1
|
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]. Rev Mal Respir 2024:S0761-8425(24)00232-8. [PMID: 39019674 DOI: 10.1016/j.rmr.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 02/25/2022] [Indexed: 07/19/2024]
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.
Collapse
Affiliation(s)
- M Georges
- Service des maladies respiratoires et des soins intensifs, centre de référence pour les maladies pulmonaires rares de l'adulte, hôpital universitaire de Dijon-Bourgogne, Dijon, France; Université de Bourgogne-Franche-Comté, Dijon, France; Centre des sciences du goût et de l'alimentation, UMR 6265, CNRS 1234, INRA, université de Bourgogne-Franche-Comté, Dijon, France.
| | - T Perez
- Service des maladies respiratoires, hôpital universitaire de Lille, Lille, France; Centre d'infection et d'immunité de Lille, Inserm U1019-UMR9017, université de Lille-Nord de France, Lille, France
| | - C Rabec
- Service des maladies respiratoires et des soins intensifs, centre de référence pour les maladies pulmonaires rares de l'adulte, hôpital universitaire de Dijon-Bourgogne, Dijon, France; Université de Bourgogne-Franche-Comté, Dijon, France
| | - L Jacquin
- Société ResMed SAS, Saint-Priest, France
| | - A Finet-Monnier
- Service des maladies neuromusculaires et de la SLA, hôpital universitaire de la Timone, Marseille, France
| | - C Ramos
- CRMR SLA-MNM, hôpital Pasteur 2, hôpital universitaire de Nice, Nice, France
| | - M Patout
- Département R3S, service des pathologies du sommeil, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Neurophysiologie respiratoire expérimentale et clinique, Inserm UMRS1158, Sorbonne université, Paris, France
| | - V Attali
- Département R3S, service des pathologies du sommeil, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Neurophysiologie respiratoire expérimentale et clinique, Inserm UMRS1158, Sorbonne université, Paris, France
| | - M Amador
- Service de neurologie, centre SLA de Paris, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - J Gonzalez-Bermejo
- Neurophysiologie respiratoire expérimentale et clinique, Inserm UMRS1158, Sorbonne université, Paris, France; Département R3S, service de pneumologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - F Salachas
- Service de neurologie, centre SLA de Paris, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - C Morelot-Panzini
- Neurophysiologie respiratoire expérimentale et clinique, Inserm UMRS1158, Sorbonne université, Paris, France; Département R3S, service de pneumologie, groupe hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| |
Collapse
|
2
|
Rabadi MH, Russell KA, Xu C. Veterans with familial ALS and bulbar and respiratory presentations at onset had shorter survival. Sci Prog 2024; 107:368504241262902. [PMID: 39096043 PMCID: PMC11298063 DOI: 10.1177/00368504241262902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
OBJECTIVE We sought to characterize the clinical prognostic factors in veterans with amyotrophic lateral sclerosis (ALS) followed in our ALS clinic. BACKGROUND ALS is a rare, progressive neurodegenerative condition associated with decreased survival compared to that in the normal population. METHOD The electronic medical records of 105 veterans diagnosed with ALS who are followed in our ALS clinic between 2010 and 2021 were reviewed. Approval from the institutional review board was obtained from the study protocol. Demographic and clinical variables included age at symptom onset, age at initial evaluation, survival (from symptom onset to death), gender, site of onset (appendicular, bulbar, and respiratory), initial amyotrophic lateral sclerosis functional-related score-revised (ALSFRS-R), total functional independence measure (TFIM) scores, initial forced vital capacity (FVC), and interventions (Riluzole, gastrostomy, noninvasive ventilation [NIV], and tracheostomy). Normally distributed data was expressed as mean ± standard deviation. Fischer's exact analysis of the distribution differences of categorical data. The Kaplan-Meier plot analyzed the time-to-event. RESULTS The mean (SD) age at symptom onset was 62.0 (11.1) years, age at diagnosis was 65 (11) years, with 72% of the patients being over 60 years at diagnosis. The median survival time from symptom onset was 4.12 (3) years. Limb-onset ALS (appendicular) was the most frequent (52%) followed by bulbar-onset ALS (43%). The mean ALSFRS-R and TFIM scores were 31 (8) and 91 (25), respectively. Family history (familial), bulbar, and respiratory presentation at diagnosis were associated with shorter survival times. CONCLUSION This study suggests that of the clinical prognostic factors veterans with familial ALS, bulbar, and respiratory onset at presentations had shorter survival. The presence of Agent Orange, PEG placement, and NIV did not affect survival.
Collapse
Affiliation(s)
- Meheroz H Rabadi
- Department of Neurology, Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK, USA
- Department of Neurology, the Oklahoma University Health Sciences Center, Oklahoma City, OK, USA
| | - Kimberly A Russell
- Department of Neurology, Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK, USA
| | - Chao Xu
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center (Statistician), Oklahoma City, OK, USA
| |
Collapse
|
3
|
Manera U, Torrieri MC, Moglia C, Canosa A, Vasta R, Palumbo F, Matteoni E, Cabras S, Grassano M, Bombaci A, Mattei A, Bellocchia M, Tabbia G, Ribolla F, Chiò A, Calvo A. Calculated Maximal Volume Ventilation (cMVV) as a Marker of Early Respiratory Failure in Amyotrophic Lateral Sclerosis (ALS). Brain Sci 2024; 14:157. [PMID: 38391731 PMCID: PMC10887238 DOI: 10.3390/brainsci14020157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/28/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024] Open
Abstract
Respiratory failure assessment is among the most debatable research topics in amyotrophic lateral sclerosis (ALS) clinical research due to the wide heterogeneity of its presentation. Among the different pulmonary function tests (PFTs), maximal voluntary ventilation (MVV) has shown potential utility as a diagnostic and monitoring marker, able to capture early respiratory modification in neuromuscular disorders. In the present study, we explored calculated MVV (cMVV) as a prognostic biomarker in a center-based, retrospective ALS population belonging to the Piemonte and Valle d'Aosta registry for ALS (PARALS). A Spearman's correlation analysis with clinical data and PFTs showed a good correlation of cMVV with forced vital capacity (FVC) and a moderate correlation with some other features such as bulbar involvement, ALSFRS-R total score, blood oxygen (pO2), carbonate (HCO3-), and base excess (BE), measured with arterial blood gas analysis. Both the Cox proportional hazard models for survival and the time to non-invasive ventilation (NIV) measurement highlighted that cMVV at diagnosis (considering cMVV(40) ≥ 80) is able to stratify patients across different risk levels for death/tracheostomy and NIV indication, especially considering patients with FVC% ≥ 80. In conclusion, cMVV is a useful marker of early respiratory failure in ALS, and is easily derivable from standard PFTs, especially in asymptomatic ALS patients with normal FVC measures.
