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Aiyappan V, Catcheside P, Antic N, Keighley-James G, Mercer J, McEvoy RD. Sleep-Disordered Breathing in Patients with Motor Neurone Disease: One Size Does Not Fit all. NEURODEGENER DIS 2021; 20:131-138. [PMID: 33735900 DOI: 10.1159/000513887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 12/14/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Sleep-disordered breathing (SDB) in patients with motor neurone disease (MND) is normally attributed to hypoventilation due to muscle weakness. However, we have observed different patterns of SDB among MND patients referred for non-invasive ventilation, which do not appear to be explained by respiratory muscle weakness alone. AIM The aim of this study was to examine the characteristics of SDB in MND. METHODS This is a retrospective analysis of sleep studies (using polysomnography [PSG]), pulmonary function tests, and arterial blood gases in MND patients referred to a tertiary sleep medicine service for clinical review. Sleep apnoeas were characterised as obstructive or central, and to further characterise the nature of SDB, hypopnoeas were classified as obstructive versus central. RESULTS Among 13 MND patients who had a diagnostic PSG, the mean ± SD age was 68.9 ± 9.8 years, BMI 23.0 ± 4.3 kg/m2, forced vital capacity 55.7 ± 20.9% predicted, and partial pressure of CO2 (arterial blood) 52.7 ± 12.1 mm Hg. A total of 38% of patients (5/13) showed evidence of sleep hypoventilation. The total apnoea/hypopnoea index (AHI) was (median [interquartile range]) 44.4(36.2-56.4)/h, with 92% (12/13) showing an AHI >10/h, predominantly due to obstructive events, although 8% (1/13) also showed frequent central apnoea/hypopnoeas. CONCLUSIONS Patients with MND exhibit a wide variety of SDB. The prevalence of obstructive sleep apnoea (OSA) is surprising considering the normal BMI in most patients. A dystonic tongue and increased upper-airway collapsibility might predispose these patients to OSA. The wide variety of SDB demonstrated might have implications for ventilator settings and patients' outcomes.
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Affiliation(s)
- Vinod Aiyappan
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Bedford Park, South Australia, Australia, .,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia,
| | - Peter Catcheside
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Nick Antic
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Graham Keighley-James
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Jeremy Mercer
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia
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Léotard A, Lévy J, Hartley S, Pages A, Genet F, Lofaso F, Prigent H, Quera-salva MA. Sleep disorders in aging polio survivors: A systematic review. Ann Phys Rehabil Med 2020; 63:543-53. [DOI: 10.1016/j.rehab.2019.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/16/2019] [Accepted: 10/15/2019] [Indexed: 01/28/2023]
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Boentert M, Glatz C, Helmle C, Okegwo A, Young P. Prevalence of sleep apnoea and capnographic detection of nocturnal hypoventilation in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2018; 89:418-424. [PMID: 29054915 DOI: 10.1136/jnnp-2017-316515] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 10/03/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This retrospective study aimed to investigate whether overnight oxymetry and early morning blood gas analysis predict nocturnal hypoventilation (NH) as reflected by night-time hypercapnia in patients with amyotrophic lateral sclerosis (ALS). In addition, prevalence and clinical determinants of sleep apnoea in ALS were evaluated. METHODS In 250 patients with non-ventilated ALS, transcutaneous capnometry was performed along with polysomnography or polygraphy and early morning blood gases. RESULTS 123 patients were female, and 84 patients had bulbar-onset ALS. 40.0% showed NH, and an apnoea-hypopnoea index (AHI) >5/hour was found in 45.6%. In 22.3%, sleep apnoea and NH coincided. The obstructive apnoea index was significantly higher than the central apnoea index (p<0.0001). Both NH and sleep apnoea were significantly more common in male than in female patients. Sleep apnoea and AHI were associated with better bulbar function. Desaturation time (t<90%) and transcutaneous CO2 were negatively correlated with upright vital capacity. Early morning base excess (EMBE), bicarbonate and t<90% were independent predictors of NH. However, among 100 patients with NH, 31 were missed by t<90% >5 min and 17 were not identified when EMBE >3 mmol/L and t<90% >5 min were combined. CONCLUSION In ALS, sleep apnoea is common and often accompanies NH. It is mainly obstructive, and central apnoea appears to be clinically irrelevant. Polygraphy or oxymetry alone are not sufficient to uncover NH. Combination of EMBE and t<90% may increase sensitivity, but transcutaneous capnography is strongly recommended for reliable detection of NH in patients with ALS.
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Affiliation(s)
- Matthias Boentert
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
| | - Christian Glatz
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
| | - Cornelia Helmle
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
| | - Angelika Okegwo
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
| | - Peter Young
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
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Abstract
Motor neurone disease (MND) is a neurodegenerative disease defined by axonal loss and gliosis of upper and lower motor neurones in the motor cortex, lower brainstem nuclei and ventral horn of the spinal cord. MND is currently incurable and has a poor prognosis, with death typically occurring 3 to 5 years after disease onset. The disease is characterised by rapidly progressive weakness leading to paralysis, fasciculations, bulbar symptoms (including dysarthria and dysphagia) and respiratory compromise. Respiratory complications arise as a result of weakness of upper airway (pharyngeal and laryngeal) muscles and respiratory muscles (diaphragm, intercostal and accessory muscles) leading to respiratory failure. Due to early involvement of respiratory muscles in MND, sleep disordered breathing (SDB) occurs at a higher frequency than compared to the general population. SDB usually precedes daytime respiratory symptoms and chronic respiratory failure. It significantly impacts upon patients' quality of life and survival and its presence may predict prognosis. Managing SDB in MND with non-invasive ventilation (NIV) improves quality of life and survival. Early identification and management of SDB in MND patients is therefore crucial. This update will review assessments of respiratory muscle function, types of SDB and the effects of NIV in patients with MND.
