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Borghero G, Pierri V, Pili F, Muroni A, Ercoli T, Pateri MI, Pilotto S, Maccabeo A, Chiò A, Defazio G. Percutaneous gastrostomy, mechanical ventilation and survival in amyotrophic lateral sclerosis: an observational study in an incident cohort. Amyotroph Lateral Scler Frontotemporal Degener 2024; 25:563-569. [PMID: 38747354 DOI: 10.1080/21678421.2024.2351185] [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: 01/16/2024] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVE To analyze disease-modifying effects of percutaneous endoscopic gastrostomy (PEG) insertion for supporting nutrition, noninvasive ventilation (NIV), and tracheostomy-assisted ('invasive') ventilation (TIV) in amyotrophic lateral sclerosis (ALS). METHODS We retrospectively analyzed survival in a large population-based incident cohort that was prospectively followed up in our center. Analysis considered several known ALS-related prognostic variables. RESULTS In this population, PEG and NIV in multivariable analysis significantly correlated to survival as computed by disease onset to death/tracheostomy. NIV was associated with better survival while PEG was associated with reduced survival. Other independent prognostic factors were age at ALS onset, diagnostic delay, and flail arm/leg and pure upper motor neuron (PUMN) phenotypes. The length of survival after TIV was significantly associated with age at ALS onset (inverse correlation) whereas other variables did not. The length of survival after TIV correlated to age at ALS onset in such a way that each additional year of age at ALS onset decreased survival by about 0.7 months. Patients who underwent both TIV and NIV did not experience a better survival than those who underwent TIV alone. CONCLUSION The lack of effect of enteral nutrition on ALS survival probably reflected the timing of PEG insertion in patients with more severe disease. By contrast, patients who used mechanical ventilation had an increased overall survival compared with non-ventilated ones. The study also provided new information showing that the combined use of NIV and TIV did not may prolong ALS survival as compared to TIV alone.
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Affiliation(s)
- Giuseppe Borghero
- Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, Italy
| | - Vincenzo Pierri
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Francesca Pili
- Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, Italy
| | - Antonella Muroni
- Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, Italy
| | - Tommaso Ercoli
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Maria Ida Pateri
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Silvy Pilotto
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Alessandra Maccabeo
- Department of Medical Sciences and Public Health, University of Cagliari, Italy
| | - Adriano Chiò
- Rita Levi Montalcini Department of Neurosciences, ALS Center, University of Turin, Turin, Italy, and
| | - Giovanni Defazio
- Institute of Neurology, Azienda Ospedaliero Universitaria di Cagliari, Italy
- Department of Translational Biomedicine and Neurosciences, University of Bari "Aldo Moro", Italy
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Kim HS, Woo H, Choi SJ, Baek JG, Ryu JS, Shin HI, Park KS, Beom J. Factors associated with adherence to noninvasive positive pressure ventilation in amyotrophic lateral sclerosis. PLoS One 2024; 19:e0302515. [PMID: 38748695 PMCID: PMC11095767 DOI: 10.1371/journal.pone.0302515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/05/2024] [Indexed: 05/19/2024] Open
Abstract
INTRODUCTION This cohort study aimed to investigate the factors associated with noninvasive positive pressure ventilation adherence and assess the long-term effects of noninvasive positive pressure ventilation adherence in patients with amyotrophic lateral sclerosis (ALS). METHODS The medical records of patients with ALS admitted to a tertiary hospital for noninvasive positive pressure ventilation initiation were retrospectively reviewed. Pulmonary function parameters, variables of blood gas analysis, the site of symptom onset, the time from onset and diagnosis to noninvasive positive pressure ventilation application, ALS Functional Rating Scale-Revised, neurophysiological index, and the length of hospital stay were evaluated. The adherence to noninvasive positive pressure ventilation was defined as the use of noninvasive positive pressure ventilation for ≥ 2 h/day or ≥ 4 h/day. The correlations between noninvasive positive pressure ventilation adherence or length of hospital stay and other clinical parameters were analyzed. RESULTS Fifty-one patients with ALS were included in the study. The time from onset and diagnosis to NIPPV application was reduced by 16 months in the adherent group than that in the non-adherent group; however, the parameters of blood gas analysis and pulmonary function tests did not differ significantly between the groups. Furthermore, the neurophysiological index of the abductor digiti minimi muscle was higher by 4.05 in the adherent group than that in the non-adherent group. The adherence to noninvasive positive pressure ventilation prolonged tracheostomy-free survival compared to that of non-adherence. Desaturation events, lower forced vital capacity, last pCO2, bicarbonate, and base excess, and higher differences in pCO2, were associated with an increase in the length of hospital stay. CONCLUSIONS Noninvasive positive pressure ventilation application shortly after symptom onset and ALS diagnosis in patients with CO2 retention and reduced forced vital capacity can be considered for successful adherence. Adherence to noninvasive positive pressure ventilation may result in reduced tracheostomy conversion rates and prolonged tracheostomy-free survival.
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Affiliation(s)
- Hee Soo Kim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Hyeonseong Woo
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Seok-Jin Choi
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong-Gyu Baek
- Department of Neurology, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Ju Seok Ryu
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Hyung-Ik Shin
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Seok Park
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
| | - Jaewon Beom
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Republic of Korea
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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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Sarasate M, González N, Córdoba-Izquierdo A, Prats E, Gonzalez-Moro JMR, Martí S, Lujan M, Calle M, Antón A, Povedano M, Farrero E. Impact of Early Non-Invasive Ventilation in Amyotrophic Lateral Sclerosis: A multicenter Randomized Controlled Trial. J Neuromuscul Dis 2023:JND221658. [PMID: 37212068 DOI: 10.3233/jnd-221658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND AND OBJECTIVE Forced vital capacity (FVC) less than 50% of predicted is one of the main parameters used for Non-Invasive Ventilation (NIV) initiation in Amyotrophic Lateral Sclerosis (ALS). Recent studies suggest that higher values of FVC could be considered as a threshold. The aim of this study is to evaluate whether early use of NIV improves the prognosis of ALS patients compared with standard initiation. METHODS This is a randomized, parallel, multicenter, open-label, controlled clinical trial, with recruitment at the ALS outpatient multidisciplinary units of six Spanish hospitals. Patients were included when their FVC reached the 75% threshold and were randomized by computer, stratifying by center in an allocation ratio of 1:1 to Early NIV (FVC below 75%) or Standard NIV (FVC below 50%) initiation. The primary outcome was time to death or tracheostomy.Trial registration number ClinicalTrials.gov: NCT01641965. RESULTS Between May 2012 and June 2014, 42 patients were randomized to two groups, 20 to Early NIV and 22 to Standard NIV initiation. We found differences in survival in favor of the intervention group: an incidence of mortality (2.68 [1.87-5.50] vs. 3.33 [1.34-4.80] person-months) and a median survival (25.2 vs. 19.4 months), although without reaching statistical significance (p = 0.267). CONCLUSIONS This trial did not reach the primary endpoint of survival; nevertheless, it is the first Randomized Controlled Trial (RCT) to demonstrate the benefits of early NIV in slowing the decline of respiratory muscle strength and reducing adverse events. Although not all the results reached statistical significance, all the analyzed data favor early NIV. In addition, this study demonstrates good tolerance and compliance with early NIV without quality of sleep impairment. These data reinforce the early respiratory evaluation of ALS patients and NIV initiation with an FVC of around 75%.
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Affiliation(s)
- Mikel Sarasate
- Department of Pneumology, UFIS-Respiratoria, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Nuria González
- Department of Pneumology, Hospital Residencia Sant Camil, Consorci Sanitari Alt Pendedés-Garraf, Barcelona, Spain
| | - Ana Córdoba-Izquierdo
- Department of Pneumology, UFIS-Respiratoria, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Enric Prats
- Department of Pneumology, UFIS-Respiratoria, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Sergi Martí
- Department of Respiratory Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Departament de Medicina, Universitat Autònoma deBarcelona (UAB), Barcelona, Spain
| | - Manel Lujan
- Department of Pneumology, Corporació Sanitaria Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Myriam Calle
- Department of Pneumology, Hospital Clínico San Carlos, Department of Medicine, Faculty of Medicine, Complutense University of Madrid, San Carlos Clinical Hospital Institute of Health Research (IdISSC), Madrid, Spain
| | - Antonio Antón
- Department of Respiratory Medicine, Hospital de laSanta Creu i Sant Pau, Barcelona, Spain
| | - Mónica Povedano
- Department of Neurology, Head of ALS Multidisciplinary Unit, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain
| | - Eva Farrero
- Department of Pneumology, UFIS-Respiratoria, Hospital Universitari de Bellvitge, Barcelona, Spain
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Fiorentino G, Mazza M, Esquinas AM. Long term survival in motor neuron disease. Insights about noninvasive ventilation efficacy. Chron Respir Dis 2022; 19:14799731221103272. [PMID: 35658551 PMCID: PMC9168847 DOI: 10.1177/14799731221103272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/05/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Giuseppe Fiorentino
- Ospedali dei Colli
Monaldi-Cotugno-CTO, U.O.C. di Fisiopatologia e Riabilitazione Respiratoria P.O. Monaldi,
1 Utsir Covid P.O. Cotugno, Napoli, Italy
| | - Mariano Mazza
- Pneumologia, Semintensiva COVID Unit, Azienda Ospedaliera di Caserta “Sant’ Anna e San
Sebastiano”, Caserta, Italy
| | - Antonio M Esquinas
- Hospital Morales Meseguer, Intensive Care and Non Invasive Ventilatory Unit, Murcia, Spain
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7
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Ayub MT, Ayub T, Rasool W, Khan MS, Ishaq M, Mba B. When nerves fail: A cause of respiratory failure in a diabetic patient. CASPIAN JOURNAL OF INTERNAL MEDICINE 2022; 13:436-438. [PMID: 35919641 PMCID: PMC9301228 DOI: 10.22088/cjim.13.2.436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 08/21/2020] [Accepted: 08/23/2020] [Indexed: 11/13/2022]
Abstract
Background Respiratory failure secondary to bilateral diabetic phrenic neuropathy is an uncommon clinical scenario. It is challenging to treat and often results in the need for long-term respiratory support. Case Presentation We report a patient with long standing diabetes mellitus (DM) who presented with respiratory failure requiring mechanical ventilation. He was subsequently found to have reduced phrenic nerve and diaphragm compound action potential amplitude bilaterally on nerve conduction studies. Conclusion Diabetic patients with unexplained shortness of breath should raise suspicion for diaphragmatic paresis from phrenic neuropathy.