Collapse
Affiliation(s)
- Umberto Manera
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | | | - Cristina Moglia
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Antonio Canosa
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- Institute of Cognitive Sciences and Technologies, Consiglio Nazionale delle Ricerche C.N.R., 00185 Rome, Italy
| | - Rosario Vasta
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Francesca Palumbo
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Enrico Matteoni
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Sara Cabras
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Maurizio Grassano
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Alessandro Bombaci
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
| | - Alessio Mattei
- S.C. Pneumologia, S. Croce and Carle Hospital, 12100 Cuneo, Italy
| | - Michela Bellocchia
- S.C. Pneumologia U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Giuseppe Tabbia
- S.C. Pneumologia U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Fulvia Ribolla
- S.C. Pneumologia U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Adriano Chiò
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
- Institute of Cognitive Sciences and Technologies, Consiglio Nazionale delle Ricerche C.N.R., 00185 Rome, Italy
| | - Andrea Calvo
- Umberto Manera, ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Via Cherasco 15, 10126 Turin, Italy
- SC Neurologia 1U, AOU Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| |
Collapse
|
4
|
Sarasate M, González N, Córdoba-Izquierdo A, Prats E, Gonzalez-Moro JMR, Martí S, Lujan M, Calle M, Antón A, Povedano M, Farrero E. Impact of Early Non-Invasive Ventilation in Amyotrophic Lateral Sclerosis: A multicenter Randomized Controlled Trial. J Neuromuscul Dis 2023:JND221658. [PMID: 37212068 DOI: 10.3233/jnd-221658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND AND OBJECTIVE Forced vital capacity (FVC) less than 50% of predicted is one of the main parameters used for Non-Invasive Ventilation (NIV) initiation in Amyotrophic Lateral Sclerosis (ALS). Recent studies suggest that higher values of FVC could be considered as a threshold. The aim of this study is to evaluate whether early use of NIV improves the prognosis of ALS patients compared with standard initiation. METHODS This is a randomized, parallel, multicenter, open-label, controlled clinical trial, with recruitment at the ALS outpatient multidisciplinary units of six Spanish hospitals. Patients were included when their FVC reached the 75% threshold and were randomized by computer, stratifying by center in an allocation ratio of 1:1 to Early NIV (FVC below 75%) or Standard NIV (FVC below 50%) initiation. The primary outcome was time to death or tracheostomy.Trial registration number ClinicalTrials.gov: NCT01641965. RESULTS Between May 2012 and June 2014, 42 patients were randomized to two groups, 20 to Early NIV and 22 to Standard NIV initiation. We found differences in survival in favor of the intervention group: an incidence of mortality (2.68 [1.87-5.50] vs. 3.33 [1.34-4.80] person-months) and a median survival (25.2 vs. 19.4 months), although without reaching statistical significance (p = 0.267). CONCLUSIONS This trial did not reach the primary endpoint of survival; nevertheless, it is the first Randomized Controlled Trial (RCT) to demonstrate the benefits of early NIV in slowing the decline of respiratory muscle strength and reducing adverse events. Although not all the results reached statistical significance, all the analyzed data favor early NIV. In addition, this study demonstrates good tolerance and compliance with early NIV without quality of sleep impairment. These data reinforce the early respiratory evaluation of ALS patients and NIV initiation with an FVC of around 75%.
Collapse
Affiliation(s)
- Mikel Sarasate
- Department of Pneumology, UFIS-Respiratoria, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Nuria González
- Department of Pneumology, Hospital Residencia Sant Camil, Consorci Sanitari Alt Pendedés-Garraf, Barcelona, Spain
| | - Ana Córdoba-Izquierdo
- Department of Pneumology, UFIS-Respiratoria, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Enric Prats
- Department of Pneumology, UFIS-Respiratoria, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Sergi Martí
- Department of Respiratory Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain; CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Departament de Medicina, Universitat Autònoma deBarcelona (UAB), Barcelona, Spain
| | - Manel Lujan
- Department of Pneumology, Corporació Sanitaria Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Myriam Calle
- Department of Pneumology, Hospital Clínico San Carlos, Department of Medicine, Faculty of Medicine, Complutense University of Madrid, San Carlos Clinical Hospital Institute of Health Research (IdISSC), Madrid, Spain
| | - Antonio Antón
- Department of Respiratory Medicine, Hospital de laSanta Creu i Sant Pau, Barcelona, Spain
| | - Mónica Povedano
- Department of Neurology, Head of ALS Multidisciplinary Unit, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Spain
| | - Eva Farrero
- Department of Pneumology, UFIS-Respiratoria, Hospital Universitari de Bellvitge, Barcelona, Spain
| |
Collapse
|
5
|
Janssens JP, Cantero C, Pasquina P, Georges M, Rabec C. Monitoring Long Term Noninvasive Ventilation: Benefits, Caveats and Perspectives. Front Med (Lausanne) 2022; 9:874523. [PMID: 35665357 PMCID: PMC9160571 DOI: 10.3389/fmed.2022.874523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/26/2022] [Indexed: 12/03/2022] Open
Abstract
Long term noninvasive ventilation (LTNIV) is a recognized treatment for chronic hypercapnic respiratory failure (CHRF). COPD, obesity-hypoventilation syndrome, neuromuscular disorders, various restrictive disorders, and patients with sleep-disordered breathing are the major groups concerned. The purpose of this narrative review is to summarize current knowledge in the field of monitoring during home ventilation. LTNIV improves symptoms related to CHRF, diurnal and nocturnal blood gases, survival, and health-related quality of life. Initially, patients with LTNIV were most often followed through elective short in-hospital stays to ensure patient comfort, correction of daytime blood gases and nocturnal oxygenation, and control of nocturnal respiratory events. Because of the widespread use of LTNIV, elective in-hospital monitoring has become logistically problematic, time consuming, and costly. LTNIV devices presently have a built-in software which records compliance, leaks, tidal volume, minute ventilation, cycles triggered and cycled by the patient and provides detailed pressure and flow curves. Although the engineering behind this information is remarkable, the quality and reliability of certain signals may vary. Interpretation of the curves provided requires a certain level of training. Coupling ventilator software with nocturnal pulse oximetry or transcutaneous capnography performed at the patient's home can however provide important information and allow adjustments of ventilator settings thus potentially avoiding hospital admissions. Strategies have been described to combine different tools for optimal detection of an inefficient ventilation. Recent devices also allow adapting certain parameters at a distance (pressure support, expiratory positive airway pressure, back-up respiratory rate), thus allowing progressive changes in these settings for increased patient comfort and tolerance, and reducing the requirement for in-hospital titration. Because we live in a connected world, analyzing large groups of patients through treatment of “big data” will probably improve our knowledge of clinical pathways of our patients, and factors associated with treatment success or failure, adherence and efficacy. This approach provides a useful add-on to randomized controlled studies and allows generating hypotheses for better management of HMV.
Collapse
Affiliation(s)
- Jean-Paul Janssens
- Division of Pulmonary Diseases, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
- Hôpital de La Tour, Centre Cardio-Respiratoire, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
- *Correspondence: Jean-Paul Janssens
| | - Chloé Cantero
- Service de Pneumologie, Hôpital Pitié-Salpêtrière AP-HP – Sorbonne Université, Paris, France
| | - Patrick Pasquina
- Division of Pulmonary Diseases, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Marjolaine Georges
- Pulmonary Department and Respiratory Critical Care Unit, University Hospital Dijon, Dijon, France
| | - Claudio Rabec
- Pulmonary Department and Respiratory Critical Care Unit, University Hospital Dijon, Dijon, France
| |
Collapse
|
6
|
Kelly CR, Parra-Cantu C, Thapa P, Boynton B, Selim BJ, Sorenson EJ, Martinez-Thompson JM, Mandrekar J, Staff NP. Comparative Performance of Different Respiratory Test Parameters for Detection of Early Respiratory Insufficiency in Patients With ALS. Neurology 2022; 99:e743-e750. [PMID: 35584920 DOI: 10.1212/wnl.0000000000200758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 04/06/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the performance of different respiratory function testing in a multidisciplinary ALS clinic. METHODS Demographics, clinical data, and respiratory testing parameters were abstracted from the medical records of patients who attended a multidisciplinary ALS clinic from 2008-2016. We compared the performance of the three primary respiratory test parameters used by Medicare for the initiation of non-invasive ventilation (NIV), (forced vital capacity (FVC) < 50% predicted, maximum inspiratory pressure (MIP) < 60 cm H20, and abnormal overnight pulse oximetry (OvOx)) on how they related to several clinically relevant attributes. RESULTS 476 subjects were identified who underwent at least one respiratory test. Abnormalities of OvOx, MIP, and FVC occurred at a median of 1.6, 1.5, and 3.8 years from disease onset, respectively (p < 0.00001). Subjects with bulbar-onset ALS exhibited earlier abnormalities in MIP and FVC than in spinal-onset ALS (p <0.005). The median survival after an abnormal OvOx, MIP, or FVC test was 1.4, 1.4, and 0.9 years, respectively (p < 0.0001). Utilizing the ALS Functional Rating Score respiratory subscales, at the time of reported respiratory symptoms there were abnormalities in OvOx (60%), MIP (69%), and FVC (19%). Conversely, when respiratory parameter abnormalities preceded reported respiratory symptoms, this occurred with frequencies in OvOx (79%), MIP (42%) or FVC (24%). Four hundred forty-three subjects (93.1%) developed at least one abnormal respiratory measure meeting Medicare criteria for NIV consideration, but fewer than 50% in our cohort demonstrated NIV use. Improved survival in subjects using NIV was statistically significant in patients with bulbar-onset ALS. CONCLUSIONS Abnormalities in OvOx and MIP perform better than FVC at early detection of neuromuscular respiratory weakness in ALS. Initiation of NIV in patients with respiratory insufficiency may improve overall survival in ALS. In the setting of the COVID-19 pandemic, FVC and MIP have not been routinely performed due to infectious aerosol generation. OvOx, which we now routinely mail to patients' homes, has been utilized exclusively during the COVID-19 pandemic, and allows for continued remote monitoring of respiratory status of patients with ALS.