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Affiliation(s)
- Rebecca F D'Cruz
- Lane Fox Respiratory Unit, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre, Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Patrick B Murphy
- Lane Fox Respiratory Unit, Guy's and St. Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Aerospace Physiological Sciences, King's College London, London, UK
| | - Georgios Kaltsakas
- Lane Fox Respiratory Unit, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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Quaranta VN, Carratù P, Damiani MF, Dragonieri S, Capozzolo A, Cassano A, Resta O. The Prognostic Role of Obstructive Sleep Apnea at the Onset of Amyotrophic Lateral Sclerosis. NEURODEGENER DIS 2016; 17:14-21. [PMID: 27595268 DOI: 10.1159/000447560] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/07/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/OBJECTIVE Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by the progressive loss of central and peripheral motor neurons. Some studies have found discordant data in the presence of sleep apnea in ALS patients. An obstructive component also occurs with upper airways hypotonia and muscle weakness that may result in an excessive reduction of airway lumen, leading to obstructive sleep apnea (OSA). The aim of this study was to assess the role of obstructive apneic events at disease onset in the ALS prognosis. METHODS A longitudinal retrospective study was conducted on 42 clinically diagnosed ALS patients. The study population was divided into 2 groups according to their obstructive apnea/hypopnea index (AHIo): group 1 consisted of 20 patients with an AHIo ≥5 and group 2 consisted of 22 patients with an AHIo <5. Both groups were compared with regard to demographic, polygraphic, and respiratory function parameters as well as ALS characteristics (bulbar onset, time between onset and first check-up, time between diagnosis and first check-up, time between first check-up and death or tracheostomy). RESULTS The mean survival in ALS patients with an AHIo ≥5 was significantly shorter than in ALS without OSA (p = 0.0237). The sniff nasal inspiratory pressure test was significantly correlated with AHIo, time of oxyhemoglobin saturation below 90% and the oxyhemoglobin desaturation index (p < 0.0001). CONCLUSIONS Our study highlights the importance of an early diagnosis of OSA in ALS patients, allowing the identification of ALS patients with an OSA phenotype (AHIo ≥5), who are characterized by a worse prognosis.
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Prell T, Ringer TM, Wullenkord K, Garrison P, Gunkel A, Stubendorff B, Witte OW, Grosskreutz J. Assessment of pulmonary function in amyotrophic lateral sclerosis: when can polygraphy help evaluate the need for non-invasive ventilation? J Neurol Neurosurg Psychiatry 2016; 87:1022-6. [PMID: 27010615 PMCID: PMC5013137 DOI: 10.1136/jnnp-2015-312185] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/18/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Non-invasive positive-pressure ventilation (NPPV) is an established, effective, long-term treatment for patients with amyotrophic lateral sclerosis (ALS), but the correct indicators for the establishment of NPPV have not been defined. METHODS In this retrospective study, records (spirometry, nocturnal polygraphy, nocturnal blood gases) of 131 patients with ALS were reviewed in order to evaluate the role of polygraphy for prediction of respiratory failure in ALS. RESULTS The patient group reporting with versus without dyspnoea had significantly lower values on the revised ALS-Functional Rating Scale (ALSFRS-R), vital capacity (VC), forced VC (FVC), arterial oxygen saturation and arterial oxygen tension readings, including a higher apnoea-hypopnoea index. 23 patients, who did not report about dyspnoea, had an FVC of <75%. Nocturnal hypoventilation was observed in 67% of the patients with ALS independent of their ALSFRS-R. The patient group with nocturnal hypoventilation was characterised by a significantly lower VC, FVC and maximal static inspiratory pressure compared with the group without nocturnal hypoventilation. However, also in the absence of nocturnal hypoventilation, 8 patients had a VC <50% as predicted. DISCUSSION Our study shows that in patients not reporting dyspnoea and having an FVC of >75%, nocturnal hypoventilation was observed in nearly every second patient. Therefore, for the question of whether NPPV should be initiated, polygraphy does not provide useful additional information if the FVC is already <75% as predicted. However, in patients with more or less normal lung function parameters or where lung spirometry cannot perform adequately (eg, bulbar ALS), it can provide sufficient evidence for the need of NPPV.
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Affiliation(s)
- Tino Prell
- Hans-Berger Department of Neurology, University Hospital Jena, Jena, Germany
| | - Thomas M Ringer
- Hans-Berger Department of Neurology, University Hospital Jena, Jena, Germany
| | - Kara Wullenkord
- Hans-Berger Department of Neurology, University Hospital Jena, Jena, Germany
| | - Philipp Garrison
- Hans-Berger Department of Neurology, University Hospital Jena, Jena, Germany
| | - Anne Gunkel
- Hans-Berger Department of Neurology, University Hospital Jena, Jena, Germany
| | | | - Otto W Witte
- Hans-Berger Department of Neurology, University Hospital Jena, Jena, Germany
| | - Julian Grosskreutz
- Hans-Berger Department of Neurology, University Hospital Jena, Jena, Germany
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Crescimanno G, Greco F, Arrisicato S, Morana N, Marrone O. Effects of positive end expiratory pressure administration during non-invasive ventilation in patients affected by amyotrophic lateral sclerosis: A randomized crossover study. Respirology 2016; 21:1307-13. [DOI: 10.1111/resp.12836] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/17/2016] [Accepted: 03/27/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Grazia Crescimanno
- Italian National Research Council; Institute of Biomedicine and Molecular Immunology; Palermo Italy
- Regional Center for Prevention and Treatment of Respiratory Complications of Rare Genetic Neuromuscular Diseases; Villa Sofia-Cervello Hospital; Palermo Italy
| | - Francesca Greco
- Italian Union Against Muscular Dystrophy (UILDM); Palermo Italy
| | - Salvo Arrisicato
- Regional Center for Prevention and Treatment of Respiratory Complications of Rare Genetic Neuromuscular Diseases; Villa Sofia-Cervello Hospital; Palermo Italy
| | - Noemi Morana
- Italian Union Against Muscular Dystrophy (UILDM); Palermo Italy
| | - Oreste Marrone
- Italian National Research Council; Institute of Biomedicine and Molecular Immunology; Palermo Italy
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Georges M, Nguyen-Baranoff D, Griffon L, Foignot C, Bonniaud P, Camus P, Pepin JL, Rabec C. Usefulness of transcutaneous PCO2to assess nocturnal hypoventilation in restrictive lung disorders. Respirology 2016; 21:1300-6. [DOI: 10.1111/resp.12812] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 02/04/2016] [Accepted: 02/12/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Marjolaine Georges
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
| | - Danièle Nguyen-Baranoff
