Non-invasive ventilation and hypercapnia-associated symptoms in amyotrophic lateral sclerosis

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

Psychological Factors Influencing Adherence to NIV in Neuromuscular Patients Dependent on Non Invasive Mechanical Ventilation: Preliminary Results

BACKGROUND

Non-invasive ventilation (NIV) is associated with improvement of both morbility and mortality in patients affected by neuromuscular diseases with chronic respiratory failure. Several studies have also shown that long-term NIV positively impacts the patient's quality of life and perception of disease status. Its effectiveness is likely related to the adherence to NIV. Several factors, patient- and not patient-related, may compromise adherence to NIV, such as physical, behavioral, familiar, and social issues. Few data are currently available on the role of psychological factors in influencing NIV adherence.

MATERIALS AND METHODS

In this pilot study, we evaluated the adherence to NIV in a group of 15 adult patients with neuromuscular diseases (Duchenne muscular dystrophy, myotonic dystrophy, and amyotrophic lateral sclerosis) in relation to their grade of depression assessed by the Beck Depression Inventory (BDI) questionnaire. Other data were collected, such as clinical features (age and sex), use of anxiolytic drugs, the presence of a family or professional caregiver, the quality of patient-physician relationship, the beginning of psychological support after BDI screening, and the family acceptance of NIV. NIV adherence was definied as the use of NIV for at least 4 h per night on 70% of nights in a month.

RESULTS

The overall rate of NIV adherence was 60%. Based on the BDI questionnaire, patients who were non-adherent to NIV had a higher rate of depression, mainly observed in the oldest patients. The acceptance of NIV by the family and positive physician-patient interaction seem to favor NIV adherence.

CONCLUSION

Depression can interfere with NIV adherence in patients with neuromuscolar diseases.

Respiratory Management of Patients With Neuromuscular Weakness: An American College of Chest Physicians Clinical Practice Guideline and Expert Panel Report

BACKGROUND

Respiratory failure is a significant concern in neuromuscular diseases (NMDs). This CHEST guideline examines the literature on the respiratory management of patients with NMD to provide evidence-based recommendations.

STUDY DESIGN AND METHODS

An expert panel conducted a systematic review addressing the respiratory management of NMD and applied the Grading of Recommendations, Assessment, Development, and Evaluations approach for assessing the certainty of the evidence and formulating and grading recommendations. A modified Delphi technique was used to reach a consensus on the recommendations.

RESULTS

Based on 128 studies, the panel generated 15 graded recommendations, one good practice statement, and one consensus-based statement.

INTERPRETATION

Evidence of best practices for respiratory management in NMD is limited and is based primarily on observational data in amyotrophic lateral sclerosis. The panel found that pulmonary function testing every 6 months may be beneficial and may be used to initiate noninvasive ventilation (NIV) when clinically indicated. An individualized approach to NIV settings may benefit patients with chronic respiratory failure and sleep-disordered breathing related to NMD. When resources allow, polysomnography or overnight oximetry can help to guide the initiation of NIV. The panel provided guidelines for mouthpiece ventilation, transition to home mechanical ventilation, salivary secretion management, and airway clearance therapies. The guideline panel emphasizes that NMD pathologic characteristics represent a diverse group of disorders with differing rates of decline in lung function. The clinician's role is to add evaluation at the bedside to shared decision-making with patients and families, including respect for patient preferences and treatment goals, considerations of quality of life, and appropriate use of available resources in decision-making.

Does one size fit all? An update on chronic ventilatory support in different respiratory illnesses

Home noninvasive ventilation (HNIV) improves outcomes in different disease categories. In this article, we discuss indications for when and how to initiate HNIV in COPD, obesity hypoventilation syndrome (OHS) and neuromuscular disorders (NMD). While in COPD, significant diurnal hypercapnia and high-intensity HNIV are essential ingredients for success, in NMD and OHS, early respiratory changes are best detected during sleep through oxy-capnography associated (or not) with respiratory polygraphy. In COPD and OHS, it is crucial to consider the coexistence of obstructive sleep apnoea because treatment with continuous positive airway pressure may be the simplest and most effective treatment that should be proposed even in hypercapnic patients as first-line therapy. In NMD, the need for continuous HNIV and eventual switching to tracheostomy ventilation makes this group's management more challenging. Achieving successful HNIV by improving quality of sleep, quality of life and keeping a good adherence to the therapy is a challenge, above all in COPD patients. In OHS patients, on top of HNIV, initiation of other interventions such as weight loss management is crucial. More resources should be invested in improving all these aspects. Telemonitoring represents a promising method to improve titration and follow-up of HNIV.