Collapse
Affiliation(s)
| | | | - Prabin Thapa
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Bradley Boynton
- Division of Pulmonary Care and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Bernardo J Selim
- Division of Pulmonary Care and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Jaywant Mandrekar
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Kashkosh A. An Investigation of the Factors Affecting Compliance When Using Home Non-Invasive Ventilation Therapy. CURRENT RESPIRATORY MEDICINE REVIEWS 2022. [DOI: 10.2174/1573398x18666220131100128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Abstract:
Home non-invasive ventilation has become a well-established form of therapy over the last few decades. Many conditions benefit from home NIV, for instance, patients with motor neurone disease (MND) and chest wall deformities that lead to respiratory complications. Home NIV has been shown to increase survival and improve quality of life in many chest wall diseases and MND. There is also substantial evidence to indicate that NIV can palliate symptoms of Obesity Hypoventilation Syndrome (OHS). Also, Home NIV is a valuable tool in the management of patients with severe COPD and has been shown to reduce mortality and morbidity in patients with chronic respiratory failure. However, the usefulness of home NIV varies according to compliance. This review investigates the factors affecting compliance with home NIV. Compliance remains to be an incredibly complex matter. Yet, due to the importance of compliance and its effect on outcomes, investigating influencing variables is a priority.
Collapse
Affiliation(s)
- Abdulrahman Kashkosh
- Institute of Medical and Biomedical Education, St George\'s Hospital Medical School, London
| |
Collapse
|
9
|
Abstract
While the traditional lung function tests are used to assess lung capacity and pulmonary function, they cannot evaluate respiratory driving function and the integrity of the conduction pathway from the central nervous system to the respiratory motor neuron in the spinal cord and to the diaphragm. The inspiratory trigger is sent from the central nervous system through the phrenic nerve and drives the diaphragm to generate inspiratory movement. Therefore, phrenic nerve stimulation and diaphragmatic electromyography are two fundamental methods to assess respiratory function. There are several useful tools to assess respiratory motor system including electrical or magnetic phrenic nerve stimulation, diaphragmatic needle electromyography, and diaphragmatic ultrasound. By these means, physicians can assess current respiratory status in different neurological diseases that affect respiratory muscles, follow-up of the severity of respiratory impairment, help to predict the chance of successfully weaning from ventilatory support, and confirm clinical diagnoses such as diaphragmatic myoclonus. Although some of these tests require special training, applying these neurophysiological assessments in clinical practice is highly recommended.
Collapse
Affiliation(s)
- Yih-Chih Jacinta Kuo
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kai-Hsiang Stanley Chen
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.
| |
Collapse
|
10
|
Walsh LJ, Deasy KF, Gomez F, O'Sullivan E, Eustace J, Ryan AM, Murphy DM. Use of non-invasive ventilation in motor neuron disease - a retrospective cohort analysis. Chron Respir Dis 2021; 18:14799731211063886. [PMID: 34854787 PMCID: PMC8646818 DOI: 10.1177/14799731211063886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Motor neuron disease (MND) is a neurodegenerative disorder which leads to progressive muscle weakness including respiratory muscle decline. The introduction of non-invasive ventilation (NIV) has been shown to improve quality of life, survival and slow the rate of pulmonary function decline. A retrospective chart analysis of patients who attended the MND clinic from 2014 to 2019 at a tertiary-referral, academic, teaching hospital was carried out to evaluate if NIV and greater compliance with NIV was associated with improved survival. 111 patients were included. The mean age at diagnosis was 63.8 years and 61.3% were males. 66.7% of our cohort used NIV and of this 66.7%, 44.1% were compliant. There was a significantly longer survival in those who used NIV (p = 0.002) and in those who used NIV optimally (p = 0.02) when both groups were compared to those who did not use NIV. In the bulbar MND group those who were compliant with NIV survived longer than who those who did not use NIV (p = 0.001). We found a significantly longer survival with the use of NIV, the use of NIV optimally and with use of NIV in those with bulbar onset MND compared to those who did not use NIV.
Collapse
Affiliation(s)
- Laura J Walsh
- Department of Respiratory Medicine, 57983Cork University Hospital, Cork, Ireland
| | - Kevin F Deasy
- Department of Respiratory Medicine, 57983Cork University Hospital, Cork, Ireland
| | - Fernando Gomez
- Department of Respiratory Medicine, 57983Cork University Hospital, Cork, Ireland
| | | | - Joseph Eustace
- Health Research Board, Clinical Research Facility, 8795University College Cork, Cork, Ireland
| | - Aisling M Ryan
- Department of Neurology, 57983Cork University Hospital, Cork, Ireland
| | - Desmond M Murphy
- Department of Respiratory Medicine, 57983Cork University Hospital, Cork, Ireland.,Health Research Board, Clinical Research Facility, 8795University College Cork, Cork, Ireland
| |
Collapse
|
11
|
Young C, Pinto S, Grosskreutz J, Hardiman O, Clawson LL, Cudkowicz ME, Andrews JA. Medical therapies for amyotrophic lateral sclerosis-related respiratory decline: an appraisal of needs, opportunities and obstacles. Amyotroph Lateral Scler Frontotemporal Degener 2021; 23:66-75. [PMID: 34392765 DOI: 10.1080/21678421.2021.1920981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
A roundtable convened in July 2020 examined issues concerning respiratory support in amyotrophic lateral sclerosis (ALS), with reference to the potential for an early-phase orally administered medication that might either postpone the introduction of noninvasive ventilation (NIV) and/or enhance the benefits to be gained from it. Attention was also given to the impact of the COVID-19 pandemic on usual practice in the assessment and management of ALS-related respiratory difficulties. Implementation of NIV marks a step-change in clinical status for patients and a major increase in burden for caregivers. All means to ease this transition should be explored: an oral therapy that supported respiratory function and patients' independence and sense of well-being would aid discussions to facilitate the eventual successful introduction of NIV. Assessment of a candidate oral therapy that might support respiratory function in ALS patients would be aided by the development of improved patient-reported outcome measures for robust quantification of treatment effect and quality of life. Such instruments could also be used to monitor patients' status during the COVID-19 pandemic, averting some of the risks of face-to-face assessment plus the patient burden and costs of traditional methods. Several oral candidate therapies have recently failed to meet their primary endpoints in clinical trials. However, understanding of the underlying physiology and appropriate trial design have grown and will inform future developments in this field.
