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Georges M, Perez T, Rabec C, Jacquin L, Finet-Monnier A, Ramos C, Patout M, Attali V, Amador M, Gonzalez-Bermejo J, Salachas F, Morelot-Panzini C. [Proposals from a French expert panel for respiratory care in ALS patients]. 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.
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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
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Réginault T, Wibart P, Mathis S, Le Masson G, Pillet O, Grassion L. Factors associated with survival after early at-home NIV initiation in ALS patients. J Neurol 2024:10.1007/s00415-024-12523-w. [PMID: 38909342 DOI: 10.1007/s00415-024-12523-w] [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: 04/17/2024] [Revised: 06/13/2024] [Accepted: 06/15/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND The initiation of early non-invasive ventilation (NIV) often involves a careful balance between tolerance and effectiveness. In amyotrophic lateral sclerosis (ALS) patients, the establishment of a strategy, including the decision to focus on adhering to a cut-off, setting specific targets, or correcting all events, is crucial. OBJECTIVE To identify factors at 1 month after early at-home NIV initiation that are associated with improved survival in ALS patients. We explored the impacts of adherence (ADH), quality of treatment, and NIV parameters at 1 month after early at-home NIV initiation on patient survival. METHODS We conducted a retrospective study of 184 ALS patients at the Bordeaux ALS Centre for whom NIV was initiated between September 2017 and June 2021, and we collected data for a minimum period of 2 years after the last patient included. The primary outcome was the risk of death according to baseline characteristics of our population and the NIV parameters and monitoring during the early NIV initiation period. The secondary outcomes were association with NIV ADH during the early NIV initiation period on prognosis, and NIV ADH cut-off for good versus poor prognosis. RESULTS Among the 178 ALS patients analysed, we found that quality of NIV treatment and device settings did not significantly influence prognosis. However, low ADH was significantly associated with a higher risk of death. The use of NIV for > 5 h/day during the early NIV initiation period was linked to a decreased risk of death [hazard ratio = 0.4; 95% confidence interval: 0.27-0.9]. CONCLUSION The use of NIV for > 5 h/day during the early NIV initiation period was associated with increased survival.
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Affiliation(s)
- Thomas Réginault
- Département de Médecine, Service de Réanimation Médicale, Hôpital Pellegrin, Bordeaux, France.
- Zéphyr Paramed, Bordeaux, France.
| | - P Wibart
- Département de Médecine, Service de Réanimation Médicale, Hôpital Pellegrin, Bordeaux, France
- Zéphyr Paramed, Bordeaux, France
| | - S Mathis
- Département de Neurologie, Centre de Référence pour La SLA, Hôpital Pellegrin, Bordeaux, France
| | - G Le Masson
- Département de Neurologie, Centre de Référence pour La SLA, Hôpital Pellegrin, Bordeaux, France
| | - O Pillet
- Département de Médecine, Service de Réanimation Médicale, Hôpital Pellegrin, Bordeaux, France
| | - L Grassion
- Département de Pneumologie, Service de Maladies respiratoires et pneumologie, Hôpital du Haut Lévêque, Pessac, France
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Tankéré P, Georges M, Abdulmalak C, Schenesse D, Beltramo G, Berrier A, Bonniaud P, Rabec C. Residual upper airway obstruction during nocturnal noninvasive ventilation despite high positive expiratory pressure. Impact of oronasal mask to nasal mask switch. Respir Med Res 2024; 85:101083. [PMID: 38232657 DOI: 10.1016/j.resmer.2023.101083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 12/08/2023] [Accepted: 12/15/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Nasal mask (NM) and oronasal masks (OM) can be used to provide noninvasive ventilation (NIV). Recent studies suggested that OM is the most used interface and that there is no difference in efficacy or in tolerance between OM and NM for chronic use. However, studies focusing on video laryngoscopy underlined the impact of OM in residual upper airway obstruction (UAO) under NIV. We sought to assess the real-life practice of switching from OM to NM when UAO events persist despite high EPAP levels. METHODS In an open-label single center prospective cohort study, data from files and full night polysomnography on NM and OM were collected for patients wearing OM and presenting an UAO index ≥15/h despite an EPAP level ≥ 10 cmH20. RESULTS Forty-four patients were included in the study. In 31 patients (74 %), switching to a NM reduced UAOi to ≥10/h. Interestingly, 92 % of these patients still had NM at 3 to 12 months of follow-up. Switching to a NM was also associated with a trend in paCO2 reduction and significant improvements in Epworth, sleep quality and NIV compliance. Successful interface switching was significantly associated with female gender, and a trend was observed in non-smokers. CONCLUSION As for CPAP, switching to a NM improved NIV efficacy in a selected group of patients presenting residual UAO events despite high EPAP levels. Additionally, this switch has an impact on compliance and subjective sleepiness. Thus, in patients with persisting UAO on OM, switching to a NM could be a first-line intervention before considering further investigation such as polygraphy or video laryngoscopy. We also derive an algorithm for mask allocation and adaptation in acute and chronic NIV use.
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Affiliation(s)
- Pierre Tankéré
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France
| | - Marjolaine Georges
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France; University of Bourgogne Franche-Comté, Dijon, France; Centre des Sciences du Goût et de l'Alimentation, INRA, UMR 6265 CNRS 1234, University of Bourgogne Franche-Comté, Dijon, France
| | - Caroline Abdulmalak
- Department of Intensive Care Medicine, William Morey General Hospital, Chalon-Sur-Saône, France
| | - Deborah Schenesse
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France
| | - Guillaume Beltramo
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France; University of Bourgogne Franche-Comté, Dijon, France; INSERM, LNC UMR1231, LipSTIC LabEx Team, Dijon, France
| | - Amaury Berrier
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France
| | - Philippe Bonniaud
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France; University of Bourgogne Franche-Comté, Dijon, France; INSERM, LNC UMR1231, LipSTIC LabEx Team, Dijon, France
| | - Claudio Rabec
- Dept of Pneumology and Intensive Care Unit, Reference Centre for Rare Lung Diseases, Dijon University Hospital, Dijon, France.
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Hobson E, McDermott C. Advances in symptom management and in monitoring disease progression in motor neuron disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 176:119-169. [PMID: 38802174 DOI: 10.1016/bs.irn.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
The aim of supportive management of motor neuron disease is to improve survival, promote good quality of life and patient independence and autonomy whilst preparing for future progression and the end of life. Multidisciplinary specialist care aims to address the multifaceted and interacting biopsychosocial problems associated with motor neuron disease that leads to proven benefits in both survival and quality of life. This chapter will explore principles, structure and details of treatment options, and make recommendations for practice and for future research.
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Affiliation(s)
- Esther Hobson
- Sheffield Institute for Translational Neuroscience, Division of Neuroscience, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom
| | - Christopher McDermott
- Sheffield Institute for Translational Neuroscience, Division of Neuroscience, School of Medicine and Population Health, University of Sheffield, Sheffield, United Kingdom.
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Pupillo E, Al-Chalabi A, Sassi S, Arippol E, Tinti L, Vitelli E, Copetti M, Leone MA, Bianchi E. Methodological Quality of Clinical Trials in Amyotrophic Lateral Sclerosis: A Systematic Review. J Neuromuscul Dis 2024; 11:749-765. [PMID: 38759021 DOI: 10.3233/jnd-230217] [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: 05/19/2024]
Abstract
Background More than 200 clinical trials have been performed worldwide in ALS so far, but no agents with substantial efficacy on disease progression have been found. Objective To describe the methodological quality of all clinical trials performed in ALS and published before December 31, 2022. Methods We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta Analyses. Results 213 trials were included. 47.4% manuscripts described preclinical study evaluation, with a positive effect in all. 67.6% of trials were conducted with a parallel-arm design, while 12.7% were cross-over studies; 77% were randomized, while in 5.6% historical-controls were used for comparison. 70% of trials were double blind. Participant inclusion allowed forced vital capacity (or corresponding slow vital capacity)<50% in 15% cases, between 55-65% in 21.6%, between 70-80% in 14.1% reports, and 49.3% of the evaluated manuscripts did not provide a minimum value for respiratory capacity at inclusion. Disease duration was < 6-months in 6 studies, 7-36 months in 68, 37-60 months in 24, 8 trials requested more than 1-month of disease duration, while in 107 reports a disease duration was not described. Dropout rate was ≥20% in 30.5% trials, while it was not reported for 8.5%. Conclusion The methodological quality of the included studies was highly variable. Major issues to be addressed in future ALS clinical trials include: the requirement for standard animal toxicology and phase I studies, the resource-intensive nature of phase II-III studies, adequate study methodology and design, a good results reporting.
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Affiliation(s)
- Elisabetta Pupillo
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Research Center for ALS, Milan, Italy
| | - Ammar Al-Chalabi
- Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- National Institute for Health Research Biomedical Research Centre and Dementia Unit at South London and Maudsley NHS Foundation Trust and King's College London, London, UK
- Department of Neurology, King's College Hospital, London, UK
| | - Serena Sassi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Research Center for ALS, Milan, Italy
| | - Emilio Arippol
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Research Center for ALS, Milan, Italy
| | - Lorenzo Tinti
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Research Center for ALS, Milan, Italy
| | - Eugenio Vitelli
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Research Center for ALS, Milan, Italy
| | - Massimiliano Copetti
- Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Maurizio A Leone
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Research Center for ALS, Milan, Italy
| | - Elisa Bianchi
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Research Center for ALS, Milan, Italy
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Saigal A, Shah AJ, Mandal S. Indications and evidence for domiciliary noninvasive ventilation. Expert Rev Respir Med 2023; 17:1141-1150. [PMID: 38112122 DOI: 10.1080/17476348.2023.2295941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Abstract
INTRODUCTION Home noninvasive ventilation (HNIV) has expanded globally, with a greater evidence base for its use. HNIV improves multiple patient related outcomes in patients with chronic hypercapnic respiratory failure. Obesity hypoventilation syndrome (OHS) is rapidly taking over as the primary indication for HNIV and COPD patients who overlap with obstructive sleep apnea hypoventilation syndromes (OSAHS) and are increasingly recognized but add to the complexity of HNIV prescribing. Optimal settings vary for differing diseases, with higher inspiratory pressures often required in those with OHS and COPD, yet which settings translate into greatest patient benefit remains unknown. AREAS COVERED We cover the evidence base underpinning the common indications for HNIV in COPD, OHS, neuromuscular disease (NMD), and chest wall disease (CWD) and highlight common HNIV modes used. EXPERT OPINION Active screening for nocturnal hypoventilation in OHS and COPD may be important to guide earlier ventilation. Further research on which HNIV modalities best improve patient related outcomes and the right time for initiation in different patient phenotypes is rapidly needed. Worldwide, clinical research trials should aim to bridge the gap by reporting on patient-related outcomes and cost effectiveness in real-world populations to best understand the true benefit of HNIV amongst heterogenous patient populations.
