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Bhat A, Dean J, Aboussouan LS. Perioperative Management in Neuromuscular Diseases: A Narrative Review. J Clin Med 2024; 13:2963. [PMID: 38792504 PMCID: PMC11122304 DOI: 10.3390/jcm13102963] [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: 03/31/2024] [Revised: 05/04/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Patients with neuromuscular diseases are particularly vulnerable in the perioperative period to the development of pulmonary and cardiac complications, or medication side effects. These risks could include hypoventilation, aspiration pneumonia, exacerbation of underlying cardiomyopathy, arrhythmias, adrenal insufficiency, prolonged neuromuscular blockade, issues related to thermoregulation, rhabdomyolysis, malignant hyperthermia, or prolonged mechanical ventilation. Interventions at each of the perioperative stages can be implemented to mitigate these risks. A careful pre-operative evaluation may help identify risk factors so that appropriate interventions are initiated, including cardiology consultation, pulmonary function tests, initiation of noninvasive ventilation, or implementation of preventive measures. Important intraoperative issues include positioning, airway and anesthetic management, and adequate ventilation. The postoperative period may require correction of electrolyte abnormalities, control of secretions with medications, manual or mechanical cough assistance, avoiding the risk of reintubation, judicious pain control, and appropriate medication management. The aim of this review is to increase awareness of the particular surgical challenges in this vulnerable population, and guide the clinician on the various evaluations and interventions that may result in a favorable surgical outcome.
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Affiliation(s)
| | | | - Loutfi S. Aboussouan
- Respiratory and Neurological Institutes, Cleveland Clinic, Cleveland, OH 44195, USA; (A.B.); (J.D.)
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Ackrivo J. Pulmonary care for ALS: Progress, gaps, and paths forward. Muscle Nerve 2023; 67:341-353. [PMID: 36655874 PMCID: PMC10619201 DOI: 10.1002/mus.27779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 12/06/2022] [Accepted: 12/11/2022] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Adults with amyotrophic lateral sclerosis (ALS) have been using home mechanical ventilation for over 50 years. More recently, home respiratory care has evolved to include portable home ventilators, airway clearance devices, and physiological assessments with telemonitoring capability. CURRENT STATE OF RESPIRATORY CARE National organizations currently offer incentives for providing a pulmonary care specialist within a multidisciplinary ALS clinic; however, several critical gaps exist between the available technology and employing a clinician with the necessary expertise. GAPS IN CARE Lack of formal training and poor financial incentives have led to a paucity of both clinicians and active clinical research engaging in the home respiratory care of ALS. Criteria for noninvasive ventilation (NIV) initiation are controversial, and few guidelines exist on the ideal subsequent adjustments of NIV with evolving disease. Consequently, many patients with ALS tolerate NIV poorly and must face the harrowing decision of hospice vs tracheostomy. Advancement of respiratory care in ALS has been hindered by critical gaps in pulmonologist availability, training in chronic respiratory failure, financial support, clinical research, and clarity on ventilation management beyond initiation. BRINGING RESPIRATORY CARE UP TO SPEED Only a multifaceted approach will suffice for addressing the voids in ALS respiratory care, including various education initiatives, financial incentives, clinical research programs, and elevating the standard of respiratory care.