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
| | - Lucie Griffon
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
| | - Clement Foignot
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
| | - Philippe Bonniaud
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
| | - Philippe Camus
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
| | - Jean-Louis Pepin
- Sleep, Exercise and Physiology Laboratory, EFCR; Grenoble University Hospital; Grenoble France
- Inserm U 1042, HP2; University of Grenoble Alpes; Grenoble France
| | - Claudio Rabec
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
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Vrijsen B, Testelmans D, Belge C, Vanpee G, Van Damme P, Buyse B. Patient-ventilator asynchrony, leaks and sleep in patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2016; 17:343-50. [DOI: 10.3109/21678421.2016.1170149] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Bart Vrijsen
- Department of Pulmonology and Leuven University Centre for Sleep and Wake disorders (LUCS) - University Hospitals Leuven,
- Faculty of Kinesiology and Rehabilitation Sciences – KU Leuven,
| | - Dries Testelmans
- Department of Pulmonology and Leuven University Centre for Sleep and Wake disorders (LUCS) - University Hospitals Leuven,
- Department of Clinical and Experimental Medicine – KU Leuven,
| | - Catharina Belge
- Department of Pulmonology and Leuven University Centre for Sleep and Wake disorders (LUCS) - University Hospitals Leuven,
- Department of Clinical and Experimental Medicine – KU Leuven,
| | - Goele Vanpee
- Department of Pulmonology and Leuven University Centre for Sleep and Wake disorders (LUCS) - University Hospitals Leuven,
- Faculty of Kinesiology and Rehabilitation Sciences – KU Leuven,
| | - Philip Van Damme
- Department of Neurology – University Hospitals Leuven,
- Department of Neurosciences, KU Leuven – University of Leuven, Experimental Neurology and Leuven Research Institute for Neuroscience and Disease (LIND), and
- Laboratory of Neurobiology, Vesalius Research Centre, VIB, Leuven, Belgium
| | - Bertien Buyse
- Department of Pulmonology and Leuven University Centre for Sleep and Wake disorders (LUCS) - University Hospitals Leuven,
- Department of Clinical and Experimental Medicine – KU Leuven,
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Vrijsen B, Buyse B, Belge C, Robberecht W, Van Damme P, Decramer M, Testelmans D. Noninvasive ventilation improves sleep in amyotrophic lateral sclerosis: a prospective polysomnographic study. J Clin Sleep Med 2015; 11:559-66. [PMID: 25766713 DOI: 10.5664/jcsm.4704] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 01/26/2015] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE To evaluate the effects of noninvasive ventilation (NIV) on sleep in patients with amyotrophic lateral sclerosis (ALS) after meticulous titration with polysomnography (PSG). METHODS In this prospective observational study, 24 ALS patients were admitted to the sleep laboratory during 4 nights for in-hospital NIV titration with PSG and nocturnal capnography. Questionnaires were used to assess subjective sleep quality and quality of life (QoL). Patients were readmitted after one month. RESULTS In the total group, slow wave sleep and REM sleep increased and the arousal-awakening index improved. The group without bulbar involvement (non-bulbar) showed the same improvements, together with an increase in sleep efficiency. Nocturnal oxygen and carbon dioxide levels improved in the total and non-bulbar group. Except for oxygen saturation during REM sleep, no improvement in respiratory function or sleep structure was found in bulbar patients. However, these patients showed less room for improvement. Patient-reported outcomes showed improvement in sleep quality and QoL for the total and non-bulbar group, while bulbar patients only reported improvements in very few subscores. CONCLUSIONS This study shows an improvement of sleep architecture, carbon dioxide, and nocturnal oxygen saturation at the end of NIV titration and after one month of NIV in ALS patients. More studies are needed to identify the appropriate time to start NIV in bulbar patients. Our results suggest that accurate titration of NIV by PSG improves sleep quality. COMMENTARY A commentary on this article appears in this issue on page 511.
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Affiliation(s)
- Bart Vrijsen
- Leuven University Centre for Sleep/Wake Disorders, Department of Pulmonology, University Hospitals Leuven, Belgium.,Department of Pulmonology, University of Leuven, Belgium
| | - Bertien Buyse
- Leuven University Centre for Sleep/Wake Disorders, Department of Pulmonology, University Hospitals Leuven, Belgium.,Department of Pulmonology, University of Leuven, Belgium
| | - Catharina Belge
- Leuven University Centre for Sleep/Wake Disorders, Department of Pulmonology, University Hospitals Leuven, Belgium.,Department of Pulmonology, University of Leuven, Belgium
| | - Wim Robberecht
- Department of Neurology, University of Leuven, Belgium.,Experimental Neurology (Department of Neurosciences) and Leuven Research Institute for Neuroscience and Disease (LIND), University of Leuven (KU Leuven), Belgium
| | - Philip Van Damme
- Department of Neurology, University of Leuven, Belgium.,Experimental Neurology (Department of Neurosciences) and Leuven Research Institute for Neuroscience and Disease (LIND), University of Leuven (KU Leuven), Belgium.,Laboratory of Neurobiology, Vesalius Research Center, VIB, Leuven, Belgium
| | - Marc Decramer
- Department of Pulmonology, University of Leuven, Belgium
| | - Dries Testelmans
- Leuven University Centre for Sleep/Wake Disorders, Department of Pulmonology, University Hospitals Leuven, Belgium.,Department of Pulmonology, University of Leuven, Belgiumd
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Chiner E, Sancho-Chust JN, Landete P, Senent C, Gómez-Merino E. Complementary home mechanical ventilation techniques. SEPAR Year 2014. Arch Bronconeumol 2014; 50:546-53. [PMID: 25138799 DOI: 10.1016/j.arbres.2014.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/13/2014] [Accepted: 06/16/2014] [Indexed: 12/16/2022]
Abstract
This is a review of the different complementary techniques that are useful for optimizing home mechanical ventilation (HMV). Airway clearance is very important in patients with HMV and many patients, particularly those with reduced peak cough flow, require airway clearance (manual or assisted) or assisted cough techniques (manual or mechanical) and suctioning procedures, in addition to ventilation. In the case of invasive HMV, good tracheostomy cannula management is essential for success. HMV patients may have sleep disturbances that must be taken into account. Sleep studies including complete polysomnography or respiratory polygraphy are helpful for identifying patient-ventilator asynchrony. Other techniques, such as bronchoscopy or nutritional support, may be required in patients on HMV, particularly if percutaneous gastrostomy is required. Information on treatment efficacy can be obtained from HMV monitoring, using methods such as pulse oximetry, capnography or the internal programs of the ventilators themselves. Finally, the importance of the patient's subjective perception is reviewed, as this may potentially affect the success of the HMV.
