Impact of Intermittent Positive Pressure Breathing on Thoracic Growth in Children With Type 1 Spinal Muscular Atrophy

ABSTRACT

Introduction

The emergence of new disease‐modifying treatments for type I spinal muscular atrophy (SMA I) has led to a paradigm shift in the respiratory management of these patients. Accompanying pulmonary and thoracic growth appears to be a key factor in their morbidity and mortality. The role of Intermittent Positive Pressure Breathing (IPPB) on thoracic growth has been described in the literature, but there are few studies available to objectively assess its impact.

Study Objective

To assess the impact of using IPPB on thoracic growth in children with SMA I.

Material/Method

In this bicentric retrospective study, the thoracic circumference‐to‐head circumference ratio (TC/HC) was compared at three time points: 4 months before the initiation of IPPB, at the start of IPPB, and 4 months after initiation.

Results

Seven children (3 girls and 4 boys) with SMA I with a median (min–max) age of 4.8 (2.6–8.2) years old were included in this study. A statistically significant increase was observed in the mean change in TC/HC between the pre‐IPPB and post‐IPPB periods (−0.05 ± 0.03 vs. +0.06 ± 0.07, p = 0.04).

Conclusion

In this study, IPPB was associated with a significant increase in TC/HC in children with SMA I. Further large‐scale studies are warranted to better characterize the extent and clinical significance of this effect.

1. Introduction

Spinal muscular atrophy (SMA) is a genetic neuromuscular disorder caused by mutations in the SMN1 gene, leading to degeneration of motor neurons and resulting in progressive muscle weakness [1]. Its incidence is estimated at 1 in 6000 births in France and from 1 in 6000 to 1 in 10,000 births in the world [2, 3]. Type I SMA (SMA I) is the most frequent and severe form of the disease, accounting for approximately 50% to 60% of all SMA cases [1, 4]. Patients with SMA I typically present with early‐onset profound muscular weakness and chronic respiratory failure. Respiratory involvement in these children is characterized by distinct chest wall deformities, tachypnea, paradoxical breathing, and alveolar hypoventilation [2].

In this population, respiratory muscle weakness severely impairs thoracic growth, leading to a characteristic bell‐shaped chest [2, 5, 6, 7]. In those infants who are too young or too weak to perform standard pulmonary function tests, the thoracic‐to‐head circumference ratio (TC/HC) could serve as one of the few objective and reliable markers for assessing and monitoring respiratory involvement. In 2019, Ropars et al. proposed the TC/HC ratio as a novel outcome measure in SMA I. Their study used this parameter to characterize chest wall growth in infants with SMA I compared with healthy children without comorbidities. While the TC/HC ratio remained stable over time in healthy controls, it consistently decreased in untreated SMA I patients, reflecting impaired thoracic development. The authors suggested that thoracic growth indirectly reflects pulmonary growth and demonstrated that the TC/HC ratio is a simple, reproducible, and clinically relevant tool for monitoring respiratory involvement in SMA I. Furthermore, in the era preceding disease‐modifying therapies, a TC/HC ratio below 0.85 was associated with a markedly increased risk of death within the following 3 months. These findings highlight the value of TC/HC as a marker of respiratory disease severity, progression, and prognosis in children with SMA I.

Since 2019, disease‐modifying treatments, such as Nusinersen (Spinraza®) and Onasemnogene abeparvovec (Zolgensma®), have profoundly transformed the management of SMA, particularly for children with SMA I [4, 8, 9, 10, 11, 12]. Respiratory care, which was previously palliative in most cases, has become proactive. New guidelines now recommend initiating respiratory physiotherapy earlier, directly post‐diagnosis, rather than waiting for chest wall deformities or airway congestion to occur. The use of non‐invasive ventilation (NIV) is recommended when children are symptomatic, that is, presenting polypnea, paradoxical breathing, and/or airway congestion [13]. However, despite these advances, respiratory involvement remains important. Moreover, the specific modalities of respiratory physiotherapy are not standardized, and current guidelines do not provide detailed recommendations, leading to significant variability across centers and countries.

