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Sarmet M, Santos DB, Mangilli LD, Million JL, Maldaner V, Zeredo JL. Chronic respiratory failure negatively affects speech function in patients with bulbar and spinal onset amyotrophic lateral sclerosis: retrospective data from a tertiary referral center. LOGOP PHONIATR VOCO 2024; 49:17-26. [PMID: 35767076 DOI: 10.1080/14015439.2022.2092209] [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: 03/22/2021] [Revised: 02/04/2022] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
Background: Although dysarthria and respiratory failure are widely described in literature as part of the natural history of Amyotrophic lateral sclerosis (ALS), the specific interaction between them has been little explored.Aim: To investigate the relationship between chronic respiratory failure and the speech of ALS patients.Materials and methods: In this cross-sectional retrospective study we reviewed the medical records of all patients diagnosed with ALS that were accompanied by a tertiary referral center. In order to determine the presence and degree of speech impairment, the Amyotrophic Lateral Sclerosis Functional Rating Scale-revised (ALSFRS-R) speech sub-scale was used. Respiratory function was assessed through spirometry and through venous blood gasometry obtained from a morning peripheral venous sample. To determine whether differences among groups classified by speech function were significant, maximum and mean spirometry values of participants were compared using multivariate analysis of variance (MANOVA) with Tukey's post hoc test.Results: Seventy-five cases were selected, of which 73.3% presented speech impairment and 70.7% respiratory impairment. Respiratory and speech functions were moderately correlated (seated FVC r = 0.64; supine FVC r = 0.60; seated FEV1 r = 0.59 and supine FEV1 r = 0.54, p < .001). Multivariable logistic regression revealed that the following variables were significantly associated with the presence of speech impairment after adjusting for other risk factors: seated FVC (odds ratio [OR] = 0.862) and seated FEV1 (OR = 1.106). The final model was 81.1% predictive of speech impairment. The presence of daytime hypercapnia was not correlated to increasing speech impairment.Conclusion: The restrictive pattern developed by ALS patients negatively influences speech function. Speech is a complex and multifactorial process, and lung volume presents a pivotal role in its function. Thus, we were able to find that lung volumes presented a significant correlation to speech function, especially in those with bulbar onset and respiratory impairment. Neurobiological and physiological aspects of this relationship should be explored in further studies with the ALS population.
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Affiliation(s)
- Max Sarmet
- Graduate Department of Health Science and Technology, University of Brasília (UnB), Brasília, Brazil
- Hospital de Apoio de Brasília (HAB), Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil
| | - Dante Brasil Santos
- Hospital de Apoio de Brasília (HAB), Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil
- UniEvangélica, Graduate Program of Human Movement and Rehabilitation, Anápolis, Brazil
| | | | - Janae Lyon Million
- Department of Human Biology, University of California Santa Cruz, Santa Cruz, CA, United States of America
| | - Vinicius Maldaner
- Hospital de Apoio de Brasília (HAB), Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil
- UniEvangélica, Graduate Program of Human Movement and Rehabilitation, Anápolis, Brazil
| | - Jorge L Zeredo
- Graduate Department of Health Science and Technology, University of Brasília (UnB), Brasília, Brazil
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Pandit C, Kennedy B, Waters K, Young H, Jones K, Fitzgerald DA. Can postural changes in spirometry in children with Duchenne muscular dystrophy predict sleep hypoventilation? Paediatr Respir Rev 2024; 49:9-13. [PMID: 37696714 DOI: 10.1016/j.prrv.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Abstract
AIM To explore the relationship between postural changes in lung function and polysomnography (PSG) in children with Duchenne muscular dystrophy (DMD). METHODS In this prospective cross-sectional study, children with DMD performed spirometry in sitting and supine positions. A control group of age and gender matched healthy children also underwent postural lung function testing. PSG was performed within six months of spirometry. RESULTS Seventeen children with DMD, aged 12.3 ± 3 years performed sitting spirometry. 14 (84%) performed acceptable spirometry in the supine position. Mean FEV1sit and FVCsit were 77% (SD ± 22) and 74% (SD ± 20.4) respectively, with mean% ΔFVC(sit-sup) 9% (SD ± 11) (range 2% to 20%), and was significantly greater than healthy controls 4% (n = 30, SD ± 3, P < 0.001). PSG data on the 14 DMD children with acceptable supine spirometry showed total AHI 6.9 ± 5.9/hour (0.3 to 29), obstructive AHI 5.2 ± 4.0/hour (0.2 to 10), and REM AHI 14.1 ± -5.3/hour (0.1 to 34.7). ΔFVC(sit-sup) had poor correlation with hypoventilation on polysomnography. CONCLUSION Children with DMD and mild restrictive lung disease showed greater postural changes in spirometry than healthy controls but lower supine spirometry was not predictive of sleep hypoventilation.
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Affiliation(s)
- C Pandit
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
| | - B Kennedy
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - K Waters
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - H Young
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Neurogenetics Service, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - K Jones
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Neurogenetics Service, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - D A Fitzgerald
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia; Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Walter U, Sobiella G, Prudlo J, Batchakaschvili M, Böhmert J, Storch A, Hermann A. Ultrasonic detection of vagus, accessory, and phrenic nerve atrophy in amyotrophic lateral sclerosis: Relation to impairment and mortality. Eur J Neurol 2024; 31:e16127. [PMID: 37933884 DOI: 10.1111/ene.16127] [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: 06/06/2023] [Revised: 09/01/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND AND PURPOSE In amyotrophic lateral sclerosis (ALS), phrenic nerve (PN) atrophy has been found, whereas there is controversy regarding vagus nerve (VN) atrophy. Here, we aimed to find out whether PN atrophy is related to respiratory function and 12-month survival. Moreover, we investigated the relevance of VN and spinal accessory nerve (AN) atrophy in ALS. METHODS This prospective observational monocentric study included 80 adult participants (40 ALS patients, 40 age- and sex-matched controls). The cross-sectional area (CSA) of bilateral cervical VN, AN, and PN was measured on high-resolution ultrasonography. Clinical assessments included the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R), the Non-Motor Symptoms Questionnaire, and handheld spirometry of forced vital capacity (FVC). One-year survival was documented. RESULTS The CSA of each nerve, VN, AN, and PN, was smaller in ALS patients compared to controls. VN atrophy was unrelated to nonmotor symptom scores. PN CSA correlated with the respiratory subscore of the ALSFRS-R (Spearman test, r = 0.59, p < 0.001), the supine FVC (r = 0.71, p < 0.001), and the relative change of sitting-supine FVC (r = -0.64, p = 0.001). Respiratory impairment was predicted by bilateral mean PN CSA (p = 0.046, optimum cutoff value of ≤0.37 mm2 , sensitivity = 92%, specificity = 56%) and by the sum of PN and AN CSA (p = 0.036). The combination of ALSFRS-R score with PN and AN CSA measures predicted 1-year survival with similar accuracy as the combination of ALSFRS-R score and FVC. CONCLUSIONS Ultrasonography detects degeneration of cranial nerve motor fibers. PN and AN calibers are tightly related to respiratory function and 1-year survival in ALS.
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Affiliation(s)
- Uwe Walter
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen Rostock/Greifswald, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock, Rostock University Medical Center, Rostock, Germany
| | - Gretlies Sobiella
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Translational Neurodegeneration Section "Albrecht Kossel," Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Johannes Prudlo
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen Rostock/Greifswald, Rostock, Germany
| | | | - Jan Böhmert
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Alexander Storch
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
- Deutsches Zentrum für Neurodegenerative Erkrankungen Rostock/Greifswald, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock, Rostock University Medical Center, Rostock, Germany
| | - Andreas Hermann
- Deutsches Zentrum für Neurodegenerative Erkrankungen Rostock/Greifswald, Rostock, Germany
- Center for Transdisciplinary Neurosciences Rostock, Rostock University Medical Center, Rostock, Germany
- Translational Neurodegeneration Section "Albrecht Kossel," Department of Neurology, Rostock University Medical Center, Rostock, Germany
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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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Georges M, Perez T, Rabec C, Jacquin L, Finet-Monnier A, Ramos C, Patout M, Attali V, Amador M, Gonzalez-Bermejo J, Salachas F, Morelot-Panzini C. Proposals from a French expert panel for respiratory care in ALS patients. Respir Med Res 2022; 81:100901. [PMID: 35378353 DOI: 10.1016/j.resmer.2022.100901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive diaphragm weakness and deteriorating lung function. Bulbar involvement and cough weakness contribute to respiratory morbidity and mortality. ALS-related respiratory failure significantly affects quality of life and is the leading cause of death. Non-invasive ventilation (NIV), which is the main recognized treatment for alleviating the symptoms of respiratory failure, prolongs survival and improves quality of life. However, the optimal timing for the initiation of NIV is still a matter of debate. NIV is a complex intervention. Multiple factors influence the efficacy of NIV and patient adherence. The aim of this work was to develop practical evidence-based advices to standardize the respiratory care of ALS patients in French tertiary care centres. METHODS For each proposal, a French expert panel systematically searched an indexed bibliography and prepared a written literature review that was then shared and discussed. A combined draft was prepared by the chairman for further discussion. All of the proposals were unanimously approved by the expert panel. RESULTS The French expert panel updated the criteria for initiating NIV in ALS patients. The most recent criteria were established in 2005. Practical advice for NIV initiation were included and the value of each tool available for NIV monitoring was reviewed. A strategy to optimize NIV parameters was suggested. Revisions were also suggested for the use of mechanically assisted cough devices in ALS patients. CONCLUSION Our French expert panel proposes an evidence-based review to update the respiratory care recommendations for ALS patients in daily practice.