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Affiliation(s)
- Eusebi Chiner
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España.
| | - José N Sancho-Chust
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España
| | - Pedro Landete
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España
| | - Cristina Senent
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España
| | - Elia Gómez-Merino
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España
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Loewen AHS, Korngut L, Rimmer K, Damji O, Turin TC, Hanly PJ. Limitations of split-night polysomnography for the diagnosis of nocturnal hypoventilation and titration of non-invasive positive pressure ventilation in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2014; 15:494-8. [DOI: 10.3109/21678421.2014.942866] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Andrea H. S. Loewen
- Sleep Centre, Foothills Medical Centre, University of Calgary,
Calgary, Alberta, Canada
| | - Lawrence Korngut
- Sleep Centre, Foothills Medical Centre, University of Calgary,
Calgary, Alberta, Canada
| | - Karen Rimmer
- Sleep Centre, Foothills Medical Centre, University of Calgary,
Calgary, Alberta, Canada
| | - Omar Damji
- Sleep Centre, Foothills Medical Centre, University of Calgary,
Calgary, Alberta, Canada
| | - Tanvir C. Turin
- Sleep Centre, Foothills Medical Centre, University of Calgary,
Calgary, Alberta, Canada
| | - Patrick J. Hanly
- Sleep Centre, Foothills Medical Centre, University of Calgary,
Calgary, Alberta, Canada
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Katzberg HD, Selegiman A, Guion L, Yuan N, Cho SC, Katz JS, Miller RG, So YT. Effects of noninvasive ventilation on sleep outcomes in amyotrophic lateral sclerosis. J Clin Sleep Med 2013; 9:345-51. [PMID: 23585750 PMCID: PMC3601313 DOI: 10.5664/jcsm.2586] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES The objective was to study the effects on noninvasive ventilation on sleep outcomes in patient with ALS, specifically oxygenation and overall sleep quality. METHODS Patients with ALS who met criteria for initiation of NIV were studied with a series of 2 home PSG studies, one without NIV and a follow-up study while using NIV. Primary outcome was a change in the maximum overnight oxygen saturation; secondary outcomes included change in mean overnight oxygen saturation, apnea and hypopnea indexes, sleep latency, sleep efficiency, sleep arousals, and sleep architecture. RESULTS A total of 94 patients with ALS were screened for eligibility; 15 were enrolled; and 12 completed study procedures. Maximum overnight oxygen saturation improved by 7.0% (p = 0.01) and by 6.7% during REM sleep (p = 0.02) with NIV. Time spent below 90% oxygen saturation was also significant-ly better with NIV (30% vs 19%, p < 0.01), and there was trend for improvement in mean overnight saturation (1.5%, p = 0.06). Apnea index (3.7 to 0.7), hypopnea index (6.2 to 5.7), and apnea hypopnea index (9.8 to 6.3) did not significantly improve after introducing NIV. NIV had no effect on sleep efficiency (mean change 10%), arousal index (7 to 12), or sleep stage distribution (Friedman chi-squared = 0.40). CONCLUSIONS NIV improved oxygenation but showed no significant effects on sleep efficiency, sleep arousals, restful sleep, or sleep architecture. The net impact of these changes for patients deserves further study in a larger group of ALS patients.
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Affiliation(s)
- Hans D Katzberg
- Division of Neurology, University Health Network, Toronto, Ontario, Canada.
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Vrijsen B, Testelmans D, Belge C, Robberecht W, Van Damme P, Buyse B. Non-invasive ventilation in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2013; 14:85-95. [DOI: 10.3109/21678421.2012.745568] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Strutt AM, Palcic J, Wager JG, Titus C, Macadam C, Brown J, Scott BM, Harati Y, Schulz PE, York MK. Cognition, behavior, and respiratory function in amyotrophic lateral sclerosis. ISRN Neurol 2012; 2012:912123. [PMID: 22852095 PMCID: PMC3407622 DOI: 10.5402/2012/912123] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 04/28/2012] [Indexed: 11/23/2022]
Abstract
Objective. To examine the relationship between respiratory functioning and neuropsychological performance, mood, and frontal-lobe-mediated behaviors in ALS patients. Methods. Forty-four patients with probable or definite ALS (El Escorial criteria) completed comprehensive pulmonary and neuropsychological assessments as part of their baseline neurological evaluation. Based on their full vital respiratory capacity, 24 and 20 patients were classified as having impaired or intact respiration, respectively. Results. Comparable demographic characteristics, neuropsychological performance, and self-reported mood symptoms were found between ALS patients with intact versus impaired respiration. However, more respiratory-impaired patients were reported by their caregivers as having clinically significant impairments in frontal-lobe-mediated behaviors. Nevertheless, declines in behavior were evidenced from pre- to post-ALS symptom onset for both respiratory groups, and exploratory analyses revealed greater executive functioning deficits in patients with bulbar versus limb onset as well as respiratory-impaired patients not receiving pulmonary interventions versus those utilizing such interventions at the time of testing. Conclusions. Results suggest that the respiratory insufficiency of ALS patients may potentially produce irreversible deficits in executive functioning; yet once treated, impairments in more basic cognitive abilities may be less evident.
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Affiliation(s)
- Adriana M Strutt
- Department of Neurology, An ALS Association Certified Center, Baylor College of Medicine, 6550 Fannin, Suite 1801, Houston, TX 77030, USA
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Lo Coco D, Cannizzaro E, Spataro R, Taiello AC, La Bella V. Sleep–wake problems in patients with amyotrophic lateral sclerosis: implications for patient management. Neurodegener Dis Manag 2012. [DOI: 10.2217/nmt.12.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Sleep–wake problems are frequent, although unrecognized, complications of amyotrophic lateral sclerosis (ALS). Sleep disorders such as insomnia, sleep-disordered breathing and restless legs syndrome have all been reported in patients with ALS, despite the limited number of studies and the small populations investigated so far. Sleep disturbances gradually worsen with disease progression, suggesting a relationship between the severity of disease and the neurodegenerative process. However, poor sleep can also be a consequence of several disturbances such as anxiety, depression, pain, choking, sialorrhea, fasciculations, cramps, nocturia and the inability to get comfortable and move freely in bed. Sleep disorders may have many reflections on patients with ALS, including excessive daytime somnolence, fatigue, impaired cognition, reduced quality of life and survival. This article reviews the recent literature on sleep–wake problems in patients with ALS, focusing on the implications for patient management.