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Affiliation(s)
- Anita Saigal
- Respiratory Department, University College London, London, UK
- Thoracic Department, Royal Free London NHS Foundation Trust, London, UK
| | - Amar J Shah
- Respiratory Department, University College London, London, UK
- Thoracic Department, Royal Free London NHS Foundation Trust, London, UK
| | - Swapna Mandal
- Respiratory Department, University College London, London, UK
- Thoracic Department, Royal Free London NHS Foundation Trust, London, UK
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Chatwin M, Hart N. International Survey of the Tools Used for Assessment, Monitoring and Management of Home Mechanical Ventilation Patients. J Clin Med 2023; 12:6803. [PMID: 37959266 PMCID: PMC10649660 DOI: 10.3390/jcm12216803] [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: 09/27/2023] [Revised: 10/19/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND There are limited data reporting diagnostic practices, compared to clinical guidelines, for patients with chronic respiratory failure requiring home mechanical ventilation (HMV). There are no data detailing the current use of downloaded physiological monitoring data in day-to-day clinical practice during initiation and follow up of patients on HMV. This survey reports clinicians' practices, with a specific focus on the clinical approaches employed to assess, monitor and manage HMV patients. METHODS A web-based international survey was open between 1 January and 31 March 2023. RESULTS In total, 114 clinicians responded; 84% of the clinicians downloaded the internal physiological ventilator data when initiating and maintaining HMV patients, and 99% of the clinicians followed up with patients within 3 months. Adherence, leak and the apnea-hypopnea index were the three highest rated items. Oxygen saturation was used to support a diagnosis of nocturnal hypoventilation and was preferred over measurements of carbon dioxide. Furthermore, 78% of the clinicians reviewed data for the assessment of patient ventilator asynchrony (PVA), although the confidence reported in identifying certain PVAs was reported as unconfident or extremely unconfident. CONCLUSIONS This survey confirmed that clinical practice varies and often does not follow the current guidelines. Despite PVA being of clinical interest, its clinical relevance was not clear, and further research, education and training are required to improve clinical confidence.
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Affiliation(s)
- Michelle Chatwin
- Royal Brompton Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SW3 6NP, UK
- National Hospital for Neurology and Neurosurgery, University College London, London WC1N 3BG, UK
| | - Nicholas Hart
- Lane Fox Respiratory Service St Thomas’ Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 7EH, UK;
- Lane Fox Clinical Respiratory Physiology Research Unit, Centre for Human and Applied Physiological Science, King’s College London, London SE1 7EH, UK
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Agossou M, Awanou B, Inamo J, Rejaudry-Lacavalerie M, Arnal JM, Dramé M. Impact of Previous Continuous Positive Airway Pressure Use on Noninvasive Ventilation Adherence and Quality in Obesity Hypoventilation Syndrome: A Pragmatic Single-Center Cross-Sectional Study in Martinique. Biomedicines 2023; 11:2753. [PMID: 37893126 PMCID: PMC10604741 DOI: 10.3390/biomedicines11102753] [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: 09/09/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/29/2023] Open
Abstract
There is a strong relationship between obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS). When OHS is combined with severe OSA, treatment consists of continuous positive airway pressure (CPAP), followed by noninvasive ventilation (NIV) in the case of CPAP failure. Currently, the impact of a previous use of CPAP on the quality of NIV is unknown. We conducted a cross-sectional study with OHS patients, to assess the quality of NIV according to previous CPAP use. We included 75 patients with OHS on NIV (65 women, 87%). Among these, 40 patients (53.3%) who had had prior CPAP (CPAP+ group) were compared to the remaining 35 patients (46.7%) (CPAP- group). Key characteristics were comparable between the CPAP+ and the CPAP- groups: age at diagnosis of OHS was 67 ± 3 vs. 66 ± 4 years (p = 0.8), age at inclusion was 73 ± 15 vs. 69 ± 15 years (p = 0.29), number of comorbidities was 3.7 ± 1.2 vs. 3.3 ± 1.5, the Charlson index was 5.1 ± 2 vs. 4.6 ± 1.8, and BMI was 41.6 ± 7.6 kg/m2 vs. 41.2 ± 8.2, respectively, all p > 0.05. Follow-up length was greater in CPAP+ vs. CPAP- patients (5.6 ± 4.2 vs. 2.9 ± 2.9 years, p = 0.001). The quality of NIV based on daily adherence, pressure support, apnea-hypopnea index (AHI) and leaks was similar in both groups. Reduced adherence (less than 4 h daily) was found in 10 CPAP+ patients (25%) versus 7 CPAP- patients (20%), p = 0.80. NIV efficacy was also similar. This study found no difference in the quality of NIV or in adherence between patients who had had prior CPAP and those who had not. Previous CPAP does not appear to improve the quality of NIV.
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Affiliation(s)
- Moustapha Agossou
- Department of Respiratory Medicine, CHU of Martinique, 97261 Fort-de-France, France;
| | - Bérénice Awanou
- Department of Respiratory Medicine, CHU of Martinique, 97261 Fort-de-France, France;
| | - Jocelyn Inamo
- Department of Cardiology, CHU of Martinique, 97261 Fort-de-France, France;
| | | | | | - Moustapha Dramé
- Department of Clinical Research and Innovation, CHU of Martinique, 97261 Fort-de-France, France;
- EpiCliV Research Unit, Faculty of Medicine, University of the French West Indies, 97261 Fort-de-France, France
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Carlucci A, Patout M, Winck JC. Does one size fit all? An update on chronic ventilatory support in different respiratory illnesses. Breathe (Sheff) 2023; 19:230046. [PMID: 37492344 PMCID: PMC10365079 DOI: 10.1183/20734735.0046-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/15/2023] [Indexed: 07/27/2023] Open
Abstract
Home noninvasive ventilation (HNIV) improves outcomes in different disease categories. In this article, we discuss indications for when and how to initiate HNIV in COPD, obesity hypoventilation syndrome (OHS) and neuromuscular disorders (NMD). While in COPD, significant diurnal hypercapnia and high-intensity HNIV are essential ingredients for success, in NMD and OHS, early respiratory changes are best detected during sleep through oxy-capnography associated (or not) with respiratory polygraphy. In COPD and OHS, it is crucial to consider the coexistence of obstructive sleep apnoea because treatment with continuous positive airway pressure may be the simplest and most effective treatment that should be proposed even in hypercapnic patients as first-line therapy. In NMD, the need for continuous HNIV and eventual switching to tracheostomy ventilation makes this group's management more challenging. Achieving successful HNIV by improving quality of sleep, quality of life and keeping a good adherence to the therapy is a challenge, above all in COPD patients. In OHS patients, on top of HNIV, initiation of other interventions such as weight loss management is crucial. More resources should be invested in improving all these aspects. Telemonitoring represents a promising method to improve titration and follow-up of HNIV.
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Affiliation(s)
- Annalisa Carlucci
- Dipartimento di Medicina e Chirurgia Malattie dell'Apparato Respiratorio, Università degli Studi dell'Insubria, Varese, Italy
- U.O. di Pneumologia Riabilitativa, Istituti Clinici Scientifici Maugeri, IRCCS Pavia, Pavia, Italy
| | - Maxime Patout
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service des Pathologies du Sommeil (Département R3S), Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - João Carlos Winck
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Centro de Reabilitação do Norte, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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Sancho J, Ferrer S. How to increase noninvasive ventilation effectiveness in bulbar amyotrophic lateral sclerosis patients. Breathe (Sheff) 2023. [DOI: 10.1183/20734735.0266-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease in which the respiratory muscles are also affected, leading to respiratory failure. Bulbar impairment develops in almost all cases during the course of the disease, becoming severe in the late stages of disease. Noninvasive ventilation (NIV) has been shown to increase survival in ALS; however, severe bulbar dysfunction has a negative impact on NIV tolerance and effectiveness. Therefore, certain steps should be taken to improve NIV outcomes in these patients including optimal ventilatory parameters, adequate interface selection, effective respiratory secretion management and control of bulbar symptoms.
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11
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Réginault T, Bouteleux B, Wibart P, Mathis S, Le Masson G, Pillet O, Grassion L. At-home noninvasive ventilation initiation with telemonitoring in amyotrophic lateral sclerosis patients: a retrospective study. ERJ Open Res 2023; 9:00438-2022. [PMID: 36861058 PMCID: PMC9969309 DOI: 10.1183/23120541.00438-2022] [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: 08/29/2022] [Accepted: 11/20/2022] [Indexed: 12/14/2022] Open
Abstract
Background Noninvasive ventilation (NIV) improves survival and quality of life in amyotrophic lateral sclerosis (ALS) patients. NIV initiation is mostly conducted at hospital, but a recurrent lack of hospital beds led to the necessity of exploring an at-home initiation process. Here, we report data from our NIV initiation cohort of ALS patients. Could our at-home NIV initiation process with telemonitoring in ALS patients be an efficient solution for adherence and nocturnal hypoxaemia correction? Methods We performed a retrospective analysis of data collected from 265 ALS patients treated at the Bordeaux ALS Centre for whom NIV initiation was carried out between September 2017 and June 2021, with two modalities: at-home initiation or in-hospital initiation. The primary outcome was adherence to NIV at 30 days. The secondary outcome was at-home NIV initiation process efficiency of nocturnal hypoxaemia correction. Results At 30 days, NIV adherence (mean >4 h·day-1) was 66% of the total population, 70% of the at-home NIV initiation subgroup and 52% of the in-hospital NIV initiation subgroup. Nocturnal hypoxaemia correction was observed in 79% of adherent patients in the at-home NIV initiation subgroup. Mean delay of NIV prescription and at-home NIV initiation was 8.7 days (+/-6.5) versus 29.5 days in hospital. Conclusion Our study shows that our at-home NIV initiation process in ALS patients is a good option to provide rapid access to NIV with good adherence and efficiency. Further literature on the benefits of at-home NIV initiation is welcomed, especially to evaluate long-term efficiency and global cost analysis.