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Affiliation(s)
- M Georges
- Department of Respiratory Diseases and Intensive Care, Reference Center for Adult Rare Pulmonary Diseases, University Hospital of Dijon-Bourgogne, Dijon, France; University of Bourgogne Franche-Comté, Dijon France; Centre des Sciences du Goût et de l'Alimentation, UMR 6265 CNRS 1234 INRA, University of Bourgogne Franche-Comté, Dijon, France.
| | - T Perez
- Department of Respiratory Diseases, University Hospital of Lille, Lille, France; Centre for Infection and Immunity of Lille, INSERM U1019-UMR9017, University of Lille Nord de France, Lille, France
| | - C Rabec
- Department of Respiratory Diseases and Intensive Care, Reference Center for Adult Rare Pulmonary Diseases, University Hospital of Dijon-Bourgogne, Dijon, France; University of Bourgogne Franche-Comté, Dijon France
| | - L Jacquin
- Clinical Training Manager for ResMed SAS company, Saint-Priest, France
| | - A Finet-Monnier
- Department of Neuromuscular Disorders and ALS, University Hospital of Timone, Marseille, France
| | - C Ramos
- CRMR SLA-MNM, Hôpital Pasteur 2, University Hospital of Nice, Nice, France
| | - M Patout
- Service des Pathologies du Sommeil (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France
| | - V Attali
- Service des Pathologies du Sommeil (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France
| | - M Amador
- Neurology Department, Paris ALS center, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - J Gonzalez-Bermejo
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France; Service de Pneumologie (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - F Salachas
- Neurology Department, Paris ALS center, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - C Morelot-Panzini
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France; Service de Pneumologie (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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Brault M, Gabrysz-Forget F, Dubé BP. Predictive value of positional change in vital capacity to identify diaphragm dysfunction. Respir Physiol Neurobiol 2021; 289:103668. [PMID: 33812064 DOI: 10.1016/j.resp.2021.103668] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 03/09/2021] [Accepted: 03/25/2021] [Indexed: 01/02/2023]
Abstract
RATIONALE Sitting-to-supine fall in vital capacity (ΔVC) can be used to help identify diaphragm dysfunction (DD), but its optimal predictive threshold value is uncertain. Our aim was to evaluate the diagnostic performance of ΔVC in identifying the presence of unilateral or bilateral DD. METHODS Patients referred to the diaphragm dysfunction clinic of our center (2017-2018) were included. All subjects had lung function testing (including measurement of ΔVC) and an ultrasound assessment of diaphragm thickening fraction (TFdi). Unilateral DD was defined as a single hemidiaphragm with TFdi ≤30 % and bilateral DD as a mean TFdi value of both hemidiaphragms ≤30 %. Clinical and physiological characteristics were compared across groups, and sensitivity/specificity analyses of ΔVC to identify DD were performed. RESULTS 84 patients were included (31 unilateral DD, 17 bilateral DD and 36 without significant DD). DD groups had similar age, gender and BMI (all p > 0.05), but patients with bilateral DD had lower FVC, FEV1, MIP, TLC, ΔVC and more frequent orthopnea than patients with unilateral DD (all p < 0.05). There was a significant correlation between TFdi and ΔVC (rho=-0.56, p < 0.001). The optimal ΔVC value to identify bilateral DD was ≤-15 % [AUC 0.97 (95 %CI 0.89-1.00), p < 0.001, with sensitivity and specificity of 100 % and 89 %, respectively]. No single threshold of ΔVC could accurately predict unilateral DD [AUC 0.58 (95 %CI 0.45-0.72), p = 0.24]. CONCLUSION ΔVC performs poorly in identifying patients with unilateral DD. However, a ΔVC value ≤-15 % is strongly associated with the presence of bilateral DD. These findings should be taken into account when using ΔVC in the evaluation of patients with suspected DD.
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Affiliation(s)
- Marilyne Brault
- Département de Médecine, Service de Pneumologie, Centre Hospitalier de l'Université de Montréal (CHUM) Montréal, Québec, Canada
| | - Fanny Gabrysz-Forget
- Département de Médecine, Centre Hospitalier de l'Université de Montréal (CHUM) Montréal, Québec, Canada
| | - Bruno-Pierre Dubé
- Département de Médecine, Service de Pneumologie, Centre Hospitalier de l'Université de Montréal (CHUM) Montréal, Québec, Canada; Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Carrefour de l'Innovation et de l'Évaluation en Santé, Montréal, Québec, Canada.
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Sarmet M, Mangilli LD, Costa GP, Paes JPRS, Codeço VM, Million JL, Maldaner V. The relationship between pulmonary and swallowing functions in patients with neuromuscular diseases followed up by a tertiary referral center: a cross-sectional study. LOGOP PHONIATR VOCO 2021; 47:117-124. [PMID: 33586591 DOI: 10.1080/14015439.2021.1879254] [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: 10/22/2022]
Abstract
INTRODUCTION Respiratory muscle weakness is common in patients with neuromuscular diseases (NMD). This puts them at risk for dysphagia and other pulmonary complications. OBJECTIVES To investigate the relationship between pulmonary function and swallowing in NMD. MATERIALS AND METHODS In this cross-sectional study, medical records of patients undergoing treatment at the Tertiary Referral Center for Neuromuscular Diseases of Hospital de Apoio de Brasília, Brazil, were reviewed. Respiratory function was assessed through spirometry (FVC and FEV1 measured) and swallowing assessed by the Dysphagia Risk Evaluation Protocol and the Functional Oral Intake Scale. RESULTS Two hundred and twenty-two patients were included. Dysphagia was present in 46.8% of patients and impairment of pulmonary function in 64.0%. The mean FVC observed was 66.9% and FEV1 was 66.0%, indicating restrictive lung disease. A correlation between the decline of pulmonary and swallowing functions was observed in patients with NMDs (FVC vs. DREP, R = 0.46; FVC vs. FOIS, R = 0.42; FEV1 vs. DREP, R = 0.42; FEV1 vs. FOIS, R = 0.40, p<.01). FVC and FEV1 values tend to be lower in patients with dysphagia in the context of NMD. CONCLUSIONS A positive correlation between pulmonary function and swallowing outcomes was observed in patients with NMD. Despite respiratory and swallowing impairment being widely present in the population with NMD, they require different treatments according to the disease's pathophysiology. Future studies should be conducted to explore the disease-specific relationship between pulmonary function and swallowing in patients with NMD.
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Affiliation(s)
- Max Sarmet
- Departments of Speech Therapy and Physical Therapy, Hospital de Apoio de Brasília, Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil.,Graduate Department of Health Sciences and Technologies, University of Brasília (UnB), Brasília, Brazil
| | | | - Geovanna Pereira Costa
- Undergraduate Program, College of Medicine, Escola Superior de Ciências da Saúde, Brasília, Brazil
| | | | - Vitor Martins Codeço
- Department of Thoracic Diseases, Hospital Regional da Asa Norte, Brasília, Brazil
| | - Janae Lyon Million
- Department of Human Biology, University of California, Santa Cruz, CA, USA
| | - Vinicius Maldaner
- Departments of Speech Therapy and Physical Therapy, Hospital de Apoio de Brasília, Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil.,Undergraduate Program, College of Medicine, Escola Superior de Ciências da Saúde, Brasília, Brazil
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Vogt S, Schreiber S, Pfau G, Kollewe K, Heinze HJ, Dengler R, Petri S, Vielhaber S, Brinkers M. Dyspnea as a Fatigue-Promoting Factor in ALS and the Role of Objective Indicators of Respiratory Impairment. J Pain Symptom Manage 2020; 60:430-438.e1. [PMID: 32145336 DOI: 10.1016/j.jpainsymman.2020.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 11/19/2022]
Abstract
CONTEXT There is no evidence-based treatment for fatigue in amyotrophic lateral sclerosis (ALS), and identification of treatable causes determines management strategies. Although dyspnea is a key symptom of ALS and effectively treatable, it has not been sufficiently investigated whether dyspnea may be a fatigue-promoting factor. OBJECTIVES To determine the level of fatigue in dyspneic ALS patients and whether fatigue is promoted by dyspnea. We further evaluated the correlation of fatigue with respiratory function tests. METHODS About 101 dyspneic patients and 20 matched controls completed the ALS Functional Rating Scale-Extension and the Fatigue Severity Scale. Dyspneic patients additionally completed the Dyspnea-ALS Scale and the ALS Assessment Questionnaire and underwent respiratory function tests (forced vital capacity, sniff nasal inspiratory pressure, mean inspiratory and expiratory pressure with respective relaxation rates, and blood gases). Multiple regression and correlation analyses were conducted. RESULTS Dyspneic patients had significantly higher fatigue scores than nondyspneic patients, and their fatigue significantly affected quality of life. Dyspnea alone explained up to 24% of the variance in fatigue. No associations were observed between fatigue and respiratory function tests. Patients with noninvasive ventilation reported significantly more dyspnea and fatigue. CONCLUSION Fatigue is a frequent and bothersome symptom in dyspneic ALS patients. Dyspnea-related distress is, in contrast to objective indicators of respiratory impairment, a determining factor of experienced fatigue. There is an urgent need for further symptom relief beyond noninvasive ventilation. Adequate treatment of dyspnea has the potential for synergies in symptom management arising from the association between fatigue and dyspnea.