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Affiliation(s)
- Muhammad Talha Ayub
- Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, IL (complete form), Chicago, USA
| | - Tooba Ayub
- Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, IL (complete form), Chicago, USA
| | - Wajeeha Rasool
- Internal Medicine, AMITA Health Saint Francis Hospital, Evanston, IL (complete form), Evanston, USA
| | | | - Muhammad Ishaq
- Internal Medicine, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | - Benjamin Mba
- Internal Medicine, John H. Stroger, Jr. Hospital of Cook County, IL (complete form), Chicago, USA
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8
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Jackson CE, Heiman-Patterson TD, Sherman M, Daohai YU, Kasarskis EJ. Factors associated with Noninvasive ventilation compliance in patients with ALS/MND. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:40-47. [PMID: 34348541 DOI: 10.1080/21678421.2021.1917617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: Although noninvasive ventilation (NIV) improves survival and quality of life (QOL) in ALS, use of NIV is suboptimal. Objective: To determine compliance with "early" NIV initiation, requisite for the feasibility of a large study of early NIV initiation, and examine factors impacting compliance. Methods: Seventy-three ALS participants with forced vital capacities (FVC) >50% were enrolled. Participants with FVC over 80% (Group 1) were initiated on NIV early (FVC between 80 and 85%). Participants with FVC between 50 and 80% (Group 2) started NIV at FVC between 50 and 55%. Symptom surveys, QOL scores, and NIV compliance (machine download documenting use ≥4 hours/night >60% of time) were collected following NIV initiation. Results: 53.6% of Group 1 and 50% of Group 2 were compliant 28 days following NIV initiation, with increased compliance over time. Participants who were unmarried, had lower income, lower educational attainment, or limited caregiver availability were less likely to be compliant. Bothersome symptoms in non-compliant participants included facial air pressure, frequent arousals with difficulty returning to sleep, and claustrophobia. Both compliant and noncompliant participants felt improved QOL with NIV; improvement was significantly greater in compliant participants. Conclusions: These data suggest ALS patients can comply with NIV early in their disease, and potentially benefit as evidenced by improved QOL scores, supporting both feasibility and need for a study comparing early versus late NIV initiation. Moreover, modifiable symptoms were identified that could be optimized to improve compliance. Further studies are needed to determine the impact of "early" intervention on survival and QOL.
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Affiliation(s)
- C E Jackson
- University of Texas Health Science Center, San Antonio, TX, USA
| | | | - M Sherman
- MCG-Hearst Health, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Y U Daohai
- Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
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9
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Chao C, Berlowitz DJ, Howard ME, Rautela L, McDonald LA, Hannan LM. Measuring Adherence to Long-Term Noninvasive Ventilation. Respir Care 2021; 66:1469-1476. [PMID: 34257099 PMCID: PMC9993864 DOI: 10.4187/respcare.08745] [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] [Indexed: 11/05/2022]
Abstract
BACKGROUND Obtaining benefits from long-term noninvasive ventilation (NIV) relies on achieving adequate adherence to treatment. Reported adherence to NIV is variable and could be influenced by high-volume users and attrition of nonusers and those who die. This observational study aimed to describe patterns of use and adherence rates in new unselected users of NIV. METHODS All adults (> 18 y old) commencing long-term NIV were consecutively enrolled and followed for 6 months. Ventilator data were manually downloaded from devices and usage (minutes per day) was collected. Subjects were categorized into adherent users (≥ 4 h/d) and nonadherent users (< 4 h/d). RESULTS Data were obtained from 86 subjects. Most (65%) had motor neuron disease, and most commenced NIV in an out-patient setting (72%). At one month after NIV implementation, overall average daily use was 302.1 min/d and categorical adherence was 57%. At 6 months or prior to death, overall average daily use increased (388.7 min/d), but categorical adherence was similar (62%). The majority of subjects (84%) remained in the same adherence category from their first month to their sixth month of use or death. Individuals with motor neuron disease demonstrated significantly lower rates of adherence compared to the rest of the cohort at 1 month (48% vs 73%, P = .03). In those who died within the study period (n = 19, all with motor neuron disease), this difference persisted to death (42% at death vs 73% at 6 months, P = .032). CONCLUSIONS Average daily usage may conceal true prevalence of adherence or nonadherence to NIV within a population. Reporting both average daily use data and categorical adherence rates (using a threshold of 4 h/d) may improve transparency of reported outcomes from clinical trials and identifies a therapeutic target for home mechanical ventilation services for quality improvement.
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Affiliation(s)
- Caroline Chao
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - David J Berlowitz
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
| | - Mark E Howard
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
| | - Linda Rautela
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Luke A McDonald
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Liam M Hannan
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
- Department of Respiratory Medicine, Northern Health, Epping, Victoria, Australia
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10
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Zoccolella S, Capozzo R, Quaranta VN, Castellana G, Marra L, Liotino V, Giorgio V, Simone IL, Resta O, Piccininni M, Tortelli R, Logroscino G. Reduction of Sniff Nasal Inspiratory Pressure (SNIP) as an Early Indicator of the Need of Enteral Nutrition in Patients with Amyotrophic Lateral Sclerosis. Brain Sci 2021; 11:brainsci11081091. [PMID: 34439710 PMCID: PMC8392198 DOI: 10.3390/brainsci11081091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/30/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
Percutaneous endoscopic gastrostomy (PEG) is the standard procedure for feeding severely dysphagic patients with amyotrophic lateral sclerosis (ALS). It is associated with prolonged survival and improvement in quality of life. Nasal inspiratory pressure during a sniff (SNIP) is a respiratory test used extensively in ALS for the assessment of inspiratory muscle strength. In this study, we aimed to investigate the role of SNIP at baseline to predict PEG placement in ALS. Data from a clinical incident cohort of 179 ALS cases attending the multidisciplinary ALS unit of the University of Bari between April 2006 and December 2012 were retrospectively analysed. At baseline, patients underwent detailed neurological, nutritional and respiratory assessments, including measurements of SNIP and forced vital capacity (FVC). Patients were therefore followed up approximately every three to six months until they were able to attend the centre. The censoring date for the survival analysis was 15 April 2014, with PEG placement as the main outcome. Cox proportional hazard regression models were used to examine the association between SNIP and PEG placement, adjusted for possible confounders. During the follow-up period, 75 participants (42%) received PEG implant. PEG placement was more frequent (57% vs. 31%; p = 0.001) and earlier (after 11.6 ± 14.0 months from the first visit, vs. 23.3 ± 15.5 months; p < 0.0001) in the group of patients with baseline SNIP ≤ 40 cm H2O. Baseline SNIP was a predictor of PEG placement even after correction for multiple potential confounders (HR 0.98; 95% CI: 0.96–0.99; p = 0.02). To conclude, the present study showed that SNIP at baseline is an early indicator of disease progression and therefore of the need for enteral nutrition in ALS.
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Affiliation(s)
| | - Rosa Capozzo
- Center for Neurodegenerative Diseases and the Aging Brain, University of Bari “Aldo Moro”–A.O. Pia Fond “Card. G. Panico” Hospital, 73039 Tricase, Italy; (R.C.); (G.L.)
| | - Vitaliano N. Quaranta
- Respiratory and Sleep Disorders Unit, Cardio-Thoracic Department, Policlinic University Hospital, UNIBA, 70124 Bari, Italy; (V.N.Q.); (L.M.); (V.L.); (O.R.)
| | - Giorgio Castellana
- Pulmonary Division, Istituti Clinici Scientifici Maugeri SpA SB Pavia, IRCCS, 70124 Bari, Italy;
| | - Lorenzo Marra
- Respiratory and Sleep Disorders Unit, Cardio-Thoracic Department, Policlinic University Hospital, UNIBA, 70124 Bari, Italy; (V.N.Q.); (L.M.); (V.L.); (O.R.)
| | - Vito Liotino
- Respiratory and Sleep Disorders Unit, Cardio-Thoracic Department, Policlinic University Hospital, UNIBA, 70124 Bari, Italy; (V.N.Q.); (L.M.); (V.L.); (O.R.)
| | | | - Isabella L. Simone
- Department of Basic Medical Science and Sense Organs, University of Bari “Aldo Moro”, 70124 Bari, Italy;
| | - Onofrio Resta
- Respiratory and Sleep Disorders Unit, Cardio-Thoracic Department, Policlinic University Hospital, UNIBA, 70124 Bari, Italy; (V.N.Q.); (L.M.); (V.L.); (O.R.)
| | - Marco Piccininni
- Institute of Public Health, Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany;
| | - Rosanna Tortelli
- Center for Neurodegenerative Diseases and the Aging Brain, University of Bari “Aldo Moro”–A.O. Pia Fond “Card. G. Panico” Hospital, 73039 Tricase, Italy; (R.C.); (G.L.)