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Affiliation(s)
- Thomas Réginault
- Département de Médecine, Service de Réanimation Médicale, Hôpital Pellegrin, Bordeaux, France,Zéphyr Paramed, Bordeaux, France,Corresponding author: Thomas Réginault ()
| | | | - Philippe Wibart
- Département de Médecine, Service de Réanimation Médicale, Hôpital Pellegrin, Bordeaux, France,Zéphyr Paramed, Bordeaux, France
| | - Stéphane Mathis
- Département de Neurologie et Centre de référence pour la SLA, Hôpital Pellegrin, Bordeaux, France
| | - Gwendal Le Masson
- Département de Neurologie et Centre de référence pour la SLA, Hôpital Pellegrin, Bordeaux, France
| | - Odile Pillet
- Département de Médecine, Service de Réanimation Médicale, Hôpital Pellegrin, Bordeaux, France
| | - Léo Grassion
- Département de Pneumologie, Service des Maladies Respiratoires, Hôpital du Haut Lévêque, Pessac, France
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12
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Boentert M. [Sleep disorders in patients with neuromuscular diseases]. SOMNOLOGIE 2023; 27:64-73. [PMID: 36789371 PMCID: PMC9912238 DOI: 10.1007/s11818-023-00401-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 02/12/2023]
Abstract
Neuromuscular diseases (NMD) may affect skeletal muscles, peripheral nerves, or motor endplates. Clinical symptoms comprise muscle weakness, which is often progressive, but also sensory disturbances, and primary or secondary pain. Sleep disturbances in NMD may result from insomnia due to immobility, pain, or sleep-related leg muscle cramps, but also restless legs syndrome and sleep-disordered breathing. Many NMD predispose to obstructive sleep apnea or progressive respiratory muscle weakness, which first manifests as sleep-related hypoventilation and eventually leads to chronic hypercapnic respiratory failure. The latter is crucial for overall prognosis in muscular dystrophies and myopathies, but even more so in motor neuron diseases such as amyotrophic lateral sclerosis and spinal muscular atrophy.
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Affiliation(s)
- Matthias Boentert
- Klinik für Neurologie mit Institut für Translationale Neurologie, Universitätsklinikum Münster (UKM), Albert-Schweitzer-Campus 1, Gebäude A1, 48149 Münster, Deutschland.,Klinik für Innere Medizin, Bereich Neurologie, UKM-Marienhospital, Steinfurt, Deutschland
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13
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Pierucci P, Portacci A, Carpagnano GE, Banfi P, Crimi C, Misseri G, Gregoretti C. The right interface for the right patient in noninvasive ventilation: a systematic review. Expert Rev Respir Med 2022; 16:931-944. [PMID: 36093799 DOI: 10.1080/17476348.2022.2121706] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Research in the field of noninvasive ventilation (NIV) has contributed to the development of new NIV interfaces. However, interface tolerance plays a crucial role in determining the beneficial effects of NIV therapy. AREAS COVERED This systematic review explores the most significant scientific research on NIV interfaces, with a focus on the potential impact that their design might have on treatment adherence and clinical outcomes. The rationale on the choice of the right interface among the wide variety of devices that are currently available is discussed here. EXPERT OPINION The paradigm "The right mask for the right patient" seems to be difficult to achieve in real life. Ranging from acute to chronic settings, the gold standard should include the tailoring of NIV interfaces to patients' needs and preferences. However, such customization may be hampered by issues of economic nature. High production costs and the increasing demand represent consistent burdens and have to be considered when dealing with patient-tailored NIV interfaces. New research focusing on developing advanced and tailored NIV masks should be prioritized; indeed, interfaces should be designed according to the specific patient and clinical setting where they need to be used.
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Affiliation(s)
- Paola Pierucci
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Andrea Portacci
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Giovanna Elisiana Carpagnano
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Paolo Banfi
- IRCCS Fondazione Don Carlo Gnocchi, Milano,Italy
| | - Claudia Crimi
- Respiratory Medicine Unit, "Policlinico-Vittorio Emanuele San Marco" University Hospital, Catania, Italy
| | | | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy and Fondazione Istituto "G.Giglio" Cefalù', Palermo, Italy
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14
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López-Brull H, Mira-Padilla E, Hussein S, Guerder A, Wozniak E, Esteban-Ronda V, Gonzalez-Bermejo J. Ventilator integrated polygraphy for patients using non-invasive ventilation; Case report. Front Med (Lausanne) 2022; 9:852896. [PMID: 35957859 PMCID: PMC9357904 DOI: 10.3389/fmed.2022.852896] [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: 01/11/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
The COVID-19 pandemic has meant that home respiratory services have needed to be reviewed. As a result, new solutions have been developed and implemented. The Vivo 45™ (Breas, Mölnlycke, Sweden) is a ventilator that offers clinicians the ability to attach effort belts to the device. This allows the clinician to review ventilator traces with the addition of thoracic and abdominal activity. This allows more flexibility for the monitoring of patients at home and in the hospital, with detection of patient ventilator asynchrony (PVA). Decreasing PVA may improve ventilator adherence and increased ventilator usage improves survival. We report three cases of patients undergoing overnight monitoring with the Vivo 45™, highlighting the benefit of ventilator integrated polygraphy. In our three cases we demonstrate a simple safe tool to optimize NIV treatment over one or two-night recordings using ventilator downloaded software with the addition of effort belts and pulse oximetry without involving more than one machine and without hospitalization in a sleep unit.
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Affiliation(s)
- Helena López-Brull
- Hospital General Universitario Alicante, Alicante, Spain
- *Correspondence: Helena López-Brull
| | | | - Sarah Hussein
- Service de Réhabilitation Respiratoire (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
| | - Antoine Guerder
- Service de Réhabilitation Respiratoire (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
| | - Estelle Wozniak
- Service de Réhabilitation Respiratoire (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
| | | | - Jésus Gonzalez-Bermejo
- Service de Réhabilitation Respiratoire (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
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15
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Brekka AK, Vollsæter M, Ntoumenopoulos G, Clemm HH, Halvorsen T, Røksund OD, Andersen TM. Adjustments of non-invasive ventilation and mechanically assisted cough by combining ultrasound imaging of the larynx with transnasal fibre-optic laryngoscopy: a protocol for an experimental study. BMJ Open 2022; 12:e059234. [PMID: 35613803 PMCID: PMC9134209 DOI: 10.1136/bmjopen-2021-059234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Application of non-invasive positive airway pressure may provoke laryngeal responses that obstruct the airways, especially in patients with disturbed laryngeal control. To control and adjust for this, transnasal fibre-optic laryngoscopy (TFL) is used to visualise laryngeal movements during therapeutic interventions. Being an invasive procedure, this may be unpleasant for patients. The aim of this study is to evaluate if ultrasound (US) imaging of the larynx may be used as an alternative less invasive diagnostic tool for evaluating the upper airway responses to non-invasive ventilation (NIV) and mechanical insufflation-exsufflation (MI-E). METHODS AND ANALYSIS This protocol presents an experimental cross-sectional study of a novel method to study laryngeal responses in adult healthy volunteers (n=30). The participants will be assessed with simultaneous TFL and laryngeal US imaging (anterior and lateral approaches) during NIV and MI-E therapy. Additionally, airflow and pressure signals will be registered during the procedures. The primary outcome is whether laryngeal US is a feasible method to study laryngeal responses and, if so, to compare the laryngeal responses visualised with TFL and US. The participants' perception of the examinations will be recorded. Secondary outcomes include airflow curve shapes and calculated ventilation volumes during the interventions. ETHICS AND DISSEMINATION The study has been approved by The Regional Committee for Medical Research Ethics in Norway, and registered in ClinicalTrials.gov. Results will be disseminated through peer-reviewed journals, presentation of scientific abstracts at international medical conventions and oral presentations in relevant medical conventions. TRIAL REGISTRATION NUMBER NCT04586855.
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Affiliation(s)
| | - Maria Vollsæter
- Norwegian Advisory Unit on Home Mechanical Ventilation, Haukeland University Hospital, Bergen, Norway
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - George Ntoumenopoulos
- Department of Physiotherapy, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Hege Havstad Clemm
- Faculty of Medicine, Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Thomas Halvorsen
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Ola Drange Røksund
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Tiina Maarit Andersen
- Norwegian Advisory Unit on Home Mechanical Ventilation, Haukeland University Hospital, Bergen, Norway
- The Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Bergen, Norway
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16
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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.
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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
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17
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Georges M, Perez T, Rabec C, Jacquin L, Finet-Monnier A, Ramos C, Patout M, Attali V, Amador M, Gonzalez-Bermejo J, Salachas F, Morelot-Panzini C. Proposals from a French expert panel for respiratory care in ALS patients. Respir Med Res 2022; 81:100901. [PMID: 35378353 DOI: 10.1016/j.resmer.2022.100901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 02/18/2022] [Accepted: 02/25/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease characterized by progressive diaphragm weakness and deteriorating lung function. Bulbar involvement and cough weakness contribute to respiratory morbidity and mortality. ALS-related respiratory failure significantly affects quality of life and is the leading cause of death. Non-invasive ventilation (NIV), which is the main recognized treatment for alleviating the symptoms of respiratory failure, prolongs survival and improves quality of life. However, the optimal timing for the initiation of NIV is still a matter of debate. NIV is a complex intervention. Multiple factors influence the efficacy of NIV and patient adherence. The aim of this work was to develop practical evidence-based advices to standardize the respiratory care of ALS patients in French tertiary care centres. METHODS For each proposal, a French expert panel systematically searched an indexed bibliography and prepared a written literature review that was then shared and discussed. A combined draft was prepared by the chairman for further discussion. All of the proposals were unanimously approved by the expert panel. RESULTS The French expert panel updated the criteria for initiating NIV in ALS patients. The most recent criteria were established in 2005. Practical advice for NIV initiation were included and the value of each tool available for NIV monitoring was reviewed. A strategy to optimize NIV parameters was suggested. Revisions were also suggested for the use of mechanically assisted cough devices in ALS patients. CONCLUSION Our French expert panel proposes an evidence-based review to update the respiratory care recommendations for ALS patients in daily practice.
