1
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Khamaysa M, Lefort M, Pélégrini-Issac M, Lackmy-Vallée A, Mendili MME, Preuilh A, Devos D, Bruneteau G, Salachas F, Lenglet T, Amador MM, Le Forestier N, Hesters A, Gonzalez J, Rolland AS, Desnuelle C, Chupin M, Querin G, Georges M, Morelot-Panzini C, Marchand-Pauvert V, Pradat PF. Quantitative brainstem and spinal MRI in amyotrophic lateral sclerosis: implications for predicting noninvasive ventilation needs. J Neurol 2024; 271:1235-1246. [PMID: 37910250 DOI: 10.1007/s00415-023-12045-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Respiratory complications resulting from motor neurons degeneration are the primary cause of death in amyotrophic lateral sclerosis (ALS). Predicting the need for non-invasive ventilation (NIV) in ALS is important for advance care planning and clinical trial design. The aim of this study was to assess the potential of quantitative MRI at the brainstem and spinal cord levels to predict the need for NIV during the first six months after diagnosis. METHODS Forty-one ALS patients underwent MRI and spirometry shortly after diagnosis. The need for NIV was monitored according to French health guidelines for 6 months. The performance of four regression models based on: clinical variables, brainstem structures volumes, cervical spinal measurements, and combined variables were compared to predict the need for NIV within this period. RESULTS Both the clinical model (R2 = 0.28, AUC = 0.85, AICc = 42.67, BIC = 49.8) and the brainstem structures' volumes model (R2 = 0.30, AUC = 0.85, AICc = 40.13, BIC = 46.99) demonstrated good predictive performance. In addition, cervical spinal cord measurements model similar performance (R2 = 0.338, AUC = 0.87, AICc = 37.99, BIC = 44.49). Notably, the combined model incorporating predictors from all three models yielded the best performance (R2 = 0.60, AUC = 0.959, AICc = 36.38, BIC = 44.8). These findings are supported by observed positive correlations between brainstem volumes, cervical (C4/C7) cross-sectional area, and spirometry-measured lung volumes. CONCLUSIONS Our study shows that brainstem volumes and spinal cord area are promising measures to predict respiratory intervention needs in ALS.
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Affiliation(s)
- M Khamaysa
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - M Lefort
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - M Pélégrini-Issac
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - A Lackmy-Vallée
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - M M El Mendili
- APHM, Hôpital Timone, CEMEREM, Marseille, France
- Aix Marseille Univ, CNRS, CRMBM, Marseille, France
| | - A Preuilh
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - D Devos
- Département de Neurologie, Centre Référent SLA, CHU de Lille, Centre LICEND COEN, ACT4-ALS-MND network, Lille, France
- Départment de Pharmacologie Médicale, Université de Lille, INSERM UMRS_1172 LilNCog, CHU de Lille, Centre LICEND COEN, ACT4-ALS-MND network, Lille, France
| | - G Bruneteau
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
| | - F Salachas
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
| | - T Lenglet
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
- Faculté de Médecine de Nice, Département de Neurologie, Université Cote d'Azur, Nice, France
- Département de Neurophysiologie, APHP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Md M Amador
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
| | - N Le Forestier
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
- Département de Recherche en Éthique, EA 1610: Etudes des Sciences et Techniques, Université Paris Sud/Paris Saclay, Paris, France
| | - A Hesters
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France
| | - J Gonzalez
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France
| | - A-S Rolland
- Départment de Pharmacologie Médicale, Université de Lille, INSERM UMRS_1172 LilNCog, CHU de Lille, Centre LICEND COEN, ACT4-ALS-MND network, Lille, France
| | - C Desnuelle
- Faculté de Médecine de Nice, Département de Neurologie, Université Cote d'Azur, Nice, France
| | - M Chupin
- CATI, Plateforme d'Imagerie Neurologique Multicentrique, Paris, France
| | - G Querin
- APHP, Service de Neuromyologie, Hôpital Pitié-Salpêtrière, Centre Référent Pour les Maladies Neuromusculaires Rares, Paris, France
- Institut de Myologie, Plateforme d'essais cliniques I-Motion, Hôpital Pitié-Salpêtrière, Paris, France
| | - M Georges
- Département des Maladies Respiratoires et Soins Intensifs, Centre de Référence pour les Maladies Pulmonaires Rares, Hôpital Universitaire de Dijon-Bourgogne, Dijon, France
- Université de Bourgogne Franche-Comté, Dijon, France
- Centre des Sciences du Goût et de l'Alimentation, UMR 6265 CNRS 1234 INRA, Université de Bourgogne Franche-Comté, Dijon, France
| | - C Morelot-Panzini
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France
- Service de Pneumologie (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - V Marchand-Pauvert
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - P-F Pradat
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France.
- APHP, Département de Neurologie, Hôpital Pitié-Salpêtrière, Centre Référent SLA, Paris, France.
- Northern Ireland Centre for Stratified Medicine, Biomedical Sciences Research Institute Ulster University, C-TRIC, Altnagelvin Hospital, Derry, Londonderry, UK.
- Institut pour la Recherche sur la Moelle Epinière et l'encephale (IRME), 15 rue Duranton, 75015, Paris, France.
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2
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Khan A, Frazer-Green L, Amin R, Wolfe L, Faulkner G, Casey K, Sharma G, Selim B, Zielinski D, Aboussouan LS, McKim D, Gay P. Respiratory Management of Patients With Neuromuscular Weakness: An American College of Chest Physicians Clinical Practice Guideline and Expert Panel Report. Chest 2023; 164:394-413. [PMID: 36921894 DOI: 10.1016/j.chest.2023.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023] Open
Abstract
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.