- Department of Basic Medical Science and Sense Organs, University of Bari “Aldo Moro”, 70124 Bari, Italy;
- Correspondence: ; Tel.: +39-0833773909; Fax: +39-08331830670
| | - Giancarlo Logroscino
- Center for Neurodegenerative Diseases and the Aging Brain, University of Bari “Aldo Moro”–A.O. Pia Fond “Card. G. Panico” Hospital, 73039 Tricase, Italy; (R.C.); (G.L.)
- Department of Basic Medical Science and Sense Organs, University of Bari “Aldo Moro”, 70124 Bari, Italy;
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11
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Young C, Pinto S, Grosskreutz J, Hardiman O, Clawson LL, Cudkowicz ME, Andrews JA. Medical therapies for amyotrophic lateral sclerosis-related respiratory decline: an appraisal of needs, opportunities and obstacles. Amyotroph Lateral Scler Frontotemporal Degener 2021; 23:66-75. [PMID: 34392765 DOI: 10.1080/21678421.2021.1920981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A roundtable convened in July 2020 examined issues concerning respiratory support in amyotrophic lateral sclerosis (ALS), with reference to the potential for an early-phase orally administered medication that might either postpone the introduction of noninvasive ventilation (NIV) and/or enhance the benefits to be gained from it. Attention was also given to the impact of the COVID-19 pandemic on usual practice in the assessment and management of ALS-related respiratory difficulties. Implementation of NIV marks a step-change in clinical status for patients and a major increase in burden for caregivers. All means to ease this transition should be explored: an oral therapy that supported respiratory function and patients' independence and sense of well-being would aid discussions to facilitate the eventual successful introduction of NIV. Assessment of a candidate oral therapy that might support respiratory function in ALS patients would be aided by the development of improved patient-reported outcome measures for robust quantification of treatment effect and quality of life. Such instruments could also be used to monitor patients' status during the COVID-19 pandemic, averting some of the risks of face-to-face assessment plus the patient burden and costs of traditional methods. Several oral candidate therapies have recently failed to meet their primary endpoints in clinical trials. However, understanding of the underlying physiology and appropriate trial design have grown and will inform future developments in this field.
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Affiliation(s)
- Carolyn Young
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Susana Pinto
- Translational and Clinical Physiology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | | | - Orla Hardiman
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Lora L Clawson
- Department of Neurology, School of Medicine , Johns Hopkins University , Baltimore, MD , USA
| | | | - Jinsy A Andrews
- Neurological Institute of New York, Columbia University, New York, NY, USA
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12
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Abstract
PURPOSE OF REVIEW Hypoventilation syndrome in neuromuscular disorders (NMDs) is primarily due to respiratory muscle weakness and results in increased morbidity and mortality. This article highlights current aspects of neuromuscular hypoventilation syndrome, including pathophysiology, clinical symptoms, assessment, respiratory involvement in various NMD, and causal and symptomatic treatments with an emphasis on recent research and advances. RECENT FINDINGS AND SUMMARY New therapeutic agents have been developed within the last years, proving a positive effect on respiratory system. Symptomatic therapies, including mechanical ventilation and cough assistance approaches, are important in NMD and respiratory muscle training may have benefit in strengthening respiratory muscles and should be offered patients with respiratory muscle weakness the same way as physiotherapy. Correct respiratory assessments and their correct interpretation are hallmarks for early diagnosis of hypoventilation syndrome and treatment.
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13
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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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14
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Kim J, Bireley JD, Hayat G, Kafaie J. Effects of noninvasive ventilation in amyotrophic lateral sclerosis: The complication of bulbar impairment. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2020. [DOI: 10.1177/2514183x20914183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis is a neurodegenerative illness that causes gradual loss of muscle function. Patients eventually develop bulbar impairment, requiring extensive respiratory support. Noninvasive ventilation (NIV) has gained attention as an easily accessible method with promising benefits. We conducted this systematic review to outline the therapeutic effects of NIV, add to previous publications discussing this topic by providing updates on newly completed and ongoing studies, and identify limitations that must be addressed in future trials. A search of PubMed and Cochran for relevant primary studies yielded 26 publications. Studies indicate NIV use is associated with improvements in quality of life, regardless of the severity of bulbar impairment. However, NIV’s benefits on survival were limited to patients with less bulbar impairment. In addition, our review found several limitations that undermine the efforts to establish a definitive treatment regimen. Future studies will need to address these problems in order to provide patients with better respiratory care.
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Affiliation(s)
- Junghyun Kim
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Ghazala Hayat
- Department of Neurology, Saint Louis University, Saint Louis, MO, USA
| | - Jafar Kafaie
- Department of Neurology, Saint Louis University, Saint Louis, MO, USA
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15
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Couto C, Pereira P, Moreira AC, Ribeiro V, Duarte J. Bilateral Isolated Phrenic Neuropathy: a Rare Cause of Dyspnoea. Eur J Case Rep Intern Med 2020; 7:001258. [PMID: 32670989 PMCID: PMC7080215 DOI: 10.12890/2020_001258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 11/22/2019] [Indexed: 11/30/2022] Open
Abstract
Bilateral diaphragm paralysis due to bilateral isolated phrenic neuropathy (BIPN) is a very rare cause of unexplained respiratory failure. We present a 65-year-old patient with no relevant previous medical history who presented in the Pulmonology Clinic with mMRC1 dyspnoea and orthopnoea. After the medical work-up, diaphragmatic paresis was diagnosed. Inspiratory muscle training resulted in mild symptomatic improvement and treatment with noninvasive mechanical ventilation (NIV) was initiated. This condition is generally chronic and has a poorer prognosis, compared to other cases of phrenic nerve involvement. In this case, NIV restored near-normal daily function. LEARNING POINTS Besides being a rare cause of dyspnoea, diaphragmatic dysfunction should be considered in the medical evaluation.Noninvasive mechanical ventilation is the mainstay of treatment for symptomatic patients.Neurologic and electrodiagnostic evaluation is essential, since the differential diagnosis of phrenic nerve dysfunction may imply different treatment strategies.
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Affiliation(s)
- Carlos Couto
- Pulmonology Department, Garcia de Orta Hospital, Almada, Portugal
| | - Pedro Pereira
- Neurology Department, Garcia de Orta Hospital, Almada, Portugal
| | | | - Vicência Ribeiro
- Pulmonology Department, Garcia de Orta Hospital, Almada, Portugal
| | - José Duarte
- Pulmonology Department, Garcia de Orta Hospital, Almada, Portugal
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16
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McNicholas WT, Hansson D, Schiza S, Grote L. Sleep in chronic respiratory disease: COPD and hypoventilation disorders. Eur Respir Rev 2019; 28:28/153/190064. [DOI: 10.1183/16000617.0064-2019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 08/20/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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17
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Fantini R, Tonelli R, Castaniere I, Tabbì L, Pellegrino MR, Cerri S, Livrieri F, Giaroni F, Monelli M, Ruggieri V, Fini N, Mandrioli J, Clini E, Marchioni A. Serial ultrasound assessment of diaphragmatic function and clinical outcome in patients with amyotrophic lateral sclerosis. BMC Pulm Med 2019; 19:160. [PMID: 31455341 PMCID: PMC6712740 DOI: 10.1186/s12890-019-0924-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
Background Diaphragmatic assessment by ultrasound (US) is a non-invasive and useful method in the clinical management of patients with Amyotrophic Lateral Sclerosis (ALS). The aim of our observational study was to evaluate the impact of serial assessment of the diaphragmatic function by US on long-term outcomes in a series of patients suffering from ALS and to correlate US indices of diaphragmatic function and respiratory function tests with these outcomes. Methods A cohort of 39 consecutive patients has been followed up to 24 months. Both lung volume (forced vital capacity, FVC) and diaphragmatic pressure generating capacity (by sniff inspiratory nasal pressure (SNIP) and by both US thickening fraction, ΔTdi, and the ratio of the thickening fraction between tidal volume and maximal lung capacity, ΔTmax) were recorded at baseline and every 3 months. Parameters were then correlated with outcomes (nocturnal hypoventilation, daily hypercapnia, start of ventilatory support (NIV), and death at 1 year) over time. Results The occurrence of ΔTmax > 0.75 increased the risk to start NIV (HR = 5.6, p = 0.001) and to die (HR = 3.7, p = 0.0001) compared with patients maintaining lower values. Moreover, compared with the occurrence of FVC < 50% of predicted, ΔTmax > 0.75 appeared slightly better correlated with NIV commencement within 6 months. Conclusions Serial diaphragmatic assessment by ultrasound is a useful and accurate method to predict the initiation of NIV earlier in patients with ALS. Electronic supplementary material The online version of this article (10.1186/s12890-019-0924-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Riccardo Fantini
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Policlinico, University Hospital of Modena, Modena, Italy
| | - Roberto Tonelli
- Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Ivana Castaniere
- Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Modena, Italy
| | - Luca Tabbì
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Policlinico, University Hospital of Modena, Modena, Italy
| | - Maria Rosaria Pellegrino
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Policlinico, University Hospital of Modena, Modena, Italy
| | - Stefania Cerri
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Policlinico, University Hospital of Modena, Modena, Italy
| | - Francesco Livrieri
- Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Francesco Giaroni
- School of Medicine, University of Modena Reggio Emilia, Modena, Italy
| | - Marco Monelli
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Policlinico, University Hospital of Modena, Modena, Italy
| | - Valentina Ruggieri
- Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy
| | - Nicola Fini
- Department of Neurosciences, St. Agostino Estense Hospital, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Jessica Mandrioli
- Department of Neurosciences, St. Agostino Estense Hospital, Azienda Ospedaliero Universitaria di Modena, Modena, Italy
| | - Enrico Clini
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Policlinico, University Hospital of Modena, Modena, Italy. .,Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Modena, Italy.