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Affiliation(s)
- Susanne Vogt
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany.
| | - Stefanie Schreiber
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - Giselher Pfau
- Department of Anesthesiology and Intensive Care, Otto-von-Guericke University, Magdeburg, Germany
| | - Katja Kollewe
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Hans-Jochen Heinze
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany; German Center for Neurodegenerative Diseases, Magdeburg, Germany; Leibniz Institute for Neurobiology, Magdeburg, Germany
| | - Reinhard Dengler
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Stefan Vielhaber
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany; German Center for Neurodegenerative Diseases, Magdeburg, Germany
| | - Michael Brinkers
- Department of Anesthesiology and Intensive Care, Otto-von-Guericke University, Magdeburg, Germany
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Pirola A, De Mattia E, Lizio A, Sannicolò G, Carraro E, Rao F, Sansone V, Lunetta C. The prognostic value of spirometric tests in Amyotrophic Lateral Sclerosis patients. Clin Neurol Neurosurg 2019; 184:105456. [PMID: 31382080 DOI: 10.1016/j.clineuro.2019.105456] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/24/2019] [Accepted: 07/28/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Amyotrophic lateral sclerosis (ALS) patients tend to develop progressive respiratory muscle weakness, leading to ventilatory failure and ineffective cough, principal causes of morbidity and mortality. Since patients are usually unaware of these symptoms, these are generally not noticed until the advanced stages and are associated with poor prognosis. The monitoring of respiratory function on a regular basis is therefore of great importance. Despite the availability of several pulmonary function tests, none of them was found to be the best indicator of the disease progression throughout the course of this condition. The main aim of our work was to evaluate the prognostic value of these respiratory measures evaluated in a brief period of observation and their correlation with motor functional impairments in an ALS cohort. PATIENTS AND METHODS Patients with ALS who had respiratory assessments performed and functional motor scales administered at baseline and six months later were included. All patients were assessed with forced vital capacity, both in seated and supine position (FVC; sFVC), peak expiratory flow (PEF), peak expiratory cough flow (PCEF), the revised ALS functional rating scale (ALSFRS-R), at baseline and after six months, and their disease progression rate (ΔFS) was obtained. RESULTS We included 73 patients with probable or definite ALS according to El-Escorial revised Criteria. At baseline, PCEF and PEF significantly correlated with ALSFRS-R total, bulbar and spinal subscores and ΔFS, while FVC% significantly correlated with ΔFS. After 6 months all the respiratory parameters significantly correlated with ALSFRS-R and all its subscores. Longitudinally, FVC%, sFVC% and PCEF significantly correlated with ΔFS and some of ALSFRS-R subscores. As concerns the survival analysis, monthly declines of FVC% and sFVC%, significantly correlated with the survival. The worse prognosis in terms of survival was finally found in those whose FVC% and sFVC% dropped below their respective cut-offs. CONCLUSION Throughout the course of ALS disease, the monitoring of several respiratory markers, namely FVC, sFVC, PEF and PCEF, plays a critical role in predicting the prognosis of these subjects, both in terms of survival and functional ability. The implementation of monthly cut-offs in the evaluation of FVC and sFVC may allow a faster recognition of those patients with worse prognosis and therefore an optimized tailored clinical care, as well as a better stratification in clinical trials.
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Affiliation(s)
- Alice Pirola
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy.
| | - Elisa De Mattia
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy
| | - Andrea Lizio
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy
| | | | - Elena Carraro
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy
| | - Fabrizio Rao
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy
| | - Valeria Sansone
- NEuroMuscular Omnicentre, Fondazione Serena Onlus, Milan, Italy; Neurorehabilitation Unit, Dept. Biomedical Sciences of Health, University of Milan, Italy
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Vogt S, Schreiber S, Kollewe K, Körner S, Heinze HJ, Dengler R, Petri S, Vielhaber S. Dyspnea in amyotrophic lateral sclerosis: The Dyspnea-ALS-Scale (DALS-15) essentially contributes to the diagnosis of respiratory impairment. Respir Med 2019; 154:116-121. [PMID: 31234039 DOI: 10.1016/j.rmed.2019.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/29/2019] [Accepted: 06/12/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Dyspnea is a cardinal but often underestimated symptom in amyotrophic lateral sclerosis (ALS). The newly developed Dyspnea-ALS-Scale (DALS-15) is highly relevant for therapeutic decisions because dyspnea is a separate criterion to consider noninvasive ventilation (NIV) in ALS. In comparison to the limited effects of neuroprotective compounds, NIV has the greatest impact on survival and improves quality of life. OBJECTIVE To investigate whether dyspnea corresponds to parameters of respiratory status mainly used in clinical neurological practice. We also investigated if the DALS-15 could help identify patients for consideration of NIV in whom neither spirometry nor blood gas parameters indicate the need for NIV (forced vital capacity (FVC) < 50% or probable <75%, pCO2 ≥45 mmHg). METHODS Seventy ALS patients with dyspnea according to the DALS-15 obtained blood gas analysis and spirometry (FVC in sitting and supine positions). The supine decline in FVC was calculated. RESULTS There was no linear relationship between dyspnea and spirometry as well as blood gases. 83% of our patients had an upright FVC still greater than 50% and no daytime hypercapnia. CONCLUSIONS Our study clearly shows that dyspnea can occur independently of objective indicators of respiratory impairment like spirometry or blood gases. Hence, the DALS-15 covers another aspect of respiratory impairment than these tests and refers to the subjective component of respiratory impairment. It detects dyspnea in a considerable proportion of patients in whom NIV should thus be considered although their spirometric and blood gas results do not point towards NIV. The DALS-15 therefore may help to improve the stratification of patients with respiratory impairment for more efficient symptom management and timely coordination of care.
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Affiliation(s)
- S Vogt
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany.
| | - S Schreiber
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany
| | - K Kollewe
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - S Körner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - H-J Heinze
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany; German Center for Neurodegenerative Diseases, Magdeburg, Germany; Leibniz Institute for Neurobiology, Magdeburg, Germany
| | - R Dengler
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - S Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - S Vielhaber
- Department of Neurology, Otto-von-Guericke University, Magdeburg, Germany; German Center for Neurodegenerative Diseases, Magdeburg, Germany
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11
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Laveneziana P, Albuquerque A, Aliverti A, Babb T, Barreiro E, Dres M, Dubé BP, Fauroux B, Gea J, Guenette JA, Hudson AL, Kabitz HJ, Laghi F, Langer D, Luo YM, Neder JA, O'Donnell D, Polkey MI, Rabinovich R, Rossi A, Series F, Similowski T, Spengler C, Vogiatzis I, Verges S. ERS statement on respiratory muscle testing at rest and during exercise. Eur Respir J 2019; 53:13993003.01214-2018. [DOI: 10.1183/13993003.01214-2018] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 02/18/2019] [Indexed: 12/12/2022]
Abstract
Assessing respiratory mechanics and muscle function is critical for both clinical practice and research purposes. Several methodological developments over the past two decades have enhanced our understanding of respiratory muscle function and responses to interventions across the spectrum of health and disease. They are especially useful in diagnosing, phenotyping and assessing treatment efficacy in patients with respiratory symptoms and neuromuscular diseases. Considerable research has been undertaken over the past 17 years, since the publication of the previous American Thoracic Society (ATS)/European Respiratory Society (ERS) statement on respiratory muscle testing in 2002. Key advances have been made in the field of mechanics of breathing, respiratory muscle neurophysiology (electromyography, electroencephalography and transcranial magnetic stimulation) and on respiratory muscle imaging (ultrasound, optoelectronic plethysmography and structured light plethysmography). Accordingly, this ERS task force reviewed the field of respiratory muscle testing in health and disease, with particular reference to data obtained since the previous ATS/ERS statement. It summarises the most recent scientific and methodological developments regarding respiratory mechanics and respiratory muscle assessment by addressing the validity, precision, reproducibility, prognostic value and responsiveness to interventions of various methods. A particular emphasis is placed on assessment during exercise, which is a useful condition to stress the respiratory system.