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Affiliation(s)
- Akram Khan
- Division of Pulmonary Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR.
| | | | - Reshma Amin
- Department of Respiratory Medicine, The Hospital for Sick Kids, Toronto
| | - Lisa Wolfe
- Department of Medicine, Northwestern University, Chicago, IL
| | | | - Kenneth Casey
- Department of Sleep Medicine, William S. Middleton Memorial Veterans Hospital, Shorewood Hills, WI
| | - Girish Sharma
- Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | - Bernardo Selim
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - David Zielinski
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | | | - Douglas McKim
- Department of Medicine, The Ottawa Hospital Research Institute, Ottawa, ON
| | - Peter Gay
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
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Melka D, Demisse H, Assefa H, Zenebe Y, A Ayele B, Awraris M, Gelan Y, Kifelew S, Fedlu M, Tsehayneh F, Zebenigus M, Alemayehu S, Tesfaye H, Gulelat H, Guta T, Tafesse A, Bekele N, Saez M, Veldink JH, Al-Chalabi A, Povedano M, Al Khleifat A. Epidemiological and clinical profile of amyotrophic lateral sclerosis in Ethiopia: a 5-year multicenter retrospective study. Amyotroph Lateral Scler Frontotemporal Degener 2023:1-9. [PMID: 37496277 DOI: 10.1080/21678421.2023.2238016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/28/2023]
Abstract
Background: Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease that results in progressive weakness of skeletal muscles including respiratory muscles. Epidemiological and clinical aspects of ALS are derived from a few world regions with very little representation of low- and middle-income countries. We therefore set out to determine the epidemiological and clinical phenotype of individuals with ALS in Ethiopia. Methods: Multicenter retrospective analysis was conducted using clinical records from ALS patients seen in Ethiopia at Tikur Anbessa Specialized Hospital and Yehuleshet specialty clinic between January 2016 and August 2021. The data collected included clinical characteristics, disease-related symptoms, a revised ALS functional rating scale, and medications. Results: Patients in Ethiopia had a younger age of onset with a mean age of disease onset of 51.9 years. 2.9% of patients had juvenile ALS, and the male-to-female ratio was almost 2:1. 4.9% had a positive family history of the disease. 68% of patients had spinal region involvement at onset, while 32% had bulbar region involvement at onset. Riluzole was used by 31% of ALS patients. 20.6% of patients had some respiratory symptoms, but none received a standard respiratory function assessment. 33.3% of patients were wheelchair-bound. Conclusion: In this retrospective study spanning 5 years, we examined the clinical phenotype of ALS in Ethiopian patients. Our findings suggest that most patients had clinically definite ALS with spinal region involvement. Further research, including genetic and epigenetic information, is necessary to understand the early onset of the disease in Ethiopia.
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Affiliation(s)
- Dereje Melka
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Hanna Demisse
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Hanna Assefa
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yared Zenebe
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Biniyam A Ayele
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Meron Awraris
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yohannese Gelan
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Selam Kifelew
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Medina Fedlu
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Fikiru Tsehayneh
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Mehila Zebenigus
- Department of Neurology, Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia
| | - Samson Alemayehu
- Department of Neurology, Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia
| | | | | | - Tsega Guta
- Yehuleshet Specialty Clinic, Addis Ababa, Ethiopia
| | - Abenet Tafesse
- Department of Neurology, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Nebiyu Bekele
- Department of Internal Medicine Neurology Unit, College of Health Science, University of Gondar, Gondar, Ethiopia
| | - Marc Saez
- Research Group on Statistics, Econometrics and Health (GRECS), University of Girona, Girona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública/Center for Biomedical Research in Epidemiology and Public Health Network (CIBERESP), Madrid, Spain
| | - Jan H Veldink
- Department of Neurology, UMC Utrecht Brain Center, Utrecht University, Utrecht, The Netherlands
| | - Ammar Al-Chalabi
- Department of Basic and Clinical, Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK, and
| | - Monica Povedano
- Department of Neurology, Bellvitge University Hospital, Barcelona, Spain
| | - Ahmad Al Khleifat
- Department of Basic and Clinical, Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK, and
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4
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Vianello A, Racca F, Vita GL, Pierucci P, Vita G. Motor neuron, peripheral nerve, and neuromuscular junction disorders. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:259-270. [PMID: 36031308 DOI: 10.1016/b978-0-323-91532-8.00014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In amyotrophic lateral sclerosis (ALS), Guillain-Barré syndrome (GBS), and neuromuscular junction disorders, three mechanisms may lead, singly or together, to respiratory emergencies and increase the disease burden and mortality: (i) reduced strength of diaphragm and accessory muscles; (ii) oropharyngeal dysfunction with possible aspiration of saliva/bronchial secretions/drink/food; and (iii) inefficient cough due to weakness of abdominal muscles. Breathing deficits may occur at onset or more often along the chronic course of the disease. Symptoms and signs are dyspnea on minor exertion, orthopnea, nocturnal awakenings, excessive daytime sleepiness, fatigue, morning headache, poor concentration, and difficulty in clearing bronchial secretions. The "20/30/40 rule" has been proposed to early identify GBS patients at risk for respiratory failure. The mechanical in-exsufflator is a device that assists ALS patients in clearing bronchial secretions. Noninvasive ventilation is a safe and helpful support, especially in ALS, but has some contraindications. Myasthenic crisis is a clinical challenge and is associated with substantial morbidity including prolonged mechanical ventilation and 5%-12% mortality. Emergency room physicians and consultant pulmonologists and neurologists must know such respiratory risks, be able to recognize early signs, and treat properly.
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Affiliation(s)
- Andrea Vianello
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Fabrizio Racca
- Department of Anaesthesiology and Intensive Care, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Gian Luca Vita
- Unit of Neurology, Emergency Department, P.O. Piemonte, IRCCS Centro Neurolesi "Bonino-Pulejo", Messina, Italy
| | - Paola Pierucci
- Cardiothoracic Department, Respiratory and Critical Care Unit, "Aldo Moro" Bari University School of Medicine, Bari, Italy
| | - Giuseppe Vita
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, Messina University Hospital, Messina, Italy.
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Abstract
Amyotrophic lateral sclerosis is a progressive neurodegenerative disease involving upper and lower motor neurons and has limited treatment options. The weakness progresses to involve the diaphragms, resulting in respiratory failure and death. Home noninvasive ventilation has been shown to improve survival and quality of life, especially in those with intact bulbar function. Once initiated, close monitoring with nocturnal oximetry, remote downloads from the home noninvasive ventilation machine, and measurement of serum bicarbonate should be conducted. Additionally, transcutaneous CO2 monitoring can be considered if available. This article discusses the indications, timing, initiation, and management of noninvasive ventilation in amyotrophic lateral sclerosis.
