Impact of tracheostomy invasive ventilation on survival in Japanese patients with multiple system atrophy

A strategic approach of the management of sleep-disordered breathing in multiple system atrophy

STUDY OBJECTIVES

Multiple system atrophy (MSA) is a rare neurodegenerative disorder characterized by autonomic dysfunction associated with a combination of cerebellar, parkinsonian, or pyramidal signs. Sleep-disordered breathing such as stridor, obstructive sleep apnea, and central sleep apnea is common in MSA and can impact survival. Several studies have evaluated treatment modalities. However, the optimal strategy often remains unclear in these patients. This review aims to provide an overview of the current evidence on treatment of sleep-disordered breathing in MSA.

METHODS

Systematic review of the current literature through combined keyword search in PubMed, Embase, the Cochrane Library, and cited references: "multiple system atrophy," "stridor," "sleep apnea syndrome," "sleep-disordered breathing," "Shy Drager syndrome."

RESULTS

Twenty-nine papers were included, with a total of 681 patients with MSA and sleep-disordered breathing. Treatment modalities are: continuous positive airway pressure, tracheostomy, tracheostomy-invasive ventilation, noninvasive positive pressure ventilation, adaptive servoventilation, vocal cord surgery, botulinum toxin injections, oral appliance therapy, cervical spinal cord stimulation, selective serotonin reuptake inhibitors.

CONCLUSIONS

Conflicting results on survival are found for continuous positive airway pressure therapy. Tracheostomy has a proven survival benefit. Most beneficial outcomes are seen with tracheostomy-invasive ventilation. Continuous positive airway pressure, other types of positive airway pressure therapy and tracheostomy can adequately control symptoms of obstructive sleep apnea. However, continuous positive airway pressure may exacerbate central sleep apnea. There was a lack of sufficient data regarding servoventilation or noninvasive positive pressure ventilation. Some patients exhibit a floppy epiglottis and require a different approach. In conclusion, due to the complex characteristics of sleep-disordered breathing in MSA, an individualized and multidisciplinary approach is mandatory.

CITATION

Laga A, Bauters F, Hertegonne K, Tomassen P, Santens P, Kastoer C. A strategic approach of the management of sleep-disordered breathing in multiple system atrophy. J Clin Sleep Med. 2025;21(4):703-711.

Decision-making trends in therapeutic interventions for multiple system atrophy: a 24-year retrospective study

BACKGROUND

Managing multiple system atrophy (MSA) is challenging. While invasive interventions for amyotrophic lateral sclerosis are well-studied, those for MSA remain less explored.

OBJECTIVES

To explore factors influencing treatment choices and trends in advanced-stage MSA.

METHODS

A retrospective cohort study analyzed 128 MSA patients at Hyogo Chuo National Hospital, Japan, from 2000 to 2024, focusing on treatment period and age at onset.

RESULTS

Tracheostomy invasive ventilation (TIV) decreased after 2014 (26.9% vs. 9.2%; P = 0.023). TIV-treated patients remained similarly young before and after 2014 (age at onset 52.7 vs. 54.5 years; P = 0.659) and tracheostomy was chosen by younger patients after 2014 (58.3 vs. 51.5 years; P < 0.001). Conversely, enteral nutrition increased in older patients (57.4 vs. 62.9 years; P = 0.011).

CONCLUSIONS

In Japanese MSA, preferences for invasive treatments shifted, with younger patients favoring TIV and tracheostomy, while older patients preferred less invasive options, emphasizing personalized care.

Early-onset dysphagia predicts short survival in multiple system atrophy

BACKGROUND

The prognostic impact of dysphagia in multiple system atrophy (MSA) remains controversial. This study aimed to investigate the relationship between dysphagia severity and survival in MSA and to elucidate whether this impact differs between MSA-cerebellar ataxia (MSA-C) and MSA-parkinsonism (MSA-P).

METHODS

This retrospective study included 297 patients with MSA: 251 met criteria for clinically established MSA and 46 for clinically probable MSA. Among them, 171 had MSA-C and 126 had MSA-P. We evaluated symptomatic dysphagia within 3 years of onset and quantified dysphagia severity using the Hyodo score (0 to 12) through fibreoptic endoscopic evaluation of swallowing (FEES) and clinical features, including autonomic dysfunction and vocal cord paralysis. Patients were followed up until death or tracheostomy, and survival factors were analysed using the log-rank test and multivariate Cox proportional hazards model.

RESULTS

Ninety patients developed symptomatic dysphagia within 3 years of onset, and 75 were evaluated for dysphagia severity using FEES. Survival from onset was shorter in patients with dysphagia within 3 years compared to those without (median: 4.2 years vs. 7.3 years; p < 0.001). Symptomatic dysphagia within 3 years of onset was an independent predictor of shorter survival in the multivariate Cox analysis. While the Hyodo score was higher in MSA-P than in MSA-C patients (p = 0.048), the Hyodo score was associated with survival in both MSA-C and MSA-P patients (log-rank p < 0.001 and p = 0.046, respectively).