| | - Alessandro Marchioni
- Respiratory Diseases Unit and Centre for Rare Lung Diseases, Policlinico, University Hospital of Modena, Modena, Italy
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18
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Seeber AA, Pols AJ, Hijdra A, Grupstra HF, Willems DL, de Visser M. Advance care planning in progressive neurological diseases: lessons from ALS. BMC Palliat Care 2019; 18:50. [PMID: 31196046 PMCID: PMC6567602 DOI: 10.1186/s12904-019-0433-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/27/2019] [Indexed: 02/08/2023] Open
Abstract
Background There is increasing awareness of the need for an integrated palliative care approach in chronic progressive neurological diseases. Advance care planning (ACP) is an integral part of this approach. As a systematically organized and ongoing communication process about patients’ values, goals and preferences regarding medical care during serious and chronic illness, ACP aims to involve patients in decision-making before they become cognitively and communicatively incapable. However, it remains underutilized in daily neurological practice except for speciality clinics such as ALS centers. Our aim was to study ACP in the tertiary ALS center Amsterdam and to investigate patients’ reflections on it. Subsequently we used this knowledge to formulate recommendations for integration of ACP in the care of patients with other chronic progressive neurological diseases. Methods Non-participating observations of all appointments of patients with amyotrophic lateral sclerosis (ALS) or progressive muscular atrophy (PMA) with the treating physician, in various stages of disease, during 6 consecutive months, followed by single in-depth interviews, and an inductive analysis. Results Twenty-eight Dutch patients participated, varying in age, gender, disease onset and severity of physical decline. ACP started directly when the diagnosis was given, by means of a general outlook on the future with progressive disability and immediate introduction to a customized multidisciplinary team. During follow-up ACP was realized by regular appointments in which monitoring of the patient’s status and clear communication strategies formed the basis of tailor-made discussions on treatment options. Patients accepted this policy as careful professional guidance. Conclusions ACP is a professional communication process throughout the whole course of progressive disease. It is feasible to integrate ACP into follow-up of patients with ALS and PMA from diagnosis onwards. Supported by recent literature, we argue that such a well-structured approach would also enhance the quality of care and life of patients with other chronic progressive neurological diseases. Electronic supplementary material The online version of this article (10.1186/s12904-019-0433-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antje A Seeber
- Department of Neurology, Amsterdam University Medical Center, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands. .,Section of Medical Ethics, Department of General Practice, Amsterdam University Medical Center, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, Amsterdam, The Netherlands.
| | - A Jeannette Pols
- Section of Medical Ethics, Department of General Practice, Amsterdam University Medical Center, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, Amsterdam, The Netherlands
| | - Albert Hijdra
- Department of Neurology, Amsterdam University Medical Center, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
| | - Hepke F Grupstra
- Department of Rehabilitation, Amsterdam University Medical Center, Academic Medical Center, University of Amsterdam, P.O. Box 22660, Amsterdam, The Netherlands
| | - Dick L Willems
- Section of Medical Ethics, Department of General Practice, Amsterdam University Medical Center, Academic Medical Centre, University of Amsterdam, P.O. Box 22660, Amsterdam, The Netherlands
| | - Marianne de Visser
- Department of Neurology, Amsterdam University Medical Center, Academic Medical Center, University of Amsterdam, P.O. Box 22660, 1100 DD, Amsterdam, The Netherlands
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19
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Geronimo A, Simmons Z. Evaluation of remote pulmonary function testing in motor neuron disease. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:348-355. [PMID: 30957547 DOI: 10.1080/21678421.2019.1587633] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Motor neuron disease (MND) causes respiratory insufficiency, which is managed in part through use of noninvasive ventilation (NIV). Guidelines for the initiation of NIV are based on pulmonary function tests (PFTs), usually performed once every three months. In the setting of MND telemedicine, remote monitoring of respiratory health may permit earlier intervention, but proof of equivalence to conventional PFTs is lacking. Methods: We implemented delivery of remote PFTs (rPFTs), based on our institution's telemedicine platform, with the goals of validating measurement equivalence to conventional forced vital capacity (FVC) and maximal inspiratory pressure (MIP) assessments, and assessing process acceptability from both patients and therapists. Results: When remotely guided by a respiratory therapist, 40 patient/caregiver teams produced respiratory parameters that were tightly correlated with those acquired through the standard evaluation. Both patients and therapists generally rated the setup and use of the devices positively, with patient ratings higher than those of the therapists. Discussion: This study suggests that rPFTs are accurate and acceptable, and thus may be incorporated into MND telemedicine for clinical and research use.
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Affiliation(s)
- Andrew Geronimo
- a Department of Neurosurgery , Penn State College of Medicine , Hershey , PA , USA
| | - Zachary Simmons
- b Department of Neurology , Penn State College of Medicine , Hershey , PA , USA and.,c Department of Humanities , Penn State College of Medicine , Hershey , PA , USA
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20
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Morelot-Panzini C, Bruneteau G, Gonzalez-Bermejo J. NIV in amyotrophic lateral sclerosis: The 'when' and 'how' of the matter. Respirology 2019; 24:521-530. [PMID: 30912216 DOI: 10.1111/resp.13525] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/09/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022]
Abstract
Non-invasive ventilation (NIV) has become an essential part of the treatment of amyotrophic lateral sclerosis (ALS) since 2006. NIV very significantly improves survival, quality of life and cognitive performances. The initial NIV settings are simple, but progression of the disease, ventilator dependence and upper airway involvement sometimes make long-term adjustment of NIV more difficult, with a major impact on survival. Unique data concerning the long-term adjustment of NIV in ALS show that correction of leaks, management of obstructive apnoea and adaptation to the patient's degree of ventilator dependence improve the prognosis. Non-ventilatory factors also impact the efficacy of NIV and various solutions have been described and must be applied, including cough assist techniques, control of excess salivation and renutrition. NIV in ALS has been considerably improved as a result of application of all of these measures, avoiding the need for tracheostomy in the very great majority of cases. More advanced use of NIV also requires pulmonologists to master the associated end-of-life palliative care, as well as the modalities of discontinuing ventilation when it becomes unreasonable.
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Affiliation(s)
- Capucine Morelot-Panzini
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France.,Service de Pneumologie et Réanimation Médicale du Département R3S, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Gaëlle Bruneteau
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France.,Département de Neurologie, Centre Référent SLA, APHP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Jesus Gonzalez-Bermejo
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France.,Service de Pneumologie et Réanimation Médicale du Département R3S, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
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21
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Sferrazza Papa GF, Pellegrino GM, Shaikh H, Lax A, Lorini L, Corbo M. Respiratory muscle testing in amyotrophic lateral sclerosis: a practical approach. Minerva Med 2019; 109:11-19. [PMID: 30642145 DOI: 10.23736/s0026-4806.18.05920-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In amyotrophic lateral sclerosis (ALS), respiratory muscle weakness leads to respiratory failure and death. Non-invasive positive pressure ventilation (NIPPV) appears to reduce lung function decline, thus improving survival and quality-of-life of patients affected by the disease. Unfortunately, clinical features and timing to start NIPPV are not well defined. Starting from recent findings, we examine established and novel tests of respiratory muscle function that could help clinicians decide whether and when to start NIPPV in ALS. Non-invasive tests estimate the function of inspiratory, expiratory, and bulbar muscles, whereas clinical examination allows to assess the overall neurologic and respiratory symptoms and general conditions. Most of the studies recommend that together with a thorough clinical evaluation of the patient according to current guidelines, vital capacity, maximal static and sniff nasal inspiratory pressures, maximal static expiratory pressures and peak cough expiratory flow, and nocturnal pulse oximetry be measured. A sound understanding of physiology can guide the physician also through the current armamentarium for additional supportive treatments for ALS, such as symptomatic drugs and new treatments to manage sialorrhea and thickened saliva, cough assistance, air stacking, and physiotherapy. In conclusion, careful clinical and functional evaluation of respiratory function and patient's preference are key determinants to decide "when" and "to whom" respiratory treatments can be provided.