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Affiliation(s)
- Daniele Lo Coco
- Sleep Disorders Clinic, Dipartimento di Neuroscienze, Ospedale Civico – ARNAS, Piazza N. Leotta, 4 – 90129, Palermo, Italy
| | - Emanuele Cannizzaro
- Dipartimento di Scienze Farmacologiche, Università di Palermo, Palermo, Italy
| | - Rossella Spataro
- ALS Clinical Research Center, Dipartimento di Biomedicina Sperimentale e Neuroscienze Cliniche (BioNeC), Università di Palermo, Palermo, Italy
| | - Alfonsa Claudia Taiello
- ALS Clinical Research Center, Dipartimento di Biomedicina Sperimentale e Neuroscienze Cliniche (BioNeC), Università di Palermo, Palermo, Italy
| | - Vincenzo La Bella
- ALS Clinical Research Center, Dipartimento di Biomedicina Sperimentale e Neuroscienze Cliniche (BioNeC), Università di Palermo, Palermo, Italy
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Singletary KG, Naidoo N. Disease and Degeneration of Aging Neural Systems that Integrate Sleep Drive and Circadian Oscillations. Front Neurol 2011; 2:66. [PMID: 22028699 PMCID: PMC3199684 DOI: 10.3389/fneur.2011.00066] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 09/28/2011] [Indexed: 12/12/2022] Open
Abstract
Sleep/wake and circadian rest-activity rhythms become irregular with age. Typical outcomes include fragmented sleep during the night, advanced sleep phase syndrome and increased daytime sleepiness. These changes lead to a reduction in the quality of life due to cognitive impairments and emotional stress. More importantly, severely disrupted sleep and circadian rhythms have been associated with an increase in disease susceptibility. Additionally, many of the same brain areas affected by neurodegenerative diseases include the sleep and wake promoting systems. Any advances in our knowledge of these sleep/wake and circadian networks are necessary to target neural areas or connections for therapy. This review will discuss research that uses molecular, behavioral, genetic and anatomical methods to further our understanding of the interaction of these systems.
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Affiliation(s)
- Kristan G Singletary
- Center for Sleep and Circadian Neurobiology, School of Medicine, University of Pennsylvania Philadelphia, PA, USA
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Fidler JA, Treleaven CM, Frakes A, Tamsett TJ, McCrate M, Cheng SH, Shihabuddin LS, Kaspar BK, Dodge JC. Disease progression in a mouse model of amyotrophic lateral sclerosis: the influence of chronic stress and corticosterone. FASEB J 2011; 25:4369-77. [PMID: 21876068 DOI: 10.1096/fj.11-190819] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease characterized by motor neuron cell loss, muscular atrophy, and a shortened life span. Survival is highly variable, as some patients die within months, while others live for many years. Exposure to stress or the development of a nonoptimal stress response to disease might account for some of this variability. We show in the SOD1(G93A) mouse model of ALS that recurrent exposure to restraint stress led to an earlier onset of astrogliosis and microglial activation within the spinal cord, accelerated muscular weakness, and a significant decrease in median survival (105 vs. 122 d) when compared to nonstressed animals. Moreover, during normal disease course, ALS mice display a cacostatic stress response by developing an aberrant serum corticosterone circadian rhythm. Interestingly, we also found that higher corticosterone levels were significantly correlated with both an earlier onset of paralysis (males: r(2)=0.746; females: r(2)=0.707) and shorter survival times (males: r(2)=0.680; females: r(2)=0.552) in ALS mice. These results suggest that stress is capable of accelerating disease progression and that strategies that modulate glucocorticoid metabolism might be a viable treatment approach for ALS.
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Affiliation(s)
- Jonathan A Fidler
- Genzyme Corporation, 49 New York Ave., Framingham, MA 01701-9322, USA
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Carratù P, Cassano A, Gadaleta F, Tedone M, Dongiovanni S, Fanfulla F, Resta O. Association between low sniff nasal-inspiratory pressure (SNIP) and sleep disordered breathing in amyotrophic lateral sclerosis: Preliminary results. ACTA ACUST UNITED AC 2011; 12:458-63. [DOI: 10.3109/17482968.2011.593038] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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McKim DA, Road J, Avendano M, Abdool S, Côté F, Duguid N, Fraser J, Maltais F, Morrison DL, O’Connell C, Petrof BJ, Rimmer K, Skomro R. Home mechanical ventilation: a Canadian Thoracic Society clinical practice guideline. Can Respir J 2011; 18:197-215. [PMID: 22059178 PMCID: PMC3205101 DOI: 10.1155/2011/139769] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Increasing numbers of patients are surviving episodes of prolonged mechanical ventilation or benefitting from the recent availability of userfriendly noninvasive ventilators. Although many publications pertaining to specific aspects of home mechanical ventilation (HMV) exist, very few comprehensive guidelines that bring together all of the current literature on patients at risk for or using mechanical ventilatory support are available. The Canadian Thoracic Society HMV Guideline Committee has reviewed the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. The guideline provides a disease-specific review of illnesses including amyotrophic lateral sclerosis, spinal cord injury, muscular dystrophies, myotonic dystrophy, kyphoscoliosis, post-polio syndrome, central hypoventilation syndrome, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease as well as important common themes such as airway clearance and the process of transition to home. The guidelines have been extensively reviewed by international experts, allied health professionals and target audiences. They will be updated on a regular basis to incorporate any new information.
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Affiliation(s)
- Douglas A McKim
- Division of Respirology, University of Ottawa, and Respiratory Rehabilitation Services, Ottawa Hospital Sleep Centre, Ottawa, Ontario
| | - Jeremy Road
- Division of Respiratory Medicine and The Lung Centre, University of British Columbia, Provincial Respiratory Outreach Program, Vancouver, British Columbia
| | - Monica Avendano
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
| | - Steve Abdool
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
- Centre for Clinical Ethics at St Michael’s Hospital, West Park Healthcare Centre, and University of Toronto, Toronto, Ontario
| | | | - Nigel Duguid
- Eastern Health, Memorial University, St John’s, Newfoundland and Labrador
| | - Janet Fraser
- Respiratory Therapy Services, West Park Healthcare Centre, Toronto, Ontario
| | - François Maltais
- Research Centre, University Institute of Cardiology and Lung Health for Québec, Laval University, Québec, Québec
| | - Debra L Morrison
- Sleep Clinic and Laboratory, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia
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Abstract
The aim of this review is to provide data on sleep disturbances in three categories of neurodegenerative disorders: synucleinopathies, tauopathies, and other diseases (this heterogeneous group includes also spinocerebellar degeneration and amyotrophic lateral sclerosis). Analysing and knowing sleep disorders in neurodegenerative diseases may offer important insights into the pathomechanism of some of these diseases and calls attention to the still insufficiently known 'sleep neurology'. The identification of sleep disorders in some neurodegenerative conditions may make their diagnosis easier and earlier; for example, rapid eye movements sleep behaviour disorder may precede any other clinical manifestation of synucleinopathies by more than 10 years.