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Affiliation(s)
- M Georges
- Department of Respiratory Diseases and Intensive Care, Reference Center for Adult Rare Pulmonary Diseases, University Hospital of Dijon-Bourgogne, Dijon, France; University of Bourgogne Franche-Comté, Dijon France; Centre des Sciences du Goût et de l'Alimentation, UMR 6265 CNRS 1234 INRA, University of Bourgogne Franche-Comté, Dijon, France.
| | - T Perez
- Department of Respiratory Diseases, University Hospital of Lille, Lille, France; Centre for Infection and Immunity of Lille, INSERM U1019-UMR9017, University of Lille Nord de France, Lille, France
| | - C Rabec
- Department of Respiratory Diseases and Intensive Care, Reference Center for Adult Rare Pulmonary Diseases, University Hospital of Dijon-Bourgogne, Dijon, France; University of Bourgogne Franche-Comté, Dijon France
| | - L Jacquin
- Clinical Training Manager for ResMed SAS company, Saint-Priest, France
| | - A Finet-Monnier
- Department of Neuromuscular Disorders and ALS, University Hospital of Timone, Marseille, France
| | - C Ramos
- CRMR SLA-MNM, Hôpital Pasteur 2, University Hospital of Nice, Nice, France
| | - M Patout
- Service des Pathologies du Sommeil (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France
| | - V Attali
- Service des Pathologies du Sommeil (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France; Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France
| | - M Amador
- Neurology Department, Paris ALS center, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - J Gonzalez-Bermejo
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France; Service de Pneumologie (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - F Salachas
- Neurology Department, Paris ALS center, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
| | - C Morelot-Panzini
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM UMRS1158, Sorbonne Université, Paris, France; Service de Pneumologie (Département R3S), Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France
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18
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Janssens PJP. Amyotrophic lateral sclerosis: a pragmatic update on recommendations for respiratory care. Respir Med Res 2022; 81:100915. [DOI: 10.1016/j.resmer.2022.100915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/11/2022] [Indexed: 11/27/2022]
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19
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Letellier C, Lujan M, Arnal JM, Carlucci A, Chatwin M, Ergan B, Kampelmacher M, Storre JH, Hart N, Gonzalez-Bermejo J, Nava S. Patient-Ventilator Synchronization During Non-invasive Ventilation: A Pilot Study of an Automated Analysis System. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 3:690442. [PMID: 35047935 PMCID: PMC8757845 DOI: 10.3389/fmedt.2021.690442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/28/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Patient-ventilator synchronization during non-invasive ventilation (NIV) can be assessed by visual inspection of flow and pressure waveforms but it remains time consuming and there is a large inter-rater variability, even among expert physicians. SyncSmart™ software developed by Breas Medical (Mölnycke, Sweden) provides an automatic detection and scoring of patient-ventilator asynchrony to help physicians in their daily clinical practice. This study was designed to assess performance of the automatic scoring by the SyncSmart software using expert clinicians as a reference in patient with chronic respiratory failure receiving NIV. Methods: From nine patients, 20 min data sets were analyzed automatically by SyncSmart software and reviewed by nine expert physicians who were asked to score auto-triggering (AT), double-triggering (DT), and ineffective efforts (IE). The study procedure was similar to the one commonly used for validating the automatic sleep scoring technique. For each patient, the asynchrony index was computed by automatic scoring and each expert, respectively. Considering successively each expert scoring as a reference, sensitivity, specificity, positive predictive value (PPV), κ-coefficients, and agreement were calculated. Results: The asynchrony index assessed by SynSmart was not significantly different from the one assessed by the experts (18.9 ± 17.7 vs. 12.8 ± 9.4, p = 0.19). When compared to an expert, the sensitivity and specificity provided by SyncSmart for DT, AT, and IE were significantly greater than those provided by an expert when compared to another expert. Conclusions:SyncSmart software is able to score asynchrony events within the inter-rater variability. When the breathing frequency is not too high (<24), it therefore provides a reliable assessment of patient-ventilator asynchrony; AT is over detected otherwise.
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Affiliation(s)
- Christophe Letellier
- Normandie Université - CORIA, Avenue de l'Université, Saint-Etienne du Rouvray, France
| | - Manel Lujan
- Servei de Pneumologia, Corporació Parc Taulí, Sabadell, Spain.,Departament de Medicina, Universitat Autònoma de Bellaterra, Barcelona, Spain
| | - Jean-Michel Arnal
- Service de Réanimation Polyvalente, Unité de Ventilation à domicile, Hôpital Sainte Musse, Toulon, France
| | - Annalisa Carlucci
- Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, Istituto di Ricovero e Cura a Carattere Scientifico, Pavia and Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Michelle Chatwin
- Clinical and Academic Department of Sleep and Breathing, Royal Brompton & Harefield, National Health Service Foundation Trust, London, United Kingdom
| | - Begum Ergan
- Division of Intensive Care, Department of Pulmonary and Critical Care, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Mike Kampelmacher
- Department of Pulmonology, Antwerp University Hospital and Antwerp University, Antwerp, Belgium
| | - Jan Hendrik Storre
- Department of Pneumology, University Medical Hospital, Freiburg, Germany.,Pneumologie Solln, Munich, Germany
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Jesus Gonzalez-Bermejo
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Soins de Suites et réhabilitation respiratoire-Département R3S, Paris, France
| | - Stefano Nava
- Respiratory and Critical Care, Sant'Orsola Malpighi Hospital, Alma Mater Studiorum, University of Bologna, Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Bologna, Italy
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20
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Sleep and Hypoventilation. Respir Med 2022. [DOI: 10.1007/978-3-030-93739-3_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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21
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Martí S, Ferré A, Sampol G, Pallero M, Romero O, Ferrer J, Sampol J. Sleep increases leaks and asynchronies during home noninvasive ventilation: a polysomnographic study. J Clin Sleep Med 2022; 18:225-233. [PMID: 34314351 PMCID: PMC8807927 DOI: 10.5664/jcsm.9546] [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: 01/03/2023]
Abstract
STUDY OBJECTIVES In patients treated with noninvasive ventilation, sleep-related breathing changes can modify patient-ventilator interactions, which could reduce its effectiveness. The aim of this prospective observational study was to determine the impact of sleep/wake state on leaks, upper airway obstructive events, and asynchronies in patients treated by long-term noninvasive ventilation. METHODS Stable patients adapted to noninvasive ventilation were considered for nocturnal polysomnography. Unintentional leaks, upper airway obstructive events, and asynchronies were compared between sleep and awake periods. RESULTS Twenty-eight patients were enrolled. Underlying diagnoses were neuromuscular disease (n = 11), chest wall disease (n = 8), and obesity-hypoventilation (n = 9). Leaks were more frequent in sleep than in awake periods, with a median of 10% (interquartile range [IQR], 0%-75%) vs 1% (IQR, 0%-9%) of time (P < .001), respectively. During sleep, asynchronies with and without associated leak affected 27% of breaths (IQR, 16%-39%) compared with non-leak-related asynchronies that were recorded in 8% (IQR, 3%-25%) of breaths (P < .001). Asynchronies affecting more than 10% of total breaths were more frequent in sleep (25 patients, 89%) than in awake time (8 patients, 29%; P = .25). Eleven patients (39%) presented with 5 or more upper airway obstructive events without reduction in ventilatory drive per hour of sleep. CONCLUSIONS In patients adapted to home noninvasive ventilation, leaks, asynchronies, and upper airway obstructive events are frequent during the night and are concentrated in sleep periods. Asynchronies are often associated with leaks. These findings may have clinical implications considering that in patients with low sleep efficiency respiratory events could be underestimated if sleep is not evaluated. CITATION Martí S, Ferré A, Sampol G, et al. Sleep increases leaks and asynchronies during home noninvasive ventilation: a polysomnographic study. J Clin Sleep Med. 2022;18(1):225-233.
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Affiliation(s)
- Sergi Martí
- Respiratory Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain,Address correspondence to: Sergi Martí, MD, PhD, Respiratory Department, Hospital Universitari Vall d’Hebron, Passeig Vall d’Hebron, 119-129, 08035 Barcelona, Spain;
| | - Alex Ferré
- Sleep Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain,Neurophysiology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Gabriel Sampol
- Respiratory Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain,Sleep Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Mercedes Pallero
- Respiratory Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Odile Romero
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain,Sleep Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain,Neurophysiology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Jaume Ferrer
- Respiratory Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Júlia Sampol
- Respiratory Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain,Sleep Unit, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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22
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Manera U, Torrieri MC, Moglia C, Canosa A, Vasta R, Ribolla F, Palumbo F, Solero L, Mora G, Mattei A, Chiò A, Calvo A. Arterial blood gas analysis: base excess and carbonate are predictive of noninvasive ventilation adaptation and survival in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:33-39. [PMID: 34348536 DOI: 10.1080/21678421.2021.1887263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: To investigate the role of arterial blood gas (ABG) analysis parameters (blood carbon dioxide, pCO2; oxygen, pO2; carbonate, HCO3-; standard base excess, SBE) in monitoring respiratory function and ventilation compliance after noninvasive mechanical ventilation (NIV) adaptation, predicting survival in ALS patients. Methods: We selected the first ABG performed after NIV start in ALS patients followed from 2000 to 2015 in Turin ALS Center. Correlations between ABG parameters and survival were calculated. Risk for death/tracheostomy was computed at modifying ABG parameters by using Cox regression models, adjusted for the main prognostic factors. Kaplan-Meier curves were then performed and compared. Results: A total of 186 post-NIV ABGs were included. HCO3- and SBE showed a significant correlation with survival after NIV (respectively, R = -0.183, p = 0.018 and R = -0.200, p = 0.010). Risk for death/tracheostomy after NIV was significantly higher at increasing HCO3- and SBE blood levels, especially when HCO3- was >29 mmol/L and SBE >4 mmol/L (respectively, HR 1.466, 95% CI 1.068-2.011, p = 0.018 and HR = 1.411, 95% CI 1.030-1.32, p = 0.032). Survival in NIV was higher in patients with HCO3- < 29.0 mmol/L and SBE < 4.0 mmol/L. Conclusions: HCO3- and SBE blood levels are markers of ventilation compliance, tolerance and efficacy, being able to predict survival after NIV start in ALS.
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Affiliation(s)
- Umberto Manera
- Department of Neuroscience "Rita Levi Montalcini" Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy
| | - Maria Claudia Torrieri
- Department of Neuroscience "Rita Levi Montalcini" Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy
| | - Cristina Moglia
- Department of Neuroscience "Rita Levi Montalcini" Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy
| | - Antonio Canosa
- Department of Neuroscience "Rita Levi Montalcini" Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy.,SC Pneumologia U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
| | - Rosario Vasta
- Department of Neuroscience "Rita Levi Montalcini" Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy
| | - Fulvia Ribolla
- SC Neurologia 1U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
| | - Francesca Palumbo
- Department of Neuroscience "Rita Levi Montalcini" Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy
| | - Luca Solero
- Department of Neuroscience "Rita Levi Montalcini" Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy
| | - Gabriele Mora
- Istituti Clinici Scientifici Maugeri, ALS Center, IRCCS Milano, Milan, Italy
| | - Alessio Mattei
- SC Neurologia 1U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
| | - Adriano Chiò
- Department of Neuroscience "Rita Levi Montalcini" Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy.,SC Pneumologia U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
| | - Andrea Calvo
- Department of Neuroscience "Rita Levi Montalcini" Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy.,SC Pneumologia U, AOU Città della Salute e della Scienza of Torino, Turin, Italy
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23
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Engel M, Glatz C, Helmle C, Young P, Dräger B, Boentert M. Respiratory parameters on diagnostic sleep studies predict survival in patients with amyotrophic lateral sclerosis. J Neurol 2021; 268:4321-4331. [PMID: 33880611 PMCID: PMC8505303 DOI: 10.1007/s00415-021-10563-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/10/2021] [Accepted: 04/13/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE In amyotrophic lateral sclerosis (ALS), respiratory muscle involvement and sleep-disordered breathing relate to worse prognosis. The present study investigated whether respiratory outcomes on first-ever sleep studies predict survival in patients with ALS, specifically taking into account subsequent initiation of non-invasive ventilation (NIV). METHODS From patients with ALS, baseline sleep study records, transcutaneous capnometry, early morning blood gas analysis, survival data and clinical disease characteristics were retrospectively analyzed. Patients were stratified according to whether enduring NIV was consecutively established ("NIV(+)") or not ("NIV(-)"). RESULTS Among the study cohort (n = 158, 72 female, 51 with bulbar onset ALS, 105 deceased) sleep-disordered breathing was present at baseline evaluation in 97 patients. Early morning base excess (EMBE) > 2 mmol/l predicted nocturnal hypercapnia. Ninety-five patients were NIV(+) and 63 were NIV(-). Survival from baseline sleep studies was significantly reduced in NIV(-) but not in NIV(+) patients with nocturnal CO2 tension ≥ 50 mmHg, apnea hypopnea index ≥ 5/h, and EMBE > 2 mmol/l. Hazard ratio for EMBE > 2 mmol/l was increased in NIV(-) patients only, and EMBE independently predicted survival in both NIV(-) and NIV(+) patients. Furthermore, EMBE on baseline sleep studies was the only predictor for survival from symptom onset, and hazard ratio for shorter survival was markedly higher in the NIV(-) than the NIV(+) group (2.85, p = 0.005, vs. 1.71, p = 0.042). INTERPRETATION In patients with ALS, EMBE > 2 mmol/l predicts nocturnal hypercapnia and shorter survival. Negative effects of sleep-disordered breathing on survival are statistically abolished by sustained NIV.