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Affiliation(s)
- Giuseppe F Sferrazza Papa
- Department of Neurorehabilitation Sciences, Casa di Cura Privata del Policlinico, Milan, Italy - .,Respiratory Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy -
| | - Giulia M Pellegrino
- Department of Neurorehabilitation Sciences, Casa di Cura Privata del Policlinico, Milan, Italy.,Respiratory Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Loyola University of Chicago Stritch School of Medicine, Maywood, IL, USA.,Edward Hines Jr. Veterans Administration Hospital Hines, Chicago, IL, USA
| | - Agata Lax
- IRCCS Don Carlo Gnocchi Foundation, Milan, Italy
| | - Luca Lorini
- Unit of Neurosurgical Intensive Care, Department of Anesthesia and Critical Care Medicine, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Massimo Corbo
- Department of Neurorehabilitation Sciences, Casa di Cura Privata del Policlinico, Milan, Italy
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22
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Parsons EC, Carter JC, Wrede JE, Donovan LM, Palen BN. Practical implementation of noninvasive ventilation in Amyotrophic Lateral Sclerosis: lessons learned from a clinical case series. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2019; 55:13-15. [PMID: 31297440 PMCID: PMC6591783 DOI: 10.29390/cjrt-2018-020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Noninvasive ventilation (NIV) may improve survival and quality of life in Amyotrophic Lateral Sclerosis (ALS) patients. There is a surprising paucity of practical guidelines for office-based implementation and management of NIV outside of tertiary ALS centers. We saw the need for a clinical protocol to allow feasible and consistent NIV management in this patient population. METHODS We created a clinical protocol for office-based initiation of NIV implemented on consecutive ALS patients referred from our regional ALS multidisciplinary clinic. The protocol provided initial empiric settings using a bilevel device in volume-assured pressure support mode. A respiratory therapist (RT) initiated NIV in an office setting and made adjustments according to patient tolerance and therapy targets outlined in the protocol. Later setting changes were performed at patient or provider request. We evaluated patient adherence and efficacy via device download at 30 days and 1 year. RESULTS We present data from a case series of the first 14 consecutive patients initiated on NIV over a 20-month period. Our protocol underwent iterative modification based on clinical experience and patient feedback. Early challenges included the significant time and resource burden required to coordinate device downloads and patient follow-up. Early 30-day NIV adherence was variable (median 20 out of 30 days), while 1-year NIV adherence was excellent (median 27.5 out of 30 days). CONCLUSIONS Our RT-driven clinical NIV protocol was feasible but labor intensive. Achieving real-world adherence of NIV in our ALS patients required iterative protocol adjustment, significant RT provider time, and tele-based follow-up.
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Affiliation(s)
- Elizabeth C. Parsons
- Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, WA
| | - John C. Carter
- Division of Pulmonary, Critical Care, and Sleep Medicine, Case Western Reserve University School of Medicine and MetroHealth, Cleveland, OH
| | - Joanna E. Wrede
- Division of Pulmonary and Sleep Medicine and Division of Neurology, Seattle Children’s Hospital, Seattle, WA
| | - Lucas M. Donovan
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA
| | - Brian N. Palen
- Division of Pulmonary, Critical Care and Sleep Medicine, Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, WA
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23
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Abstract
ALS is a neurodegenerative disease in which the primary symptoms result in progressive neuromuscular weakness. Recent studies have highlighted that there is significant heterogeneity with regard to anatomical and temporal disease progression. Importantly, more recent advances in genetics have revealed new causative genes to the disease. New efforts have focused on the development of biomarkers that could aid in diagnosis, prognosis, and serve as pharmacodynamics markers. Although traditional pharmaceuticals continue to undergo trials for ALS, new therapeutic strategies including stem cell transplantation studies, gene therapies, and antisense therapies targeting some of the familial forms of ALS are gaining momentum.
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Wu YY, Acharya D, Xu C, Cheng B, Rana S, Shimada K. Custom-Fit Three-Dimensional-Printed BiPAP Mask to Improve Compliance in Patients Requiring Long-Term Noninvasive Ventilatory Support. J Med Device 2018; 12:0310031-310038. [PMID: 32328209 PMCID: PMC7164498 DOI: 10.1115/1.4040187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 04/17/2018] [Indexed: 12/14/2022] Open
Abstract
Noninvasive ventilator support using bi-level positive airway pressure/continuous positive airway pressure (BiPAP/CPAP) is commonly utilized for chronic medical conditions like sleep apnea and neuromuscular disorders like amyotrophic lateral sclerosis (ALS) that lead to weakness of respiratory muscles. Generic masks come in standard sizes and are often perceived by patients as being uncomfortable, ill-fitting, and leaky. A significant number of patients are unable to tolerate the masks and eventually stop using their devices. The goal of this project is to develop custom-fit masks to increase comfort, decrease air leakage, and thereby improve patient compliance. A single-patient case study of a patient with variant ALS was performed to evaluate the custom-fit masks. His high nose bridge and overbite of lower jaw caused poor fit with generic masks, and he was noncompliant with his machine. Using desktop Stereolithography three-dimensional (3D) printing and magnetic resonance imaging (MRI) data, a generic mask was extended with a rigid interface such that it was complementary to the patient's unique facial contours. Patient or clinicians interactively select a desired mask shape using a newly developed computer program. Subsequently, a compliant silicone layer was applied to the rigid interface. Ten different custom-fit mask designs were made using computer-aided design software. Patient evaluated the comfort, extent of leakage, and satisfaction of each mask via a questionnaire. All custom-fit masks were rated higher than the standard mask except for two. Our results suggest that modifying generic masks with a 3D-printed custom-fit interface is a promising strategy to improve compliance with BiPAP/CPAP machines.
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Affiliation(s)
- Ying Ying Wu
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213 e-mail:
| | - Deepshikha Acharya
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213 e-mail:
| | - Camilla Xu
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213 e-mail:
| | - Boyle Cheng
- Neuroscience Institute, Allegheny General Hospital, 320 E North Avenue, Pittsburgh, PA 15212 e-mail:
| | - Sandeep Rana
- Department of Neurology, Allegheny General Hospital, 320 E North Avenue, Pittsburgh, PA 15212 e-mail:
| | - Kenji Shimada
- Department of Mechanical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213 e-mail:
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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: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [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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Vitacca M, Montini A, Lunetta C, Banfi P, Bertella E, De Mattia E, Lizio A, Volpato E, Lax A, Morini R, Paneroni M. Impact of an early respiratory care programme with non-invasive ventilation adaptation in patients with amyotrophic lateral sclerosis. Eur J Neurol 2018; 25:556-e33. [PMID: 29266547 DOI: 10.1111/ene.13547] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 12/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Forced vital capacity (FVC) <80% is one of the key indications for starting non-invasive ventilation (NIV) in amyotrophic lateral sclerosis (ALS). It was hypothesized that a very early start of NIV could lengthen the free interval before death compared to later-start NIV; as a secondary outcome, the survival rate of patients on NIV without tracheotomy was also evaluated. METHODS This retrospective study was conducted on 194 ALS patients, divided into a later group (LG) with FVC <80% at NIV prescription (n = 129) and a very early group (VEG) with FVC ≥80% at NIV prescription (n = 65). Clinical and respiratory functional data and time free to death between groups over a 3-year follow-up were compared. RESULT At 36 months from diagnosis, mortality was 35% for the VEG versus 52.7% for the LG (P = 0.022). Kaplan-Meier survival curves adjusted for tracheotomy showed a lower probability of death (P = 0.001) for the VEG as a whole (P = 0.001) and for the non-bulbar (NB) subgroup (P = 0.007). Very early NIV was protective of survival for all patients [hazard ratio (HR) 0.45; 95% confidence interval (CI) 0.28-0.74; P = 0.001] and for the NB subgroup (HR 0.43; 95% CI 0.23-0.79; P = 0.007), whilst a tracheotomy was protective for all patients (HR 0.27; 95% CI 0.15-0.50; P = 0.000) and both NB (HR 0.26; 95% CI 0.12-0.56; P = 0.001) and bulbar subgroups (HR 0.29; 95% CI 0.11-0.77; P = 0.013). Survival in VEG patients on NIV without tracheotomy was three times that for the LG (43.1% vs. 14.7%). CONCLUSION Very early NIV prescription prolongs the free time from diagnosis to death in NB ALS patients whilst tracheotomy reduces the mortality risk in all patients.