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Affiliation(s)
- Jason Ackrivo
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Song Y, Cheng H, Liu J, Kazuo S, Feng L, Wei Y, Zhang C, Gao Y. Effectiveness of herbal medicine on patients with amyotrophic lateral sclerosis: Analysis of the PRO-ACT data using propensity score matching. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2022; 107:154461. [PMID: 36198223 DOI: 10.1016/j.phymed.2022.154461] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 09/10/2022] [Accepted: 09/14/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Patients with amyotrophic lateral sclerosis (ALS) have restricted pharmacotherapy options and thus resort to herbal medicines (HMs), despite limited and conflicting evidence. Therefore, use of HMs needs to be assessed in patients with ALS. PURPOSE This study aimed to evaluate the benefits of HMs in ALS and to describe the characteristics of HM users. STUDY DESIGN The correlation between HMs and prognosis was determined based on data obtained from the largest ALS database with high-quality clinical trials. Propensity score (PS) matching was used to address confounding and selection bias. METHODS In total, 321 and 231 HM users with at least a 4-week HM prescription were identified and PS-matched with non-HM users at a 1:1 ratio based on predefined confounders. Time-to-event models with censoring at 12 or 18 months were established for survival analyses. For evaluating activity limitation and respiratory function, 320 and 376 HM users were included, respectively, and analyzed using multivariate analysis of variance (MANOVA). RESULTS The profiles of 321 HM users indicated a better condition compared with that of non-HM users before PS-matching, including higher weight (median [IQR], 77.90 [21.8] kg vs. 74.00 [21.2] kg, p < 0.01), higher body mass index (26.00 [5.4] vs. 25.20 [5.8], p < 0.01), more percentage of limb onset (261 [81.3%] vs. 2366 [67.2%], p < 0.01), and slower progression (0.47 [0.5] vs. 0.51 [0.5], p = 0.03). HM did not significantly affect survival at 12 months (adjusted hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.49-1.03; log-rank p = 0.069), but it significantly prolonged survival at 18 months (adjusted HR 0.74, 95% CI 0.56-0.98; log-rank p = 0.038). After imputation of missing data, MANOVA revealed significant effectiveness of HMs in improving activity limitation (Pillai trace, 0.0195; p = 0.03). CONCLUSION PS-based methods eliminated baseline differences between HM and non-HM users. Overall, the use of HM to treat patients with ALS is favored based on their association with prolonged overall survival within 18 months and improved activity limitation.
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Affiliation(s)
- Yuebo Song
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Hao Cheng
- National Academy of Innovation Strategy, China Association for Science and Technology, Beijing 100038, China
| | - Jia Liu
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Sugimoto Kazuo
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China; Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing 100010, China
| | - Luda Feng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China
| | - Yufei Wei
- The First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning 530022, China
| | - Chi Zhang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China.
| | - Ying Gao
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China; Institute for Brain Disorders, Beijing University of Chinese Medicine, Beijing 100700, China.
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Thakore NJ, Lapin BR, Mitsumoto H, Pooled Resource Open‐Access ALS Clinical Trials Consortium. Early initiation of riluzole may improve absolute survival in amyotrophic lateral sclerosis. Muscle Nerve 2022; 66:702-708. [PMID: 36117390 PMCID: PMC9828202 DOI: 10.1002/mus.27724] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 01/12/2023]
Abstract
INTRODUCTION/AIMS Riluzole improves survival in amyotrophic lateral sclerosis (ALS), but optimal time and duration of treatment are unknown. The aim of this study was to examine if timing of riluzole initiation and duration of treatment modified its effect on survival. METHODS Patients from the PRO-ACT dataset with information on ALS Functional Rating Scale, time from onset to enrollment (TFOE), and riluzole use were selected for analysis. Survival from enrollment was the outcome. Multivariable Cox proportional hazard models were examined for interactions between riluzole and TFOE. Inverse probability of treatment weighting (IPTW) was used to assess average treatment effect. RESULTS Of 4778 patients, 3446 (72.1%) had received riluzole. In unadjusted analyses, riluzole improved median survival significantly (22.6 vs. 20.2 months, log-rank p < 0.001). In multivariable analyses, no significant interaction between TFOE and riluzole was found. Riluzole effect was uniform during follow-up. By IPTW, estimated riluzole hazard ratio was 0.798 (95% confidence interval 0.686-0.927). Delaying riluzole initiation by 1 y (6 to 18 months from onset) may translate to reducing median survival from onset by 1.9 months (40.1 to 38.2 months). DISCUSSION Riluzole appears to reduce risk of death uniformly, regardless of time from onset to treatment, and duration of treatment. Earlier treatment with riluzole may be associated with greater absolute survival gain from onset. Early diagnosis of ALS will facilitate early treatment and is expected to improve survival.