Der Einsatz von Patient-reported Outcome Measures (PROM) und die Perspektive digitaler Biomarker bei der Amyotrophen Lateralsklerose

Die systematische Erfassung des klinischen Zustands sowie der Erfahrung mit Behandlung oder Versorgung durch einen strukturierten Bericht des Patienten wird als „Patient-reported Outcome Measures“ (PROM) bezeichnet. Bei der Amyotrophen Lateralsklerose (ALS) haben sich PROM insbesondere zur Dokumentation funktioneller Defizite, z. B. mit der ALS-Funktionsskala, und weiterer komplexer Symptome im Rahmen von klinischer Forschung etabliert. In der Behandlungspraxis werden PROM dazu genutzt, den Verlauf und die Prognose der Erkrankung einzuschätzen. Mit PROM werden neue biologische Biomarker (z. B. Neurofilamente) und digitale Biomarker (z. B. durch den Einsatz von Sensorik) auf ihre patientenzentrierte Relevanz evaluiert. Durch die digitale Anwendung von PROM und die Verknüpfung mit digitalen Biomarkern kann eine engmaschigere Erhebung von zu Hause aus erfolgen und damit die Datenqualität erhöht werden. Patienten können selbst den Gesundheitszustand monitorieren sowie Behandlungs- und Versorgungsergebnisse dokumentieren. Damit nehmen sie zunehmend eine aktive Rolle in der individuellen Behandlung und Versorgung ein.

Predictive parameters of early respiratory decline in Amyotrophic Lateral Sclerosis

BACKGROUND

Respiratory insufficiency is a common symptom during the course of Amyotrophic Lateral Sclerosis (ALS). The diagnostic workup may be challenging and includes a wide array of diagnostic measures. In this study, we aimed at analyzing the relationship between hypercapnia-associated symptoms, blood gas parameters, and pulmonary function tests.

METHODS

We included 109 patients (56 women, 53 men, 62.4 ± 11.9 years) with definite, possible or probable ALS according to El Escorial criteria. All patients received either arterial blood gas analysis, nocturnal capnometry, or both. Pulmonary function was assessed by spirometry and peak-cough flow. Clinical symptoms potentially indicating hypercapnia were assessed using 17 dichotomous (yes/no) items.

RESULTS

Of 109 ALS-patients, 40 had hypercapnia. The highest accuracy and specificity for predicting hypercapnia was observed for dyspnea at rest (Youden's index 17%; 95% CI 2%-34%; sensitivity 23%, 95% CI 9%-38%; specificity 95%; 95% CI 88%-100%). Daytime fatigue yielded the highest sensitivity of 58% (95% CI 40% - 76%). Logistic regression for all assessed symptoms combined yielded an area under the ROC of 0.8 (95% CI 0.7-0.9). Compared to the clinical symptoms, FVC and peak-cough flow showed higher sensitivity (70% and 87%, respectively) but lacked specificity (33% and 20%).

CONCLUSION

Evaluation of the presence of hypercapnic symptoms can be utilized to predict incipient respiratory insufficiency and should complement pulmonary function tests. Further studies are needed to validate specific questionnaires in this regard. No single hypercapnia-associated symptom or pulmonary function test on its own seems sufficient to safely predict hypercapnia.

Fatigue and anxiety mediate the effect of dyspnea on quality of life in amyotrophic lateral sclerosis