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Affiliation(s)
- M Vitacca
- Respiratory Rehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
| | - A Montini
- Respiratory Rehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
| | - C Lunetta
- NEMO Clinical Centre, Fondazione Serena Onlus, Milano, Italy
| | - P Banfi
- Don Gnocchi Foundation IRCCS - Onlus, Milano, Italy
| | - E Bertella
- Respiratory Rehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
| | - E De Mattia
- NEMO Clinical Centre, Fondazione Serena Onlus, Milano, Italy
| | - A Lizio
- NEMO Clinical Centre, Fondazione Serena Onlus, Milano, Italy
| | - E Volpato
- Don Gnocchi Foundation IRCCS - Onlus, Milano, Italy.,Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | - A Lax
- Don Gnocchi Foundation IRCCS - Onlus, Milano, Italy
| | - R Morini
- Neurorehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
| | - M Paneroni
- Respiratory Rehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
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Radunovic A, Annane D, Rafiq MK, Brassington R, Mustfa N. Mechanical ventilation for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev 2017; 10:CD004427. [PMID: 28982219 PMCID: PMC6485636 DOI: 10.1002/14651858.cd004427.pub4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease, is a fatal neurodegenerative disease. Neuromuscular respiratory failure is the most common cause of death, which usually occurs within two to five years of the disease onset. Supporting respiratory function with mechanical ventilation may improve survival and quality of life. This is the second update of a review first published in 2009. OBJECTIVES To assess the effects of mechanical ventilation (tracheostomy-assisted ventilation and non-invasive ventilation (NIV)) on survival, functional measures of disease progression, and quality of life in ALS, and to evaluate adverse events related to the intervention. SEARCH METHODS We searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL Plus, and AMED on 30 January 2017. We also searched two clinical trials registries for ongoing studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs involving non-invasive or tracheostomy-assisted ventilation in participants with a clinical diagnosis of ALS, independent of the reported outcomes. We included comparisons with no intervention or the best standard care. DATA COLLECTION AND ANALYSIS For the original review, four review authors independently selected studies for assessment. Two review authors reviewed searches for this update. All review authors independently extracted data from the full text of selected studies and assessed the risk of bias in studies that met the inclusion criteria. We attempted to obtain missing data where possible. We planned to collect adverse event data from the included studies. MAIN RESULTS For the original Cochrane Review, the review authors identified two RCTs involving 54 participants with ALS receiving NIV. There were no new RCTs or quasi-RCTs at the first update. One new RCT was identified in the second update but was excluded for the reasons outlined below.Incomplete data were available for one published study comparing early and late initiation of NIV (13 participants). We contacted the trial authors, who were not able to provide the missing data. The conclusions of the review were therefore based on a single study of 41 participants comparing NIV with standard care. Lack of (or uncertain) blinding represented a risk of bias for participant- and clinician-assessed outcomes such as quality of life, but it was otherwise a well-conducted study with a low risk of bias.The study provided moderate-quality evidence that overall median survival was significantly different between the group treated with NIV and the standard care group. The median survival in the NIV group was 48 days longer (219 days compared to 171 days for the standard care group (estimated 95% confidence interval 12 to 91 days, P = 0.0062)). This survival benefit was accompanied by an enhanced quality of life. On subgroup analysis, in the subgroup with normal to moderately impaired bulbar function (20 participants), median survival was 205 days longer (216 days in the NIV group versus 11 days in the standard care group, P = 0.0059), and quality of life measures were better than with standard care (low-quality evidence). In the participants with poor bulbar function (21 participants), NIV did not prolong survival or improve quality of life, although there was significant improvement in the mean symptoms domain of the Sleep Apnea Quality of Life Index by some measures. Neither trial reported clinical data on intervention-related adverse effects. AUTHORS' CONCLUSIONS Moderate-quality evidence from a single RCT of NIV in 41 participants suggests that it significantly prolongs survival, and low-quality evidence indicates that it improves or maintains quality of life in people with ALS. Survival and quality of life were significantly improved in the subgroup of people with better bulbar function, but not in those with severe bulbar impairment. Adverse effects related to NIV should be systematically reported, as at present there is little information on this subject. More RCT evidence to support the use of NIV in ALS will be difficult to generate, as not offering NIV to the control group is no longer ethically justifiable. Future studies should examine the benefits of early intervention with NIV and establish the most appropriate timing for initiating NIV in order to obtain its maximum benefit. The effect of adding cough augmentation techniques to NIV also needs to be investigated in an RCT. Future studies should examine the health economics of NIV. Access to NIV remains restricted in many parts of the world, including Europe and North America. We need to understand the factors, personal and socioeconomic, that determine access to NIV.
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Affiliation(s)
| | - Djillali Annane
- Center for Neuromuscular Diseases; Raymond Poincaré Hospital (AP‐HP)Department of Critical Care, Hyperbaric Medicine and Home Respiratory UnitFaculty of Health Sciences Simone Veil, University of Versailles SQY‐ University of Paris Saclay104 Boulevard Raymond PoincaréGarchesFrance92380
| | | | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Naveed Mustfa
- Royal Stoke University Hospital, University Hospital of North MidlandsDepartment of Respiratory MedicineNewcastle RoadStoke‐on‐TrentUKST4 6QG
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Zhang HG, Chen L, Tang L, Zhang N, Fan DS. Clinical Features of Isolated Bulbar Palsy of Amyotrophic Lateral Sclerosis in Chinese Population. Chin Med J (Engl) 2017; 130:1768-1772. [PMID: 28748847 PMCID: PMC5547826 DOI: 10.4103/0366-6999.211538] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Progressive bulbar palsy (PBP) is a classic phenotype of bulbar onset amyotrophic lateral sclerosis (ALS) with more rapid progression and worse prognosis. However, as an often under-understood variant of ALS, isolated bulbar palsy (IBP) appears to progress more slowly and has a relatively benign prognosis. This study aimed to investigate the natural course and clinical features of IBP in Chinese population and to compare them with those of PBP. METHODS The clinical data of patients with bulbar onset ALS were collected from January 2009 to December 2013. Revised ALS Functional Rating Scale (ALSFRS-R), forced vital capacity (FVC), and follow-up evaluation were performed, and the differences in basic clinical features, ALSFRS-R, FVC, and primary outcome measures between IBP and PBP were analyzed. The independent t-test, Chi-square test, Mann-Whitney U-test, and Kaplan-Meier analysis were used. RESULTS Totally 154 patients with bulbar onset ALS were categorized into two groups, 33 with IBP and 121 with PBP. In the IBP group, the male to female ratio was 0.7 to 1.0, and the mean onset age was 58.5 years. The mean duration from the onset was 16.0 months, and the mean ALSFRS-R score was 43.4 at patients' first visit to our hospital. In 14 IBP patients performing FVC examination, the mean FVC value was 90.5% and there were only two cases with abnormal FVC. In 26 IBP patients completing follow-up, 15 (58%) suffered death or tracheotomy and the mean survival time was 40.5 months. Significant differences were noted in sex ratio, onset age, ALSFRS-R score, upper motor neuron limb signs, pure lower motor neuron (LMN) bulbar signs, FVC, and survival time between IBP and PBP. CONCLUSIONS IBP was evidently different from PBP, which was characterized with the predominance of female, pure LMN bulbar signs, an older onset age, a relative preservation of respiratory function, and a better prognosis.
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Affiliation(s)
- Hua-Gang Zhang
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
| | - Lu Chen
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
| | - Lu Tang
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
| | - Nan Zhang
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
| | - Dong-Sheng Fan
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
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Thulaseedharan NK, Geetha P, Arathi N, Shameer VK, Jayachandran NV, Subramaniam G, Narayanan S. An unusual cause of orthopnoea-hashimoto's thyroiditis presenting as bilateral diaphragmatic palsy. Respir Med Case Rep 2017; 21:132-134. [PMID: 28480162 PMCID: PMC5407574 DOI: 10.1016/j.rmcr.2017.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/13/2017] [Accepted: 04/18/2017] [Indexed: 11/29/2022] Open
Abstract
We report a case of 36 yr old male without any comorbidities, who presented with a history of gradually progressive dyspnoea and orthopnoea for 6 months. Physical examination revealed bradycardia, paradoxical respiration suggestive of bilateral diaphragmatic palsy. Fluoroscopy demonstrated the presence of bilateral diaphragmatic paralysis. Etiological work up showed evidence of autoimmune hypothyroidism due to hashimoto's thyroiditis. Other possibilities were ruled out with appropriate tests. He was started on thyroxine and showed symptomatic improvement.
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Affiliation(s)
| | - P Geetha
- Department of Medicine, Govt. Medical College, Kozhikode, Kerala, India
| | - N Arathi
- Department of Medicine, Govt. Medical College, Kozhikode, Kerala, India
| | - V K Shameer
- Department of Medicine, Govt. Medical College, Kozhikode, Kerala, India
| | - N V Jayachandran
- Department of Medicine, Govt. Medical College, Kozhikode, Kerala, India
| | - Gomathy Subramaniam
- Department of Radiodiagnosis, Govt. Medical College, Kozhikode, Kerala, India
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Augelli DM, Krieger AC. Social and Economic Impacts of Managing Sleep Hypoventilation Syndromes. Sleep Med Clin 2017; 12:87-98. [DOI: 10.1016/j.jsmc.2016.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Georges M, Golmard JL, Llontop C, Shoukri A, Salachas F, Similowski T, Morelot-Panzini C, Gonzalez-Bermejo J. Initiation of non-invasive ventilation in amyotrophic lateral sclerosis and clinical practice guidelines: Single-centre, retrospective, descriptive study in a national reference centre. Amyotroph Lateral Scler Frontotemporal Degener 2016; 18:46-52. [DOI: 10.1080/21678421.2016.1236817] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Marjolaine Georges
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, France,
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ‘3S’), Paris, France,
- Centre Hospitalier Universitaire Dijon Bourgogne, Service de Pneumologie et Soins Intensifs Respiratoires, Dijon, France,
| | - Jean-Louis Golmard
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Biostatistiques, Paris, France,
| | - Claudia Llontop
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ‘3S’), Paris, France,
| | - Amr Shoukri
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ‘3S’), Paris, France,
- An Shams University, Cairo, Egypt, and
| | - François Salachas
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Neurologie, Paris, France
| | - Thomas Similowski
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, France,
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ‘3S’), Paris, France,
| | - Capucine Morelot-Panzini
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, France,
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ‘3S’), Paris, France,
| | - Jésus Gonzalez-Bermejo
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, France,
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département ‘3S’), Paris, France,
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Randerath W, Verbraecken J, Andreas S, Arzt M, Bloch KE, Brack T, Buyse B, De Backer W, Eckert DJ, Grote L, Hagmeyer L, Hedner J, Jennum P, La Rovere MT, Miltz C, McNicholas WT, Montserrat J, Naughton M, Pepin JL, Pevernagie D, Sanner B, Testelmans D, Tonia T, Vrijsen B, Wijkstra P, Levy P. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J 2016; 49:13993003.00959-2016. [DOI: 10.1183/13993003.00959-2016] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/25/2016] [Indexed: 02/07/2023]
Abstract
The complexity of central breathing disturbances during sleep has become increasingly obvious. They present as central sleep apnoeas (CSAs) and hypopnoeas, periodic breathing with apnoeas, or irregular breathing in patients with cardiovascular, other internal or neurological disorders, and can emerge under positive airway pressure treatment or opioid use, or at high altitude. As yet, there is insufficient knowledge on the clinical features, pathophysiological background and consecutive algorithms for stepped-care treatment. Most recently, it has been discussed intensively if CSA in heart failure is a “marker” of disease severity or a “mediator” of disease progression, and if and which type of positive airway pressure therapy is indicated. In addition, disturbances of respiratory drive or the translation of central impulses may result in hypoventilation, associated with cerebral or neuromuscular diseases, or severe diseases of lung or thorax. These statements report the results of an European Respiratory Society Task Force addressing actual diagnostic and therapeutic standards. The statements are based on a systematic review of the literature and a systematic two-step decision process. Although the Task Force does not make recommendations, it describes its current practice of treatment of CSA in heart failure and hypoventilation.