Collapse
Affiliation(s)
- Carolyn Young
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Susana Pinto
- Translational and Clinical Physiology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | | | - Orla Hardiman
- Department of Neurology, Beaumont Hospital, Dublin, Ireland
| | - Lora L Clawson
- Department of Neurology, School of Medicine , Johns Hopkins University , Baltimore, MD , USA
| | | | - Jinsy A Andrews
- Neurological Institute of New York, Columbia University, New York, NY, USA
| |
Collapse
|
12
|
Walsh LJ, Murphy DM. The Benefit of Non-invasive Ventilation in Motor Neuron Disease. Open Respir Med J 2021; 14:53-61. [PMID: 33425067 PMCID: PMC7774097 DOI: 10.2174/1874306402014010053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/09/2020] [Accepted: 10/02/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Motor Neuron Disease (MND) is a progressive neurodegenerative disorder leading to respiratory muscle weakness with dyspnoea, morning headaches, orthopnoea, poor concentration, unrefreshing sleep, fatigue and daytime somnolence. Respiratory failure is the primary cause of death in those with MND. Methods: Although guidelines suggest the use of non-invasive ventilation (NIV) in MND, there lacks clear guidance as to when is the optimal time to initiate NIV and which markers of respiratory muscle decline are the best predictors of prognosis. There have been a number of studies that have found a significant survival advantage to the use of NIV in MND. Similarly, in quality-of-life questionnaires, those treated with NIV tend to perform better and maintain a better quality of life for longer. Furthermore, studies also suggest that improved compliance and greater tolerance of NIV confer a survival advantage. Results and Discussion: Forced Vital Capacity (FVC) has traditionally been the main pulmonary function test to determine the respiratory function in those with MND; however, FVC may not be entirely reflective of early respiratory muscle dysfunction. Evidence suggests that sniff nasal inspiratory pressure and maximum mouth inspiratory pressure may be better indicators of early respiratory muscle decline. These measures have been shown to be easier to perform later in the disease, in patients with bulbar onset disease, and may indeed be better prognostic indicators. Conclusion: Despite ongoing research, there remains a paucity of randomised controlled data in this area. This review aims to summarise the evidence to date on these topics.
Collapse
Affiliation(s)
- Laura J Walsh
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland
| | - Desmond M Murphy
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,The HRB- Clinical Research Facility, University College Cork, Cork, Ireland
| |
Collapse
|
13
|
Crescimanno G, Sorano A, Greco F, Canino M, Abbate A, Marrone O. Heterogeneity of predictors of nocturnal hypoventilation in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2020; 22:46-52. [DOI: 10.1080/21678421.2020.1813309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Grazia Crescimanno
- Institute for Biomedical Research and Innovation, National Research Council of Italy, Palermo, Italy
- Regional Center for Prevention and Treatment of Respiratory Complications of Rare Genetic Neuromuscular Diseases, Villa Sofia-Cervello Hospital, Palermo, Italy
| | - Alessandra Sorano
- Division of Pulmonology (DIBIMIS), Department of Internal medicine, Villa Sofia-Cervello Hospital, Palermo, Italy, and
| | - Francesca Greco
- Italian Union Against Muscular Dystrophy (UILDM), Palermo, Italy
| | - Maria Canino
- Regional Center for Prevention and Treatment of Respiratory Complications of Rare Genetic Neuromuscular Diseases, Villa Sofia-Cervello Hospital, Palermo, Italy
| | - Alessia Abbate
- Italian Union Against Muscular Dystrophy (UILDM), Palermo, Italy
| | - Oreste Marrone
- Institute for Biomedical Research and Innovation, National Research Council of Italy, Palermo, Italy
| |
Collapse
|
14
|
Abstract
Overnight pulse oximetry (OPO) has proven to be an effective and beneficial technique to determine the cardiorespiratory status of patients in both the inpatient and outpatient settings. It is a cheap, safe, reliable, simple, and accurate method of patient monitoring as compared to the expensive and labor-intensive method of multichannel polysomnography for detecting sleep-disordered breathing. It provides accurate information about patient's oxygenation status and also helps in monitoring the response to continuous positive airway pressure and in the surgical treatment of obstructive sleep apnea (OSA). Nocturnal hypoxemia portends a poor prognosis in patients of chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), and neuromuscular diseases. OPO can help its early detection and management.
Collapse
Affiliation(s)
- Shruti Singh
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, NY, USA
| | - Sara Z Khan
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, NY, USA
| | - Dilbagh Singh
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, NY, USA
| | - Sameer Verma
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, NY, USA
| | - Arunabh Talwar
- Division of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, New Hyde Park, NY, USA
| |
Collapse
|
15
|
Baxter SK, Johnson M, Clowes M, O’Brien D, Norman P, Stavroulakis T, Bianchi S, Elliott M, McDermott C, Hobson E. Optimizing the noninvasive ventilation pathway for patients with amyotrophic lateral sclerosis/motor neuron disease: a systematic review. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:461-472. [DOI: 10.1080/21678421.2019.1627372] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | | | | | | | | | | | - Stephen Bianchi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK, and
| | | | | | | |
Collapse
|
16
|
Braun AT, Caballero-Eraso C, Lechtzin N. Amyotrophic Lateral Sclerosis and the Respiratory System. Clin Chest Med 2019; 39:391-400. [PMID: 29779597 DOI: 10.1016/j.ccm.2018.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder that always affects the respiratory muscles. It is characterized by degeneration of motor neurons in the brain and spinal cord. Respiratory complications are the most common causes of death in ALS and typically occur within 3 to 5 years of diagnosis. Because ALS affects both upper and lower motor neurons, it causes hyperreflexia, spasticity, muscle fasciculations, muscle atrophy, and weakness. It ultimately progresses to functional quadriplegia. ALS most commonly begins in the limbs, but in about one-third of cases it begins in the bulbar muscles responsible for speech and swallowing.
Collapse
Affiliation(s)
- Andrew T Braun
- Division of Pulmonary and Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, MD 21205, USA; Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Candelaria Caballero-Eraso
- Division of Pulmonary and Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, MD 21205, USA; Medical-Surgical Unit of Respiratory Diseases, Institute of Biomedicine of Seville (IBiS), Centre for Biomedical Research in Respiratory Diseases Network (CIBERES), University Hospital Virgen del Rocío, University of Seville, Avenida Dr. Fedriani, 41009 Sevilla, Spain
| | - Noah Lechtzin
- Division of Pulmonary and Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, MD 21205, USA.
| |
Collapse
|
17
|
Caga J, Hsieh S, Lillo P, Dudley K, Mioshi E. The Impact of Cognitive and Behavioral Symptoms on ALS Patients and Their Caregivers. Front Neurol 2019; 10:192. [PMID: 30915018 PMCID: PMC6421295 DOI: 10.3389/fneur.2019.00192] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 02/14/2019] [Indexed: 12/11/2022] Open
Abstract
Previously thought to be a pure motor disease, amyotrophic lateral sclerosis (ALS) is now established as multisystem neurodegenerative disorder that lies on a continuum with frontotemporal dementia (FTD). Cognitive and behavioral symptoms primarily extend to executive function, personality, social conduct, and emotion processing. The assessment and management of cognitive and behavioral symptoms is complicated as they must be differentiated from psychological responses to a terminal diagnosis and progressive physical impairment. This is made more difficult by the limited number of studies investigating how these symptoms specifically affect patients and caregivers well-being. The current review focuses on the impact of cognitive and behavioral symptoms on patient and caregiver well-being and their implications for future research and interventions in ALS. This is an important area of research that could form the basis for more tailored, and potentially more successful, non-pharmacological interventions to improve psychological well-being among patients with ALS and their caregivers.