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Affiliation(s)
- Nimish J. Thakore
- Neuromuscular Center, Department of NeurologyCleveland ClinicClevelandOhioUSA
| | - Brittany R. Lapin
- Neurological Institute Center for Outcomes Research and Evaluation (NICORE) and Lerner Research Institute Department of Quantitative Health SciencesCleveland ClinicClevelandOhioUSA
| | - Hiroshi Mitsumoto
- Department of Neurology, Division of Neuromuscular MedicineColumbia University Medical CenterNew YorkNew YorkUSA
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Barry C, Larner E, Copsey H, Smith M, Peryer G. Non-invasive ventilation support for people with amyotrophic lateral sclerosis: multidisciplinary team management. Curr Opin Support Palliat Care 2021; 15:214-218. [PMID: 34561341 DOI: 10.1097/spc.0000000000000570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To summarise recent developments in the use of noninvasive ventilation (NIV) for people with amyotrophic lateral sclerosis (pwALS), with a specific focus on how multidisciplinary teams (MDT) can support best practice. RECENT FINDINGS We included 13 papers, 12 with observational designs and one qualitative interview design. The review is structured using four content domains: prognosis, the effectiveness of NIV, NIV tolerance, and MDT structure and delivery. Findings suggest a modest survival benefit of NIV for pwALS. Further evidence is needed to consider the appropriate time of initiation in the context of respiratory status and the influence of NIV on cognitive function over the course of the disease. A key emerging determinant of tolerability of NIV is secretion load. Palliative care professionals within the MDT can play a key role in supporting pwALS to consider the potential benefits of NIV in the context of their preferences, prognosis, symptom burden, and ALS variant. SUMMARY ALS MDTs allow timely information sharing about NIV between experts that is likely to improve outcomes. MDT practice must continually adapt to reflect pwALS's preferences for care and ensure those caring for them at home have access to support using digital innovations.
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Affiliation(s)
- Caroline Barry
- Norfolk and Norwich University Hospitals NHS Foundation Trust
| | - Emma Larner
- Norfolk and Norwich University Hospitals NHS Foundation Trust
| | - Helen Copsey
- Norfolk and Norwich University Hospitals NHS Foundation Trust
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Yoon SY, Kim HK, Kim MJ, Suh JH, Leigh JH. Factors associated with assisted ventilation use in amyotrophic lateral sclerosis: a nationwide population-based study in Korea. Sci Rep 2021; 11:19682. [PMID: 34608192 PMCID: PMC8490422 DOI: 10.1038/s41598-021-98990-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/30/2021] [Indexed: 11/09/2022] Open
Abstract
Few studies have investigated the factors associated with assisted ventilation use in amyotrophic lateral sclerosis (ALS) in western countries with a relatively small number of participants. This study aimed to evaluate the factors associated with assisted ventilation use using a large nationwide cohort covering the entire Korean population. We selected patients with primary or secondary diagnoses of ALS (ICD-10 code: G12.21) and a registration code for ALS (V123) in the rare intractable disease registration program. Covariates included in the analyses were age, sex, socioeconomic status and medical condition. Factors associated with non-invasive ventilation (NIV) and tracheostomy invasive ventilation (TIV) were evaluated. Logistic regression analyses were performed using odds ratios and 95% confidence intervals. In total, 3057 patients with ALS were enrolled. During the 6-year follow-up period, 1228 (40%) patients started using assisted ventilation: 956 with NIV and 272 with TIV. There was no significant difference in the assisted ventilation use according to sex, whereas different patterns of discrepancies were noted between the sexes: Females living in non-metropolitan areas showed decreased use of assisted ventilation, whereas high income levels showed a positive relationship with assisted ventilation use only in males. Patients aged ≥ 70 years showed decreased use of NIV. NIV use was more affected by socioeconomic status than TIV, whereas TIV showed a significant relationship with medical conditions such as nasogastric tube insertion and gastrostomy. We found that various factors, including age, socioeconomic status, and medical condition, were related with assisted ventilation use. Understanding the pattern of assisted ventilation use would help set optimal management strategies in patients with ALS.