Beyond its role in airway clearance, respiratory physiotherapy may also support thoracic growth through techniques that promote lung inflation and chest wall expansion. Repeated positive‐pressure insufflations may help maintain chest wall mobility, prevent stiffness and retractions, enhance lung recruitment, and optimize thoracic development. Different types of these techniques have been described in patients with neuromuscular disorders [6, 14, 15, 16, 17, 18], including SMA I patients [3, 6, 7, 11, 15]. These include the use of a self‐inflating bag with a one‐way valve [16, 18], high‐pressure settings on mechanical ventilators [7, 15], insufflation mode of mechanical insufflation‐exsufflation devices (MI‐E) [7, 15], and intermittent positive pressure breathing (IPPB) devices [3, 6, 11, 19].

Although thoracic growth support appears to be a key component in the respiratory management of children with SMA I, no studies to date have objectively assessed its impact on chest wall development. In the present study, we hypothesized that IPPB could influence the evolution of the TC/HC ratio and reduce hospitalization for respiratory exacerbations in a cohort of children with SMA I receiving disease‐modifying therapies.

2. Materiel and Methods

2.1. Study Design

This retrospective observational bicentric study included patients with genetically confirmed SMA I (with two or three copies of the SMN2 gene), who were treated with the IPPB device Alpha 300® (Air Liquide Medical Systems, Antony, France) between 2016 and 2024. Patients were followed in two French Reference Centers for Rare Diseases: Armand Trousseau University Hospital in Paris and Brest University Hospital. Patients with missing or incomplete TC/HC ratio measurements in their medical records during the study period were excluded. This study was approved by the Research Protocol Evaluation Committee (CEPR) of the French Learned Society for Respiratory Medicine (SPLF) (CEPRO 2023–024).

2.2. Thoracic Circumference/Head Circumference Ratio (TC/HC)

In our centers, the measurement of the thoracic‐to‐head circumference ratio was standardized, following the recommendation in the previously mentioned article [20]. Thoracic circumference was measured with a tape measure, on the nipple line, at the end of inspiration. The same person realized the measure in time for each patient to limit the risk of interobserver variability.

2.3. Intermittent Positive Pressure Breathing Intervention

Both study centers followed the same standardized, stepwise approach for the initiation and monitoring of IPPB therapy. Information on posology and session duration performed at home was collected via family statements. Data settings were collected by physiotherapists on the device during the setup and follow‐up.

IPPB was administered at home by families. Parents received training on device usage at the time of installation, and regular follow‐up ensured correct use of the device. To ensure good tolerance and adherence to the exercise program by the child and their families, with a view to long‐term use, the session duration was set at 5 to 10 min at the start, with the aim of gradually increasing this to a total of 20 min per day, spread over one or two sessions. Instructions given were to perform daily sessions. All patients used a facial mask and an abdominal belt to compensate for abdominal muscle weakness [14, 15].

Device settings were individualized based on clinical evaluation to obtain a chest wall expansion greater than the one in spontaneous ventilation. The device was set up by a physiotherapist who compared ventilation during spontaneous breathing with ventilation with the device. During the setup, the initial pressure was set low at 10–15 cmH2O, then progressively increased by two or three points at a time until the maximum tolerable thoracic elevation was obtained. The initial flow was set to medium/low at 20–25 L/min to familiarize the child with the sensation of airflow and allow insufflation. If possible, this was lowered by two or three points at a time to lengthen the inspiratory time with the aim of achieving longer chest wall mobilization and greater pulmonary recruitment. Device settings were progressively adjusted during the follow‐up of the device. During the 4‐month window of our study, settings were not modified: the inspiratory trigger was set at −1 cmH₂O, the expiratory trigger, that is, inspiratory target pressure, ranged from 15 to 23 cmH₂O, and the inspiratory flow rates from 15 to 25 L/min. Nebulization and expiratory resistance were not used.

2.4. Data Collection

Data were collected through a review of the patients' electronic medical records. General information collected included: age, sex, age at symptom onset, number of SMN2 gene copies, age at genetic diagnosis, disease‐modifying treatments prescribed, and age at treatment initiation. Data related to respiratory management included the use of IPPB (device settings, usage modalities, and age at initiation), non invasive ventilation (NIV) and its initiation age, intrapulmonary percussive ventilation (IPV) and its initiation age, insufflator‐exsufflator device (MI‐E) and its initiation age, the use of an abdominal belt, nasopharyngeal suction systems, prescription of respiratory physiotherapy, and medical treatments such as antibiotics. Information on orthopedic and nutritional management was also collected, including the use of a Garchois brace and age at initiation, nasogastric tube feeding, and gastrostomy placement. Finally, respiratory outcomes were recorded, including the evolution of the TC/HC ratio, the number of hospitalizations, and the number of hospitalization days for respiratory exacerbations—both in general wards and intensive care units.