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Affiliation(s)
- A Raggi
- Department of Neurology I.C., Oasi Institute for Research on Mental Retardation and Brain Aging (IRCCS), Troina, Italy
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Affiliation(s)
- R Robert Auger
- Department of Psychiatry and Psychology, Mayo Clinic College of Medicine, Rochester, MN, USA.
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Poon CA, Becker KA, Littner MR. Noninvasive Positive Airway Pressure in Hypercapnic Respiratory Failure in Noncardiac Medical Disorders. Sleep Med Clin 2010; 5:451-470. [DOI: 10.1016/j.jsmc.2010.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Indications for exercise and pulmonary rehabilitation extend to neuromuscular diseases tough these conditions pose particular challenges given the associated skeletal muscle impairment and respiratory muscle dysfunction. These challenges are compounded by the variety of exercise prescriptions (aerobic, muscle strengthening, and respiratory muscle training) and the variety of neuromuscular disorders (muscular, motor neuron, motor nerve root, and neuromuscular transmission disorders). Studies support a level II evidence of effectiveness (i.e., likely to be effective) for a combination of aerobic exercise and strengthening exercises in muscular disorders, and for strengthening exercises in amyotrophic lateral sclerosis. The potential deleterious effects of work overload in the dystrophinopathies have not been confirmed in Becker muscular dystrophy. Adjunctive pharmacologic interventions (e.g., theophylline, steroids, PDE5 inhibitors, creatine), training recommendations (e.g., interval or lower intensity training) and supportive techniques (e.g., noninvasive ventilation, neuromuscular electrical stimulation, and diaphragm pacing) may result in more effective training but require more study before formal recommendations can be made. The exercise prescription should include avoidance of inspiratory muscle training in hypercapnia or low vital capacity, and should match the desired outcome (e.g., extremity training for task-specific performance, exercise training to enhance exercise performance, respiratory muscle training where respiratory muscle involvement contributes to the impairment).
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Affiliation(s)
- L S Aboussouan
- Cleveland Clinic Foundation, Respiratory Institute, Cleveland, OH 44195, USA.
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De Carvalho M, Costa J, Pinto S, Pinto A. Percutaneous nocturnal oximetry in amyotrophic lateral sclerosis: Periodic desaturation. ACTA ACUST UNITED AC 2009; 10:154-61. [DOI: 10.1080/17482960802382305] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Atalaia A, De Carvalho M, Evangelista T, Pinto A. Sleep characteristics of amyotrophic lateral sclerosis in patients with preserved diaphragmatic function. ACTA ACUST UNITED AC 2009; 8:101-5. [PMID: 17453638 DOI: 10.1080/17482960601029883] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
There are a number of sleep studies in amyotrophic lateral sclerosis (ALS), in general including a heterogeneous population of patients. We aimed to study sleep in a population of selected ALS patients by investigating nocturnal polysomnography (PSG) characteristics in ALS patients with normal respiratory function tests and preserved diaphragmatic innervation. Ninety-two ALS patients were screened by percutaneous nocturnal oximetry (PNO). Eleven ALS patients with normal respiratory function tests, phrenic motor responses and preserved motor units on needle electromyography of the diaphragm, but abnormal PNO, were selected for PSG. REM was present in eight patients, but normal in only three. Three patients had mixed apnoea-hypopnoea, severe in one. Seven showed a pattern of periodic mild O(2) desaturation, which occurred in REM 3, REM and NREM 3 and in NREM sleep 1. One patient studied six months later had more severe changes in the second evaluation. In conclusion, the most common sleep disordered breathing was periodic mild O(2) desaturation independent of the sleep stage (REM, NREM). This might represent central drive dysfunction or respiratory muscle fatigue in ALS.
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Affiliation(s)
- António Atalaia
- Laboratory of Clinical Neurophysiology, British Hospital--Lisbon XXI, Lisbon. Portugal.
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Carratù P, Spicuzza L, Cassano A, Maniscalco M, Gadaleta F, Lacedonia D, Scoditti C, Boniello E, Di Maria G, Resta O. Early treatment with noninvasive positive pressure ventilation prolongs survival in Amyotrophic Lateral Sclerosis patients with nocturnal respiratory insufficiency. Orphanet J Rare Dis 2009; 4:10. [PMID: 19284546 PMCID: PMC2660903 DOI: 10.1186/1750-1172-4-10] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Accepted: 03/10/2009] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease, which rapidly leads to chronic respiratory failure requiring mechanical ventilation. Currently, forced vital capacity (FVC) < 50% is considered as physiologic marker for admitting patients to Noninvasive Positive Pressure Ventilation (NPPV) intervention, although it has been recently shown the median survival of patients with baseline FVC < 75% much shorter than median survival of patients with baseline FVC > 75%, independently by any treatment. AIM To assess the role of NPPV in improving outcome of ALS, a retrospective analysis was performed to investigate 1 year survival of ALS patients with FVC < 75% and nocturnal respiratory insufficiency, treated with NPPV, compared to a well-matched population of ALS patients, who refused or was intolerant to NPPV. METHODS We investigated seventy-two consecutive ALS patients who underwent pulmonary function test. Forty-four presented a FVC > 75% and served as control group. Twenty-eight patients presented a FVC < 75% and showed, at polysomnography analysis, nocturnal respiratory insufficiency, requiring NPPV; sixteen were treated with NPPV, while twelve refused or were intolerant. RESULTS Increased survival rate at 1 year in patients with FVC < 75% treated with NPPV, as compared to those who refused or could not tolerate NPPV (p = 0.02), was observed. The median rate of decline in FVC% was slower in NPPV patients than in patients who did not use NPPV (95% CI: 0.72 to 1.85; p < 0.0001). CONCLUSION This report demonstrates that early treatment with NPPV prolongs survival and reduces decline of FVC% in ALS.