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Esquinas AM, Garuti G, Pellegrino GM, Sferrazza Papa GF. Survival in amyotrophic lateral sclerosis patients on non-invasive ventilation. What can we do more? Amyotroph Lateral Scler Frontotemporal Degener 2016; 18:305-306. [DOI: 10.1080/21678421.2016.1223141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Antonio M. Esquinas
- Intensive Care Unit and Non Invasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain,
| | - Giancarlo Garuti
- Pneumology Unit, Santa Maria Bianca Hospital, Mirandola (MO), Modena, Italy,
| | - Giulia Michela Pellegrino
- Respiratory Unit, ASST Santi Paolo e Carlo, Dipartimento Scienze della Salute, Università degli Studi di Milano, Milan, and
| | - Giuseppe Francesco Sferrazza Papa
- Respiratory Unit, ASST Santi Paolo e Carlo, Dipartimento Scienze della Salute, Università degli Studi di Milano, Milan, and
- Casa di Cura del Policlinico, Dipartimento di Scienze Neuroriabilitative, Milan, Italy
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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] [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] [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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Hobson EV, McDermott CJ. Supportive and symptomatic management of amyotrophic lateral sclerosis. Nat Rev Neurol 2016; 12:526-38. [PMID: 27514291 DOI: 10.1038/nrneurol.2016.111] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The main aims in the care of individuals with amyotrophic lateral sclerosis (ALS) are to minimize morbidity and maximize quality of life. Although no cure exists for ALS, supportive and symptomatic care provided by a specialist multidisciplinary team can improve survival. The basis for supportive management is shifting from expert consensus guidelines towards an evidence-based approach, which encourages the use of effective treatments and could reduce the risk of harm caused by ineffective or unsafe interventions. For example, respiratory support using noninvasive ventilation has been demonstrated to improve survival and quality of life, whereas evidence supporting other respiratory interventions is insufficient. Increasing evidence implicates a causal role for metabolic dysfunction in ALS, suggesting that optimizing nutrition could improve quality of life and survival. The high incidence of cognitive dysfunction and its impact on prognosis is increasingly recognized, although evidence for effective treatments is lacking. A variety of strategies are used to manage the other physical and psychological symptoms, the majority of which have yet to be thoroughly evaluated. The need for specialist palliative care throughout the disease is increasingly recognized. This Review describes the current approaches to symptomatic and supportive care in ALS and outlines the current guidance and evidence for these strategies.
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Affiliation(s)
- Esther V Hobson
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385a Glossop Rd, Sheffield, S10 2HQ, UK
| | - Christopher J McDermott
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385a Glossop Rd, Sheffield, S10 2HQ, UK
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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] [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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Fantini R, Mandrioli J, Zona S, Antenora F, Iattoni A, Monelli M, Fini N, Tonelli R, Clini E, Marchioni A. Ultrasound assessment of diaphragmatic function in patients with amyotrophic lateral sclerosis. Respirology 2016; 21:932-8. [PMID: 26994409 DOI: 10.1111/resp.12759] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 11/29/2015] [Accepted: 11/29/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Evaluation of diaphragm function in Amyotrophic Lateral Sclerosis (ALS) is critical in determining when to commence non-invasive mechanical ventilation (NIV). Currently, forced vital capacity (FVC) and sniff nasal inspiratory pressure (SNIP) are volitional measures for this evaluation, but require collaboration and are poorly specific. The primary aim of this study was to assess whether diaphragmatic thickness measured by ultrasound (US) correlates with lung function impairment in ALS patients. The secondary aim was then to compare US diaphragm thickness index (ΔTdi) with a new parameter (ΔTmax index). METHODS 41 patients with ALS and 30 healthy subjects were enrolled in the study. All subjects underwent spirometry, SNIP and diaphragm US evaluation, while arterial blood gases were measured in some patients only. US assessed diaphragm thickness (Tdi) at tidal volume (Vt) or total lung capacity (TLC), and their ratio (ΔTmax) were recorded. Changes (Δ) in Tdi indices during tidal volume (ΔTdiVt) and maximal inspiration (ΔTdiTLC) were also assessed. RESULTS ΔTdiTLC (p <0.001) and ΔTmax (p = 0.007), but not ΔTdiVt, differed between patients and controls. Significant correlation (p < 0.05) was found between ΔTdiTLC, ΔTmax and FVC. The ROC curve analysis for comparison of individual testing showed better accuracy with Δtmax than with ΔtdiTLC for FVC (AUC 0.76 and 0.27) and SNIP (AUC 0.71 and 0.25). CONCLUSION Diaphragm thickness assessed by ultrasound significantly correlates with global respiratory alterations in patients with ALS. ΔTmax represents a new US index of early diaphragmatic dysfunction, better related with the routinely performed lung function tests.
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Affiliation(s)
- Riccardo Fantini
- Respiratory Disease Clinic, Policlinico Modena, University of Modena and Reggio Emilia
| | - Jessica Mandrioli
- Department of Neuroscience, St Agostino-Estense Hospital, University of Modena and Reggio Emilia
| | - Stefano Zona
- Infectious Diseases Clinic, Policlinico Modena, University of Modena and Reggio Emilia
| | - Federico Antenora
- Respiratory Disease Clinic, Policlinico Modena, University of Modena and Reggio Emilia
| | - Andrea Iattoni
- Respiratory Disease Clinic, Policlinico Modena, University of Modena and Reggio Emilia
| | - Marco Monelli
- Respiratory Disease Clinic, Policlinico Modena, University of Modena and Reggio Emilia
| | - Nicola Fini
- Department of Neuroscience, St Agostino-Estense Hospital, University of Modena and Reggio Emilia
| | - Roberto Tonelli
- Respiratory Disease Clinic, Policlinico Modena, University of Modena and Reggio Emilia
| | - Enrico Clini
- Respiratory Disease Clinic, Policlinico Modena, University of Modena and Reggio Emilia
| | - Alessandro Marchioni
- Respiratory Disease Clinic, Policlinico Modena, University of Modena and Reggio Emilia
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Ahmed RM, Newcombe REA, Piper AJ, Lewis SJ, Yee BJ, Kiernan MC, Grunstein RR. Sleep disorders and respiratory function in amyotrophic lateral sclerosis. Sleep Med Rev 2015; 26:33-42. [PMID: 26166297 DOI: 10.1016/j.smrv.2015.05.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/07/2015] [Accepted: 05/20/2015] [Indexed: 12/11/2022]
Abstract
Sleep disorders in amyotrophic lateral sclerosis (ALS) present a significant challenge to the management of patients. Issues include the maintenance of adequate ventilatory status through techniques such as non-invasive ventilation, which has the ability to modulate survival and improve patient quality of life. Here, a multidisciplinary approach to the management of these disorders is reviewed, from concepts about the underlying neurobiological basis, through to current management approaches and future directions for research.
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Affiliation(s)
- Rebekah M Ahmed
- Brain and Mind Research Institute and Department of Neurology Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia.
| | - Rowena E A Newcombe
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia
| | - Amanda J Piper
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Australia
| | - Simon J Lewis
- Brain and Mind Research Institute and Department of Neurology Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia; NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia
| | - Brendon J Yee
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Australia
| | - Matthew C Kiernan
- Brain and Mind Research Institute and Department of Neurology Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Ron R Grunstein
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Australia
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Gladman M, Zinman L. The economic impact of amyotrophic lateral sclerosis: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2015; 15:439-50. [DOI: 10.1586/14737167.2015.1039941] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Matthew Gladman
- 1Department of Medicine, Sunnybrook Health Sciences Centre, Queen’s University, Ontario, Canada
| | - Lorne Zinman
- 2Department of Medicine, University of Toronto, Ontario, Canada
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Rosenfeld J, Strong MJ. Challenges in the Understanding and Treatment of Amyotrophic Lateral Sclerosis/Motor Neuron Disease. Neurotherapeutics 2015; 12:317-25. [PMID: 25572957 PMCID: PMC4404444 DOI: 10.1007/s13311-014-0332-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
With the acceleration in our understanding of ALS and the related motor neuron disease has come even greater challenges in reconciling all of the proposed pathogenic mechanisms and how this will translate into impactful treatments. Fundamental issues such as diagnostic definition(s) of the disease spectrum, relevant biomarkers, the impact of multiple novel genetic mutations and the significant effect of symptomatic treatments on disease progression are all areas of active investigation. In this review, we will focus on these key issues and highlight the challenges that confront both clinicians and basic science researchers.