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12
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Laveneziana P, Niérat MC, LoMauro A, Aliverti A. A case of unexplained dyspnoea: when lung function testing matters! Breathe (Sheff) 2018; 14:325-332. [PMID: 30519301 PMCID: PMC6269186 DOI: 10.1183/20734735.025018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
“Lung function corner” articles in Breathe present the results of a lung function test and the authors then debate the interpretation, including potential controversies and background from the literature. As section editors of this newly created section of Breathe, we felt it was important to write the first article, which highlights the usefulness of lung function testing in guiding clinical diagnosis especially in difficult cases such the one we discuss here. Diverse methods are available for assessment of the respiratory muscles; the technique used should be tailored to the question posed.http://ow.ly/ChbX30m91bt
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Affiliation(s)
- Pierantonio Laveneziana
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service des Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée du Département R3S, Paris, France
| | - Marie-Cécile Niérat
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France
| | - Antonella LoMauro
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
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13
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Theme 12 Respiratory and nutritional management. Amyotroph Lateral Scler Frontotemporal Degener 2018; 19:325-352. [DOI: 10.1080/21678421.2018.1510582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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14
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Adler D, Janssens JP. The Pathophysiology of Respiratory Failure: Control of Breathing, Respiratory Load, and Muscle Capacity. Respiration 2018; 97:93-104. [PMID: 30423557 DOI: 10.1159/000494063] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 09/24/2018] [Indexed: 11/19/2022] Open
Abstract
The purpose of this review is to provide an overview on how interactions between control of breathing, respiratory load, and muscle function may lead to respiratory failure. The mechanisms involved vary according to the underlying pathology, but respiratory failure is most often the result of an imbalance between the muscular pump and the mechanical load placed upon it. Changes in respiratory drive and response to CO2 seem to be important contributors to the pathophysiology of respiratory failure. Inspiratory muscle dysfunction is also frequent but is not a mandatory prerequisite to respiratory failure since increased load may also be sufficient to precipitate it. It is crucial to recognize these interactions to be able to timeously establish patients on mechanical ventilation and adapt the ventilator settings to their respiratory system physiology.
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Affiliation(s)
- Dan Adler
- Division of Lung Diseases, University Hospitals of Geneva and Geneva Medical School, Geneva, Switzerland,
| | - Jean-Paul Janssens
- Division of Lung Diseases, University Hospitals of Geneva and Geneva Medical School, Geneva, Switzerland
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Katz S, Arish N, Rokach A, Zaltzman Y, Marcus EL. The effect of body position on pulmonary function: a systematic review. BMC Pulm Med 2018; 18:159. [PMID: 30305051 PMCID: PMC6180369 DOI: 10.1186/s12890-018-0723-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 09/17/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Pulmonary function tests (PFTs) are routinely performed in the upright position due to measurement devices and patient comfort. This systematic review investigated the influence of body position on lung function in healthy persons and specific patient groups. METHODS A search to identify English-language papers published from 1/1998-12/2017 was conducted using MEDLINE and Google Scholar with key words: body position, lung function, lung mechanics, lung volume, position change, positioning, posture, pulmonary function testing, sitting, standing, supine, ventilation, and ventilatory change. Studies that were quasi-experimental, pre-post intervention; compared ≥2 positions, including sitting or standing; and assessed lung function in non-mechanically ventilated subjects aged ≥18 years were included. Primary outcome measures were forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC, FEV1/FVC), vital capacity (VC), functional residual capacity (FRC), maximal expiratory pressure (PEmax), maximal inspiratory pressure (PImax), peak expiratory flow (PEF), total lung capacity (TLC), residual volume (RV), and diffusing capacity of the lungs for carbon monoxide (DLCO). Standing, sitting, supine, and right- and left-side lying positions were studied. RESULTS Forty-three studies met inclusion criteria. The study populations included healthy subjects (29 studies), lung disease (nine), heart disease (four), spinal cord injury (SCI, seven), neuromuscular diseases (three), and obesity (four). In most studies involving healthy subjects or patients with lung, heart, neuromuscular disease, or obesity, FEV1, FVC, FRC, PEmax, PImax, and/or PEF values were higher in more erect positions. For subjects with tetraplegic SCI, FVC and FEV1 were higher in supine vs. sitting. In healthy subjects, DLCO was higher in the supine vs. sitting, and in sitting vs. side-lying positions. In patients with chronic heart failure, the effect of position on DLCO varied. CONCLUSIONS Body position influences the results of PFTs, but the optimal position and magnitude of the benefit varies between study populations. PFTs are routinely performed in the sitting position. We recommend the supine position should be considered in addition to sitting for PFTs in patients with SCI and neuromuscular disease. When treating patients with heart, lung, SCI, neuromuscular disease, or obesity, one should take into consideration that pulmonary physiology and function are influenced by body position.
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Affiliation(s)
- Shikma Katz
- Chronic Ventilator-Dependent Division, Herzog Medical Center, POB 3900, Jerusalem, Israel
- 0000 0004 1937 0511grid.7489.2Recanati School for Community Health Professions, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Nissim Arish
- Pulmonary Institute, Shaare Zedek Medical Center, POB 3235, Jerusalem, Israel
- 0000 0004 1937 0538grid.9619.7Hebrew University-Hadassah Faculty of Medicine, Jerusalem, Israel
| | - Ariel Rokach
- Pulmonary Institute, Shaare Zedek Medical Center, POB 3235, Jerusalem, Israel
- 0000 0004 1937 0538grid.9619.7Hebrew University-Hadassah Faculty of Medicine, Jerusalem, Israel
| | - Yacov Zaltzman
- Chronic Ventilator-Dependent Division, Herzog Medical Center, POB 3900, Jerusalem, Israel
| | - Esther-Lee Marcus
- Chronic Ventilator-Dependent Division, Herzog Medical Center, POB 3900, Jerusalem, Israel
- 0000 0004 1937 0538grid.9619.7Hebrew University-Hadassah Faculty of Medicine, Jerusalem, Israel
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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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17
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Elman LB, Stanley L, Gibbons P, McCluskey L. A Cost Comparison of Hospice Care in Amyotrophic Lateral Sclerosis and Lung Cancer. Am J Hosp Palliat Care 2016; 23:212-6. [PMID: 17060281 DOI: 10.1177/1049909106289083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The authors compare the cost of hospice care provided to 25 amyotrophic lateral sclerosis (ALS) patients and 159 lung cancer patients by the Wissahickon Hospice of the University of Pennsylvania. The mean length of stay was 86.7 days for ALS patients and 35.0 days for patients with lung cancer ( P = .011). The mean per patient cost was $5622.93 for the ALS patients and $2658.91 for patients with lung cancer ( P = .057) The average operating margin excluding administrative costs was $5293.04 for ALS patients and $2126.74 for patients with lung cancer ( P = .008). The longer length of stay (LOS) accounts for this difference. Longer LOS can be accomplished by close clinical monitoring of ALS patients for the development of life threatening respiratory and/or nutritional compromise and by liberalizing the present hospice admission guidelines.
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Affiliation(s)
- Lauren B Elman
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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18
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Cho HE, Lee JW, Kang SW, Choi WA, Oh H, Lee KC. Comparison of Pulmonary Functions at Onset of Ventilatory Insufficiency in Patients With Amyotrophic Lateral Sclerosis, Duchenne Muscular Dystrophy, and Myotonic Muscular Dystrophy. Ann Rehabil Med 2016; 40:74-80. [PMID: 26949672 PMCID: PMC4775761 DOI: 10.5535/arm.2016.40.1.74] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 07/31/2015] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate pulmonary functions of patients with amyotrophic lateral sclerosis (ALS), Duchenne muscular dystrophy (DMD), and myotonic muscular dystrophy (MMD) at the onset of ventilatory insufficiency. METHODS This retrospective study included ALS, DMD, and MMD patients with regular outpatient clinic follow-up in the Department of Rehabilitation Medicine at Gangnam Severance Hospital before the application of non-invasive positive pressure ventilation (NIPPV). The patients were enrolled from August 2001 to March 2014. If patients experienced ventilatory insufficiency, they were treated with NIPPV, and their pulmonary functions were subsequently measured. RESULTS Ninety-four DMD patients, 41 ALS patients, and 21 MMD patients were included in the study. The mean SpO2 was lower in the MMD group than in the other two groups. The mean forced vital capacity (FVC) in the supine position was approximately low to mid 20% on average in DMD and ALS patients, whereas it was 10% higher in MMD patients. ALS patients showed a significantly lower FVC in the supine position than in the sitting position. Maximal insufflation capacity, unassisted peak cough flow, maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP) were significantly higher in MMD group than in the other groups. MEP was significantly the lowest in DMD patients, followed by in ALS, and MMD patients, in order. CONCLUSION Disease-specific values of pulmonary function, including FVC, MEP, and MIP, can be accurately used to assess the onset of ventilatory insufficiency in patients with ALS, DMD, and MMD.