Collapse
Affiliation(s)
- Jashelle Caga
- Sydney Medical School, University of Sydney, Camperdown, NSW, Australia.,Brain & Mind Centre, University of Sydney, Camperdown, NSW, Australia
| | - Sharpley Hsieh
- Faculty of Health and Behavioural Sciences, School of Psychology, University of Queensland, QLD, Australia
| | - Patricia Lillo
- Departamento de Neurología Sur/Neurociencia, Facultad de Medicina, Universidad de Chile & Geroscience Center for Brain Health and Metabolism, Santiago, Chile
| | - Kaitlin Dudley
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - Eneida Mioshi
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| |
Collapse
|
18
|
de Carvalho M, Swash M, Pinto S. Diaphragmatic Neurophysiology and Respiratory Markers in ALS. Front Neurol 2019; 10:143. [PMID: 30846968 PMCID: PMC6393326 DOI: 10.3389/fneur.2019.00143] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 02/04/2019] [Indexed: 12/11/2022] Open
Abstract
The main reason for short survival in amyotrophic lateral sclerosis (ALS) is involvement of respiratory muscles. Severe compromise of diaphragmatic function due to marked loss of motor units causes poor inspiratory strength leading to symptomatic respiratory fatigue, and hypercapnia and hypoxemia, often firstly detected while sleeping supine. Weakness of expiratory muscles leads to cough weakness and poor bronchial clearance, increasing the risk of respiratory infection. Respiratory tests should therefore encompass inspiratory and expiratory function, and include measurements of blood gases during sleep. Non-volitional tests, such as phrenic nerve stimulation, are particularly convenient for investigating respiratory function in patients unable to perform standard respiratory function tests due to poor cooperation or facial weakness. However, SNIP is a sensitive test when patients with bulbar involvement are able to perform the necessary maneuvers. It is likely that central respiratory regulation is disturbed in some ALS patients, but its evaluation is more complex and not regularly implemented. Practical tests should incorporate tolerability, sensitivity, easy application for regular monitoring, and prognostic value. Impending respiratory failure can cause increased circulating inflammatory markers, but molecular assessment of respiratory distress requires further study. In future, home-monitoring of patients with accessible devices should be developed.
Collapse
Affiliation(s)
- Mamede de Carvalho
- Instituto de Fisiologia-Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Department of Neurosciences and Mental Health, Hospital de Santa Maria-CHLN, Lisbon, Portugal
| | - Michael Swash
- Instituto de Fisiologia-Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Barts and the London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Susana Pinto
- Instituto de Fisiologia-Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| |
Collapse
|
19
|
Sferrazza Papa GF, Pellegrino GM, Shaikh H, Lax A, Lorini L, Corbo M. Respiratory muscle testing in amyotrophic lateral sclerosis: a practical approach. Minerva Med 2019; 109:11-19. [PMID: 30642145 DOI: 10.23736/s0026-4806.18.05920-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In amyotrophic lateral sclerosis (ALS), respiratory muscle weakness leads to respiratory failure and death. Non-invasive positive pressure ventilation (NIPPV) appears to reduce lung function decline, thus improving survival and quality-of-life of patients affected by the disease. Unfortunately, clinical features and timing to start NIPPV are not well defined. Starting from recent findings, we examine established and novel tests of respiratory muscle function that could help clinicians decide whether and when to start NIPPV in ALS. Non-invasive tests estimate the function of inspiratory, expiratory, and bulbar muscles, whereas clinical examination allows to assess the overall neurologic and respiratory symptoms and general conditions. Most of the studies recommend that together with a thorough clinical evaluation of the patient according to current guidelines, vital capacity, maximal static and sniff nasal inspiratory pressures, maximal static expiratory pressures and peak cough expiratory flow, and nocturnal pulse oximetry be measured. A sound understanding of physiology can guide the physician also through the current armamentarium for additional supportive treatments for ALS, such as symptomatic drugs and new treatments to manage sialorrhea and thickened saliva, cough assistance, air stacking, and physiotherapy. In conclusion, careful clinical and functional evaluation of respiratory function and patient's preference are key determinants to decide "when" and "to whom" respiratory treatments can be provided.
Collapse
Affiliation(s)
- Giuseppe F Sferrazza Papa
- Department of Neurorehabilitation Sciences, Casa di Cura Privata del Policlinico, Milan, Italy - .,Respiratory Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy -
| | - Giulia M Pellegrino
- Department of Neurorehabilitation Sciences, Casa di Cura Privata del Policlinico, Milan, Italy.,Respiratory Unit, Department of Health Sciences, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Hameeda Shaikh
- Division of Pulmonary and Critical Care Medicine, Loyola University of Chicago Stritch School of Medicine, Maywood, IL, USA.,Edward Hines Jr. Veterans Administration Hospital Hines, Chicago, IL, USA
| | - Agata Lax
- IRCCS Don Carlo Gnocchi Foundation, Milan, Italy
| | - Luca Lorini
- Unit of Neurosurgical Intensive Care, Department of Anesthesia and Critical Care Medicine, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Massimo Corbo
- Department of Neurorehabilitation Sciences, Casa di Cura Privata del Policlinico, Milan, Italy
| |
Collapse
|
20
|
Abstract
ALS is a neurodegenerative disease in which the primary symptoms result in progressive neuromuscular weakness. Recent studies have highlighted that there is significant heterogeneity with regard to anatomical and temporal disease progression. Importantly, more recent advances in genetics have revealed new causative genes to the disease. New efforts have focused on the development of biomarkers that could aid in diagnosis, prognosis, and serve as pharmacodynamics markers. Although traditional pharmaceuticals continue to undergo trials for ALS, new therapeutic strategies including stem cell transplantation studies, gene therapies, and antisense therapies targeting some of the familial forms of ALS are gaining momentum.
Collapse
|
21
|
Miranda B, Pinto S, de Carvalho M. The impact of spasticity on diaphragm contraction: Electrophysiological assessment. Clin Neurophysiol 2018; 129:1544-1550. [DOI: 10.1016/j.clinph.2018.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 05/11/2018] [Accepted: 05/18/2018] [Indexed: 11/28/2022]
|
22
|
The Role of Moderate Aerobic Exercise as Determined by Cardiopulmonary Exercise Testing in ALS. Neurol Res Int 2018; 2018:8218697. [PMID: 29666705 PMCID: PMC5832023 DOI: 10.1155/2018/8218697] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/05/2017] [Indexed: 12/11/2022] Open
Abstract
Introduction The efficacy of cardiopulmonary exercise testing (CPET) to determining exercise intensity has not been established in Amyotrophic Lateral Sclerosis (ALS). We studied this intervention. Methods We included 48 ALS patients randomized in 2 groups: G1 (n = 24), exercise intensity leveled by CPET; G2 (n = 24), standard care limited by fatigue, during 6 months. ALS functional scale (ALSFRS-R) and forced vital capacity (FVC) were performed every 3 months; CPET was done at admission (T1) and 6 months later (T2). We registered oxygen uptake, carbon dioxide output, and ventilation at anaerobic threshold and at peak effort. Primary outcome was functional change. We used parametric statistics for comparisons and multiple regression analyses to identify independent predictors of functional decline. Results At T1 both groups were identical, except for higher FVC in G1 (p = 0.02). At T2, ALSFRS-R was higher (p = 0.035) in G1. Gas exchange variables at T2 did not change in G1 but had significant differences in G2 (p < 0.05). Multiregression analyses showed the Spinal ALSFRS-R slope and Intervention group (p < 0.001) as significant predictors of ALSFRS-R at T2. Conclusion Aerobic exercise defined by CPET is feasible and can improve functional outcome in ALS. This trial is registered with Clinical trials.gov ID: NCT03326622.
Collapse
|
23
|
Vitacca M, Montini A, Lunetta C, Banfi P, Bertella E, De Mattia E, Lizio A, Volpato E, Lax A, Morini R, Paneroni M. Impact of an early respiratory care programme with non-invasive ventilation adaptation in patients with amyotrophic lateral sclerosis. Eur J Neurol 2018; 25:556-e33. [PMID: 29266547 DOI: 10.1111/ene.13547] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 12/04/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Forced vital capacity (FVC) <80% is one of the key indications for starting non-invasive ventilation (NIV) in amyotrophic lateral sclerosis (ALS). It was hypothesized that a very early start of NIV could lengthen the free interval before death compared to later-start NIV; as a secondary outcome, the survival rate of patients on NIV without tracheotomy was also evaluated. METHODS This retrospective study was conducted on 194 ALS patients, divided into a later group (LG) with FVC <80% at NIV prescription (n = 129) and a very early group (VEG) with FVC ≥80% at NIV prescription (n = 65). Clinical and respiratory functional data and time free to death between groups over a 3-year follow-up were compared. RESULT At 36 months from diagnosis, mortality was 35% for the VEG versus 52.7% for the LG (P = 0.022). Kaplan-Meier survival curves adjusted for tracheotomy showed a lower probability of death (P = 0.001) for the VEG as a whole (P = 0.001) and for the non-bulbar (NB) subgroup (P = 0.007). Very early NIV was protective of survival for all patients [hazard ratio (HR) 0.45; 95% confidence interval (CI) 0.28-0.74; P = 0.001] and for the NB subgroup (HR 0.43; 95% CI 0.23-0.79; P = 0.007), whilst a tracheotomy was protective for all patients (HR 0.27; 95% CI 0.15-0.50; P = 0.000) and both NB (HR 0.26; 95% CI 0.12-0.56; P = 0.001) and bulbar subgroups (HR 0.29; 95% CI 0.11-0.77; P = 0.013). Survival in VEG patients on NIV without tracheotomy was three times that for the LG (43.1% vs. 14.7%). CONCLUSION Very early NIV prescription prolongs the free time from diagnosis to death in NB ALS patients whilst tracheotomy reduces the mortality risk in all patients.