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Affiliation(s)
- Jeffrey Rosenfeld
- Central California Neuroscience Institute, UCSF Fresno, Division of Neurology, Fresno, CA, USA,
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Kamide N, Asakawa T, Shibasaki N, Kasahara Y, Tamada Y, Kitano K, Kikuchi Y, Yorimoto K, Kobayashi Y, Komori T. Identification of the type of exercise therapy that affects functioning in patients with early-stage amyotrophic lateral sclerosis: A multicenter, collaborative study. ACTA ACUST UNITED AC 2014. [DOI: 10.1111/ncn3.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Naoto Kamide
- School of Allied Health Sciences; Kitasato University; Sagamihara Japan
- Graduate School of Medicine; Kitasato University; Sagamihara Kanagawa Japan
| | - Takashi Asakawa
- Department of Rehabilitation; Yoshino Neurology Clinic; Ichikawa Chiba Japan
| | - Nobuhiko Shibasaki
- Department of Rehabilitation; Sayama Neurological Hospital; Sayama Saitama Japan
| | - Yoshio Kasahara
- Department of Rehabilitation; Tokyo Metropolitan Neurological Hospital; Futyu Tokyo Japan
| | - Yoshiki Tamada
- Department of Rehabilitation; Kohnodai Hospital; National Center for Global Health and Medicine; Ichikawa Chiba Japan
| | - Kosuke Kitano
- Department of Rehabilitation; Murakami Karindoh Hospital; Fukuoka Fukuoka Japan
| | - Yutaka Kikuchi
- Department of Rehabilitation; Mihara Memorial Hospital; Isesaki Gunma Japan
| | - Keisuke Yorimoto
- Department of Rehabilitation; National Center of Neurology and Psychiatry; Kodaira Tokyo Japan
| | - Yoko Kobayashi
- Department of Rehabilitation; National Center of Neurology and Psychiatry; Kodaira Tokyo Japan
| | - Testuo Komori
- Department of Neurology; National Hakone Hospital; Odawara Kanagawa Japan
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Javad Mousavi SA, Zamani B, Shahabi Shahmiri S, Rohani M, Shahidi GA, Mostafapour E, Hemasian H, Raji H. Pulmonary function tests in patients with amyotrophic lateral sclerosis and the association between these tests and survival. IRANIAN JOURNAL OF NEUROLOGY 2014; 13:131-7. [PMID: 25422731 PMCID: PMC4240929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 04/09/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND The rapidity of progression of amyotrophic lateral sclerosis (ALS) to death or respiratory failure impacts patients, clinicians, and clinical investigators. The aim of this study is to evaluate of the pulmonary function tests (PFTs) in patients with ALS and the association between these PFTs and survival Methods: A total of 36 ALS patients who PFTs, including vital capacity (VC), maximum mid-expiratory flow rate (MMEFR), forced vital capacity (FVC), and forced expiratory volume in 1 s (FEV1), were available from the time of diagnosis were included in this study. Non-pulmonary characteristics assessed at the time of PFTs. Data were analyzed using chi-square, Student's independent t-test, Kaplan-Meier, correlation, and receiver operating characteristic (ROC) curve. RESULTS The mean age of subjects was 55.36 (SD = 12.24) year, and the male to female ratio was 2.6. Twenty-five (69.4%) were died in 5 years period of our study. The mean and median survival time (In months) was calculated as 42.51 (95% confidence interval [CI] 33.64-51.39) and 38 (95% CI 27.23-48.77) months, respectively. The rate of ALS survival was 74% at 1(st) year, 41% at 3(rd) year and 10% at 5(th) year of starting symptoms. The results of Kaplan-Meier test showed survival was significantly longer in the group with PFTs closer to normal. In addition, ROC analysis showed that FVC < 50% could potentially be a predictor of death in ALS patients(P = 0.003, area under curve = 0.649). CONCLUSION We found single measures of upright FVC, FEV1 to be significantly associated with survival, even after controlling for relevant non-pulmonary patient characteristics. Our study demonstrated that upright FVC, FEV1, VC, and MMEFR are useful non-invasive measures in the prediction of survival in ALS.
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Affiliation(s)
- Seyed-Ali Javad Mousavi
- Department of Internal Medicine, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Babak Zamani
- Department of Neurology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Shahab Shahabi Shahmiri
- Department of Scientific Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Rohani
- Department of Neurology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Gholam Ali Shahidi
- Department of Neurology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Elyas Mostafapour
- Department of Scientific Research Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Helia Hemasian
- Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Hanieh Raji
- Department of Internal Medicine, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Sheers N, Berlowitz DJ, Rautela L, Batchelder I, Hopkinson K, Howard ME. Improved survival with an ambulatory model of non-invasive ventilation implementation in motor neuron disease. Amyotroph Lateral Scler Frontotemporal Degener 2014; 15:180-4. [PMID: 24555916 DOI: 10.3109/21678421.2014.881376] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Non-invasive ventilation (NIV) increases survival and quality of life in motor neuron disease (MND). NIV implementation historically occurred during a multi-day inpatient admission at this institution; however, increased demand led to prolonged waiting times. The aim of this study was to evaluate the introduction of an ambulatory model of NIV implementation. A prospective cohort study was performed. Inclusion criteria were referral for NIV implementation six months pre- or post-commencement of the Day Admission model. This model involved a 4-h stay to commence ventilation with follow-up in-laboratory polysomnography titration and outpatient attendance. Outcome measures included waiting time, hospital length of stay, adverse events and polysomnography data. Results indicated that after changing to the Day Admission model the median waiting time fell from 30 to 13.5 days (p < 0.04) and adverse events declined (4/17 pre- (three deaths, one acute admission) vs. 0/12 post-). Survival was also prolonged (median (IQR) 278 (51-512) days pre- vs 580 (306-1355) days post-introduction of the Day Admission model; hazard ratio 0.41, p = 0.04). Daytime PaCO2 was no different. In conclusion, reduced waiting time to commence ventilation and improved survival were observed following introduction of an ambulatory model of NIV implementation in people with MND, with no change in the effectiveness of ventilation.
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Affiliation(s)
- Nicole Sheers
- Victorian Respiratory Support Service (VRSS), Austin Health , Heidelberg, Victoria , Australia
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Pinto S, Carvalho MD. Breathing new life into treatment advances for respiratory failure in amyotrophic lateral sclerosis patients. Neurodegener Dis Manag 2014; 4:83-102. [DOI: 10.2217/nmt.13.74] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
SUMMARY In the last three decades, improvements in respiratory management are responsible for increasing survival and improving quality of life for amyotrophic lateral sclerosis (ALS) patients. Nowadays, ALS patients with respiratory involvement are offered a support treatment other than the traditional respiratory palliative care. Knowledge about available respiratory support potentialities is essential for appropriate, customized and effective treatment of ALS, which should probably be started sooner than the conventional approach. There is evidence supporting that respiratory support has a larger impact than riluzole on survival. Noninvasive ventilation is essential in the treatment of ALS patients with respiratory involvement. In this article methods to determine respiratory failure in ALS, mechanical invasive and noninvasive ventilation, telemetry, diaphragm pacing, cough aids and respiratory exercise are reviewed, after a brief overlook of respiratory insufficiency in ALS.
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Affiliation(s)
- Susana Pinto
- Translational Clinical Physiology Unit, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, 1648-028 Lisbon, Portugal
| | - Mamede de Carvalho
- Translational Clinical Physiology Unit, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, 1648-028 Lisbon, Portugal
- Neuroscience Department, Santa Maria Hospital, Lisbon, Portugal
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47
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Goyal NA, Mozaffar T. Respiratory and Nutritional Support in Amyotrophic Lateral Sclerosis. Curr Treat Options Neurol 2014; 16:270. [DOI: 10.1007/s11940-013-0270-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Gruis KL, Lechtzin N. Respiratory therapies for amyotrophic lateral sclerosis: a primer. Muscle Nerve 2012; 46:313-31. [PMID: 22907221 DOI: 10.1002/mus.23282] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Respiratory complications are a common cause of morbidity and mortality in amyotrophic lateral sclerosis (ALS). Treatment of respiratory insufficiency with noninvasive ventilation (NIV) improves ALS patients' quality of life and survival. Evidence-based practice guidelines for the management of ALS patients recommend treatment of respiratory insufficiency with NIV as well as consideration of insufflation/exsufflation to improve clearance of airway secretions. Despite these recommendations respiratory therapies remain underused. In this review we provide a practical guide for the clinician to prescribe and manage respiratory therapies for the patient with ALS.
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Affiliation(s)
- Kirsten L Gruis
- Department of Neurology, University of Michigan, 1C327 UH, EMG Lab, SPC 5036, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109, USA.
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50
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Amirjani N, Kiernan MC, McKenzie DK, Butler JE, Gandevia SC. Is there a case for diaphragm pacing for amyotrophic lateral sclerosis patients? ACTA ACUST UNITED AC 2012; 13:521-7. [PMID: 22632380 DOI: 10.3109/17482968.2012.673169] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Respiratory pacing has advanced the long-term management of respiratory failure secondary to neurological disorders. It has an established role in curtailing invasive mechanical ventilation after upper motor neuron lesions such as spinal cord injury. There is increasing interest to expand the application of intramuscular diaphragm pacing to amyotrophic lateral sclerosis (ALS), a progressive and fatal neurodegenerative disease. Although diaphragm pacing has been offered to ALS patients, evidence-based data to determine its benefits remain lacking. The limited current literature indicates progression of respiratory dysfunction in ALS patients despite diaphragm pacing. The data from clinical trials are inadequate to substantiate its survival and sleep benefits. Its advantages over non-invasive mechanical ventilation have not been directly investigated. Furthermore, there are cautions for ALS patients to consider when opting for diaphragm pacing. Progressive degeneration of the phrenic motor neurons in classic ALS will interrupt the transmission of pacer signals to sustain diaphragm contractions. Pacing protocols that are safe for other neurological conditions may be detrimental for ALS, at least as suggested by transgenic animal models. Issues inherent to the device warrant expert intervention in implanted patients. At present, clinical effectiveness and long-term safety concerns about diaphragm pacing in ALS remain to be addressed.
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Affiliation(s)
- Nasim Amirjani
- Neuroscience Research Australia, University of New South Wales, Sydney, NSW, Australia.
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