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Affiliation(s)
- Han Eol Cho
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Jang Woo Lee
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Seong Woong Kang
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ah Choi
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Hyeonjun Oh
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Kil Chan Lee
- Department Rehabilitation Medicine and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, Korea
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Rudnicki S, McVey AL, Jackson CE, Dimachkie MM, Barohn RJ. Symptom Management and End-of-Life Care in Amyotrophic Lateral Sclerosis. Neurol Clin 2015; 33:889-908. [PMID: 26515628 PMCID: PMC5031364 DOI: 10.1016/j.ncl.2015.07.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The number of available symptomatic treatments has markedly enhanced the care of patients with amyotrophic lateral sclerosis (ALS). Once thought to be untreatable, patients with ALS today clearly benefit from multidisciplinary care. The impact of such care on the disease course, including rate of progression and mortality, has surpassed the treatment effects commonly sought in clinical drug trials. Unfortunately, there are few randomized controlled trials of medications or interventions addressing symptom management. In this review, the authors provide the level of evidence, when available, for each intervention that is currently considered standard of care by consensus opinion.
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Affiliation(s)
- Stacy Rudnicki
- University of Arkansas for Medical Sciences, 501 Jackson Stephens Drive, Room 769, Little Rock, Arkansas 72205-7199
| | - April L. McVey
- University of Kansas Medical Center, Dept. of Neurology, 3901 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160
| | - Carlayne E. Jackson
- University of Texas Health Science Center, 8300 Floyd Curl Drive, Mail Code 7883, San Antonio, TX 78229-3900
| | - Mazen M. Dimachkie
- University of Kansas Medical Center, Dept. of Neurology, 3901 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160
| | - Richard J. Barohn
- University of Kansas Medical Center, Dept. of Neurology, 3901 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160
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Won YH, Choi WA, Kim DH, Kang SW. Postural vital capacity difference with aging in duchenne muscular dystrophy. Muscle Nerve 2015; 52:722-7. [DOI: 10.1002/mus.24623] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Revised: 02/16/2015] [Accepted: 02/23/2015] [Indexed: 11/06/2022]
Affiliation(s)
- Yu Hui Won
- Department of Physical Medicine and Rehabilitation; Research Institute of Clinical Medicine, and Institute for medical science, Chonbuk National University Medical School & Hospital; Korea
- Yonsei University Graduate School of Medicine; Seoul Korea
| | - Won Ah Choi
- Department of Rehabilitation Medicine; Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine; Seoul Korea
| | - Dong Hyun Kim
- Department of Rehabilitation Medicine; Kangdong Sacred Heart Hospital, Hallym University College of Medicine; Seoul Korea 135-720
| | - Seong-Woong Kang
- Yonsei University Graduate School of Medicine; Seoul Korea
- Department of Rehabilitation Medicine; Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine; Seoul Korea
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21
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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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Poussel M, Kaminsky P, Renaud P, Laroppe J, Pruna L, Chenuel B. Supine changes in lung function correlate with chronic respiratory failure in myotonic dystrophy patients. Respir Physiol Neurobiol 2014; 193:43-51. [PMID: 24440340 DOI: 10.1016/j.resp.2014.01.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Revised: 01/07/2014] [Accepted: 01/08/2014] [Indexed: 10/25/2022]
Abstract
Quality of life and prognosis of patients with myotonic dystrophy type 1 (MD1) often depend on the degree of lung function impairment. This study was designed to assess the respective prevalence of ventilatory restriction, hypoxaemia and hypercapnia in MD1 patients and to determine whether postural changes in lung function could contribute to the early diagnosis of poor respiratory outcome. Fifty-eight patients (42.6±12.9 years) with MD1 were prospectively evaluated from April 2008 to June 2010 to determine their supine and upright lung function and arterial blood gases. The prevalence of ventilatory restriction was 36% and increased with the severity of muscular disability (from 7.7% to 70.6%). The prevalence of hypoxaemia and hypercapnia was 37.9% and 25.9%, respectively. Multiple regression analysis showed that the supine fall in FEV1 was the only variable associated with ventilatory restriction, hypoxaemia and hypercapnia. Our data indicate that supine evaluation of lung function could be helpful to predict poor respiratory outcome, which is closely correlated with hypoxaemia and/or hypercapnia.
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Affiliation(s)
- Mathias Poussel
- Department of Pulmonary Function Testing and Exercise Testing, CHU Nancy, Nancy F-54000, France; EA 3450 DevAH - Development, Adaptation and Disadvantage, Cardiorespiratory regulations and motor control, Université de Lorraine, F-54000, France.
| | - Pierre Kaminsky
- Department of Internal Medicine and Orphan Diseases, CHU Nancy, Nancy F-54000, France; Reference Centre in Inherited Metabolism Diseases, CHU Nancy, Nancy F-54000, France
| | - Pierre Renaud
- Department of Pulmonary Function Testing and Exercise Testing, CHU Nancy, Nancy F-54000, France; EA 3450 DevAH - Development, Adaptation and Disadvantage, Cardiorespiratory regulations and motor control, Université de Lorraine, F-54000, France
| | - Julien Laroppe
- Department of Pulmonary Function Testing and Exercise Testing, CHU Nancy, Nancy F-54000, France; EA 3450 DevAH - Development, Adaptation and Disadvantage, Cardiorespiratory regulations and motor control, Université de Lorraine, F-54000, France
| | - Lelia Pruna
- Department of Internal Medicine and Orphan Diseases, CHU Nancy, Nancy F-54000, France; Reference Centre in Inherited Metabolism Diseases, CHU Nancy, Nancy F-54000, France
| | - Bruno Chenuel
- Department of Pulmonary Function Testing and Exercise Testing, CHU Nancy, Nancy F-54000, France; EA 3450 DevAH - Development, Adaptation and Disadvantage, Cardiorespiratory regulations and motor control, Université de Lorraine, F-54000, France
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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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Radunovic A, Annane D, Rafiq MK, Mustfa N. Mechanical ventilation for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev 2013:CD004427. [PMID: 23543531 DOI: 10.1002/14651858.cd004427.pub3] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [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, also known as motor neuron disease, is a fatal neurodegenerative disease. Neuromuscular respiratory failure is the commonest cause of death, usually 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 first update of a review first published in 2009. OBJECTIVES The primary objective of the review is to examine the efficacy of mechanical ventilation (tracheostomy and non-invasive ventilation) in improving survival in ALS. The secondary objectives are to examine the effect of mechanical ventilation on functional measures of disease progression and quality of life in people with ALS; and assess adverse events related to the intervention. SEARCH METHODS We searched The Cochrane Neuromuscular Disease Group Specialized Register (1 May 2012), CENTRAL (2012, Issue 4), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), CINAHL Plus (January 1937 to April 2012), and AMED (January 1985 to April 2012). We also searched for ongoing studies on ClinicalTrials.gov. SELECTION CRITERIA Randomised and quasi-randomised controlled trials involving non-invasive or tracheostomy assisted ventilation in participants with a clinical diagnosis of amyotrophic lateral sclerosis, independent of the reported outcomes. We planned to include comparisons with no intervention or the best standard care. DATA COLLECTION AND ANALYSIS For the original review, four authors independently selected studies for assessment and two authors reviewed searches for this update. All authors extracted data independently 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 included studies. MAIN RESULTS For the original Cochrane review, the review authors identified and included two randomised controlled trials involving 54 participants with ALS receiving non-invasive ventilation. There were no new randomised or quasi-randomised controlled trials at this first update.Incomplete data were published for one study and we contacted the trial authors who were not able to provide the missing data. Therefore, the results of the review were based on a single study of 41 participants that compared non-invasive ventilation with standard care. It was a well conducted study with low risk of bias.The study showed that the overall median survival was significantly different between the group treated with non-invasive ventilation and the standard care group. The median survival in the non-invasive ventilation group was 48 days longer (219 days compared to 171 days for the standard care group (estimated 95% CI 12 to 91 days, P = 0.0062)). This survival benefit was accompanied by an enhanced quality of life. On subgroup analysis, the survival and quality of life benefit was much more in the subgroup with normal to moderately impaired bulbar function (20 participants); median survival was 205 days longer (216 days in NIV group versus 11 days in the standard care group, P = 0.0059). Non-invasive ventilation did not prolong survival in participants with poor bulbar function (21 participants), although it showed significant improvement in the mean symptoms domain of the Sleep Apnoea Quality of Life Index but not in the Short Form-36 Health Survey Mental Component Summary score. Neither trial reported clinical data on intervention related adverse effects. AUTHORS' CONCLUSIONS Evidence from a single randomised trial of non-invasive ventilation in 41 participants suggests that it significantly prolongs survival and improves or maintains quality of life in people with ALS. Survival and some measures of quality of life were significantly improved in the subgroup of people with better bulbar function, but not in those with severe bulbar impairment. Future studies should examine the health economics of NIV and factors influencing access to NIV. We need to understand the factors, personal and socioeconomic, that determine access to NIV.