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Affiliation(s)
- Jessica A Cooksey
- Northwestern University, 1475 East Belvidere Road, Suite 185, Grayslake, IL 60030, USA
| | - Amen Sergew
- Division of Pulmonary, Critical Care and Sleep Medicine, Section of Critical Care Medicine, Department of Medicine, National Jewish Health, 1400 Jackson Street, B140, Denver, CO 80207, USA.
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6
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Spittel S, Maier A, Kettemann D, Walter B, Koch B, Krause K, Norden J, Münch C, Meyer T. Non-invasive and tracheostomy invasive ventilation in amyotrophic lateral sclerosis: Utilization and survival rates in a cohort study over 12 years in Germany. Eur J Neurol 2020; 28:1160-1171. [PMID: 33210770 DOI: 10.1111/ene.14647] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/29/2020] [Accepted: 11/08/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to investigate utilization rates, treatment pathways and survival prognosis in patients with amyotrophic lateral sclerosis (ALS) undergoing non-invasive (NIV) and tracheostomy invasive ventilation (TIV) in a real-world setting. METHODS A prospective cohort study using a single-centre register of 2702 ALS patients (2007 to 2019) was conducted. Utilization of NIV/TIV and survival data were analysed in three cohorts: (i) non-NIV; (ii) NIV (NIV without subsequent TIV); and (iii) TIV (including TIV preceded by NIV). RESULTS A total of 1720 patients with available data were identified, 72.0% of whom (n = 1238) did not receive ventilation therapy. NIV was performed in 20.8% of patients (n = 358). TIV was performed in 9.5% of patients (n = 164), encompassing both primary TIV (7.2%, n = 124) and TIV with preceding NIV (2.3%, n = 40). TIV was more often utilized without previous NIV (25.7% vs. 8.3% of all ventilated patients), demonstrating that primary TIV was the prevailing pathway for invasive ventilation. The median (range) survival was significantly longer in the NIV cohort (40.8 [37.2-44.3] months) and the TIV cohort (82.1 [68.7-95.6] months) as compared to the non-NIV cohort (33.6 [31.6-35.7] months). CONCLUSIONS Although NIV represents the standard of care, its utilization rate was low. TIV was mainly started without preceding NIV, suggesting that TIV may not be confined to NIV treatment escalation. However, TIV was pursued in a minority of patients who had previously undergone NIV. The survival benefit observed in the patients with NIV was equal to that reported in a controlled pivotal trial, but the prognosis with TIV is highly variable. The determinants of utilization of NIV/TIV and of survival (bulbar syndrome, availability of ventilation-related home nursing, cultural factors) warrant further investigation.
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Affiliation(s)
- Susanne Spittel
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
| | - André Maier
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dagmar Kettemann
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bertram Walter
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Birgit Koch
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kerstin Krause
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jenny Norden
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Münch
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
| | - Thomas Meyer
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
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7
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Lind LA, Andel EM, McCall AL, Dhindsa JS, Johnson KA, Stricklin OE, Mueller C, ElMallah MK, Lever TE, Nichols NL. Intralingual Administration of AAVrh10-miR SOD1 Improves Respiratory But Not Swallowing Function in a Superoxide Dismutase-1 Mouse Model of Amyotrophic Lateral Sclerosis. Hum Gene Ther 2020; 31:828-838. [PMID: 32498636 DOI: 10.1089/hum.2020.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal disease characterized by degeneration of motor neurons and muscles, and death is usually a result of impaired respiratory function due to loss of motor neurons that control upper airway muscles and/or the diaphragm. Currently, no cure for ALS exists and treatments to date do not significantly improve respiratory or swallowing function. One cause of ALS is a mutation in the superoxide dismutase-1 (SOD1) gene; thus, reducing expression of the mutated gene may slow the progression of the disease. Our group has been studying the SOD1G93A transgenic mouse model of ALS that develops progressive respiratory deficits and dysphagia. We hypothesize that solely treating the tongue in SOD1 mice will preserve respiratory and swallowing function, and it will prolong survival. At 6 weeks of age, 11 SOD1G93A mice (both sexes) received a single intralingual injection of gene therapy (AAVrh10-miRSOD1). Another 29 mice (both sexes) were divided into two control groups: (1) 12 SOD1G93A mice that received a single intralingual vehicle injection (saline); and (2) 17 non-transgenic littermates. Starting at 13 weeks of age, plethysmography (respiratory parameters) at baseline and in response to hypoxia (11% O2) + hypercapnia (7% CO2) were recorded and videofluoroscopic swallow study testing were performed twice monthly until end-stage disease. Minute ventilation during hypoxia + hypercapnia and mean inspiratory flow at baseline were significantly reduced (p < 0.05) in vehicle-injected, but not AAVrh10-miRSOD1-injected SOD1G93A mice as compared with wild-type mice. In contrast, swallowing function was unchanged by AAVrh10-miRSOD1 treatment (p > 0.05). AAVrh10-miRSOD1 injections also significantly extended survival in females by ∼1 week. In conclusion, this study indicates that intralingual AAVrh10-miRSOD1 treatment preserved respiratory (but not swallowing) function potentially via increasing upper airway patency, and it is worthy of further exploration as a possible therapy to preserve respiratory capacity in ALS patients.