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Desai H, Mador MJ. Sleep in Patients with Respiratory Muscle Weakness. Sleep Med Clin 2008. [DOI: 10.1016/j.jsmc.2008.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Real-time diaphragmatic movement was evaluated with ultrasonography in three patients with amyotrophic lateral sclerosis (ALS). The initial complaint of two patients was weakness of the extremities followed by dyspnoea later in the disease course, while the third patient had dyspnoea as the initial symptom. Ultrasonographic analyses revealed that the contractile function of the diaphragm was not maintained during maximum inspiratory effort, with unsatisfactory diaphragmatic excursion and no change in diaphragmatic thickness during respiration, indicating diaphragmatic paralysis. Ultrasonography may be useful for the diagnosis and follow up of diaphragmatic involvement with amyotrophic lateral sclerosis and other motor-neuron diseases.
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Affiliation(s)
- Yasuko Yoshioka
- Department of Respiratory Medicine, Juntendo University, School of Medicine, Tokyo, Japan.
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Affiliation(s)
- Abhilasha Ahuja
- Department of Respiratory Medicine, T.N. Medical College, BYL Nair Hospital, Mumbai 400 008, India
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Heffernan C, Jenkinson C, Holmes T, Macleod H, Kinnear W, Oliver D, Leigh N, Ampong MA. Management of respiration in MND/ALS patients: an evidence based review. ACTA ACUST UNITED AC 2006; 7:5-15. [PMID: 16546753 DOI: 10.1080/14660820510043235] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This systematic review comprises an objective appraisal of the evidence in regard to the management of respiration in patients with motor neuron disease (MND/ALS). Studies were identified through computerised searches of 32 databases. Internet searches of websites of drug companies and MND/ALS research web sites, 'snow balling' and hand searches were also employed to locate any unpublished study or other 'grey literature' on respiration and MND/ALS. Since management of MND/ALS involves a number of health professionals and care workers, searches were made across multiple disciplines. No time frame was imposed on the search in order to increase the probability of identifying all relevant studies, although there was a final limit of March 2005. Recommendations for patient and carer-based guidelines for the clinical management of respiration for MND/ALS patients are suggested on the basis of qualitative analyses of the available evidence. However, these recommendations are based on current evidence of best practice, which largely comprises observational research and clinical opinion. There is a clear need for further evidence, in particular randomised and non-randomised controlled trials on the effects of non-invasive ventilation and additional larger scale cohort studies on the issues of initial assessment of respiratory symptoms, and management and timing of interventions.
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Pinet C. Évaluation des fonctions ventilatoires. Rev Neurol (Paris) 2006; 162:195-199. [DOI: 10.1016/s0035-3787(06)75185-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Abstract
PURPOSE OF REVIEW Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder characterized by progressive loss of motor neurones, but it is increasingly recognized to be a more disseminated disease. The autonomic nervous system may also be involved. Here we review the literature with specific emphasis on autonomic functions in ALS. RECENT STUDIES Ample evidence exists for subclinical dysfunction of cardiovascular, sudomotor, gastrointestinal, salivary and lacrimal regulation, even in early ALS cases. Autonomic disturbances may lead to circulatory collapse or sudden death in respirator dependent patients. Several studies suggest the existence of sympathetic hyperactivity in ALS. We discuss some possible pathophysiological mechanisms of the subtle abnormalities and some clinical and treatment implications. SUMMARY The wide range of autonomic involvement, together with results suggesting cognitive and extrapyramidal dysfunction, supports the view that ALS is a multisystem degenerative disease.
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Affiliation(s)
- Rositsa Baltadzhieva
- Neurology Department, Tel-Aviv Medical Center and the Sieratzki Chair of Neurology, Tel-Aviv University, Ramat-Aviv, Israel
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Abstract
INTRODUCTION In amyotrophic lateral sclerosis (ALS), respiratory muscle involvement is highly predictive of survival and quality of life (QOL). There is compelling evidence that non invasive ventilation (NIV) prolongs survival by several months and improves QOL more than any other currently available treatment. Frequent testing of pulmonary function and regular evaluations are recommended since 1999 by the American Academy of Neurology in order to take appropriate treatment decisions. STATE OF ART There are numerous tests available to evaluate respiratory status in ALS and it is important to know their sensitivity and specificity to recognize clinical risk situations. Some recent data suggest that sniff nasal pressure and maximal inspiratory pressure (MIP) can be performed reliably by most ALS patients and are more sensitive to decrements in inspiratory muscle strength than spirometry or arterial blood gasometry. PERSPECTIVES Airway obstruction caused by ineffective coughing is the principal cause of intolerance to NIV. Several factors other than respiratory muscle strength may affect pulmonary function: postural changes, nutritional status, infectious disease, drugs. CONCLUSION The neurologist has to coordinate multidisciplinary care, with attention to individual patient preferences, and with a frank and compassionate discussion between the patient, the family, the physicians and the caregivers.
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Affiliation(s)
- V Danel-Brunaud
- Centre SLA, Clinique de Neurologie, Hôpital Roger-Salengro, EA 2683 CHRU, Lille.
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Abstract
Neuromuscular disorders are caused by the primary involvement of the motor unit. In these patients, sleep-disordered breathing (SDB) due to respiratory muscle weakness is often encountered during sleep. Because there is a tendency to overlook this disorder, all patients with neuromuscular disorders should be questioned about SDB. Overnight polysomnography is the best investigation for SDB and nocturnal desaturations. In the management of these patients, noninvasive intermittent positive pressure ventilation results in improvement of SDB and breathing.
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Affiliation(s)
- Ibrahim Oztura
- Stanford University Sleep Disorders Clinic, 401 Quarry Road, - Suite 3301, Palo Alto, CA 94305, USA.
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Carvalho MD. Electrodiagnostic assessment of respiratory dysfunction in motor neuron disease. Clinical Neurophysiology of Motor Neuron Diseases. Elsevier; 2004. pp. 513-28. [DOI: 10.1016/s1567-4231(04)04029-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Abstract
The act of breathing depends on coordinated activity of the respiratory muscles to generate subatmospheric pressure. This action is compromised by disease states affecting anatomical sites ranging from the cerebral cortex to the alveolar sac. Weakness of the respiratory muscles can dominate the clinical manifestations in the later stages of several primary neurologic and neuromuscular disorders in a manner unique to each disease state. Structural abnormalities of the thoracic cage, such as scoliosis or flail chest, interfere with the action of the respiratory muscles-again in a manner unique to each disease state. The hyperinflation that accompanies diseases of the airways interferes with the ability of the respiratory muscles to generate subatmospheric pressure and it increases the load on the respiratory muscles. Impaired respiratory muscle function is the most severe consequence of several newly described syndromes affecting critically ill patients. Research on the respiratory muscles embraces techniques of molecular biology, integrative physiology, and controlled clinical trials. A detailed understanding of disease states affecting the respiratory muscles is necessary for every physician who practices pulmonary medicine or critical care medicine.