Collapse
Affiliation(s)
- M Vitacca
- Respiratory Rehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
| | - A Montini
- Respiratory Rehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
| | - C Lunetta
- NEMO Clinical Centre, Fondazione Serena Onlus, Milano, Italy
| | - P Banfi
- Don Gnocchi Foundation IRCCS - Onlus, Milano, Italy
| | - E Bertella
- Respiratory Rehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
| | - E De Mattia
- NEMO Clinical Centre, Fondazione Serena Onlus, Milano, Italy
| | - A Lizio
- NEMO Clinical Centre, Fondazione Serena Onlus, Milano, Italy
| | - E Volpato
- Don Gnocchi Foundation IRCCS - Onlus, Milano, Italy.,Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | - A Lax
- Don Gnocchi Foundation IRCCS - Onlus, Milano, Italy
| | - R Morini
- Neurorehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
| | - M Paneroni
- Respiratory Rehabilitation Division, ICS Maugeri IRCCS, Lumezzane, Brescia, Italy
| | | |
Collapse
|
24
|
Abstract
PURPOSE OF REVIEW Although there is no cure for motor neurone disease (MND), the advent of multidisciplinary care and neuroprotective agents has improved treatment interventions and enhanced quality of life for MND patients and their carers. RECENT FINDINGS Evidence-based multidisciplinary care, respiratory management and disease-modifying therapy have improved the outcomes of patients diagnosed with MND. Supportive approaches to nutritional maintenance and optimization of symptomatic treatments, including management of communication and neuropsychiatric issues, improve the quality of life for MND patients. SUMMARY Recent progress in the understanding of the clinical, pathophysiological and genetic heterogeneity of MND has improved the approach of clinicians to treatment. Notwithstanding improvement to care and quality of life, survival benefit has become evident with the advent of a multidisciplinary care framework, early treatment with riluzole and noninvasive ventilation. Weight maintenance remains critical, with weight loss associated with more rapid disease progression. The end-of-life phase is poorly defined and treatment is challenging, but effective symptom control through palliative care is achievable and essential. Encouragingly, current progress of clinical trials continues to close the gap towards the successful development of curative treatment in MND.
Collapse
|
25
|
Abstract
Prevalence studies have shown heterogeneous use of home mechanical ventilation in different conditions, with a marked increase in uptake especially in users of noninvasive ventilation. Although randomized controlled trials have examined noninvasive ventilation in acute exacerbations of chronic obstructive pulmonary disease, for weaning from invasive ventilation and for postextubation respiratory failure, the evidence base for long-term noninvasive ventilation and comparisons with invasive ventilation are less well developed. The combination of noninvasive ventilation and cough-assist devices has reduced the indications for tracheotomy ventilation in some situations (e.g., Duchenne muscular dystrophy, spinal muscular atrophy, myopathies, and amyotrophic lateral sclerosis) and has also prolonged survival. Several excellent overviews have been written on the history of home mechanical ventilation and its evolution from negative pressure to positive pressure techniques, including a systematic review of outcomes. This review, instead, will cover recent trials, trends in the field, outcomes, and safety. Because the greatest growth has been in home noninvasive ventilation, this will be the main focus of this article.
Collapse
|
26
|
Aboussouan LS, Mireles-Cabodevila E. Sleep in Amyotrophic Lateral Sclerosis. CURRENT SLEEP MEDICINE REPORTS 2017. [DOI: 10.1007/s40675-017-0094-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
27
|
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.
Collapse
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
| | | |
Collapse
|
28
|
Sleep-disordered breathing in patients with neuromuscular disease. Sleep Breath 2017; 22:277-286. [DOI: 10.1007/s11325-017-1538-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/09/2017] [Accepted: 07/04/2017] [Indexed: 12/12/2022]
|
29
|
Pinto S, de Carvalho M. Correlation between Forced Vital Capacity and Slow Vital Capacity for the assessment of respiratory involvement in Amyotrophic Lateral Sclerosis: a prospective study. Amyotroph Lateral Scler Frontotemporal Degener 2016; 18:86-91. [DOI: 10.1080/21678421.2016.1249486] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Susana Pinto
- Instituto de Medicina Molecular and Institute of Physiology, Faculty of Medicine, University of Lisbon, Portugal and
| | - Mamede de Carvalho
- Instituto de Medicina Molecular and Institute of Physiology, Faculty of Medicine, University of Lisbon, Portugal and
- Department of Neurosciences and Mental Health, Hospital de Santa Maria-Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| |
Collapse
|
30
|
Rabec C, Cuvelier A, Cheval C, Jaffre S, Janssens JP, Mercy M, Prigent A, Rouault S, Talbi S, Vandenbroeck S, Gonzalez-Bermejo J. Ventilation non invasive. Les conseils 2015 du Groupe assistance ventilatoire (GAV) de la Société de pneumologie de langue française (SPLF). Rev Mal Respir 2016; 33:905-910. [DOI: 10.1016/j.rmr.2016.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/17/2016] [Indexed: 01/22/2023]
|
31
|
Hobson EV, McDermott CJ. Supportive and symptomatic management of amyotrophic lateral sclerosis. Nat Rev Neurol 2016; 12:526-38. [PMID: 27514291 DOI: 10.1038/nrneurol.2016.111] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The main aims in the care of individuals with amyotrophic lateral sclerosis (ALS) are to minimize morbidity and maximize quality of life. Although no cure exists for ALS, supportive and symptomatic care provided by a specialist multidisciplinary team can improve survival. The basis for supportive management is shifting from expert consensus guidelines towards an evidence-based approach, which encourages the use of effective treatments and could reduce the risk of harm caused by ineffective or unsafe interventions. For example, respiratory support using noninvasive ventilation has been demonstrated to improve survival and quality of life, whereas evidence supporting other respiratory interventions is insufficient. Increasing evidence implicates a causal role for metabolic dysfunction in ALS, suggesting that optimizing nutrition could improve quality of life and survival. The high incidence of cognitive dysfunction and its impact on prognosis is increasingly recognized, although evidence for effective treatments is lacking. A variety of strategies are used to manage the other physical and psychological symptoms, the majority of which have yet to be thoroughly evaluated. The need for specialist palliative care throughout the disease is increasingly recognized. This Review describes the current approaches to symptomatic and supportive care in ALS and outlines the current guidance and evidence for these strategies.
Collapse
Affiliation(s)
- Esther V Hobson
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385a Glossop Rd, Sheffield, S10 2HQ, UK
| | - Christopher J McDermott
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385a Glossop Rd, Sheffield, S10 2HQ, UK
| |
Collapse
|
32
|
|
33
|
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.