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Affiliation(s)
- Lori A Lind
- Department of Biomedical Sciences, University of Missouri, Columbia, Missouri, USA
| | - Ellyn M Andel
- Department of Otolaryngology, University of Missouri, Columbia, Missouri, USA
| | - Angela L McCall
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Justin S Dhindsa
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Katherine A Johnson
- Department of Biomedical Sciences, University of Missouri, Columbia, Missouri, USA
| | - Olivia E Stricklin
- Department of Biomedical Sciences, University of Missouri, Columbia, Missouri, USA
| | - Christian Mueller
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, Massachusetts, USA.,Department of Pediatrics, University of Massachusetts Medical School, Worcester Massachusetts, USA
| | - Mai K ElMallah
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - Teresa E Lever
- Department of Biomedical Sciences, University of Missouri, Columbia, Missouri, USA.,Department of Otolaryngology, University of Missouri, Columbia, Missouri, USA
| | - Nicole L Nichols
- Department of Biomedical Sciences, University of Missouri, Columbia, Missouri, USA.,Dalton Cardiovascular Research Center, University of Missouri, Columbia, Missouri, USA
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8
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Keeler AM, Zieger M, Semple C, Pucci L, Veinbachs A, Brown RH, Mueller C, ElMallah MK. Intralingual and Intrapleural AAV Gene Therapy Prolongs Survival in a SOD1 ALS Mouse Model. Mol Ther Methods Clin Dev 2020; 17:246-257. [PMID: 31970202 PMCID: PMC6962641 DOI: 10.1016/j.omtm.2019.12.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 12/13/2019] [Indexed: 02/07/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease that results in death from respiratory failure. No cure exists for this devastating disease, but therapy that directly targets the respiratory system has the potential to prolong survival and improve quality of life in some cases of ALS. The objective of this study was to enhance breathing and prolong survival by suppressing superoxide dismutase 1 (SOD1) expression in respiratory motor neurons using adeno-associated virus (AAV) expressing an artificial microRNA targeting the SOD1 gene. AAV-miRSOD1 was injected in the tongue and intrapleural space of SOD1G93A mice, and repetitive respiratory and behavioral measurements were performed until the end stage. Robust silencing of SOD1 was observed in the diaphragm and tongue as well as systemically. Silencing of SOD1 prolonged survival by approximately 50 days, and it delayed weight loss and limb weakness in treated animals compared to untreated controls. Histologically, there was preservation of the neuromuscular junctions in the diaphragm as well as the number of axons in the phrenic and hypoglossal nerves. Although SOD1 suppression improved breathing and prolonged survival, it did not ameliorate the restrictive lung phenotype. Suppression of SOD1 expression in motor neurons that underlie respiratory function prolongs survival and enhances breathing until the end stage in SOD1G93A ALS mice.
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Affiliation(s)
- Allison M. Keeler
- Division of Pulmonary Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA 01655, USA
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Marina Zieger
- Division of Pulmonary Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA 01655, USA
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Carson Semple
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Logan Pucci
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
| | - Alessandra Veinbachs
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Robert H. Brown
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA 01655, USA
- Department of Neurology, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Christian Mueller
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA 01655, USA
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA 01655, USA
| | - Mai K. ElMallah
- Division of Pulmonary Medicine, University of Massachusetts Medical School, Worcester, MA 01655, USA
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA 01655, USA
- Horae Gene Therapy Center, University of Massachusetts Medical School, Worcester, MA 01655, USA
- Department of Pediatrics, Duke University, Durham, NC 27710, USA
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9
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Pirola A, De Mattia E, Lizio A, Sannicolò G, Carraro E, Rao F, Sansone V, Lunetta C. The prognostic value of spirometric tests in Amyotrophic Lateral Sclerosis patients. Clin Neurol Neurosurg 2019; 184:105456. [PMID: 31382080 DOI: 10.1016/j.clineuro.2019.105456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/24/2019] [Accepted: 07/28/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Amyotrophic lateral sclerosis (ALS) patients tend to develop progressive respiratory muscle weakness, leading to ventilatory failure and ineffective cough, principal causes of morbidity and mortality. Since patients are usually unaware of these symptoms, these are generally not noticed until the advanced stages and are associated with poor prognosis. The monitoring of respiratory function on a regular basis is therefore of great importance. Despite the availability of several pulmonary function tests, none of them was found to be the best indicator of the disease progression throughout the course of this condition. The main aim of our work was to evaluate the prognostic value of these respiratory measures evaluated in a brief period of observation and their correlation with motor functional impairments in an ALS cohort. PATIENTS AND METHODS Patients with ALS who had respiratory assessments performed and functional motor scales administered at baseline and six months later were included. All patients were assessed with forced vital capacity, both in seated and supine position (FVC; sFVC), peak expiratory flow (PEF), peak expiratory cough flow (PCEF), the revised ALS functional rating scale (ALSFRS-R), at baseline and after six months, and their disease progression rate (ΔFS) was obtained. RESULTS We included 73 patients with probable or definite ALS according to El-Escorial revised Criteria. At baseline, PCEF and PEF significantly correlated with ALSFRS-R total, bulbar and spinal subscores and ΔFS, while FVC% significantly correlated with ΔFS. After 6 months all the respiratory parameters significantly correlated with ALSFRS-R and all its subscores. Longitudinally, FVC%, sFVC% and PCEF significantly correlated with ΔFS and some of ALSFRS-R subscores. As concerns the survival analysis, monthly declines of FVC% and sFVC%, significantly correlated with the survival. The worse prognosis in terms of survival was finally found in those whose FVC% and sFVC% dropped below their respective cut-offs. CONCLUSION Throughout the course of ALS disease, the monitoring of several respiratory markers, namely FVC, sFVC, PEF and PCEF, plays a critical role in predicting the prognosis of these subjects, both in terms of survival and functional ability. The implementation of monthly cut-offs in the evaluation of FVC and sFVC may allow a faster recognition of those patients with worse prognosis and therefore an optimized tailored clinical care, as well as a better stratification in clinical trials.
