (xviii) no distress in video recording of a respiratory sprint test; and (xix) respiratory rate within age-adjusted criteria, as assessed by PSG performed with an open tracheostomy; and d. Continue to wean the patient off mechanical ventilation during the daytime.

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