CONCLUSION

Symptomatic dysphagia within 3 years of onset predicts shorter survival in MSA-C and MSA-P patients.

Neurological update: the palliative care landscape for atypical parkinsonian syndromes

Atypical parkinsonian syndromes are neurodegenerative conditions, characterised by rapid disease progression and shorter life expectancy compared to idiopathic Parkinson's disease. These conditions inflict substantial physical and psychosocial burden on patients and their families; hence, there is a clear rationale for a palliative care approach from diagnosis. An interdisciplinary care model has been shown to improve symptom burden, quality of life and engagement with advance care planning, in a heterogeneous group of neurodegenerative conditions. In this update, we summarise how the landscape for treating these patients has changed and the questions that still need to be resolved.

Nocturnal Pulse Event Frequency Is Reduced in Multiple System Atrophy

Risk of sudden death in multiple system atrophy (MSA) is greatest during sleep with unknown mechanisms. We compared nocturnal pulse event frequency in 46 MSA patients and age-/sex-matched controls undergoing overnight pulse oximetry. Nocturnal oxyhemoglobin desaturation indices and pulse event indices (PEIs) were recorded, and relationships between pulse oximetry variables and survival were analyzed. MSA patients had lower PEI (3.1 ± 5.3 vs. 12.8 ± 10.8, p < 0.001) despite greater hypoxic burden and similar frequency of respiratory events. Nocturnal pulse events were not associated with severity of daytime autonomic failure. Two MSA patients had suspected sudden death, both with severely reduced PEI. MSA patients have fewer nocturnal pulse events compared with controls, despite similar respiratory event frequency, suggesting abnormal cardiac responses to sleep-disordered breathing. Whether this contributes to sudden death in MSA requires further study. ANN NEUROL 2023;93:205-212.

Clinical and pathological characteristics of later onset multiple system atrophy

BACKGROUND

In the current consensus criteria, onset after age 75 is considered as non-supporting for diagnosis of multiples system atrophy (MSA); however, some MSA patients present after age 75. Clinical and pathological characteristics of such later onset MSA (LO-MSA) compared to usual onset MSA (UO-MSA) remain poorly understood.

METHODS

The clinical cohort included patients from Kobe University Hospital and Amagasaki General Medical Center Hospital, while the autopsy cohort was from the brain bank at Mayo Clinic Florida. We identified 83 patients in the clinical cohort and 193 patients in the autopsy cohort. We divided MSA into two groups according to age at onset: UO-MSA (≤ 75) and LO-MSA (> 75). We compared clinical features and outcomes between the two groups in the clinical cohort and compared the findings to the autopsy cohort.

RESULTS

LO-MSA accounted for 8% in the clinical cohort and 5% in the autopsy cohort. The median time from onset to death or to life-saving tracheostomy was significantly shorter in LO-MSA than in UO-MSA in both cohorts (4.8 vs 7.9 years in the clinical cohort and 3.9 vs 7.5 years in the autopsy cohort; P = 0.043 and P < 0.0001, respectively). The median time from diagnosis to death was less than 3 years in LO-MSA in the clinical cohort.

CONCLUSIONS

Some MSA patients have late age of onset and short survival, limiting time for clinical decision making. MSA should be considered in the differential diagnosis of elderly patients with autonomic symptoms and extrapyramidal and/or cerebellar syndromes.

Tracheostomy is associated with increased survival in multiple system atrophy patients with stridor

Background and purpose

Stridor treatment in multiple system atrophy (MSA) mainly comprises tracheostomy or continuous positive airway pressure (CPAP), but guidelines for the use of these treatments are lacking. The aim of the study was to evaluate the predictive value of stridor treatment in an MSA cohort.

Methods

This is a retrospective and prospective monocentric cohort study including MSA patients evaluated at least once a year during the disease course. Stridor was video‐polysomnography confirmed. The time of stridor treatment (CPAP or tracheostomy) and latency from stridor onset were collected. Survival and predictors of survival were calculated.

Results

A total of 182 (107 males, mean age at disease onset 57.3 ± 8.4 years) MSA patients were included in the study; 141 were deceased at the time of study. Of the total sample, 75 patients were diagnosed with stridor: 22 patients were treated with tracheostomy and 29 with CPAP, whilst 24 patients did not receive treatment. Treatment with tracheostomy showed longer survival compared with both treatment with CPAP or no treatment (incidence rate of death 12 vs. 21 vs. 23 per 100 person‐years, respectively). Tracheostomy remained an independent factor associated with longer survival (hazard ratio 0.38, p = 0.029), also after adjustment for other confounders and latency for stridor treatment.

Conclusions

This is the largest monocentric and long‐term follow‐up study comparing survival between tracheostomy and CPAP in MSA patients with stridor. Treatment with tracheostomy showed longer survival compared with both treatment with CPAP or no treatment. A careful multidisciplinary approach is required for the management of MSA patients with stridor.