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Affiliation(s)
- Alice Pirola
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy.
| | - Elisa De Mattia
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy
| | - Andrea Lizio
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy
| | | | - Elena Carraro
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy
| | - Fabrizio Rao
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy
| | - Valeria Sansone
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy; Neurorehabilitation Unit, Dept. Biomedical Sciences of Health, University of Milan, Italy
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10
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Vogt S, Schreiber S, Kollewe K, Körner S, Heinze HJ, Dengler R, Petri S, Vielhaber S. Dyspnea in amyotrophic lateral sclerosis: The Dyspnea-ALS-Scale (DALS-15) essentially contributes to the diagnosis of respiratory impairment. Respir Med 2019; 154:116-121. [PMID: 31234039 DOI: 10.1016/j.rmed.2019.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/29/2019] [Accepted: 06/12/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Dyspnea is a cardinal but often underestimated symptom in amyotrophic lateral sclerosis (ALS). The newly developed Dyspnea-ALS-Scale (DALS-15) is highly relevant for therapeutic decisions because dyspnea is a separate criterion to consider noninvasive ventilation (NIV) in ALS. In comparison to the limited effects of neuroprotective compounds, NIV has the greatest impact on survival and improves quality of life. OBJECTIVE To investigate whether dyspnea corresponds to parameters of respiratory status mainly used in clinical neurological practice. We also investigated if the DALS-15 could help identify patients for consideration of NIV in whom neither spirometry nor blood gas parameters indicate the need for NIV (forced vital capacity (FVC) < 50% or probable <75%, pCO2 ≥45 mmHg). METHODS Seventy ALS patients with dyspnea according to the DALS-15 obtained blood gas analysis and spirometry (FVC in sitting and supine positions). The supine decline in FVC was calculated. RESULTS There was no linear relationship between dyspnea and spirometry as well as blood gases. 83% of our patients had an upright FVC still greater than 50% and no daytime hypercapnia. CONCLUSIONS Our study clearly shows that dyspnea can occur independently of objective indicators of respiratory impairment like spirometry or blood gases. Hence, the DALS-15 covers another aspect of respiratory impairment than these tests and refers to the subjective component of respiratory impairment. It detects dyspnea in a considerable proportion of patients in whom NIV should thus be considered although their spirometric and blood gas results do not point towards NIV. The DALS-15 therefore may help to improve the stratification of patients with respiratory impairment for more efficient symptom management and timely coordination of care.
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Affiliation(s)
- S Vogt
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany.
| | - S Schreiber
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - K Kollewe
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - S Körner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - H-J Heinze
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany; German Center for Neurodegenerative Diseases, Magdeburg, Germany; Leibniz Institute for Neurobiology, Magdeburg, Germany
| | - R Dengler
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - S Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - S Vielhaber
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany; German Center for Neurodegenerative Diseases, Magdeburg, Germany
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Chipika RH, Finegan E, Li Hi Shing S, Hardiman O, Bede P. Tracking a Fast-Moving Disease: Longitudinal Markers, Monitoring, and Clinical Trial Endpoints in ALS. Front Neurol 2019; 10:229. [PMID: 30941088 PMCID: PMC6433752 DOI: 10.3389/fneur.2019.00229] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/22/2019] [Indexed: 12/13/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) encompasses a heterogeneous group of phenotypes with different progression rates, varying degree of extra-motor involvement and divergent progression patterns. The natural history of ALS is increasingly evaluated by large, multi-time point longitudinal studies, many of which now incorporate presymptomatic and post-mortem assessments. These studies not only have the potential to characterize patterns of anatomical propagation, molecular mechanisms of disease spread, but also to identify pragmatic monitoring markers. Sensitive markers of progressive neurodegenerative change are indispensable for clinical trials and individualized patient care. Biofluid markers, neuroimaging indices, electrophysiological markers, rating scales, questionnaires, and other disease-specific instruments have divergent sensitivity profiles. The discussion of candidate monitoring markers in ALS has a dual academic and clinical relevance, and is particularly timely given the increasing number of pharmacological trials. The objective of this paper is to provide a comprehensive and critical review of longitudinal studies in ALS, focusing on the sensitivity profile of established and emerging monitoring markers.
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Affiliation(s)
| | - Eoin Finegan
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Stacey Li Hi Shing
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Orla Hardiman
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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12
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Crimi C, Pierucci P, Carlucci A, Cortegiani A, Gregoretti C. Long-Term Ventilation in Neuromuscular Patients: Review of Concerns, Beliefs, and Ethical Dilemmas. Respiration 2019; 97:185-196. [PMID: 30677752 DOI: 10.1159/000495941] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/03/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Noninvasive mechanical ventilation (NIV) is an effective treatment in patients with neuromuscular diseases (NMD) to improve symptoms, quality of life, and survival. SUMMARY NIV should be used early in the course of respiratory muscle involvement in NMD patients and its requirements may increase over time. Therefore, training on technical equipment at home and advice on problem solving are warranted. Remote monitoring of ventilator parameters using built-in ventilator software is recommended. Telemedicine may be helpful in reducing hospital admissions. Anticipatory planning and palliative care should be carried out to lessen the burden of care, to maintain or withdraw from NIV, and to guarantee the most respectful management in the last days of NMD patients' life. Key Message: Long-term NIV is effective but challenging in NMD patients. Efforts should be made by health care providers in arranging a planned transition to home and end-of-life discussions for ventilator-assisted individuals and their families.