Collapse
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
| |
Collapse
|
34
|
Abstract
An optimized management of amyotrophic lateral sclerosis (ALS) is an added value of a follow-up by an interdisciplinary team. The aim of this study was to identify which professionals are involved in care of ALS patients at Portugal and their impact on quality of life (QoL). We divided the sample in Group 1 (G1; Southern) and Group 2 (G2; Northern) and used a semi-structured questionnaire, functional status scale (Amyotrophic Lateral Sclerosis Functional Rating Scale–Revised [ALSFRS-R]), and QoL evaluation to perform the study. There were observed differences at admission in ALSFRS-R, higher in G1, presence of specialized professionals higher in G2; non-invasive ventilation equipment had higher use and compliance in G1. Multiple regression analysis shows gender, education level, and technical aids as predictors of QoL. The study showed that, despite regional differences, there were external factors common to both groups that influenced QoL.
Collapse
Affiliation(s)
- Anna Caroline Braga
- Santa Maria Hospital, Lisbon, Portugal
- Medical School of Lisbon - University of Lisbon, Portugal
| | - Anabela Pinto
- Santa Maria Hospital, Lisbon, Portugal
- Medical School of Lisbon - University of Lisbon, Portugal
| |
Collapse
|
35
|
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.
Collapse
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
| |
Collapse
|
36
|
Gladman M, Zinman L. The economic impact of amyotrophic lateral sclerosis: a systematic review. Expert Rev Pharmacoecon Outcomes Res 2015; 15:439-50. [DOI: 10.1586/14737167.2015.1039941] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Matthew Gladman
- 1Department of Medicine, Sunnybrook Health Sciences Centre, Queen’s University, Ontario, Canada
| | - Lorne Zinman
- 2Department of Medicine, University of Toronto, Ontario, Canada
| |
Collapse
|
37
|
Franchignoni F, Mandrioli J, Giordano A, Ferro S. A further Rasch study confirms that ALSFRS-R does not conform to fundamental measurement requirements. Amyotroph Lateral Scler Frontotemporal Degener 2015; 16:331-7. [PMID: 25916346 DOI: 10.3109/21678421.2015.1026829] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Our objective was to verify and expand previous evidence of psychometric inadequacies in the ALSFRS-R, in a different sample of subjects suffering from ALS. Since 2009, a prospective registry records all incident cases of ALS in Emilia Romagna Region, Italy (4.4 million inhabitants) referred to its 17 neurological departments. For each patient, demographic and clinical information is collected by the physician in charge, including compilation of the ALSFRS-R at each clinical follow-up. Results showed that a confirmatory factor analysis on the three-factor model previously found (bulbar, motor, respiratory function) showed a good fit. Rasch analysis on the whole scale showed the need to collapse some rating categories, confirmed the multidimensionality of the ALSFRS-R, and demonstrated the presence of differential item functioning between patients with spinal versus bulbar onset. Moreover, some items included in the three ALSFRS-R subscales showed a problematic fit to the respective construct they were intended to measure. In conclusion, the interpretation of a total raw score of ALSFRS-R is hampered by ambiguities due to the different metric properties of the three domains the scale aggregates, and their content and structure. This study confirms that a refinement of ALSFRS-R is warranted, pointing to the need to revise its whole structure, and providing detailed guidelines for its revision.
Collapse
Affiliation(s)
- Franco Franchignoni
- a Unit of Occupational Rehabilitation and Ergonomics, Salvatore Maugeri Foundation, Scientific Institute of Veruno (NO) , Italy
| | - Jessica Mandrioli
- b Department of Neuroscience , St. Agostino-Estense Hospital , Modena , Italy
| | - Andrea Giordano
- c Unit of Bioengineering, Salvatore Maugeri Foundation, Scientific Institute of Veruno (NO) , Italy
| | - Salvatore Ferro
- d Department of Hospital Services , Emilia Romagna Regional Health Authority , Bologna , Italy
| | | |
Collapse
|
38
|
Abstract
Objective:The purpose of this study was to evaluate Canadian amyotrophic lateral sclerosis (ALS) centres with respect to: 1) the prevalence of Non-invasive positive pressure ventilation (NIPPV) and invasive mechanical ventilation via tracheostomy (TV) utilization, 2) the approach to NIPPV use, focusing upon the currently employed initiation criteria and 3) the barriers influencing NIPPV administration.Methods:A descriptive survey research design aimed to obtain quantitative data and open-ended responses from an active physician at each of the 15 multidisciplinary Canadian ALS centres.Results:The principal findings of this study were: 1) NIPPV and TV are used in 18.3% and 1.5% of patients at Canadian ALS centres, respectively, 2) symptoms of respiratory insufficiency, namely orthopnea (clinical significance rated at 9.00/10 ± 1.48), dyspnea (8.27 ± 1.95) and morning headache (7.55 ± 1.21) are the most significant indicators for NIPPV initiation, 3) the primary barriers to NIPPV utilization are patient intolerance (70% of centres) and inaccessibility of respirologists and ventilation technologists (50% of centres).Conclusions:Variability in NIPPV use has an impact upon the management of Canadian ALS patients. The establishment of more definitive NIPPV initiation criteria, emphasizing respiratory symptoms, and the attenuation of barriers to NIPPV use should be targeted so as to ensure optimal care for all ALS patients.
Collapse
|
39
|
Simon NG, Turner MR, Vucic S, Al-Chalabi A, Shefner J, Lomen-Hoerth C, Kiernan MC. Quantifying disease progression in amyotrophic lateral sclerosis. Ann Neurol 2014; 76:643-57. [PMID: 25223628 PMCID: PMC4305209 DOI: 10.1002/ana.24273] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/12/2014] [Accepted: 09/12/2014] [Indexed: 12/28/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) exhibits characteristic variability of onset and rate of disease progression, with inherent clinical heterogeneity making disease quantitation difficult. Recent advances in understanding pathogenic mechanisms linked to the development of ALS impose an increasing need to develop strategies to predict and more objectively measure disease progression. This review explores phenotypic and genetic determinants of disease progression in ALS, and examines established and evolving biomarkers that may contribute to robust measurement in longitudinal clinical studies. With targeted neuroprotective strategies on the horizon, developing efficiencies in clinical trial design may facilitate timely entry of novel treatments into the clinic.
Collapse
Affiliation(s)
- Neil G Simon
- Department of Neurology, University of California, San Francisco, San Francisco, CA; Prince of Wales Clinical School, University of New South Wales, Randwick, Australia; Neuroscience Research Australia, Barker St, Randwick, Australia
| | | | | | | | | | | | | |
Collapse
|
40
|
|
41
|
Pinto S, Carvalho MD. Breathing new life into treatment advances for respiratory failure in amyotrophic lateral sclerosis patients. Neurodegener Dis Manag 2014; 4:83-102. [DOI: 10.2217/nmt.13.74] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
SUMMARY In the last three decades, improvements in respiratory management are responsible for increasing survival and improving quality of life for amyotrophic lateral sclerosis (ALS) patients. Nowadays, ALS patients with respiratory involvement are offered a support treatment other than the traditional respiratory palliative care. Knowledge about available respiratory support potentialities is essential for appropriate, customized and effective treatment of ALS, which should probably be started sooner than the conventional approach. There is evidence supporting that respiratory support has a larger impact than riluzole on survival. Noninvasive ventilation is essential in the treatment of ALS patients with respiratory involvement. In this article methods to determine respiratory failure in ALS, mechanical invasive and noninvasive ventilation, telemetry, diaphragm pacing, cough aids and respiratory exercise are reviewed, after a brief overlook of respiratory insufficiency in ALS.