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Vrijsen B, Testelmans D, Belge C, Robberecht W, Van Damme P, Buyse B. Non-invasive ventilation in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2013; 14:85-95. [DOI: 10.3109/21678421.2012.745568] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Hiwatani Y, Sakata M, Miwa H. Ultrasonography of the diaphragm in amyotrophic lateral sclerosis: Clinical significance in assessment of respiratory functions. Amyotroph Lateral Scler Frontotemporal Degener 2012; 14:127-31. [DOI: 10.3109/17482968.2012.729595] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Mandibuloptosis as a cause of supine choking in a patient with amyotrophic lateral sclerosis. J Neurol 2012; 259:1485-6. [PMID: 22274790 DOI: 10.1007/s00415-012-6416-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 01/06/2012] [Accepted: 01/08/2012] [Indexed: 11/27/2022]
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29
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Kim MK, Hwangbo G. The Effect of Position on Measured Lung Capacity of Patients with Spinal Cord Injury. J Phys Ther Sci 2012. [DOI: 10.1589/jpts.24.655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Gak Hwangbo
- Department of Physical Therapy, Daegu University
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McKim DA, Road J, Avendano M, Abdool S, Côté F, Duguid N, Fraser J, Maltais F, Morrison DL, O’Connell C, Petrof BJ, Rimmer K, Skomro R. Home mechanical ventilation: a Canadian Thoracic Society clinical practice guideline. Can Respir J 2011; 18:197-215. [PMID: 22059178 PMCID: PMC3205101 DOI: 10.1155/2011/139769] [Citation(s) in RCA: 126] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Increasing numbers of patients are surviving episodes of prolonged mechanical ventilation or benefitting from the recent availability of userfriendly noninvasive ventilators. Although many publications pertaining to specific aspects of home mechanical ventilation (HMV) exist, very few comprehensive guidelines that bring together all of the current literature on patients at risk for or using mechanical ventilatory support are available. The Canadian Thoracic Society HMV Guideline Committee has reviewed the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. The guideline provides a disease-specific review of illnesses including amyotrophic lateral sclerosis, spinal cord injury, muscular dystrophies, myotonic dystrophy, kyphoscoliosis, post-polio syndrome, central hypoventilation syndrome, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease as well as important common themes such as airway clearance and the process of transition to home. The guidelines have been extensively reviewed by international experts, allied health professionals and target audiences. They will be updated on a regular basis to incorporate any new information.
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Affiliation(s)
- Douglas A McKim
- Division of Respirology, University of Ottawa, and Respiratory Rehabilitation Services, Ottawa Hospital Sleep Centre, Ottawa, Ontario
| | - Jeremy Road
- Division of Respiratory Medicine and The Lung Centre, University of British Columbia, Provincial Respiratory Outreach Program, Vancouver, British Columbia
| | - Monica Avendano
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
| | - Steve Abdool
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
- Centre for Clinical Ethics at St Michael’s Hospital, West Park Healthcare Centre, and University of Toronto, Toronto, Ontario
| | | | - Nigel Duguid
- Eastern Health, Memorial University, St John’s, Newfoundland and Labrador
| | - Janet Fraser
- Respiratory Therapy Services, West Park Healthcare Centre, Toronto, Ontario
| | - François Maltais
- Research Centre, University Institute of Cardiology and Lung Health for Québec, Laval University, Québec, Québec
| | - Debra L Morrison
- Sleep Clinic and Laboratory, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia
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Park JH, Kang SW, Lee SC, Choi WA, Kim DH. How respiratory muscle strength correlates with cough capacity in patients with respiratory muscle weakness. Yonsei Med J 2010; 51:392-7. [PMID: 20376892 PMCID: PMC2852795 DOI: 10.3349/ymj.2010.51.3.392] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE The purpose of this study is to investigate how respiratory muscle strength correlates to cough capacity in patients with respiratory muscle weakness. MATERIALS AND METHODS Forty-five patients with amyotrophic lateral sclerosis (ALS), 43 with cervical spinal cord injury (SCI), and 42 with Duchenne muscular dystrophy (DMD) were recruited. Pulmonary function tests including forced vital capacity (FVC) and respiratory muscle strength (maximal expiratory pressure, MEP; maximal inspiratory pressure, MIP) were performed. The correlation between respiratory muscle strength and cough capacity was analyzed. RESULTS In the SCI group, FVC in a supine position (2,597 +/- 648 mL) was significantly higher than FVC in a sitting position (2,304 +/- 564 mL, p < 0.01). Conversely, in the ALS group, FVC sitting (1,370 +/- 604 mL) was significantly higher than in supine (1,168 +/- 599 mL, p < 0.01). In the DMD group, there was no statistically significant difference between FVC while sitting (1,342 +/- 506 mL) and FVC while supine (1,304 +/- 500 mL). In addition, the MEP and MIP of all three groups showed a significant correlation with peak cough flow (PCF) (p < 0.01, Pearson's correlation analysis). In the SCI group, MIP was more closely correlated with PCF, while in the ALS and DMD groups, MEP was more closely correlated with PCF (p < 0.01, multiple regression analysis). CONCLUSION To generate cough flow, inspiratory muscle strength is significantly more important for SCI patients, while expiratory muscle function is significantly more important for ALS and DMD patients.
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Affiliation(s)
- Jung Hyun Park
- Department of Rehabilitation Medicine, Eulji University Hospital, Daejeon, Korea
| | - Seong-Woong Kang
- Department of Rehabilitation Medicine and Rehabilitation Institute of Muscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Chul Lee
- Department of Physical Medicine and Rehabilitation, Myongji Hospital, Kwandong University College of Medicine, Seoul, Korea
| | - Won Ah Choi
- Department of Rehabilitation Medicine and Rehabilitation Institute of Muscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Hyun Kim
- Department of Rehabilitation Medicine and Rehabilitation Institute of Muscular Disease, Yonsei University College of Medicine, Seoul, Korea
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Miller RG, Jackson CE, Kasarskis EJ, England JD, Forshew D, Johnston W, Kalra S, Katz JS, Mitsumoto H, Rosenfeld J, Shoesmith C, Strong MJ, Woolley SC. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2009; 73:1218-26. [PMID: 19822872 PMCID: PMC2764727 DOI: 10.1212/wnl.0b013e3181bc0141] [Citation(s) in RCA: 467] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To systematically review evidence bearing on the management of patients with amyotrophic lateral sclerosis (ALS). METHODS The authors analyzed studies from 1998 to 2007 to update the 1999 practice parameter. Topics covered in this section include slowing disease progression, nutrition, and respiratory management for patients with ALS. RESULTS The authors identified 8 Class I studies, 5 Class II studies, and 43 Class III studies in ALS. Important treatments are available for patients with ALS that are underutilized. Noninvasive ventilation (NIV), percutaneous endoscopic gastrostomy (PEG), and riluzole are particularly important and have the best evidence. More studies are needed to examine the best tests of respiratory function in ALS, as well as the optimal time for starting PEG, the impact of PEG on quality of life and survival, and the effect of vitamins and supplements on ALS. RECOMMENDATIONS Riluzole should be offered to slow disease progression (Level A). PEG should be considered to stabilize weight and to prolong survival in patients with ALS (Level B). NIV should be considered to treat respiratory insufficiency in order to lengthen survival (Level B) and to slow the decline of forced vital capacity (Level B). NIV may be considered to improve quality of life (Level C) [corrected].Early initiation of NIV may increase compliance (Level C), and insufflation/exsufflation may be considered to help clear secretions (Level C).