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Affiliation(s)
- Markus Engel
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Christian Glatz
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Cornelia Helmle
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Peter Young
- Department of Neurology, Medical Park Reithofpark, Bad Feilnbach, Germany
| | - Bianca Dräger
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany.,Department of Medicine, UKM Marienhospital Steinfurt, Steinfurt, Germany
| | - Matthias Boentert
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster, Germany. .,Department of Medicine, UKM Marienhospital Steinfurt, Steinfurt, Germany.
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24
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Aiyappan V, Catcheside P, Antic N, Keighley-James G, Mercer J, McEvoy RD. Sleep-Disordered Breathing in Patients with Motor Neurone Disease: One Size Does Not Fit all. NEURODEGENER DIS 2021; 20:131-138. [PMID: 33735900 DOI: 10.1159/000513887] [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: 06/15/2020] [Accepted: 12/14/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Sleep-disordered breathing (SDB) in patients with motor neurone disease (MND) is normally attributed to hypoventilation due to muscle weakness. However, we have observed different patterns of SDB among MND patients referred for non-invasive ventilation, which do not appear to be explained by respiratory muscle weakness alone. AIM The aim of this study was to examine the characteristics of SDB in MND. METHODS This is a retrospective analysis of sleep studies (using polysomnography [PSG]), pulmonary function tests, and arterial blood gases in MND patients referred to a tertiary sleep medicine service for clinical review. Sleep apnoeas were characterised as obstructive or central, and to further characterise the nature of SDB, hypopnoeas were classified as obstructive versus central. RESULTS Among 13 MND patients who had a diagnostic PSG, the mean ± SD age was 68.9 ± 9.8 years, BMI 23.0 ± 4.3 kg/m2, forced vital capacity 55.7 ± 20.9% predicted, and partial pressure of CO2 (arterial blood) 52.7 ± 12.1 mm Hg. A total of 38% of patients (5/13) showed evidence of sleep hypoventilation. The total apnoea/hypopnoea index (AHI) was (median [interquartile range]) 44.4(36.2-56.4)/h, with 92% (12/13) showing an AHI >10/h, predominantly due to obstructive events, although 8% (1/13) also showed frequent central apnoea/hypopnoeas. CONCLUSIONS Patients with MND exhibit a wide variety of SDB. The prevalence of obstructive sleep apnoea (OSA) is surprising considering the normal BMI in most patients. A dystonic tongue and increased upper-airway collapsibility might predispose these patients to OSA. The wide variety of SDB demonstrated might have implications for ventilator settings and patients' outcomes.
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Affiliation(s)
- Vinod Aiyappan
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Bedford Park, South Australia, Australia, .,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia,
| | - Peter Catcheside
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Nick Antic
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Bedford Park, South Australia, Australia.,Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Graham Keighley-James
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Jeremy Mercer
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - R Doug McEvoy
- Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia
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25
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Mycroft K, Nasiłowski J, Klimiuk J, Przybyłowski T. Complex home assessment of long-term non-invasive ventilation efficacy using transcutaneous monitoring of PCO 2 and polygraphy - A feasibility study. Adv Med Sci 2021; 66:105-112. [PMID: 33461098 DOI: 10.1016/j.advms.2021.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/21/2020] [Accepted: 01/04/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Home non-invasive ventilation (HNIV) during sleep is a standard treatment for chronic hypercapnic respiratory failure (CHRF). The aim of this study was to evaluate the feasibility of the complex overnight assessment of HNIV in adults performed at home and the efficacy of HNIV after one year of treatment. METHODS Stable patients with CHRF on HNIV for more than 12 months had unattended polygraphy (PG) with transcutaneous monitoring of PCO2 (tcPCO2) at home during one night. The recording quality was regarded as excellent when 100% and good if 80-99% of the analysis time was registered. The following efficacy criteria were approved: (1) SpO2<90% for <10% of analysis time, (2) increase in PtcCO2 ≤7.5 mmHg between baseline and average value at night, (3) apnea-hypopnea index (AHI) ≤5/h. RESULTS Eighteen patients with CHRF (median age 66 [60-74] years, 10 female) were included. The quality of the PG tracings was good to excellent in 16 (89%) patients and the quality of the tcPCO2 data was good to excellent in 14 (78%) patients. There was no difference in the quality of tcPCO2 between patients who lived alone and those who lived with family (100 [50-100]% vs. 100 [90-100]% of analysis time, respectively). Only 4 (22%) patients fulfilled all three efficacy criteria. CONCLUSIONS Home-based monitoring using PG and tcPCO2 is a feasible and adequate tool to assess the efficacy of HNIV. In most of the patients on HNIV for more than 12 months, the treatment was not effective based on the predefined efficacy criteria.
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Affiliation(s)
- Katarzyna Mycroft
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland.
| | - Jacek Nasiłowski
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Klimiuk
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
| | - Tadeusz Przybyłowski
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Warsaw, Poland
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26
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Abstract
Amyotrophic lateral sclerosis is a progressive neurodegenerative disease involving upper and lower motor neurons and has limited treatment options. The weakness progresses to involve the diaphragms, resulting in respiratory failure and death. Home noninvasive ventilation has been shown to improve survival and quality of life, especially in those with intact bulbar function. Once initiated, close monitoring with nocturnal oximetry, remote downloads from the home noninvasive ventilation machine, and measurement of serum bicarbonate should be conducted. Additionally, transcutaneous CO2 monitoring can be considered if available. This article discusses the indications, timing, initiation, and management of noninvasive ventilation in amyotrophic lateral sclerosis.
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Affiliation(s)
- Jessica A Cooksey
- Northwestern University, 1475 East Belvidere Road, Suite 185, Grayslake, IL 60030, USA
| | - Amen Sergew
- Division of Pulmonary, Critical Care and Sleep Medicine, Section of Critical Care Medicine, Department of Medicine, National Jewish Health, 1400 Jackson Street, B140, Denver, CO 80207, USA.
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27
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Georges M, Rabec C, Monin E, Aho S, Beltramo G, Janssens JP, Bonniaud P. Monitoring of noninvasive ventilation: comparative analysis of different strategies. Respir Res 2020; 21:324. [PMID: 33302961 PMCID: PMC7725884 DOI: 10.1186/s12931-020-01586-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 11/24/2020] [Indexed: 12/14/2022] Open
Abstract
Background Noninvasive ventilation (NIV) represents an effective treatment for chronic respiratory failure. However, empirically determined NIV settings may not achieve optimal ventilatory support. Therefore, the efficacy of NIV should be systematically monitored. The minimal recommended monitoring strategy includes clinical assessment, arterial blood gases (ABG) and nocturnal transcutaneous pulsed oxygen saturation (SpO2). Polysomnography is a theoretical gold standard but is not routinely available in many centers. Simple tools such as transcutaneous capnography (TcPCO2) or ventilator built-in software provide reliable informations but their role in NIV monitoring has yet to be defined. The aim of our work was to compare the accuracy of different combinations of tests to assess NIV efficacy. Methods This retrospective comparative study evaluated the efficacy of NIV in consecutive patients through four strategies (A, B, C and D) using four different tools in various combinations. These tools included morning ABG, nocturnal SpO2, TcPCO2 and data provided by built-in software via a dedicated module. Strategy A (ABG + nocturnal SpO2), B (nocturnal SpO2 + TcPCO2) and C (TcPCO2 + builtin software) were compared to strategy D, which combined all four tools (NIV was appropriate if all four tools were normal). Results NIV was appropriate in only 29 of the 100 included patients. Strategy A considered 53 patients as appropriately ventilated. Strategy B considered 48 patients as appropriately ventilated. Strategy C misclassified only 6 patients with daytime hypercapnia. Conclusion Monitoring ABG and nocturnal SpO2 is not enough to assess NIV efficacy. Combining data from ventilator built-in software and TcPCO2 seems to represent the best strategy to detect poor NIV efficacy. Trialregistration Institutional Review Board of the Société de Pneumologie de Langue Française (CEPRO 2016 Georges)
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Affiliation(s)
- Marjolaine Georges
- Department of Pulmonary Medicine and Intensive Care Unit, University Hospital, Dijon, France. .,University Burgundy Franche-Comté, Dijon, France. .,Centre Des Sciences du Goût Et de L'Alimentation, UMR 6265 CNRS 1234 INRA, University Burgundy Franche-Comté, Dijon, France. .,Service de Pneumologie Et Soins Intensifs Respiratoires, Centre Hospitalier Et Universitaire de Dijon, Hôpital François Mitterrand, 14 rue Paul Gaffarel, 21079, Dijon, France.
| | - Claudio Rabec
- Department of Pulmonary Medicine and Intensive Care Unit, University Hospital, Dijon, France
| | - Elise Monin
- Department of Pulmonary Medicine and Intensive Care Unit, University Hospital, Dijon, France
| | - Serge Aho
- University Burgundy Franche-Comté, Dijon, France.,Department of Epidemiology, Dijon University Hospital, Dijon, France
| | - Guillaume Beltramo
- Department of Pulmonary Medicine and Intensive Care Unit, University Hospital, Dijon, France
| | - Jean-Paul Janssens
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Bonniaud
- Department of Pulmonary Medicine and Intensive Care Unit, University Hospital, Dijon, France.,University Burgundy Franche-Comté, Dijon, France.,INSERM U1231, University Burgundy Franche-Comté, Dijon, France
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28
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Maarouf A, Domanski U, Schröder M, Franke KJ, Nilius G. Respiratorische Ereigniserkennung unter nichtinvasiver Beatmung (NIV) in Abhängigkeit von der genutzten Flowmessung. SOMNOLOGIE 2020. [DOI: 10.1007/s11818-020-00261-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Zusammenfassung
Hintergrund
Beim chronisch hyperkapnischem Atemversagen stellt die nächtliche nichtinvasive Beatmung (NIV) die Standardtherapie dar. Die Einstellung auf die NIV erfordert jedoch viel Erfahrung. Nur eine Polysomnografie (PSG) im Schlaflabor ermöglicht die genaue Analyse von residualen Obstruktionen der oberen Atemwege, zentralen Apnoen, Triggerfehlfunktionen und Leckagen. Die Flowmessung unter NIV ist technisch jedoch nicht einfach, insbesondere da normierte Schnittstellen zur Einbindung der Respiratoren in die PSG fehlen.