Introduction: Dyspnea (or breathlessness) due to progressive neuromuscular respiratory failure is common in amyotrophic lateral sclerosis (ALS). It is associated with anxiety, depression and reduced quality of life (QoL). For effective treatment, it is essential to understand the relationships between dyspnea, anxiety, depression and QoL.Methods: The UK Trajectories of Outcomes in Neurological Conditions-ALS study (TONiC-ALS) collected self-report measures from patients with ALS. Ordinal scales were transformed to interval-scaled estimates by the Rasch Measurement model. They were subsequently included in a series of path models where the focal relationships were dyspnea to QoL and dyspnea to depression.Results: Path analyses using 1022 participants showed that 60.5% of the variance of QoL was explained by fatigue, anxiety, dyspnea and disability. For depression, 54.1% of the variance was explained by a model of these factors. Dyspnea played an important but mostly indirect role in influencing QoL and depressive symptoms. Disability was dominated by all other factors in the model.Discussion: Dyspnea in ALS influences quality of life and depression largely through indirect effects, principally acting via anxiety and fatigue. Recognition of this is essential for clinicians to understand where to intervene for greatest benefit. Researchers must be aware that studies of the effect of dyspnea on QoL and depression require path models, measuring both direct and indirect effects, as the impact of dyspnea is likely to be significantly miscalculated if only direct effects are assessed.

[Amyotrophic lateral sclerosis and frontotemporal dementia-On the way to common gene-specific treatment approaches]

BACKGROUND

Amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) share common neuropathological features and in the case of a gene mutation, also a genetic cause. To date five ALS-FTD genes are described in the literature in addition to other rare variants.

OBJECTIVE

The current state of research on treatment options for ALS and FTD is presented and an outlook on possible gene-specific approaches for ALS-FTD is provided.

MATERIAL AND METHODS

Analysis of the progression of ALS and FTD research by considering the increasing state of knowledge on the underlying pathomechanisms of the diseases.

RESULTS

In addition to anti-inflammatory approaches and stabilization of protein folding, promising gene-specific treatment approaches are currently being developed, which target common causes of ALS and FTD and therefore have an effect on both diseases.

CONCLUSION

So far there are no causal treatment options for ALS and FTD. The increasing importance of genetic causes directs the focus to the development of gene-specific treatment.

Disorders of sleep and wakefulness in amyotrophic lateral sclerosis (ALS): a systematic review

Disorders of sleep and wakefulness are common among neurodegenerative diseases. While amyotrophic lateral sclerosis (ALS) predominately manifests as motor symptoms, there is emerging evidence that disruptions to sleep and wakefulness also occur. This systematic review aims to report the most common disorders of sleep and wakefulness in ALS. We conducted a qualitative systematic review as per PRISMA guidelines and searched literature assessing the association between disorders of sleep and wakefulness with ALS using the PubMed and Medline database. Overall, 50-63% of patients with ALS have poor sleep quality as reported using the Pittsburgh Sleep Quality Index Questionnaire (PSQI). A higher proportion of ALS patients are categorized as poor sleepers, however there is conflicting evidence as to whether patients with ALS are more likely to exhibit excessive daytime sleepiness. Of the studies that utilized polysomnography, all reported various degrees of impairment to sleep microstructure and architecture among ALS patients. In future, longitudinal clinical studies will be essential for establishing the significance of impaired sleep in ALS. Future studies are also needed to establish whether the self-reported measures of poor sleep and impairment to sleep architecture occurs as a direct consequence of the disease, whether they are an early manifestation of the disease, and/or if they contribute to the neurodegenerative process.

Sleep in chronic respiratory disease: COPD and hypoventilation disorders

COPD and obstructive sleep apnoea (OSA) are highly prevalent and different clinical COPD phenotypes that influence the likelihood of comorbid OSA. The increased lung volumes and low body mass index (BMI) associated with the predominant emphysema phenotype protects against OSA whereas the peripheral oedema and higher BMI often associated with the predominant chronic bronchitis phenotype promote OSA. The diagnosis of OSA in COPD patients requires clinical awareness and screening questionnaires which may help identify patients for overnight study. Management of OSA-COPD overlap patients differs from COPD alone and the survival of overlap patients treated with nocturnal positive airway pressure is superior to those untreated. Sleep-related hypoventilation is common in neuromuscular disease and skeletal disorders because of the effects of normal sleep on ventilation and additional challenges imposed by the underlying disorders. Hypoventilation is first seen during rapid eye movement (REM) sleep before progressing to involve non-REM sleep and wakefulness. Clinical presentation is nonspecific and daytime respiratory function measures poorly predict nocturnal hypoventilation. Monitoring of respiration and carbon dioxide levels during sleep should be incorporated in the evaluation of high-risk patient populations and treatment with noninvasive ventilation improves outcomes.