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Affiliation(s)
- Seo Yeon Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Han-Kyoul Kim
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Republic of Korea.,National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital, Yang-Pyeong, Republic of Korea
| | - Mi Ji Kim
- Department of Biostatistics and Computing, Yonsei University Graduate School, Seoul, Republic of Korea
| | - Jee Hyun Suh
- Department of Rehabilitation Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Ja-Ho Leigh
- Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Republic of Korea. .,National Traffic Injury Rehabilitation Research Institute, National Traffic Injury Rehabilitation Hospital, Yang-Pyeong, Republic of Korea. .,Department of Rehabilitation Medicine, Seoul National University College of Medicine, 101, Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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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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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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Rudnicki SA, Andrews JA, Bian A, Cockroft BM, Cudkowicz ME, Hardiman O, Malik FI, Meng L, Wolff AA, Shefner JM. Noninvasive ventilation use by patients enrolled in VITALITY-ALS. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:486-494. [PMID: 33792451 DOI: 10.1080/21678421.2021.1904993] [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: 10/21/2022]
Abstract
Objectives: To evaluate the prescribing practices of noninvasive ventilation (NIV) and patient compliance during VITALITY-ALS. Methods: VITALITY-ALS enrolled patients with a slow vital capacity (SVC) ≥70% of predicted who were not using NIV at screening. Physicians prescribed NIV without restriction following randomization. Reason(s) for NIV prescription, dates prescribed and initiated, and compliance were recorded. Compliance was recorded as prescribed but never initiated, used ≥2 h/24 h, used ≥4 h/24 h, or used ≥22 h/24 h. In addition to other outcome measures, SVC and the revised ALS functional rating scale (ALSFRS-R) were performed at all visits. Patients were followed up to 56 weeks. Results: 565 patients were randomized and dosed with placebo or tirasemtiv in VITALITY-ALS; 195 (34.5%) were prescribed NIV: of these, 78.5% used it for ≥2 h/24 h, 71.3% for ≥4 h/24 h, and 11.8% for ≥22 h/24 h. The three most common reasons NIV was prescribed were decline in vital capacity, respiratory symptoms, and sleep-related symptoms. During the trial, 179/565 (31.7%) patients had a decline of SVC below 50%; of these patients, 122/179 (68.2%) were prescribed NIV. Reasons for prescribing NIV were different for patients from North America compared with Europe. Conclusions: Despite allowing for NIV initiation at any point following randomization in VITALITY-ALS, only slightly more than two out of three patients whose SVC fell below 50% were prescribed NIV; this was similar in Europe and in North America. Underutilization of NIV could influence survival outcomes in patients with ALS including those involved in clinical trials.