2.5. Statistical Analysis

A descriptive analysis was conducted to summarize patient baseline characteristics, management strategies, and clinical outcomes. Quantitative variables are presented as means with standard deviations (SD), as well as medians with interquartile ranges [IQR] and ranges (min–max). Qualitative variables are reported as counts and percentages.

To assess changes in the TC/HC ratio before (M−4 to M0) and after (M0 to M4) the initiation of IPPB, Wilcoxon signed‐rank tests for paired samples were used. A two‐sided p‐value < 0.05 was considered statistically significant. All analyses were performed using R software (version 4.3).

3. Results

Between November 2016 and June 2024, seven children with SMA I (3 girls and 4 boys), aged between 2.6 and 8.2 years (median age: 4.6 years), treated with IPPB and with complete measures of TC/HC, were included in this study. The general characteristics of the study population are summarized in Table 1.

Table 1.

General characteristics of the study population.

		Min–max
Age (years)	4.8 [3.3; 7.9]	(2.6–8.2)
Sex female (n, %)	3 (43)
Age at onset of neurological symptoms* (months)	6 [3; 6]	(2–8)
Two copies of SMN2 gene (n, %)	4 (58)
Three copies of SMN2 gene (n, %)	3 (43)
Age at genetic testing (months)	8 [4; 11]	(2–12)
SMA treatment with Nusinersen (n, %)	3 (43)
SMA treatment with Onasemnogene abeparvovec (n, %)	4 (58)
Age at initiation of SMA treatment (months)	10 [4; 12]	(4–16)

Note: are expressed as median [IQR] and extremes

Abbreviations: min = minimum, max = maximum.

* Symptoms are referred to hypotonia, paradoxical breathing, fasciculation of the tongue, and loss of osteotendinous reflexes.

Data on respiratory, orthopedic, and nutritional management are presented in Table 2.

Table 2.

Overview of respiratory, orthopedic, and nutritional management strategies.

		Min–max
NIV (n, %)	5 (71)
Age at NIV initiation (months)	16 [7; 22]	(4–26)
Abdominal belt (n, %)	5 (71)
IPPB (n, %)	7 (100)
Age at IPPB initiation (months)	16 [13; 22]	(9–41)
IPV (n, %)	3 (42.8)
Age at IPV initiation (months)	16 [4; 25]	(4–25)
MI‐E (n, %)	4 (57)
Age at MI‐E initiation (months)	28.5 [13.5; 39]	(10–41)
Nasopharyngeal suction (n, %)	5 (71)
Respiratory physiotherapy (n, %)	6 (86)
Antibiotics (n, %)	2 (29)
Garchois brace (n, %)	5 (71)
Age at Garchois brace initiation (months)	19 [15; 2.5]	(14–33)
Nasogastric tube (n, %)	2 (29)
Gastrostomy (n, %)	2 (29)

Note: Results are expressed as median [IQR] and extremes.

Abbreviations: IPPB = Intermittent Positive Pressure Breathing; IPV = Intrapulmonary Percussive Ventilation; MI‐E = Mechanical Insufflation‐Exsufflation; min = minimum; max = maximum; NIV = Non‐Invasive ventilation.

All seven patients received IPPB; in addition, five were treated with NIV, three with IPV, and four with MI‐E. Six patients were followed by a respiratory physiotherapist, and five received home suctioning. The data available for each patient concerning IPPB, NIV, and MI‐E settings are presented in Table 3.

Table 3.

Caracteristics of respiratory devices, garchois brace prescription, and disease modifying treatments in the study population.

Patient	1	2	3	4	5	6	7
Age at IPPB initiation (months)	13	14	16	19	9	22	41
Inspiratory trigger (cmH2O)	N/A	−1	−1	−1	N/A	−1	−1
Inspiratory target pressure (cmH2O)	N/A	17	23	15	N/A	18	15
Inspiratory flow (L/min)	N/A	15	15	25	N/A	15	15
Duration of session (min)	10	5 to 10	10	N/A	N/A	N/A	N/A
Number of sessions per week	N/A	N/A	7	N/A	N/A	N/A	N/A
Age at NIV initiation	16		4		18	10	26
NIV settings					N/A
‐EPAP (cmH2O)	4		4			4	5
‐IPAP (cmH2O)	12		10			9	9
‐Bf (/min)	24		30			20	20
‐Ti (sec)	0.7−1		0.5−0.7			0.2−0.7	N/A
Age at MI‐E initiation	33				24	10	41
Garchois brace	+	+	+			+	+
Age at onset (months)	22	19	16	—	—	33	14
Age at gene therapy administration (months)		12	4	10		9
Age at Nusinersen initiation (months)	16				4		11