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Affiliation(s)
- R G Miller
- Department of Neurology, California Pacific Medical Center, San Francisco, California, USA
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Radunovic A, Annane D, Jewitt K, Mustfa N. Mechanical ventilation for amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev 2009:CD004427. [PMID: 19821325 DOI: 10.1002/14651858.cd004427.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis, also known as motor neuron disease, is a fatal neurodegenerative disease. Without mechanical ventilation, death from respiratory failure usually follows within two to five years of the onset of symptoms. OBJECTIVES To examine the efficacy of mechanical ventilation (tracheostomy and non-invasive ventilation) in improving survival, on disease progression and quality of life in amyotrophic lateral sclerosis. SEARCH STRATEGY We searched The Cochrane Neuromuscular Disease Group Trials Specialized Register (December 8 2008), The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2008), MEDLINE (January 1966 to December 2008), EMBASE (January 1947 to December 2008), CINAHL Plus (January 1937 to December 2008), and AMED (January 1985 to December 2008). We also searched for ongoing studies on clinicaltrials.gov. SELECTION CRITERIA Randomised and quasi-randomised controlled trials involving non-invasive or tracheostomy assisted ventilation in participants with a clinical diagnosis of amyotrophic lateral sclerosis. DATA COLLECTION AND ANALYSIS Four authors independently selected studies for assessment. All authors extracted data independently 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. MAIN RESULTS Two randomised controlled trials involving 54 participants receiving non-invasive ventilation were identified and included. Incomplete data were published for one study and we contacted the trial authors who were not able to provide the missing data. Therefore the results of the review were based on a single study of 41 participants. The study showed that the overall median survival in the whole cohort after initiation of assisted ventilation was significantly different between the non-invasive ventilation and standard care groups (P = 0.0062) with a median survival for the non-invasive ventilation group patients of 48 days longer than the standard care group participants. Non-invasive ventilation significantly improved survival and quality of life in the subgroup with normal to moderately impaired bulbar function. Non-invasive ventilation did not prolong survival in patients with poor bulbar function although it showed significant improvement in the mean symptoms domain of the sleep apnoea quality-of-life index but not in the Short Form-36 quality of life mental component summary score . AUTHORS' CONCLUSIONS Evidence from a single randomised trial of non-invasive ventilation in 41 participants suggests that it significantly prolongs survival and improves or maintains quality of life in people with ALS. Survival and some measures of quality of life were significantly improved in the subgroup of people with better bulbar function, but not in those with severe bulbar impairment.
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Affiliation(s)
- Aleksandar Radunovic
- Barts and the London MND Centre, Royal London Hospital, Whitechapel, London, UK, E1 1BB
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35
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Abstract
Clinical trials in amyotrophic lateral sclerosis have significantly evolved over the last decade. New outcome measures have been developed that have reduced the sample size requirement as compared with survival studies. There has been increasing recognition that dose-ranging studies are crucial to full evaluation of experimental agents. While the requirements of late stage trials have not changed, many new designs have been suggested for earlier phase development. While no design achieves the perfect balance of sensitivity and efficiency, clinical trialists continue to work toward the goals of smaller and shorter trials so that more compounds can be studied concurrently.
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36
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Elman LB, Houghton DJ, Wu GF, Hurtig HI, Markowitz CE, McCluskey L. Palliative care in amyotrophic lateral sclerosis, Parkinson's disease, and multiple sclerosis. J Palliat Med 2007; 10:433-57. [PMID: 17472516 DOI: 10.1089/jpm.2006.9978] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis, Parkinson's disease, atypical parkinsonian syndromes, and multiple sclerosis are progressive neurologic disorders that cumulatively afflict a large number of people. Effective end-of-life palliative care depends upon an understanding of the clinical aspects of each of these disorders. OBJECTIVES The authors review the unique and overlapping aspects of each of these disorders with an emphasis upon the clinical management of symptoms. DESIGN The authors review current management and the supporting literature. CONCLUSIONS Clinicians have many effective therapeutic options to choose from when managing the symptoms produced by these disorders.
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Affiliation(s)
- Lauren B Elman
- ALS Association Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Shoesmith CL, Findlater K, Rowe A, Strong MJ. Prognosis of amyotrophic lateral sclerosis with respiratory onset. J Neurol Neurosurg Psychiatry 2007; 78:629-31. [PMID: 17088331 PMCID: PMC2077959 DOI: 10.1136/jnnp.2006.103564] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Respiratory muscle involvement is a recognised, but often late, complication of amyotrophic lateral sclerosis (ALS). The clinical features and prognosis of 21 patients with respiratory onset ALS are reported here. On a retrospective chart review, it was found that 2.7% of patients with ALS presenting to a tertiary care specialty clinic have respiratory symptoms as their first clinical symptom of ALS. Only 14% of these individuals presented acutely and required emergency intubation. The mean survival time of the total group from symptom onset to death or permanent ventilation was 27.0 (14.9) months, which was not significantly different from the survival time in patients with bulbar onset ALS. Non-invasive positive pressure ventilation (NIPPV) significantly improved survival compared with those who did not use NIPPV. This study suggests that ALS with respiratory onset does not necessarily follow a rapidly progressive course.
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Affiliation(s)
- Christen L Shoesmith
- Department of Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada.
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38
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Abstract
In neuromuscular disease (NMD) patients with progressive muscle weakness, respiratory muscles are also affected and hypercapnia can increase gradually as the disease progresses. The fundamental respiratory problems NMD patients experience are decreased alveolar ventilation and coughing ability. For these reasons, it is necessary to precisely evaluate pulmonary function to provide the proper inspiratory and expiratory muscle aids in order to maintain adequate respiratory function. As inspiratory muscle weakening progresses, NMD patients experience hypoventilation. At this point, respiratory support by mechanical ventilator should be initiated to relieve respiratory distress symptoms. Patients with adequate bulbar muscle strength and cognitive function who use a non-invasive ventilation aid, via a mouthpiece or a nasal mask, may have their hypercapnia and associated symptoms resolved. For a proper cough assist, it is necessary to provide additional insufflation to patients with inspiratory muscle weakness before using abdominal thrust. Another effective method for managing airway secretions is a device that performs mechanical insufflation-exsufflation. In conclusion, application of non-invasive respiratory aids, taking into consideration characterization of respiratory pathophysiology, have made it possible to maintain a better quality of life in addition to prolonging the life span of patients with NMD.
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Affiliation(s)
- Seong-Woong Kang
- Department of Physical Medicine and Rehabilitation, Yongdong Severance Hospital, Yonsei University College of Medicine, Kangnam-gu, Seoul 135-720, Korea.
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Heffernan C, Jenkinson C, Holmes T, Macleod H, Kinnear W, Oliver D, Leigh N, Ampong MA. Management of respiration in MND/ALS patients: an evidence based review. ACTA ACUST UNITED AC 2006; 7:5-15. [PMID: 16546753 DOI: 10.1080/14660820510043235] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
This systematic review comprises an objective appraisal of the evidence in regard to the management of respiration in patients with motor neuron disease (MND/ALS). Studies were identified through computerised searches of 32 databases. Internet searches of websites of drug companies and MND/ALS research web sites, 'snow balling' and hand searches were also employed to locate any unpublished study or other 'grey literature' on respiration and MND/ALS. Since management of MND/ALS involves a number of health professionals and care workers, searches were made across multiple disciplines. No time frame was imposed on the search in order to increase the probability of identifying all relevant studies, although there was a final limit of March 2005. Recommendations for patient and carer-based guidelines for the clinical management of respiration for MND/ALS patients are suggested on the basis of qualitative analyses of the available evidence. However, these recommendations are based on current evidence of best practice, which largely comprises observational research and clinical opinion. There is a clear need for further evidence, in particular randomised and non-randomised controlled trials on the effects of non-invasive ventilation and additional larger scale cohort studies on the issues of initial assessment of respiratory symptoms, and management and timing of interventions.
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41
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Évaluation des fonctions ventilatoires. Rev Neurol (Paris) 2006. [DOI: 10.1016/s0035-3787(06)75185-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Brissot R, Gonzalez-Bermejo J, Lassalle A, Desrues B, Doutrellot PL. Fatigue and respiratory disorders. ACTA ACUST UNITED AC 2006; 49:320-30, 403-12. [PMID: 16780993 DOI: 10.1016/j.annrmp.2006.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Accepted: 04/03/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To analyze the factors at the origin of fatigue in respiratory disorders. To assess fatigue and its functional impact on patients affected from respiratory diseases. To evaluate the results of comprehensive care on fatigue and functional capacity. MATERIALS AND METHODS We systematically reviewed the literature in Medline and the Cochrane Library, using the following keywords: fatigue, respiratory disorders, questionnaire, evaluation, assessment, randomized controlled trial, meta-analysis. RESULTS Fatigue is a high frequency symptom (90%) and takes an important place, as much as dyspnea, in the genesis of the respiratory induced handicap. Its assessment is varied, according to the studies. It originates from multiple causes, as shown from clinical and experimental studies. The main treatment consists in rehabilitation, using physical exercises. Its efficacy is demonstrated on physical endurance, but is not clear in terms of general fatigue. CONCLUSION Although fatigue is very frequent complaint, along with a major disabling condition, the comprehensive assessment of fatigue, in respiratory disorders, including its physical and cognitive components, is not still really codified. Rehabilitation is the main treatment. Its efficiency has been demonstrated on the physical and functional components of fatigue. Its results on perceived fatigue remains to be evaluated.