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Affiliation(s)
- Stacy A Rudnicki
- Clinical Research and Development, Cytokinetics, Inc, South San Francisco, CA, USA
| | - Jinsy A Andrews
- The Eleanor and Lou Gehrig ALS Center, The Neurological Institute, New York, NY, USA
| | - Amy Bian
- Clinical Research and Development, Cytokinetics, Inc, South San Francisco, CA, USA
| | - Bettina M Cockroft
- Clinical Research and Development, Cytokinetics, Inc, South San Francisco, CA, USA
| | - Merit E Cudkowicz
- Department of Neurology, Neurological Clinical Research Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Orla Hardiman
- Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Trinity College, Dublin, Ireland
| | - Fady I Malik
- Clinical Research and Development, Cytokinetics, Inc, South San Francisco, CA, USA
| | - Lisa Meng
- Clinical Research and Development, Cytokinetics, Inc, South San Francisco, CA, USA
| | - Andrew A Wolff
- Clinical Research and Development, Cytokinetics, Inc, South San Francisco, CA, USA
| | - Jeremy M Shefner
- St. Joseph's Hospital and Medical Cente, Barrow Neurological Institute, Phoenix, AZ, USA
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Spittel S, Maier A, Kettemann D, Walter B, Koch B, Krause K, Norden J, Münch C, Meyer T. Non-invasive and tracheostomy invasive ventilation in amyotrophic lateral sclerosis: Utilization and survival rates in a cohort study over 12 years in Germany. Eur J Neurol 2020; 28:1160-1171. [PMID: 33210770 DOI: 10.1111/ene.14647] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/29/2020] [Accepted: 11/08/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to investigate utilization rates, treatment pathways and survival prognosis in patients with amyotrophic lateral sclerosis (ALS) undergoing non-invasive (NIV) and tracheostomy invasive ventilation (TIV) in a real-world setting. METHODS A prospective cohort study using a single-centre register of 2702 ALS patients (2007 to 2019) was conducted. Utilization of NIV/TIV and survival data were analysed in three cohorts: (i) non-NIV; (ii) NIV (NIV without subsequent TIV); and (iii) TIV (including TIV preceded by NIV). RESULTS A total of 1720 patients with available data were identified, 72.0% of whom (n = 1238) did not receive ventilation therapy. NIV was performed in 20.8% of patients (n = 358). TIV was performed in 9.5% of patients (n = 164), encompassing both primary TIV (7.2%, n = 124) and TIV with preceding NIV (2.3%, n = 40). TIV was more often utilized without previous NIV (25.7% vs. 8.3% of all ventilated patients), demonstrating that primary TIV was the prevailing pathway for invasive ventilation. The median (range) survival was significantly longer in the NIV cohort (40.8 [37.2-44.3] months) and the TIV cohort (82.1 [68.7-95.6] months) as compared to the non-NIV cohort (33.6 [31.6-35.7] months). CONCLUSIONS Although NIV represents the standard of care, its utilization rate was low. TIV was mainly started without preceding NIV, suggesting that TIV may not be confined to NIV treatment escalation. However, TIV was pursued in a minority of patients who had previously undergone NIV. The survival benefit observed in the patients with NIV was equal to that reported in a controlled pivotal trial, but the prognosis with TIV is highly variable. The determinants of utilization of NIV/TIV and of survival (bulbar syndrome, availability of ventilation-related home nursing, cultural factors) warrant further investigation.
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Affiliation(s)
- Susanne Spittel
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
| | - André Maier
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dagmar Kettemann
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bertram Walter
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Birgit Koch
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kerstin Krause
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jenny Norden
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Münch
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
| | - Thomas Meyer
- Department of Neurology, Center for ALS and other Motor Neuron Disorders, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
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Helleman J, Kruitwagen-van Reenen ET, Bakers J, Kruithof WJ, van Groenestijn AC, Jaspers Focks RJH, de Grund A, van den Berg LH, Visser-Meily JMA, Beelen A. Using patient-reported symptoms of dyspnea for screening reduced respiratory function in patients with motor neuron diseases. J Neurol 2020; 267:3310-3318. [PMID: 32577867 PMCID: PMC7578163 DOI: 10.1007/s00415-020-10003-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/10/2020] [Accepted: 06/16/2020] [Indexed: 12/11/2022]
Abstract