Abbreviations: EPAP = Expiratory Positive Airway Pressure, IPAP = Inspiratory Positive Airway Pressure, Bf = Breathing frequency, IPPB = Intermittent Positive Pressure Breathing, N/A = Data non available, Ti = Inspiratory time.

The evolution of TC/HC ratio during the course of the study, along with the initiation of IPPB and NIV, is presented in Figure 1. Three of the seven patients (patients 3, 6, and 7) had been prescribed NIV 12, 12, and 15 months prior to the initiation of IPPB, respectively. Two of them (patients 1 and 5) had been started on NIV 3 and 9 months after IPPB initiation, respectively.

Figure 1.

Thoracic‐to‐Head circumference ratio evolution during the study period. X‐axis values = months; Y‐axis values = TC/HC. TC/HC = thoracic‐to‐head circumference ratio; IPPB = Intermittent Positive Pressure Breathing; NIV = Non‐Invasive Ventilation; M = month with M0 = IPPB initiation; red dot: IPPB initiation; triangle: NIV initiation; diamond: Nusinersen (Spinraza®) treatment initiation; hexagon: Onasemnogene abeparvovec (Zolgensma®) treatment initiation. [Color figure can be viewed at wileyonlinelibrary.com]

Three patients out of seven were hospitalized for respiratory exacerbations during the course of the study. Two of them (patients 3 and 7) had one hospitalization in the 4 months period before IPPB initiation in the pediatric department during 5 and 3 days, respectively. One patient (patient 1) had one hospitalization in the 4 months period after IPPB initiation with 1 day in the intensive care unit (ICU) and 13 days in the pediatric department.

3.1. Change in TC/HC

Changes in the TC/HC between the 4 months preceding IPPB initiation (M−4 to M0) and the 4 months following it (M0 to M4) are presented in Table 4. Individual changes in TC/HC over the course of the study, along with the timing of specific SMA treatments and NIV initiation, are shown in Figure 1.

Table 4.

Evolution of the thoracic‐to‐head circumference ratio before and after IPPB initiation.

	M−4	M0	M + 4	Difference M−4/M0	Difference M0/M + 4
1	1.00	0.98	0.96	−0.02	−0.02
2	1.07	1.05	1.11	−0.02	+0.07
3	0.97	0.93	0.97	−0.03	+0.03
4	1.09	1.00	1.11	−0.09	+0.11
5	1.01	0.91	1.10	−0.10	+0.19
6	0.95	0.91	0.92	−0.04	+0.01
7	1.01	1	1.02	−0.01	+0.02

Abbreviations: IPPB = Intermittent positive pressure breathing, TC/HC = thoracic‐to‐head circumference ratio, M−4 = four months before IPPB initiation, M0 = IPPB initiation, M + 4 = four months following IPPB initiation.

The mean (SD) change in TC/HC was –0.05 (0.03) during the 4 months preceding IPPB (M−4 to M0) and +0.06 (0.07) during the 4 months following initiation (M0 to M4), representing a statistically significant difference (p = 0.04).

All seven patients showed a decrease in TC/HC before IPPB initiation, whereas only one out of seven showed a decline after IPPB initiation.

This patient, who had an unfavorable TC/HC trajectory post‐IPPB, also experienced the highest number of hospitalizations in both the pediatric department (n = 9; total of 60 days) and ICU (n = 5; total of 10 days), including one hospitalization during the study period (M0 to M4) with 13 days in the pediatric department and 1 day in ICU. Additionally, this patient had the latest initiation of Nusinersen (at 16 months of age) and presented with digestive and swallowing disorders requiring nasogastric feeding followed by gastrostomy.

For the 4 patients with available data on TC/HC ratio evolution 1 year after IPPB initiation, the changes were +0.04 cm, +0.06 cm, –0.01 cm, and +0.04 cm for patients 1, 2, 6, and 7, respectively. The only patient who showed a negative outcome was the same as described in the previous paragraph.