Ziel der Arbeit
Vergleich eines Druck‑/Flow-Monitors mit den Signalen aus den Schnittstellen der Respiratoren bezüglich der Erkennung sowohl von Apnoen/Hypopnoen als auch von NIV-spezifischen Ereignissen in der PSG.
Methoden
Retrospektiv wurden 20 Aufzeichnungen von Patienten unter NIV, die unter einem standardisierten Protokoll aufgezeichnet worden waren, erneut verblindet ausgewertet. Es erfolgte ein Vergleich der Auswertung dreier verschiedener Verfahren der Flowmessung (effortbasiert, Staudruckmessung, Schnittstelle) hinsichtlich der Häufigkeit von respiratorischen Ereignissen.
Ergebnisse
Durch eine einfach zu integrierende Staudruckmessung mittels Druck‑/Flow-Monitor waren signifikant weniger Ereignisse diagnostizierbar, als wenn der Flow über die Abdomen- und Thoraxgurte oder über die Schnittstelle zu den Respiratoren ermittelt wurde. Auch die NIV-induzierten Ereignisse wie Fehltriggerungen oder Leckagen ließen sich nur mittels der Schnittstelle zuverlässig erkennen.
Schlussfolgerung
Eine Messung des Flows mit einem Standard Druck‑/Flow-Monitor bietet keine ausreichend nachvollziehbaren Ergebnisse. Eine Einbindung des Beatmungsgeräts in die PSG über eine Schnittstelle ist daher zu fordern.
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Barp A, Gerardi F, Lizio A, Sansone VA, Lunetta C. Emerging Drugs for the Treatment of Amyotrophic Lateral Sclerosis: A Focus on Recent Phase 2 Trials. Expert Opin Emerg Drugs 2020; 25:145-164. [PMID: 32456491 DOI: 10.1080/14728214.2020.1769067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS) is a rapidly progressive neurodegenerative disease involving both upper and lower motor neurons and resulting in increasing disability and death 3-5 years after onset of symptoms. Over 40 large clinical trials for ALS have been negative, except for Riluzole that offers a modest survival benefit, and Edaravone that modestly reduces disease progression in patients with specific characteristics. Thus, the discovery of efficient disease modifying therapy is an urgent need. AREAS COVERED Although the cause of ALS remains unclear, many studies have demonstrated that neuroinflammation, proteinopathies, glutamate-induced excitotoxicity, microglial activation, oxidative stress, and mitochondrial dysfunction may play a key role in the pathogenesis. This review highlights recent discoveries relating to these diverse mechanisms and their implications for the development of therapy. Ongoing phase 2 clinical trials aimed to interfere with these pathophysiological mechanisms are discussed. EXPERT OPINION This review describes the challenges that the discovery of an efficient drug therapy faces and how these issues may be addressed. With the continuous advances coming from basic research, we provided possible suggestions that may be considered to improve performance of clinical trials and turn ALS research into a 'fertile ground' for drug development for this devastating disease.
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Affiliation(s)
- Andrea Barp
- NEuroMuscular Omnicentre, Fondazione Serena Onlus , Milan, Italy.,Dept. Biomedical Sciences of Health, University of Milan , Milan, Italy
| | | | - Andrea Lizio
- NEuroMuscular Omnicentre, Fondazione Serena Onlus , Milan, Italy
| | - Valeria Ada Sansone
- NEuroMuscular Omnicentre, Fondazione Serena Onlus , Milan, Italy.,Dept. Biomedical Sciences of Health, University of Milan , Milan, Italy
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30
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Abstract
PURPOSE OF REVIEW In amyotrophic lateral sclerosis (ALS), sleep disruption is frequently present and substantially adds to disease burden. This review aims to summarize current knowledge on causes, pathophysiology, and treatment of sleep disturbances in ALS. RECENT FINDINGS Motor neuron degeneration and muscle weakness may lead to muscle cramps, pain, spasticity, immobilization, restless legs, sleep-disordered breathing, and difficulties to clear secretions. Furthermore, existential fears and depression may promote insomnia. Sleep-disordered breathing, and nocturnal hypoventilation in particular, requires ventilatory support which meaningfully prolongs survival and improves health-related quality of life albeit respiratory failure is inevitable. Early indication for non-invasive ventilation can be achieved by inclusion of capnometry in diagnostic sleep studies. Sleep disruption is extremely common in ALS and may arise from different etiologies. The absence of causative therapeutic options for ALS underlines the importance of symptomatic and palliative treatment strategies that acknowledge sleep-related complaints.
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Affiliation(s)
- Matthias Boentert
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster (UKM), Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
- Department of Medicine, UKM Marienhospital Steinfurt, Steinfurt, Germany.
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31
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Kim J, Bireley JD, Hayat G, Kafaie J. Effects of noninvasive ventilation in amyotrophic lateral sclerosis: The complication of bulbar impairment. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2020. [DOI: 10.1177/2514183x20914183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis is a neurodegenerative illness that causes gradual loss of muscle function. Patients eventually develop bulbar impairment, requiring extensive respiratory support. Noninvasive ventilation (NIV) has gained attention as an easily accessible method with promising benefits. We conducted this systematic review to outline the therapeutic effects of NIV, add to previous publications discussing this topic by providing updates on newly completed and ongoing studies, and identify limitations that must be addressed in future trials. A search of PubMed and Cochran for relevant primary studies yielded 26 publications. Studies indicate NIV use is associated with improvements in quality of life, regardless of the severity of bulbar impairment. However, NIV’s benefits on survival were limited to patients with less bulbar impairment. In addition, our review found several limitations that undermine the efforts to establish a definitive treatment regimen. Future studies will need to address these problems in order to provide patients with better respiratory care.
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Affiliation(s)
- Junghyun Kim
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Ghazala Hayat
- Department of Neurology, Saint Louis University, Saint Louis, MO, USA
| | - Jafar Kafaie
- Department of Neurology, Saint Louis University, Saint Louis, MO, USA
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32
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Respiratory Involvement in Patients with Neuromuscular Diseases: A Narrative Review. Pulm Med 2019; 2019:2734054. [PMID: 31949952 PMCID: PMC6944960 DOI: 10.1155/2019/2734054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 04/08/2019] [Accepted: 11/20/2019] [Indexed: 12/11/2022] Open
Abstract
Respiratory muscle weakness is a major cause of morbidity and mortality in patients with neuromuscular diseases (NMDs). Respiratory involvement in NMDs can manifest broadly, ranging from milder insufficiency that may affect only sleep initially to severe insufficiency that can be life threatening. Patients with neuromuscular diseases exhibit very often sleep-disordered breathing, which is frequently overlooked until symptoms become more severe leading to irreversible respiratory failure necessitating noninvasive ventilation (NIV) or even tracheostomy. Close monitoring of respiratory function and sleep evaluation is currently the standard of care. Early recognition of sleep disturbances and initiation of NIV can improve the quality of life and prolong survival. This review discusses the respiratory impairment during sleep in patients with NMDs, the diagnostic tools available for early recognition of sleep-disordered breathing and the therapeutic options available for overall respiratory management of patients with NMDs.
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Ergan B, Oczkowski S, Rochwerg B, Carlucci A, Chatwin M, Clini E, Elliott M, Gonzalez-Bermejo J, Hart N, Lujan M, Nasilowski J, Nava S, Pepin JL, Pisani L, Storre JH, Wijkstra P, Tonia T, Boyd J, Scala R, Windisch W. European Respiratory Society guidelines on long-term home non-invasive ventilation for management of COPD. Eur Respir J 2019; 54:13993003.01003-2019. [DOI: 10.1183/13993003.01003-2019] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 07/13/2019] [Indexed: 02/07/2023]
Abstract
BackgroundWhile the role of acute non-invasive ventilation (NIV) has been shown to improve outcome in acute life-threatening hypercapnic respiratory failure in COPD, the evidence of clinical efficacy of long-term home NIV (LTH-NIV) for management of COPD is less. This document provides evidence-based recommendations for the clinical application of LTH-NIV in chronic hypercapnic COPD patients.Materials and methodsThe European Respiratory Society task force committee was composed of clinicians, methodologists and experts in the field of LTH-NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology. The GRADE Evidence to Decision framework was used to formulate recommendations. A number of topics were addressed under a narrative format which provides a useful context for clinicians and patients.ResultsThe task force committee delivered conditional recommendations for four actionable PICO (target population-intervention-comparator-outcome) questions, 1) suggesting for the use of LTH-NIV in stable hypercapnic COPD; 2) suggesting for the use of LTH-NIV in COPD patients following a COPD exacerbation requiring acute NIV 3) suggesting for the use of NIV settings targeting a reduction in carbon dioxide and 4) suggesting for using fixed pressure support as first choice ventilator mode.ConclusionsManaging hypercapnia may be an important intervention for improving the health outcome of COPD patients with chronic respiratory failure. The task force conditionally supports the application of LTH-NIV to improve health outcome by targeting a reduction in carbon dioxide in COPD patients with persistent hypercapnic respiratory failure. These recommendations should be applied in clinical practice by practitioners that routinely care for chronic hypercapnic COPD patients.