Background Poor monitoring of respiratory function may lead to late initiation of non-invasive ventilation (NIV) in patients with motor neuron diseases (MND). Monitoring could be improved by remotely assessing hypoventilation symptoms between clinic visits. We aimed to determine which patient-reported hypoventilation symptoms are best for screening reduced respiratory function in patients with MND, and compared them to the respiratory domain of the amyotrophic lateral sclerosis functional rating scale (ALSFRS-R). Methods This prospective multi-center study included 100 patients with MND, who were able to perform a supine vital capacity test. Reduced respiratory function was defined as a predicted supine vital capacity ≤ 80%. We developed a 14-item hypoventilation symptom questionnaire (HYSQ) based on guidelines, expert opinion and think-aloud interviews with patients. Symptoms of the HYSQ were related to dyspnea, sleep quality, sleepiness/fatigue and pneumonia. The diagnostic performances of these symptoms and the ALSFRS-R respiratory domain were determined from the receiver operating characteristic (ROC) curves, area under the curve (AUC), sensitivity, specificity, predictive values and accuracy. Results Dyspnea-related symptoms (dyspnea while eating/talking, while lying flat and during light activity) were combined into the MND Dyspnea Scale (MND-DS). ROC curves showed that the MND-DS had the best diagnostic performance, with the highest AUC = 0.72, sensitivity = 75% and accuracy = 71%. Sleep-quality symptoms, sleepiness/fatigue-related symptoms and the ALSFRS-R respiratory domain showed weak diagnostic performance. Conclusion The diagnostic performance of the MND-DS was better than the respiratory domain of the ALSFRS-R for screening reduced respiratory function in patients with MND, and is, therefore, the preferred method for (remotely) monitoring respiratory function. Electronic supplementary material The online version of this article (10.1007/s00415-020-10003-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jochem Helleman
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Esther T Kruitwagen-van Reenen
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - J Bakers
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Willeke J Kruithof
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Annerieke C van Groenestijn
- Department of Rehabilitation, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | | | - Arthur de Grund
- Basalt, Center for Rehabilitation, Den Haag, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna M A Visser-Meily
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands
| | - Anita Beelen
- Department of Rehabilitation, Physical Therapy Science and Sports, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- Center of Excellence for Rehabilitation Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, and De Hoogstraat Rehabilitation, Utrecht, The Netherlands.
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Panchabhai TS, Mireles Cabodevila E, Pioro EP, Wang X, Han X, Aboussouan LS. Pattern of lung function decline in patients with amyotrophic lateral sclerosis: implications for timing of noninvasive ventilation. ERJ Open Res 2019; 5:00044-2019. [PMID: 31579678 PMCID: PMC6759589 DOI: 10.1183/23120541.00044-2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 07/20/2019] [Indexed: 12/11/2022] Open
Abstract
Background The course of lung function decline in amyotrophic lateral sclerosis (ALS) and the effect of noninvasive positive-pressure ventilation (NIPPV) on that decline are uncertain. We sought to model lung function decline, determine when NIPPV is initiated along that course, and assess its impact on the course of decline. Methods An observed sigmoid pattern of forced vital capacity decline was reproduced with a four-parameter nonlinear mixed-effects logistic model. Results Analyses were performed on 507 patients overall and in 353 patients for whom a determination of adherence to NIPPV was ascertained. A sigmoid bi-asymptotic model provided a statistical fit of the data and showed a period of stable vital capacity, followed by an accelerated decline, an inflection point, then a slowing in decline to a plateau. By the time NIPPV was initiated in accordance with reimbursement guidelines, vital capacity had declined by ≥85% of the total range. Nearly half of the total loss of vital capacity occurred over 6.2 months centred at an inflection point occurring 17 months after disease onset and 5.2 months before initiation of NIPPV at a vital capacity of about 60%. Fewer bulbar symptoms and a faster rate of decline of lung function predicted adherence to NIPPV, but the intervention had no impact on final vital capacity. Conclusions In patients with ALS, vital capacity decline is rapid but slows after an inflection point regardless of NIPPV. Initiating NIPPV along reimbursement guidelines occurs after ≥85% of vital capacity loss has already occurred. In patients with amyotrophic lateral sclerosis, vital capacity decline is rapid but slows after an inflection point regardless of NIPPV. Initiation of NIPPV according to guidelines occurs when >85% of vital capacity loss has already occurred.http://bit.ly/2JOiEZG
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Affiliation(s)
- Tanmay S Panchabhai
- Section of Interventional Pulmonology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Erik P Pioro
- Dept of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaofeng Wang
- Dept of Qualitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Xiaozhen Han
- Dept of Qualitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Loutfi S Aboussouan
- Dept of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Dept of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
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