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Affiliation(s)
- Claudia Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Paola Pierucci
- Cardiothoracic Department, Respiratory and Sleep Medicine Unit, Policlinico University Hospital, Bari, Italy
| | - Annalisa Carlucci
- Respiratory Intensive Care Unit, Pulmonary Rehabilitation Unit, IRCCS Fondazione S. Maugeri, Pavia, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy,
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
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13
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Jackson C, De Carvalho M, Genge A, Heiman-Patterson T, Shefner JM, Wei J, Wolff AA. Relationships between slow vital capacity and measures of respiratory function on the ALSFRS-R. Amyotroph Lateral Scler Frontotemporal Degener 2018; 19:506-512. [DOI: 10.1080/21678421.2018.1497658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Mamede De Carvalho
- Faculty of Medicine, IMM, University of Lisbon, Department of Neurosciences-CHLN, Lisbon, Portugal
| | - Angela Genge
- Montreal Neurological Institute, Montreal, QC, Canada,
| | | | - Jeremy M. Shefner
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA, and
| | - Jenny Wei
- Cytokinetics, Inc., South San Francisco, CA, USA
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14
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Heiman-Patterson TD, Cudkowicz ME, De Carvalho M, Genge A, Hardiman O, Jackson CE, Lechtzin N, Mitsumoto H, Silani V, Andrews JA, Chen D, Kulke S, Rudnicki SA, van den Berg LH. Understanding the use of NIV in ALS: results of an international ALS specialist survey. Amyotroph Lateral Scler Frontotemporal Degener 2018; 19:331-341. [DOI: 10.1080/21678421.2018.1457058] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | | | - Mamede De Carvalho
- Faculty of Medicine, IMM, University of Lisbon, Department of Neurosciences-CHLN, Lisbon, Portugal,
| | - Angela Genge
- Montreal Neurological Institute, Montreal, QC, Canada,
| | - Orla Hardiman
- Trinity Biomedical Sciences Institute, Trinity College, Dublin, Ireland,
| | | | - Noah Lechtzin
- Johns Hopkins University School of Medicine, Baltimore, MD, USA,
| | - Hiroshi Mitsumoto
- Eleanor and Lou Gehrig ALS Center, The Neurological Institute Columbia University, New York, NY, USA,
| | - Vincenzo Silani
- Department of Neurology-Stroke Unit and Laboratory of Neuroscience, Department of Pathophysiology and Transplantation, “Dino Ferrari” Center, Università degli Studi di Milano - IRCCS Istituto Auxologico Italiano, Milan, Italy,
| | | | - Dafeng Chen
- Cytokinetics, Inc., South San Francisco, CA, USA,
| | - Sarah Kulke
- Cytokinetics, Inc., South San Francisco, CA, USA,
| | | | - Leonard H. van den Berg
- Department of Neurology, Brain Centre Rudolf Magnus, University Medical Centre Utrecht, Utrecht, The Netherlands
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15
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Lechtzin N, Cudkowicz ME, de Carvalho M, Genge A, Hardiman O, Mitsumoto H, Mora JS, Shefner J, Van den Berg LH, Andrews JA. Respiratory measures in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2018; 19:321-330. [PMID: 29566571 DOI: 10.1080/21678421.2018.1452945] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease that causes skeletal muscle weakness, including muscles involved with respiration. Death often results from respiratory failure within 3-5 years. Monitoring respiratory status is therefore critical to ALS management, as respiratory/pulmonary function tests (PFTs) are used to make decisions including when to initiate noninvasive ventilation. Understanding the different respiratory and PFTs as they relate to disease progression and survival may help determine which tests are most suitable. METHODS This review describes the tests used to assess respiratory muscle and pulmonary function in patients with ALS and the correlations between different respiratory measures and clinical outcomes measures. RESULTS The most commonly used measurement, forced vital capacity (VC), has been shown to correlate with clinical milestones including survival, but also requires good motor coordination and facial strength to form a tight seal around a mouthpiece. Other tests such as slow VC, sniff inspiratory pressure, or transdiaphragmatic pressure with magnetic stimulation are also associated with distinct advantages and disadvantages. CONCLUSIONS Therefore, how and when to use different tests remains unclear. Understanding how each test relates to disease progression and survival may help determine which is best suited for specific clinical decisions.
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Affiliation(s)
- Noah Lechtzin
- a Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | | | - Mamede de Carvalho
- c Faculty of Medicine, IMM, University of Lisbon , Department of Neurosciences-CHLN , Lisbon , Portugal
| | - Angela Genge
- d Montreal Neurological Institute , Montreal , Canada
| | - Orla Hardiman
- e Trinity Biomedical Sciences Institute, Trinity College , Dublin , Ireland
| | - Hiroshi Mitsumoto
- f Eleanor and Lou Gehrig ALS Center, The Neurological Institute, Columbia University , New York , NY , USA
| | - Jesus S Mora
- g Unidad de ELA-Hospital Universitario La Paz-Hospital Carlos III , Madrid , Spain
| | - Jeremy Shefner
- h Department of Neurology , Barrow Neurological Institute , Phoenix , AZ , USA
| | - Leonard H Van den Berg
- i Department of Neurology , Brain Centre Rudolf Magnus, University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Jinsy A Andrews
- f Eleanor and Lou Gehrig ALS Center, The Neurological Institute, Columbia University , New York , NY , USA
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16
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Yates E, Rafiq MK. Prognostic factors for survival in patients with amyotrophic lateral sclerosis: analysis of a multi-centre clinical trial. J Clin Neurosci 2016; 32:51-6. [PMID: 27401224 DOI: 10.1016/j.jocn.2015.12.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 12/11/2015] [Accepted: 12/27/2015] [Indexed: 12/13/2022]
Abstract
Information regarding factors influencing prognosis and quality of life (QoL) in patients with amyotrophic lateral sclerosis (ALS) is useful for clinicians and also for patients and their carers. The aims of this study are to identify prognostic factors for survival in ALS and to determine the physical factors influencing QoL. This study is a retrospective analysis of a cohort of 512 patients who participated in a phase II/III clinical trial of olesoxime. Cox multivariate regression analysis found older age, bulbar onset disease, low baseline forced vital capacity, low baseline manual muscle test (MMT) scores and a shorter diagnostic delay to be independently associated with poor survival outcome. Physical factors shown to have the strongest correlation with poor QoL were low weight and a reduced ability to climb stairs. Therapeutic interventions including gastrostomy and non-invasive ventilation had no positive impact on QoL in this cohort. The prognostic factors for survival identified here are consistent with other studies of ALS patients, with the additional identification of baseline MMT score as another predictor of prognosis. Furthermore, the correlation between both weight and poor lower limb function with QoL is novel and underlines the importance of careful nutritional management in this hypercatabolic condition.
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Affiliation(s)
- Emma Yates
- From the Academic Neurology Unit, Sheffield Institute for Translational Neuroscience (SITraN), 385A Glossop Road, University of Sheffield, Sheffield S10 2HQ, UK
| | - Muhammad K Rafiq
- From the Academic Neurology Unit, Sheffield Institute for Translational Neuroscience (SITraN), 385A Glossop Road, University of Sheffield, Sheffield S10 2HQ, UK.