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Boentert M. Sleep disturbances in patients with amyotrophic lateral sclerosis: current perspectives. Nat Sci Sleep 2019; 11:97-111. [PMID: 31496852 PMCID: PMC6701267 DOI: 10.2147/nss.s183504] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/16/2019] [Indexed: 01/08/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disease inevitably leading to generalized muscle weakness and premature death. Sleep disturbances are extremely common in patients with ALS and substantially add to the burden of disease for both patients and caregivers. Disruption of sleep can be caused by physical symptoms, such as muscle cramps, pain, reduced mobility, spasticity, mucus retention, and restless legs syndrome. In addition, depression and anxiety may lead to significant insomnia. In a small subset of patients, rapid eye movement (REM) sleep behavioral disorder may be present, reflecting neurodegeneration of central nervous system pathways which are involved in REM sleep regulation. With regard to overall prognosis, sleep-disordered breathing (SDB) and nocturnal hypoventilation (NH) are of utmost importance, particularly because NH precedes respiratory failure. Timely mechanical ventilation is one of the most significant therapeutic measures to prolong life span in ALS, and transcutaneous capnometry is superior to pulse oxymetry to detect NH early. In addition, it has been shown that in patients on home ventilatory support, survival time depends on whether normocapnia, normoxia, and elimination of apneic events during sleep can be reliably achieved. Several studies have investigated sleep patterns and clinical determinants of sleep disruption in ALS, but exact prevalence numbers are unknown. Thus, constant awareness for sleep-related symptoms is appropriate. Since no curative treatment can be offered to affected patients, sleep complaints should be thoroughly investigated in order to identify any treatable etiology and improve or stabilize quality of life as much as possible. The use of hypnotics should be confined to palliation during the terminal phase and refractory insomnia in earlier stages of the disease, taking into account that most compounds potentially aggravate SDB.
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Affiliation(s)
- Matthias Boentert
- Department of Neurology, University Hospital Muenster, Muenster, Germany
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Sancho J, Burés E, Ferrer S, Ferrando A, Bañuls P, Servera E. Unstable control of breathing can lead to ineffective noninvasive ventilation in amyotrophic lateral sclerosis. ERJ Open Res 2019; 5:00099-2019. [PMID: 31360697 PMCID: PMC6646962 DOI: 10.1183/23120541.00099-2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 05/30/2019] [Indexed: 12/15/2022] Open
Abstract
Upper airway obstruction with decreased central drive (ODCD) is one of the causes of ineffective noninvasive ventilation (NIV) in amyotrophic lateral sclerosis (ALS). The aim of this study is to determine the mechanism responsible for ODCD in ALS patients using NIV. This is a prospective study that included ALS patients with home NIV. Severity of bulbar dysfunction was assessed with the Norris scale bulbar subscore; data on upper or lower bulbar motor neuron predominant dysfunction on physical examination were collected. Polysomnography was performed on every patient while using NIV and the ODCD index (ODCDI: number of ODCD events/total sleep time) was calculated. To determine the possible central origin of ODCD, controller gain was measured by inducing a hypocapnic hyperventilation apnoea. Sonography of the upper airway during NIV was performed to determine the location of the ODCD. 30 patients were enrolled; three (10%) had ODCDI >5 h−1. The vast majority of ODCD events were produced during non-rapid eye movement sleep stages and were a consequence of an adduction of the vocal folds. Patients with ODCDI >5 h−1 had upper motor neuron predominant dysfunction at the bulbar level, and had greater controller gain (1.97±0.33 versus 0.91±0.36 L·min−1·mmHg−1; p<0.001) and lower carbon dioxide (CO2) reserve (4.00±0.00 versus 10.37±5.13 mmHg; p=0.043). ODCDI was correlated with the severity of bulbar dysfunction (r= −0.37; p=0.044), controller gain (r=0.59; p=0.001) and CO2 reserve (r= −0.35; p=0.037). ODCD events in ALS patients using NIV have a central origin, and are associated with instability in the control of breathing and an upper motor neuron predominant dysfunction at the bulbar level. Upper airway obstructions in ALS patients using NIV have a central origin, and are associated with instability in the control of breathing and an upper motor neuron predominant dysfunction at the bulbar levelhttp://bit.ly/2WEMt28
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Affiliation(s)
- Jesús Sancho
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain.,Research Group for Respiratory Problems in Neuromuscular Diseases, Fundación para la Investigación HCUV-INCLIVA, Valencia, Spain
| | - Enric Burés
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain.,Research Group for Respiratory Problems in Neuromuscular Diseases, Fundación para la Investigación HCUV-INCLIVA, Valencia, Spain
| | - Santos Ferrer
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain.,Research Group for Respiratory Problems in Neuromuscular Diseases, Fundación para la Investigación HCUV-INCLIVA, Valencia, Spain
| | - Ana Ferrando
- Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain
| | - Pilar Bañuls
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain.,Research Group for Respiratory Problems in Neuromuscular Diseases, Fundación para la Investigación HCUV-INCLIVA, Valencia, Spain
| | - Emilio Servera
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain.,Research Group for Respiratory Problems in Neuromuscular Diseases, Fundación para la Investigación HCUV-INCLIVA, Valencia, Spain.,Physical Medicine Dept, Universitat de Valencia, Valencia, Spain
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O'Brien D, Stavroulakis T, Baxter S, Norman P, Bianchi S, Elliott M, Johnson M, Clowes M, Garcia-Sánchez A, Hobson E, McDermott C. The optimisation of noninvasive ventilation in amyotrophic lateral sclerosis: a systematic review. Eur Respir J 2019; 54:13993003.00261-2019. [DOI: 10.1183/13993003.00261-2019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 06/25/2019] [Indexed: 12/11/2022]
Abstract
BackgroundNoninvasive ventilation (NIV) prolongs survival and quality of life in amyotrophic lateral sclerosis (ALS); however, its benefits depend upon the optimisation of both ventilation and adherence. We aimed to identify factors associated with effective initiation and ongoing use of NIV in ALS to develop evidence-based guidance and identify areas for further research.MethodsWe searched 11 electronic databases (January 1998 to May 2018) for all types of quantitative and qualitative studies. Supplementary grey literature searches were conducted. Records were screened against eligibility criteria, data were extracted from included studies and risk of bias was assessed. We present findings using a narrative synthesis.ResultsWe screened 2430 unique records and included 52 quantitative and six qualitative papers. Factors reported to be associated with NIV optimisation included coordinated multidisciplinary care, place of initiation, selection of interfaces, ventilator modes and settings appropriate for the individual patient, and adequate secretion management. The literature indicated that patients with significant bulbar dysfunction can still derive considerable benefit from NIV if their needs are met. Research emphasises that obstructive airway events, mask leak and uncontrolled secretions should be addressed by adjustments to the interface and machine settings, and the concomitant use of cough augmentation.ConclusionThis review highlights that NIV optimisation requires an individualised approach to respiratory management tailored to the differing needs of each patient. Ultimately, this should lead to improved survival and quality of life. This review expands on recommendations in current international guidelines for NIV use in ALS and identifies areas for future research.
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Dorst J, Ludolph AC. Non-invasive ventilation in amyotrophic lateral sclerosis. Ther Adv Neurol Disord 2019; 12:1756286419857040. [PMID: 31258624 PMCID: PMC6589990 DOI: 10.1177/1756286419857040] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 05/23/2019] [Indexed: 12/11/2022] Open
Abstract
Non-invasive ventilation (NIV) has become an important cornerstone of symptomatic treatment in amyotrophic lateral sclerosis (ALS), improving survival and quality of life. In this review, we summarize the most important recent developments and insights, including evidence of efficacy, indication criteria and time of initiation, ventilation parameters and adaptation strategies, treatment of complicating factors, transition from NIV to invasive ventilation, termination of NIV and end-of-life management. Recent publications have questioned former conventions and guideline recommendations, especially with regard to timing and prognostic factors; therefore, a fresh look and re-evaluation of current evidence is needed.
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Affiliation(s)
- Johannes Dorst
- Universitätsklinik Ulm, Abteilung für Neurologie, Oberer Eselsberg 45, D-89081 Ulm, Germany
| | - Albert C. Ludolph
- Universitätsklinik Ulm, Abteilung für Neurologie, Oberer Eselsberg 45, D-89081 Ulm, Germany
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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
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Morelot-Panzini C, Bruneteau G, Gonzalez-Bermejo J. NIV in amyotrophic lateral sclerosis: The 'when' and 'how' of the matter. Respirology 2019; 24:521-530. [PMID: 30912216 DOI: 10.1111/resp.13525] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 02/09/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022]
Abstract
Non-invasive ventilation (NIV) has become an essential part of the treatment of amyotrophic lateral sclerosis (ALS) since 2006. NIV very significantly improves survival, quality of life and cognitive performances. The initial NIV settings are simple, but progression of the disease, ventilator dependence and upper airway involvement sometimes make long-term adjustment of NIV more difficult, with a major impact on survival. Unique data concerning the long-term adjustment of NIV in ALS show that correction of leaks, management of obstructive apnoea and adaptation to the patient's degree of ventilator dependence improve the prognosis. Non-ventilatory factors also impact the efficacy of NIV and various solutions have been described and must be applied, including cough assist techniques, control of excess salivation and renutrition. NIV in ALS has been considerably improved as a result of application of all of these measures, avoiding the need for tracheostomy in the very great majority of cases. More advanced use of NIV also requires pulmonologists to master the associated end-of-life palliative care, as well as the modalities of discontinuing ventilation when it becomes unreasonable.
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Affiliation(s)
- Capucine Morelot-Panzini
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France.,Service de Pneumologie et Réanimation Médicale du Département R3S, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Gaëlle Bruneteau
- Institut du Cerveau et de la Moelle épinière, ICM, Inserm U 1127, CNRS UMR 7225, Sorbonne Université, Paris, France.,Département de Neurologie, Centre Référent SLA, APHP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Jesus Gonzalez-Bermejo
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France.,Service de Pneumologie et Réanimation Médicale du Département R3S, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
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Abstract
Neuromuscular and chest wall diseases include a diverse group of conditions that share common risk factors for sleep-disordered breathing, including respiratory muscle weakness and/or thoracic restriction. Sleep-disordered breathing results from both the effects of normal sleep on ventilation and the additional challenges imposed by the underlying disorders. Patterns of sleep- disordered breathing vary with the specific diagnosis and stage of disease. Sleep hypoventilation precedes diurnal respiratory failure and may be difficult to recognize clinically because symptoms are nonspecific. Polysomnography has a role in both the diagnosis of sleep-disordered breathing and in the titration of effective noninvasive positive-pressure ventilation.
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Affiliation(s)
- Janet Hilbert
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University, Yale University School of Medicine, 300 Cedar Street, PO Box 208057, New Haven, CT 06520-8057, USA.