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Affiliation(s)
- R Brissot
- Service de Médecine Physique et de Réadaptation, Hôpital de Pontchaillou, CHU de Rennes, France.
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Abstract
Involvement of respiratory muscles is a nearly constant feature of neuromuscular disorders, leading to respiratory failure. A careful respiratory follow up adapted to the variable time course of each disease is therefore mandatory. As the first step, a systematic clinical evaluation is essential to detect the subtle respiratory symptoms and signs related to respiratory muscle failure. Dyspnea and orthopnea are often late findings in patients with a usually severe functional impairment due to peripheral muscle weakness. Nocturnal respiratory events (obstructive sleep apnea syndrome and hypoventilation) are strongly suggested by daytime hypersomnolence and frequent morning headaches. Physical evaluation is essential to detect accessory muscle recruitment, supine abdominal paradox, and encumbrance of upper or lower airways. Vital capacity (VC) is the most classical lung function test. The major limitation of spirometry is its poor sensitivity to detect a moderate inspiratory muscle weakness. Supine VC may improve the detection of diaphragmatic involvement. Peak expiratory flow during cough (cough PEF) gives an overall evaluation of cough efficiency, values below 160 to 270 L/min suggesting poor airway clearance. Arterial blood gases are performed in case of clinical signs, significant deterioration of lung function tests, or sleep desaturations. Hypercapnia is weakly related to lung function results in patients with Steinert dystrophy and those with bulbar involvement. A specific evaluation of respiratory muscle strength is mandatory, as these tests are both sensitive and highly prognostic. Possible discrepancies (particularly in bulbar patients) between maximal inspiratory pressure (PImax) and sniff nasal inspiratory pressure (SNIP) justify to perform both measurements and to select the highest pressure. A maximal expiratory pressure (PEmax) below 45 cm H2O may indicate a compromised cough efficiency but the correlation with cough PEF may be poor. A screening nocturnal oxymetry is useful to detect sleep apneas and hypoventilation. Criteria defining significant desaturations remain however controversial. Suspicion of obstructive sleep apnea syndrome on clinical grounds or oxymetry findings should be confirmed by a conventional polysomnography.
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Affiliation(s)
- T Perez
- Service d'Explorations Fonctionnelles Respiratoires et Clinique des Maladies Respiratoires Hôpital Calmette, CHRU de Lille, Lille.
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44
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Abstract
Even after administration in routine clinical dosages, muscle relaxants can lead to long-lasting residual blockades which increase the risk of severe postoperative pulmonary complications. Even without the additional effects from analgetics, sedatives or anaesthetics, a partial neuromuscular blockade, which cannot reliably be avoided either by the anaesthetist alone or by the additional use of nerve stimulators (train-of-four [TOF] ratio 0.5-0.9), can cause reductions in the vital capacity and the hypoxic breathing response, as well as obstruction of the upper airway and disruption of pharangeal function. The extent of neuromuscular recovery after an operation depends on the muscle relaxant used, the duration of administration, the anaesthetic technique and possible accompanying illnesses of the patient. It must basically be assumed that residual neuromuscular blockades are more frequent after administration of slow acting muscle relaxants such as pancuronium, than after the use of medium or rapid acting substances. If the course of a neuromuscular blockade is continually monitored during the whole anaesthetic procedure using the TOF ratio and not only occasionally at the end, a TOF ratio of 1 measured with an acceleromyograph (e.g. TOF-watch) promises an adequate neuromuscular recovery from the effects of muscle relaxants.
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Affiliation(s)
- T Fuchs-Buder
- Département d'Anesthésie-Réanimation, Centre Hospitalier Universitaire de Nancy/Brabois.
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45
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Simmons Z. Management strategies for patients with amyotrophic lateral sclerosis from diagnosis through death. Neurologist 2005; 11:257-70. [PMID: 16148733 DOI: 10.1097/01.nrl.0000178758.30374.34] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disorder that is inevitably fatal. There are no effective treatments to stop or reverse the natural course of the disease. The role of the physician is to provide comfort and optimize quality of life. REVIEW SUMMARY Management of patients with ALS is a process extending over months to years. It begins with breaking the news of the diagnosis and extends through the terminal phase. Medication may extend lifespan by a small amount. However, most efforts are centered around symptom management. Areas of importance include respiration, nutrition, secretions, communication, pseudobulbar affect, therapy and exercise, spasticity and cramps, pain, depression and suicide, spirituality and religion, cognitive changes, the development of advance directives, and care at the end of life. Multidisciplinary ALS clinics provide much-needed support for patients with ALS and their caregivers. CONCLUSION Although physicians cannot cure ALS or even halt progression, there is much that can be done to manage the physical and emotional symptoms, thereby maintaining or enhancing quality of life.
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Affiliation(s)
- Zachary Simmons
- Department of Neurology, Penn State College of Medicine, Hershey, 17033, USA.
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46
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Leal JC, Mateus SRM, Beraldo PSS. Water Immersion Effects on Severe Diaphragm Weakness. Chest 2005; 127:2286-7; author reply 2287. [PMID: 15947355 DOI: 10.1378/chest.127.6.2286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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47
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Eikermann M, Groeben H, Bünten B, Peters J. Fade of Pulmonary Function During Residual Neuromuscular Blockade. Chest 2005; 127:1703-9. [PMID: 15888849 DOI: 10.1378/chest.127.5.1703] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVES A decrement in evoked muscle force with repetitive nerve stimulation (fade) suggests impaired neuromuscular transmission. We tested the hypothesis that fade of pulmonary function, ie, a decrease in values of FVC with the second spirometric maneuver compared to the first maneuver, occurs during impaired neuromuscular transmission. DESIGN Prospective study. PARTICIPANTS Six healthy male volunteers. INTERVENTIONS A series of three consecutive spirometric maneuvers was performed every 5 min in six awake healthy volunteers before, during, and after partial paralysis evoked by rocuronium (0.01 mg/kg IV plus 2 to 8 microg/kg/min). MEASUREMENTS AND RESULTS We measured FVC, FEV(1), forced inspiratory volume in 1 s (FIV(1)), peak expiratory flow (PEF), and peak inspiratory flow (PIF) by spirometry, and force of adductor pollicis muscle by mechanomyography (train-of-four [TOF] stimulation). A statistically significant fade (reduction of the second maneuver from the first maneuver) of FVC, FEV(1), FIV(1), PEF, and PIF was observed during neuromuscular blockade. With peak relaxation (TOF ratio, 0.5) fade amounted to medians of 10% (interquartile range [IQR], 9 to 23%), 7% (IQR, 2 to 16%), 31 (IQR, 19 to 47%), 9% (IQR, 3 to 24%), and 30% (IQR, 5 to 43%), respectively. A fade of >or= 10% was always associated with a clinically relevant (>or= 10%) FVC reduction from baseline (ie, FVC before rocuronium administration). However, FVC reduction from baseline was still present in 23% of measurements without a relevant FVC fade. CONCLUSIONS A clinically relevant fall (fade) in FVC from the first to the second value during or after neuromuscular blockade suggests impaired pulmonary function and may be due to muscle paralysis. For this reason, the first (best) FVC value may overestimate pulmonary function and expose the patient to an unidentified risk.
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Affiliation(s)
- Matthias Eikermann
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Hufelandstr. 55, D-45122 Essen, Germany.
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48
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49
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Cudkowicz M, Qureshi M, Shefner J. Measures and markers in Amyotrophic Lateral Sclerosis. Neurotherapeutics 2004. [DOI: 10.1007/bf03206611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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50
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Abstract
Amyotrophic Lateral Sclerosis (ALS) is a neurodegenerative disorder characterized by loss of spinal and cortical motor neurons, leading to progressive weakness and ultimately, death. Clinically, there appears to be an anatomic focus at disease onset, from which the disease then spreads. Because the focus of initial symptoms and the subsequent direction of spread can vary from patient to patient, disease monitoring is difficult, especially in a clinical trial, in which outcome measures must be identical and able to capture progression of all types. Thus, the search for markers of disease progression is especially important in ALS. Many approaches have been taken, from voluntary strength assessment and functional rating scales to physiological and pathological sampling of affected portions of nervous system. No proposed marker has been demonstrated to meet the desired criteria of biological meaning, sensitivity to disease progression, clear relationship to overall prognosis and survival, and ease of measurement. However, progress is being made in all of these regards.
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Affiliation(s)
- Merit Cudkowicz
- Neurology Clinical Trial Unit, Massachusetts General Hospital, Charlestown, Massachusetts 02129, USA.
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