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17
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Berlowitz DJ, Howard ME, Fiore JF, Vander Hoorn S, O'Donoghue FJ, Westlake J, Smith A, Beer F, Mathers S, Talman P. Identifying who will benefit from non-invasive ventilation in amyotrophic lateral sclerosis/motor neurone disease in a clinical cohort. J Neurol Neurosurg Psychiatry 2016; 87:280-6. [PMID: 25857659 DOI: 10.1136/jnnp-2014-310055] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 03/18/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Respiratory failure is associated with significant morbidity and is the predominant cause of death in motor neurone disease/amyotrophic lateral sclerosis (MND/ALS). This study aimed to determine the effect of non-invasive ventilatory (NIV) support on survival and pulmonary function decline across MND/ALS phenotypes. METHODS Cohort recruited via a specialist, multidisciplinary clinic. Patients were categorised into four clinical phenotypes (ALS, flail arm, flail leg and primary lateral sclerosis) according to site of presenting symptom and the pattern of upper versus lower motor neurone involvement. NIV was initiated according to current consensus practice guidelines. RESULTS Between 1991 and 2011, 1198 patients diagnosed with ALS/MND were registered. 929 patients (77.5%) fulfilled the selection criteria and their data were analysed. Median tracheostomy free survival from symptom onset was 28 months in NIV-treated patients compared to 15 months in untreated (Univariate Cox regression HR=0.61 (0.51 to 0.73), p<0.001). The positive survival effect of NIV persisted when the model was adjusted for age, gender, riluzole and percutaneous endoscopic gastrostomy use (HR=0.72 (0.60 to 0.88, p=0.001). In contrast with the only randomised controlled trial, NIV statistically significantly increased survival by 19 months in those with ALS-bulbar onset (Univariate HR=0.50 (0.36 to 0.70), multivariate HR=0.59 (0.41 to 0.83)). These data confirm that NIV improves survival in MND/ALS. The overall magnitude of benefit is 13 months and was largest in those with ALS-bulbar disease. Future research should explore the optimal timing of NIV initiation within phenotypes in order to optimise respiratory function, quality of life and survival.
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Affiliation(s)
- David J Berlowitz
- Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Mark E Howard
- Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Julio F Fiore
- Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Stephen Vander Hoorn
- Statistical Consulting Centre, The University of Melbourne, Melbourne, Victoria, Australia
| | - Fergal J O'Donoghue
- Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Justine Westlake
- Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Anna Smith
- Neurology Unit, Calvary Health Care, Bethlehem Hospital, Caulfield, Victoria, Australia
| | - Fiona Beer
- Institute for Breathing and Sleep, Bowen Centre, Austin Hospital, Heidelberg, Victoria, Australia
| | - Susan Mathers
- Neurology Unit, Calvary Health Care, Bethlehem Hospital, Caulfield, Victoria, Australia
| | - Paul Talman
- Neurology Unit, Calvary Health Care, Bethlehem Hospital, Caulfield, Victoria, Australia
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18
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Proudfoot M, Jones A, Talbot K, Al-Chalabi A, Turner MR. The ALSFRS as an outcome measure in therapeutic trials and its relationship to symptom onset. Amyotroph Lateral Scler Frontotemporal Degener 2016; 17:414-25. [PMID: 26864085 PMCID: PMC4950444 DOI: 10.3109/21678421.2016.1140786] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The reduction in ALS Functional Rating Score (ALSFRS) from reported symptom onset to diagnosis is used to estimate rate of disease progression. ALSFRS decline may be non-linear or distorted by drop-outs in therapeutic trials, reducing the reliability of change in slope as an outcome measure. The PRO-ACT database uniquely allows such measures to be explored using historical data from negative therapeutic trials. The decline of functional scores was analysed in 18 pooled trials, comparing rates of decline based on symptom onset with rates calculated between interval assessments. Strategies to mitigate the effects of trial drop-out were considered. Results showed that progression rate calculated by symptom onset underestimated the subsequent rate of disability accumulation, although it predicted survival more accurately than four-month interval estimates of δALSFRS or δFVC. Individual ALSFRS and FVC progression within a typical trial duration were linear. No simple solution to correct for trial drop-out was identified, but imputation using δALSFRS appeared least disruptive. In conclusion, there is a trade-off between the drive to recruit trial participants soon after symptom onset, and reduced reliability of the ALSFRS-derived progression rate at enrolment. The need for objective markers of disease activity as an alternative to survival-based end-points is clear and pressing.
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Affiliation(s)
- Malcolm Proudfoot
- a Nuffield Department of Clinical Neuroscience , University of Oxford and
| | - Ashley Jones
- b Department of Clinical Neuroscience , Institute of Psychiatry, King's College London , London SE5 8AF , UK
| | - Kevin Talbot
- a Nuffield Department of Clinical Neuroscience , University of Oxford and
| | - Ammar Al-Chalabi
- b Department of Clinical Neuroscience , Institute of Psychiatry, King's College London , London SE5 8AF , UK
| | - Martin R Turner
- a Nuffield Department of Clinical Neuroscience , University of Oxford and
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Leonardis L, Blagus R, Dolenc Groselj L. Sleep and breathing disorders in myotonic dystrophy type 2. Acta Neurol Scand 2015; 132:42-8. [PMID: 25496235 DOI: 10.1111/ane.12355] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVES In patients who exhibit myotonic dystrophy type 1 (DM1), sleep disorders and breathing impairments are common; however, in those with DM type 2 (DM2), limited studies on polysomnography (PSG) and none on phrenic compound motor action potential (CMAP) have been performed, which is the aim of this study. MATERIALS AND METHODS Sixteen patients with DM2 were questioned about respiratory symptoms. They underwent PSG with morning arterial gas analyses (AGA). Respiratory functions and phrenic CMAPs were studied. The data were compared to those of 16 healthy controls and 25 patients with DM1. RESULTS Daytime tiredness is the most common symptom, but orthopnea was reported in 13% of patients with DM2. A detailed sleep architecture analysis revealed a significantly greater proportion of time in stage 3 and REM sleep, and a shorter time in stage 2 in the DM2 than in controls. Lower respiratory volumes and pressures, abnormalities in AGA, night oxygen desaturation and higher EtCO2 are present in DM2, but are less pronounced than in the DM1 population. Small CMAP amplitudes were presented in 12% of patients with DM2, correlating with smaller respiratory functions and poorer sleep quality. AHI was abnormal in 38% of DM2, mainly due to obstructive apneas. PSG did not reveal hypoventilation. CONCLUSIONS Diaphragm weakness and sleep apneas might be present in patients with DM2; therefore, we suggest regular questioning about symptoms of respiratory insufficiency and monitoring of phrenic CMAP. PSG should be recorded, when patients have suggestive symptoms, abnormalities in AGA or higher BMI.