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Affiliation(s)
- Franco Laghi
- Division of Pulmonary and Critical Care Medicine, Edward Hines, Jr. VA Hospital, 111 N. 5th Avenue and Roosevelt Road, Hines, IL 60141, USA.
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Farrero E, Prats E, Escarrabill J. [Series 4: respiratory muscles in neuromuscular diseases and the chest cavity. Decision making in the clinical management of patients with lateral amyotrophic sclerosis]. Arch Bronconeumol 2003; 39:226-32. [PMID: 12749806 DOI: 10.1016/s0300-2896(03)75366-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- E Farrero
- UFISS-Respiratòria. Servei de Pneumologia. Hospital Universitari de Bellvitge. L'Hospitalet de Llobregat. Barcelona. España.
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Autret A. Sleep and lesions in the central nervous system. Sleep 2003. [DOI: 10.1007/978-1-4615-0217-3_57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Scelsa SN, Yakubov B, Salzman SH. Dyspnea-fasciculation syndrome: early respiratory failure in ALS with minimal motor signs. Amyotroph Lateral Scler Other Motor Neuron Disord 2002; 3:239-43. [PMID: 12710515 DOI: 10.1080/146608202760839011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Respiratory failure (RF) in ALS typically occurs as a late manifestation. While there are uncommon patient reports of early RF, most had moderate limb and bulbar weakness. DESIGN/METHODS We reviewed clinical and laboratory data from 3 patients with ALS, early RF, and minor motor signs. RESULTS Patients were male, ages 62, 75 and 80 years. The patients presented with 6 months to 2 years of exertional and nocturnal dyspnea, daytime hypersomnolence, limb fatigability, and weight loss. Exam showed tachypnea, slight distal limb weakness, and hyperreflexia. All three patients had prominent fasciculations, insomnia, supportive EMG findings, FVC (32-74% predicted), PO2 (50-80 mmHg), PCO2(52-76 mmHg) and required BiPAP (Bi-level positive airway pressure). One patient had a reduced FEV1/FVC of 0.55 and a 15% increase in FEV1 post-bronchodilator suggesting concurrent chronic obstructive pulmonary disease (COPD). However, his P(A-a)O2 was only 7 mmHg suggesting COPD was not the major factor causing respiratory failure; his extreme hypercapnea could not be explained by ALS or COPD alone. CONCLUSIONS ALS may present with unexplained RF, or sleep disturbance resembling sleep apnea, without significant bulbar or limb weakness. In our experience, such patients are elderly with dyspnea, fasciculations, and other minor motor signs: the Dyspnea-Fasciculation Syndrome. Concurrent COPD may augment the effect of ALS, resulting in earlier RF. FVC may be relatively preserved, despite hypercapnia.
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Affiliation(s)
- Stephen N Scelsa
- Department of Neurology, Beth Israel Medical Center, New York, NY 10003, USA.
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Abstract
Motor neurone disease is a progressive neurodegenerative disorder leading to severe disability and death. It is clinically characterised by mixed upper and lower motor neurone involvement affecting bulbar, limb, and respiratory musculature. Recent guidelines have established diagnostic criteria and defined management of the condition. In a proportion of familial amyotrophic lateral sclerosis there is a mutation in the gene encoding the enzyme copper/zinc superoxide dismutase 1; this has allowed mutation screening and generated considerable laboratory based research. The diagnosis must be given with care and consideration and close follow up is essential. Management involves a multidisciplinary team based in the hospital and the community. Riluzole is the only drug shown to have a disease modifying effect and has been approved by the National Institute for Clinical Excellence. The essence of care is good symptomatic management, including nutritional support with percutaneous endoscopic gastrostomy and ventilatory care with non-invasive ventilation. Palliative care should be introduced before the terminal stages after careful discussion with the patient and carers. Knowledge of this condition has grown dramatically recently with a parallel improvement in treatment and ability to deal with the most troublesome problems.
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Affiliation(s)
- R S Howard
- Batten/Harris Intensive Care Unit, National Hospital for Neurology and Neurosurgery, London, UK.
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Bradley MD, Orrell RW, Clarke J, Davidson AC, Williams AJ, Kullmann DM, Hirsch N, Howard RS. Outcome of ventilatory support for acute respiratory failure in motor neurone disease. J Neurol Neurosurg Psychiatry 2002; 72:752-6. [PMID: 12023419 PMCID: PMC1737909 DOI: 10.1136/jnnp.72.6.752] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To review the outcome of acute ventilatory support in patients presenting acutely with respiratory failure, either with an established diagnosis of motor neurone disease (MND) or with a clinical event where the diagnosis of MND has not yet been established. METHODS Outcome was reviewed in 24 patients with respiratory failure due to MND who received endotracheal intubation and intermittent positive pressure ventilation either at presentation or as a result of the unexpected development of respiratory failure. Patients presenting to local hospitals with acute respiratory insufficiency and requiring tracheal intubation, ventilatory support, and admission to an intensive therapy unit (ITU) before transfer to a regional respiratory care unit were selected. Clinical features of presentation, management, and outcome were studied. RESULTS 24 patients with MND were identified, all being intubated and ventilated acutely within hours of presentation. 17 patients (71%) were admitted in respiratory failure before the diagnosis of MND had been made; the remaining seven patients (29%) were already known to have MND but deteriorated rapidly such that intubation and ventilation were initiated acutely. Seven patients (29%) died on ITU (between seven and 54 days after admission). 17 patients (71%) were discharged from ITU. 16 patients (67%) received long term respiratory support and one patient required no respiratory support following tracheal extubation. The daily duration of support that was required increased gradually with time. CONCLUSION When a patient with MND is ventilated acutely, with or without an established diagnosis, independence from the ventilator is rarely achieved. Almost all of these patients need long term ventilatory support and the degree of respiratory support increases with time as the disease progresses. The aim of management should be weaning the patient to the minimum support compatible with symptomatic relief and comfort. Respiratory failure should be anticipated in patients with MND when the diagnosis has been established.
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Affiliation(s)
- M D Bradley
- Department of Clinical Neurosciences, Royal Free and University College Medical School, Royal Free Campus, London NW3 2QG, UK
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