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One Plus One Might not make Two: Patient-Ventilator Interaction in Non-Invasive Ventilation. Who Does What? Arch Bronconeumol 2019; 55:403-406. [PMID: 30846203 DOI: 10.1016/j.arbres.2019.01.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 01/11/2019] [Accepted: 01/30/2019] [Indexed: 11/20/2022]
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Crimi C, Pierucci P, Carlucci A, Cortegiani A, Gregoretti C. Long-Term Ventilation in Neuromuscular Patients: Review of Concerns, Beliefs, and Ethical Dilemmas. Respiration 2019; 97:185-196. [PMID: 30677752 DOI: 10.1159/000495941] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/03/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Noninvasive mechanical ventilation (NIV) is an effective treatment in patients with neuromuscular diseases (NMD) to improve symptoms, quality of life, and survival. SUMMARY NIV should be used early in the course of respiratory muscle involvement in NMD patients and its requirements may increase over time. Therefore, training on technical equipment at home and advice on problem solving are warranted. Remote monitoring of ventilator parameters using built-in ventilator software is recommended. Telemedicine may be helpful in reducing hospital admissions. Anticipatory planning and palliative care should be carried out to lessen the burden of care, to maintain or withdraw from NIV, and to guarantee the most respectful management in the last days of NMD patients' life. Key Message: Long-term NIV is effective but challenging in NMD patients. Efforts should be made by health care providers in arranging a planned transition to home and end-of-life discussions for ventilator-assisted individuals and their families.
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Affiliation(s)
- Claudia Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Paola Pierucci
- Cardiothoracic Department, Respiratory and Sleep Medicine Unit, Policlinico University Hospital, Bari, Italy
| | - Annalisa Carlucci
- Respiratory Intensive Care Unit, Pulmonary Rehabilitation Unit, IRCCS Fondazione S. Maugeri, Pavia, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy,
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
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Aarrestad S, Qvarfort M, Kleiven AL, Tollefsen E, Skjønsberg OH, Janssens JP. Diagnostic accuracy of simple tools in monitoring patients with chronic hypoventilation treated with non-invasive ventilation; a prospective cross-sectional study. Respir Med 2018; 144:30-35. [DOI: 10.1016/j.rmed.2018.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/14/2022]
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Hirose T, Kimura F, Tani H, Ota S, Tsukahara A, Sano E, Shigekiyo T, Nakamura Y, Kakiuchi K, Motoki M, Unoda K, Ishida S, Nakajima H, Arawaka S. Clinical characteristics of long-term survival with noninvasive ventilation and factors affecting the transition to invasive ventilation in amyotrophic lateral sclerosis. Muscle Nerve 2018; 58:770-776. [DOI: 10.1002/mus.26149] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 04/12/2018] [Accepted: 04/17/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Takahiko Hirose
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Fumiharu Kimura
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Hiroki Tani
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Shin Ota
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Akihiro Tsukahara
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Eri Sano
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Taro Shigekiyo
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Yoshitsugu Nakamura
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Kensuke Kakiuchi
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Mikiko Motoki
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Kiichi Unoda
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Simon Ishida
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Hideto Nakajima
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
| | - Shigeki Arawaka
- Division of Neurology, Department of Internal Medicine IV; Osaka Medical College, Daigakumachi 2-7; Takatsukishi Osaka 569-8686 Japan
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Abstract
PURPOSE OF REVIEW This article provides a review of disturbances of sleep comorbid with common neurologic disorders. RECENT FINDINGS A wide variety of neurologic disorders are frequently complicated by comorbid sleep disturbances. In many cases, a bidirectional relationship appears to occur between sleep function and the neurologic disease, such that treatment of comorbid sleep disturbances may improve the symptoms of the neurologic disease. SUMMARY Neurologic disorders are often associated with abnormalities of sleep. Sleep influences the severity of both epilepsy and headache, and treatment of comorbid sleep disorders may improve seizure and headache frequency. Alzheimer disease is characterized by circadian phase delay and poor nighttime sleep and is strongly associated with obstructive sleep apnea. Parkinson disease is associated with several sleep disorders, including insomnia, restless legs syndrome, rapid eye movement (REM) sleep behavior disorder, daytime hypersomnia, and sleep-disordered breathing. Hypoventilation in amyotrophic lateral sclerosis and other neuromuscular disorders often presents initially with sleep problems, and treatment with noninvasive ventilation improves survival and quality of life.
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Comment régler un ventilateur de domicile ? Rev Mal Respir 2018; 35:574-577. [DOI: 10.1016/j.rmr.2017.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 04/08/2017] [Indexed: 11/17/2022]
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Boentert M, Glatz C, Helmle C, Okegwo A, Young P. Prevalence of sleep apnoea and capnographic detection of nocturnal hypoventilation in amyotrophic lateral sclerosis. J Neurol Neurosurg Psychiatry 2018; 89:418-424. [PMID: 29054915 DOI: 10.1136/jnnp-2017-316515] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 10/03/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This retrospective study aimed to investigate whether overnight oxymetry and early morning blood gas analysis predict nocturnal hypoventilation (NH) as reflected by night-time hypercapnia in patients with amyotrophic lateral sclerosis (ALS). In addition, prevalence and clinical determinants of sleep apnoea in ALS were evaluated. METHODS In 250 patients with non-ventilated ALS, transcutaneous capnometry was performed along with polysomnography or polygraphy and early morning blood gases. RESULTS 123 patients were female, and 84 patients had bulbar-onset ALS. 40.0% showed NH, and an apnoea-hypopnoea index (AHI) >5/hour was found in 45.6%. In 22.3%, sleep apnoea and NH coincided. The obstructive apnoea index was significantly higher than the central apnoea index (p<0.0001). Both NH and sleep apnoea were significantly more common in male than in female patients. Sleep apnoea and AHI were associated with better bulbar function. Desaturation time (t<90%) and transcutaneous CO2 were negatively correlated with upright vital capacity. Early morning base excess (EMBE), bicarbonate and t<90% were independent predictors of NH. However, among 100 patients with NH, 31 were missed by t<90% >5 min and 17 were not identified when EMBE >3 mmol/L and t<90% >5 min were combined. CONCLUSION In ALS, sleep apnoea is common and often accompanies NH. It is mainly obstructive, and central apnoea appears to be clinically irrelevant. Polygraphy or oxymetry alone are not sufficient to uncover NH. Combination of EMBE and t<90% may increase sensitivity, but transcutaneous capnography is strongly recommended for reliable detection of NH in patients with ALS.
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Affiliation(s)
- Matthias Boentert
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
| | - Christian Glatz
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
| | - Cornelia Helmle
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
| | - Angelika Okegwo
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
| | - Peter Young
- Department of Sleep Medicine and Neuromuscular Disorders, University Hospital Münster, Münster, Germany
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Sancho J, Martínez D, Bures E, Díaz JL, Ponz A, Servera E. Bulbar impairment score and survival of stable amyotrophic lateral sclerosis patients after noninvasive ventilation initiation. ERJ Open Res 2018; 4:00159-2017. [PMID: 29670892 PMCID: PMC5900060 DOI: 10.1183/23120541.00159-2017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/09/2018] [Indexed: 11/17/2022] Open
Abstract
There is general agreement that noninvasive ventilation (NIV) prolongs survival in amyotrophic lateral sclerosis (ALS) and that the main cause of NIV failure is the severity of bulbar dysfunction. However, there is no evidence that bulbar impairment is a contraindication for NIV. The aim of this study was to determine the effect of bulbar impairment on survival in ALS patients with NIV. ALS patients for whom NIV was indicated were included. Those patients who refused NIV were taken as the control group. 120 patients who underwent NIV and 20 who refused NIV were included. The NIV group presented longer survival (median 18.50 months, 95% CI 12.62-24.38 months) than the no-NIV group (3.00 months, 95% CI 0.82-5.18 months) (p<0.001) and also in those patients with severe bulbar dysfunction (13.00 months (95% CI 9.49-16.50 months) versus 3.00 months (95% CI 0.85-5.15 months), p<0.001). Prognostic factors for ALS using NIV, adjusted for NIV failure, were severity of bulbar dysfunction (hazard ratio (HR) 0.5, 95% CI 0.92-0.97; p=0.001) and time spent with oxygen saturation measured by pulse oximetry <90% (%sleepSpO2 <90) using NIV (HR 1.12, 95% CI 1.01-1.24; p=0.02). Severe bulbar impairment in ALS does not always prevent NIV from being used, but the severity of bulbar dysfunction at NIV initiation and %sleepSpO2 <90 while using NIV appear to be the main prognostic factors of NIV failure in ALS.
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Affiliation(s)
- Jesús Sancho
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain
- Research Group for Respiratory Problems in Neuromuscular Disease, Institute of Health Research INCLIVA, Valencia, Spain
| | - Daniel Martínez
- Respiratory Medicine Section, Hospital Marina Baixa, Villajoyosa, Spain
| | - Enric Bures
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain
- Research Group for Respiratory Problems in Neuromuscular Disease, Institute of Health Research INCLIVA, Valencia, Spain
| | - José Luis Díaz
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain
- Research Group for Respiratory Problems in Neuromuscular Disease, Institute of Health Research INCLIVA, Valencia, Spain
- Gasmedi SLU, Grupo Air Liquide, Madrid, Spain
| | - Alejandro Ponz
- Neurology Dept, Hospital Clínico Universitario, Valencia, Spain
| | - Emilio Servera
- Respiratory Care Unit, Respiratory Medicine Dept, Hospital Clínico Universitario, Valencia, Spain
- Research Group for Respiratory Problems in Neuromuscular Disease, Institute of Health Research INCLIVA, Valencia, Spain
- Universitat de Valencia, Valencia, Spain
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49
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Upper airway obstruction induced by non-invasive ventilation using an oronasal interface. Sleep Breath 2018; 22:781-788. [DOI: 10.1007/s11325-018-1640-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/15/2018] [Accepted: 02/06/2018] [Indexed: 12/14/2022]
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50
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Prigent A, Grassion L, Guesdon S, Gonzalez-Bermejo J. Efficacy of the Addition of a Cervical Collar in the Treatment of Persistent Obstructive Apneas Despite Continuous Positive Airway Pressure. J Clin Sleep Med 2017; 13:1473-1476. [PMID: 28728616 DOI: 10.5664/jcsm.6852] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 06/19/2017] [Indexed: 11/13/2022]
Abstract
ABSTRACT Continuous positive airway pressure (CPAP) is currently the reference treatment for obstructive sleep apnea (OSA). The use of a face mask, although sometimes necessary, is often associated with increased airway obstruction due to mandibular retrusion. We report a small group of patients in whom addition of a cervical collar to a face mask allowed correction of obstructive events.
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Affiliation(s)
- Arnaud Prigent
- Clinique Saint Laurent, Groupe medical de pneumologie, Rennes, France.,GAV (Groupe Assistance ventilatoire) of the Société de Pneumologie de Langue Française
| | - Leo Grassion
- GAV (Groupe Assistance ventilatoire) of the Société de Pneumologie de Langue Française.,Service des Maladies Respiratoires, Hôpital du Haut Lévèque, Pessac, France
| | | | - Jesus Gonzalez-Bermejo
- GAV (Groupe Assistance ventilatoire) of the Société de Pneumologie de Langue Française.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, INSERM, Neurophysiologie respiratoire expérimentale et clinique, Paris, France
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