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Affiliation(s)
- L. Leonardis
- Institute of Clinical Neurophysiology; University Medical Center Ljubljana; Ljubljana Slovenia
| | - R. Blagus
- Medical Faculty; Institute for Biostatistics and Medical Informatics; Ljubljana Slovenia
| | - L. Dolenc Groselj
- Institute of Clinical Neurophysiology; University Medical Center Ljubljana; Ljubljana Slovenia
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Georges M, Morélot-Panzini C, Similowski T, Gonzalez-Bermejo J. Noninvasive ventilation reduces energy expenditure in amyotrophic lateral sclerosis. BMC Pulm Med 2014; 14:17. [PMID: 24507664 PMCID: PMC3922008 DOI: 10.1186/1471-2466-14-17] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 02/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) leads to chronic respiratory failure. Diaphragmatic dysfunction, a major driver of dyspnea and mortality, is associated with a shift of the burden of ventilation to extradiaphragmatic inspiratory muscles, including neck muscles. Besides, energy expenditure is often abnormally high in ALS, and this is associated with a negative prognostic value. We hypothesized that noninvasive ventilation (NIV) would relieve inspiratory neck muscles and reduce resting energy expenditure (REE). METHODS Using indirect calorimetry, we measured REE during spontaneous breathing (REESB) and NIV (REENIV) in 16 ALS patients with diaphragmatic dysfunction, during the first 3 months of NIV. Measured values were compared with predicted REE (REEpred)(Harris-Benedict equation). RESULTS NIV abolished inspiratory neck muscle activity. Even though our patients were not hypermetabolic, on the contrary, with a REESB that was lower than REEpred (average 11%), NIV did reduce energy expenditure. Indeed, median REENIV, in this population with a mean body mass index of 21.4 kg.m-2, was 1149 kcal/24 h [interquartile 970-1309], lower than REESB (1197 kcal/24 h, 1054-1402; mean difference 7%; p = 0.03, Wilcoxon). REESB and REENIV were correlated with forced vital capacity and maximal inspiratory pressure. CONCLUSIONS NIV can reduce energy expenditure in ALS patients probably by alleviating the ventilatory burden imposed on inspiratory neck muscles to compensate diaphragm weakness. It remains to be elucidated whether or not, in which population, and to what extent, NIV can be beneficial in ALS through the corresponding reduction in energy expenditure.
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Affiliation(s)
| | | | | | - Jesus Gonzalez-Bermejo
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 "Neurophysiologie Respiratoire Expérimentale et Clinique", F-75005 Paris, France.
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Leonardis L, Dolenc Grošelj L. Non-invasive positive-pressure ventilation in patients with amyotrophic lateral sclerosis: spinal versus bulbar form. Eur J Neurol 2013; 20:e66. [DOI: 10.1111/ene.12105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 12/19/2012] [Indexed: 11/27/2022]
Affiliation(s)
- L. Leonardis
- Institute of Clinical Neurophysiology; University Medical Center Ljubljana; Ljubljana; Slovenia
| | - L. Dolenc Grošelj
- Institute of Clinical Neurophysiology; University Medical Center Ljubljana; Ljubljana; Slovenia
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Esquinas Rodriguez AM, Paladini L, Vianello A. Respiratory function deterioration and the effect of non-invasive mechanical ventilation in amyotrophic lateral sclerosis: the crucial importance of bulbar muscle involvement. Eur J Neurol 2013; 20:e65. [PMID: 23577607 DOI: 10.1111/ene.12106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Accepted: 11/21/2012] [Indexed: 12/14/2022]
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Raaphorst J, Tuijp J, Verweij L, Westermann EJA, van der Kooi AJ, Gaytant MA, van den Berg LH, de Visser M, Kampelmacher MJ. Treatment of respiratory impairment in patients with motor neuron disease in the Netherlands: patient preference and timing of referral. Eur J Neurol 2013; 20:1524-30. [PMID: 23398243 DOI: 10.1111/ene.12096] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Accepted: 12/11/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE We assessed the first evaluation at a large ventilation clinic in the Netherlands to: (i) determine what proportion of patients with motor neuron disease would benefit from earlier referral; and (ii) examine the patient preferences regarding ventilatory support. METHODS Observational study at a single centre with a catchment area of 7.6 million inhabitants. Data on disease status, the referral process and patients' preferences regarding ventilatory support were collected during the first home ventilation services (HVS) assessment and analysed for correlation with the presence of daytime hypercapnia and suspected nocturnal hypoventilation. The latter conditions require immediate (within 48 h) or subacute (within 3 weeks) initiation of ventilatory support. RESULTS Vital capacity (in percentage of predicted value, VC%pred) was assessed by referring physicians in 84% of the 217 referred patients; the mean VC%pred was 69% (SD 16). One-hundred and ninety-one patients attended the first HVS assessment without ventilatory support, at a median of 21 days following referral: 18% had respiratory failure (daytime hypercapnia), 19% had normocapnia but were suspected of nocturnal hypoventilation, and 63% had normocapnia without symptoms. Following the HVS assessment, 25 patients (13%) declined home mechanical ventilation; this occurred more often in patients with (14/70) compared with patients without respiratory impairment (11/121; P < 0.05). CONCLUSION A meaningful proportion of patients who desire ventilatory support are referred to a ventilation clinic after already developing respiratory failure. Future studies could examine means, including more sensitive respiratory measures, to detect those patients who could benefit from earlier referral.
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Affiliation(s)
- J Raaphorst
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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