Collapse
Affiliation(s)
- Susana Pinto
- Translational Clinical Physiology Unit, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, 1648-028 Lisbon, Portugal
| | - Mamede de Carvalho
- Translational Clinical Physiology Unit, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, 1648-028 Lisbon, Portugal
- Neuroscience Department, Santa Maria Hospital, Lisbon, Portugal
| |
Collapse
|
42
|
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]
|
43
|
Is the effect of non-invasive ventilation on survival in amyotrophic lateral sclerosis age-dependent? BMC Palliat Care 2013; 12:23. [PMID: 23705902 PMCID: PMC3698107 DOI: 10.1186/1472-684x-12-23] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 05/20/2013] [Indexed: 12/11/2022] Open
Abstract
Background Hypoventilation due to respiratory muscle atrophy is the most common cause of death as a result of amyotrophic lateral sclerosis (ALS). Patients aged over 65 years and presenting bulbar symptoms are likely to have a poorer prognosis. The aim of the study was to assess the possible impact of age and treatment with non-invasive ventilation (NIV) on survival in ALS. Based on evidence from earlier studies, it was hypothesized that NIV increases rates of survival regardless of age. Methods Eighty-four patients diagnosed with ALS were followed up on from January 2001 to June 2012. These patients were retrospectively divided into two groups according to their age at the time of diagnosis: Group 1 comprised patients aged ≤ 65 years while Group 2 comprised those aged > 65 years. Each group included 42 patients. NIV was tolerated by 23 patients in Group 1 and 18 patients in Group 2. Survival was measured in months from the date of diagnosis. Results The median age in Group 1 was 59 years (range 49 – 65) and 76 years in Group 2 (range 66 – 85). Among patients in Group 1 there was no difference in probability of survival between the NIV users and non-users (Hazard Ratio = 0.88, 95% CI 0.44 – 1.77, p = 0.7). NIV users in Group 2 survived longer than those following conventional treatment (Hazard Ratio = 0.25, CI 95% 0.11 – 0.55, p <0.001). ALS patients in Group 2 who did not use NIV had a 4-fold higher risk for death compared with NIV users. Conclusions This retrospective study found that NIV use was associated with improved survival outcomes in ALS patients older than 65 years. Further studies in larger patient populations are warranted to determine which factors modify survival outcomes in ALS.
Collapse
|
44
|
Riemenschneider KA, Forshew DA, Miller RG. Multidisciplinary clinics: optimizing treatment for patients with amyotrophic lateral sclerosis. Neurodegener Dis Manag 2013. [DOI: 10.2217/nmt.13.7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
SUMMARY Amyotrophic lateral sclerosis is an incurable, lethal neurodegenerative disease. The majority of patients die from respiratory failure within 2–5 years after symptom onset. Recent studies show a paradigm shift in the method of delivering a number of effective treatments through an emerging network of multidisciplinary clinics. This article focuses on the role played by these clinics in raising the standard-of-care for patients with amyotrophic lateral sclerosis. Although newly developed treatments are still underutilized, substantial progress is being made by multidisciplinary clinics, which play a pivotal role in coordinating access to effective therapeutics.
Collapse
Affiliation(s)
- Karina A Riemenschneider
- University of Copenhagen, Copenhagen, Denmark
- Forbes Norris ALS Research Center, California Pacific Medical Center, 2324 Sacramento Street, San Francisco, CA 94115, USA
| | - Dallas A Forshew
- Forbes Norris ALS Research Center, California Pacific Medical Center, 2324 Sacramento Street, San Francisco, CA 94115, USA
| | - Robert G Miller
- Forbes Norris ALS Research Center, California Pacific Medical Center, 2324 Sacramento Street, San Francisco, CA 94115, USA.
| |
Collapse
|
45
|
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.
Collapse
|
46
|
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]
|
47
|
Pinto S, Pinto A, de Carvalho M. Phrenic nerve studies predict survival in amyotrophic lateral sclerosis. Clin Neurophysiol 2012; 123:2454-9. [DOI: 10.1016/j.clinph.2012.05.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 04/07/2012] [Accepted: 05/15/2012] [Indexed: 11/25/2022]
|
48
|
Gruis KL, Lechtzin N. Respiratory therapies for amyotrophic lateral sclerosis: a primer. Muscle Nerve 2012; 46:313-31. [PMID: 22907221 DOI: 10.1002/mus.23282] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Respiratory complications are a common cause of morbidity and mortality in amyotrophic lateral sclerosis (ALS). Treatment of respiratory insufficiency with noninvasive ventilation (NIV) improves ALS patients' quality of life and survival. Evidence-based practice guidelines for the management of ALS patients recommend treatment of respiratory insufficiency with NIV as well as consideration of insufflation/exsufflation to improve clearance of airway secretions. Despite these recommendations respiratory therapies remain underused. In this review we provide a practical guide for the clinician to prescribe and manage respiratory therapies for the patient with ALS.
Collapse
Affiliation(s)
- Kirsten L Gruis
- Department of Neurology, University of Michigan, 1C327 UH, EMG Lab, SPC 5036, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109, USA.
| | | |
Collapse
|
49
|
Lopes de Almeida JP, Pinto A, Pinto S, Ohana B, de Carvalho M. Economic cost of home-telemonitoring care for BiPAP-assisted ALS individuals. ACTA ACUST UNITED AC 2012; 13:533-7. [PMID: 22873565 DOI: 10.3109/17482968.2012.703675] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Our objective was to measure direct (hospital and NHS) and indirect (patient/caregiver) costs of following up in-home compliance to non-invasive ventilation via wireless modem. We constructed a prospective controlled trial of 40 consecutive ALS home-ventilated patients, randomly assigned according to their residence area to G1 (nearby hospital, office-based follow-up) and G2 (outside hospital area, telemetry device-based follow-up). Total NHS direct cost encompassed costs related to outpatients' visits (office and emergency room) and hospitalizations. Hospital direct costs included transportation to/from hospital, office visit per hour cost and equipment maintenance. Non-medical costs considered days of wages lost due to absenteeism. G1 included 20 patients aged 60 ± 10 years and G2 included 19 patients aged 62 ± 13 years. Results showed that no differences were found regarding clinical/demographic characteristics at admission. NHS costs showed a 55% reduction in average total costs with a statistically significant decrease of 81% in annual costs per patient in G2. Hospital costs were found to be significantly higher in G2 with regard to total costs (64% average increase) but not annual costs (7%). No statistical difference was found with regard to expenses from absenteeism. In conclusion, at the cost of an initial financial constraint to the hospital per year (non-significant), telemonitoring is cost-effective, representing major cost savings to the NHS in the order of 700 euros/patient/year.
Collapse
|
50
|
Lo Coco D, Cannizzaro E, Spataro R, Taiello AC, La Bella V. Sleep–wake problems in patients with amyotrophic lateral sclerosis: implications for patient management. Neurodegener Dis Manag 2012. [DOI: 10.2217/nmt.12.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Sleep–wake problems are frequent, although unrecognized, complications of amyotrophic lateral sclerosis (ALS). Sleep disorders such as insomnia, sleep-disordered breathing and restless legs syndrome have all been reported in patients with ALS, despite the limited number of studies and the small populations investigated so far. Sleep disturbances gradually worsen with disease progression, suggesting a relationship between the severity of disease and the neurodegenerative process. However, poor sleep can also be a consequence of several disturbances such as anxiety, depression, pain, choking, sialorrhea, fasciculations, cramps, nocturia and the inability to get comfortable and move freely in bed. Sleep disorders may have many reflections on patients with ALS, including excessive daytime somnolence, fatigue, impaired cognition, reduced quality of life and survival. This article reviews the recent literature on sleep–wake problems in patients with ALS, focusing on the implications for patient management.
Collapse
Affiliation(s)
- Daniele Lo Coco
- Sleep Disorders Clinic, Dipartimento di Neuroscienze, Ospedale Civico – ARNAS, Piazza N. Leotta, 4 – 90129, Palermo, Italy
| | - Emanuele Cannizzaro
- Dipartimento di Scienze Farmacologiche, Università di Palermo, Palermo, Italy
| | - Rossella Spataro
- ALS Clinical Research Center, Dipartimento di Biomedicina Sperimentale e Neuroscienze Cliniche (BioNeC), Università di Palermo, Palermo, Italy
| | - Alfonsa Claudia Taiello
- ALS Clinical Research Center, Dipartimento di Biomedicina Sperimentale e Neuroscienze Cliniche (BioNeC), Università di Palermo, Palermo, Italy
| | - Vincenzo La Bella
- ALS Clinical Research Center, Dipartimento di Biomedicina Sperimentale e Neuroscienze Cliniche (BioNeC), Università di Palermo, Palermo, Italy
| |
Collapse
|