4. Discussion

The aim of this retrospective observational study was to assess the impact of IPPB on thoracic growth in children with SMA I. Considering the natural decline in TC/HC reported in SMA I, stabilization of the ratio may represent a clinically relevant therapeutic response. In this context, six of the seven patients could be considered responders to IPPB, although the magnitude of the effect varied between individuals. The respiratory management of the children included in this study reflects the shift toward a proactive approach following the introduction of disease‐modifying therapies [13]. Indeed, all participants were prescribed NIV and/or airway clearance devices, including IPPB, IPV, or MI‐E. While the role of NIV in compensating for respiratory muscle weakness and in preventing alveolar hypoventilation, and of IPV and MI‐E on supporting airway clearance, are well established, the specific role of IPPB in chest mobilization and thoracic growth remains understudied in this population. In all but one child included in the study, TC/HC ratio increased during the follow‐up period.

Ropars et al. conducted a study between 2011 and 2014 involving 19 infants with SMA I aged 0 to 13 months [20]. At that time, disease‐modifying therapies were not yet available, and none of the patients received ventilatory support, as management was primarily palliative. That study reported a systematic decline in the TC/HC ratio in all participants. On the contrary, TC/HC ratio increased during the follow‐up period in all but one child included in our study. This trend tended to persist at 1 year in the children for whom follow‐up data were available. These results suggest that IPPB may have a positive effect on thoracic growth in children with SMA I, potentially counteracting the restrictive thoracic development typically observed in the natural history of the disease. This observation is consistent with the findings of Ménard et al., who reported stable or increasing TC/HC ratios in 17 SMA I patients treated with Nusinersen and proactive respiratory management between 2016 and 2018 [11].

Another objective of our study was to evaluate the impact of IPPB on the number and duration of hospitalizations for respiratory exacerbations. We hypothesized that IPPB might reduce hospital admissions through its dual mechanism of action—by limiting the development of restrictive lung disease and thus preserving respiratory function, and by promoting lung volume recruitment and airway clearance, thereby reducing the risk of respiratory infections [19]. Our results showed no difference in the number of hospitalization during the 4 months before IPPB and the 4 months after IPPB initiation; highlighting a potential disconnection between morphological improvement and clinical stabilization. However, we observed that only one out of seven children was hospitalized following IPPB initiation, a decrease in the number of child concerned by those hospitalizations. This may suggest that IPPB could help reducing respiratory‐related morbidity but that the 4 months window was too short to observe a significant impact. Another consideration is that IPPB could contribute to reducing the severity of respiratory exacerbations by limiting the restrictive syndrome, but we lack data to study this point. Other techniques specifically aimed at airway clearance, such as IPV and MI‐E, could be interesting to study regarding the prevention and treatment of airway congestion and their impact on hospitalization for respiratory causes.

SMA‐specific treatments—such as Nusinersen or gene therapy—may represent a source of bias in our study, as these therapies can independently influence respiratory function, growth, and overall disease progression, apart from the effects of IPPB. Although a synergistic effect between disease‐modifying therapies and IPPB is likely, thoracic growth continued to decline before IPPB initiation despite ongoing treatment, whereas stabilization or improvement was observed thereafter, suggesting an additional benefit of IPPB. A 2022 meta‐analysis by J. Erdos highlighted the lack of objective respiratory data in descriptive studies evaluating Nusinersen and Onasemnogene abeparvovec [21]. The meta‐analysis reported, nonetheless, no significant change in the number of patients requiring NIV with the adjunction of Nusinersen for patient with SMA I. However, in a 2019 study, LoMauro observed the resolution of paradoxical breathing, a reduction in the bell‐shaped chest index, and a decrease in the number of hours of mechanical ventilation in children with SMA Ic treated with Nusinersen [5, 22]. Children with more severe SMA subtypes (Ia and Ib), however, continued to present with marked chest deformities and paradoxical breathing. In our study, more than half of the children had only two copies of the SMN2 gene, indicating high disease severity. Despite this, IPPB still showed a beneficial effect on thoracic growth in these patients. These findings underscore the importance of precise phenotypic characterization of SMA I subgroups and highlight the potential benefit of early, proactive respiratory management across all disease severities ‐ particularly in the most severe cases.

IPPB is one of several Lung Volume Recruitment (LVR) techniques. While the short‐term benefit of LVR techniques—including IPPB—has been well documented in neuromuscular diseases, their long‐term effects on preventing chest wall deformity and the decline of slowing Forced Vital Capacity remains uncertain [6, 14, 16, 17, 23, 24]. We found no studies exploring the long‐term effect of IPPB specifically, nor the effect of LVR techniques in neuromuscular patients as young and severe as children with SMA I.

The role of NIV in preventing chest deformity in patients with SMA I is well documented in the literature and may therefore represent a potential source of bias in this study [2, 7, 11, 15, 19]. However, in these studies, NIV was often combined with other interventions such as IPPB and/or MI‐E, making it difficult to isolate the specific contribution of each modality. Interestingly, in our study, the two patients who did not receive NIV (Patients 2 and 4) demonstrated a favorable evolution of their overall TC/HC ratio. A third patient (Patient 5), who began NIV at a later stage, also showed a positive trend in TC/HC, while the ratio decreased between NIV initiation and IPPB onset. These observations suggest that IPPB may contribute independently to thoracic growth, even in the absence or delayed initiation of NIV.

The main limit of our study was that it had limited statistical power due to its retrospective design and small sample size. In addition, we were unable to properly assess the duration and frequency of IPPB use, treatment adherence or the correct use of IPPB. A potential limitation is the variability that can occur when measurements are performed by different evaluators. In our study, this bias was reduced as all measurements were conducted by the same two physicians using standardized methods to minimize interrater variability. Finally, SMA‐specific treatments may also influence respiratory outcomes, representing a potential confounding factor in this study.

5. Conclusion

The respiratory management of children with SMA I has evolved significantly with the advent of disease‐modifying therapies. However, respiratory outcomes, including thoracic growth, remain a critical determinant of long‐term evolution, morbidity, and mortality. Preventing thoracic deformities must therefore be a key component of the respiratory management of these patients. Our study showed a statistically significant increase in the TC/HC ratio following IPPB initiation, suggesting a positive impact on thoracic growth. However, given the small sample size, this study should be considered a pilot study, and its findings need to be confirmed in a larger population. IPPB appears to be a promising adjunct to respiratory management and NIV, particularly as part of a proactive strategy aimed at preserving chest wall development. The introduction of IPPB in very young children remains complex, and a structured adaptation period is necessary. For this reason, we recommend early initiation, before chest deformities are established. Regular TC/HC monitoring in clinical practice is crucial and may serve as a useful decision‐making tool. Our findings also highlight the need to better understand the respective contributions of IPPB and NIV, as both techniques may exert complementary effects. Given the variability in current practices between centers and countries, randomized controlled trials are urgently needed to guide evidence‐based recommendations and establish standardized care protocols for thoracic growth monitoring and ventilatory support in SMA I. Prospective studies incorporating objective adherence monitoring will be required to better characterize dose–response relationships and identify optimal treatment regimens.

Author Contributions

Charlotte Thébault: conceptualization, methodology, data curation, investigation, validation, formal analysis, supervision, visualization, project administration, writing – original draft, writing – review and editing. Sophie Denamur: data curation, supervision, validation. Gilles Thomas: data curation, supervision, validation. Audrey Barzic: data curation, validation, supervision. Elsa Schwartz: data curation, supervision, validation. Maëlle Dupuis: data curation, supervision, validation. Marie‐Christine Nougues: data curation, validation, supervision. Arnaud Isapof: data curation, validation, supervision. Guillaume Aubertin: data curation, validation, supervision. Jessica Taytard: conceptualization, data curation, formal analysis, investigation, methodology, project administration, supervision, validation, writing – original draft, writing – review and editing.

Funding

The authors have nothing to report.

Ethics Statement

All subjects gave their informed consent for inclusion before they participated in the study. This study was approved by the Research Protocol Evaluation Committee (CEPR) of the French Learned Society for Respiratory Medicine (SPLF) (CEPRO 2023–024).

Conflicts of Interest

Charlotte Thébault reports a relationship with Elivie SAS that includes: speaking and lecture fees, and travel reimbursement. This relationship is out of the scope of the actual work. Other authors declare no conflicts of interest or personal relationships that could have appeared to influence the work reported in this paper.

Declaration of Generative AI and AI‐Assisted Technologies in the Manuscript Preparation Process

During the preparation of this work, the authors used DeepL and ChatGPT (OpenAI) in order to improve language and readability, as English is not their primary language. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.