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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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Continuous noninvasive ventilatory support outcomes for patients with neuromuscular disease: a multicenter data collaboration. Pulmonology 2021; 27:509-517. [PMID: 34656524 DOI: 10.1016/j.pulmoe.2021.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Typically, patients with progressive neuromuscular disorders (NMDs) develop acute respiratory failure (ARF), are intubated, and when failing spontaneous breathing trials (SBTs) undergo a tracheotomy and receive tracheostomy mechanical ventilation (TMV). However, increasing numbers of patients use nasal noninvasive ventilation (NIV), initially for sleep and this is extended to continuous dependence (CNVS). This can be used as a strategy to assist in successful extubation . We retrospectively reviewed 19 centers offering CNVS and mechanical insufflation-exsufflation (MI-E) as an alternative to TMV. METHODS Centers with publications or presentations concerning CNVS outcomes data were pooled for amyotrophic lateral sclerosis (ALS), Duchenne muscular dystrophy (DMD), and spinal muscular atrophy type 1 (SMA1). Progression to CNVS dependence without hospitalization, duration of dependence, and extubations and decannulations to CNVS were recorded. Prolongation of life was defined by duration of CNVS dependence without ventilator free breathing ability (VFBA). RESULTS There were 1623 part time (<23 h/day) NVS users with ALS, DMD, and SMA1 from 19 centers in 16 countries of whom 761 (47%) were CNVS dependent for 2218 patient-years. This included: 335 ALS patients for a mean 1.2 ± 1.0 (range to 8) years each; 385 DMD patients for 5.4 ± 1.6 (range to 29) years; and 41 SMA1 patients for 5.9 ± 1.8 (range to 20) years. Thirty-five DMD and ALS TMV users were decannulated to CNVS and MI-E. At data collection 494 (65%) patients were CNVS dependent but 110 (74 of whom with bulbar ALS), had undergone tracheotomies. CONCLUSIONS ALS, DMD, and SMA1 patients can become CNVS dependent without requiring hospitalization but CNVS cannot be used indefinitely for many patients with advanced upper motor neuron diseases.
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Rao F, Garuti G, Vitacca M, Banfi P, Racca F, Cutrera R, Pavone M, Pedemonte M, Schisano M, Pedroni S, Casiraghi J, Vianello A, Sansone VA. Management of respiratory complications and rehabilitation in individuals with muscular dystrophies: 1st Consensus Conference report from UILDM - Italian Muscular Dystrophy Association (Milan, January 25-26, 2019). ACTA MYOLOGICA : MYOPATHIES AND CARDIOMYOPATHIES : OFFICIAL JOURNAL OF THE MEDITERRANEAN SOCIETY OF MYOLOGY 2021; 40:8-42. [PMID: 33870094 PMCID: PMC8033426 DOI: 10.36185/2532-1900-045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/16/2021] [Indexed: 12/03/2022]
Abstract
Respiratory complications are common in the patient with muscular dystrophy. The periodic clinical and instrumental respiratory evaluation is extremely important. Despite the presence in the literature of updated guidelines, patient associations often report lack of knowledge of these pathologies, particularly in peripheral hospitals. The purpose of this work, inspired by the Italian Muscular Dystrophy Association (UILDM) is to improve management of respiratory problems necessary for the management of these patients complex. To this end, the main items that the specialist can meet in the follow-up of these pathologies have been analyzed and discussed, among which the respiratory basal evaluation, the criteria of adaptation to non-invasive ventilation, management of bronchial secretions, situations of respiratory emergency, indications for tracheostomy and the subject of advance directives of treatment (DAT).
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Affiliation(s)
- Fabrizio Rao
- Respiratory Unit, NEuroMuscular OmniCentre (NeMO), Serena Onlus Foundation, Niguarda Hospital, Milan, Italy
| | - Giancarlo Garuti
- Pneumology Unit, Santa Maria Bianca Hospital, AUSL Modena, Italy
| | | | - Paolo Banfi
- IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Fabrizio Racca
- Department of Anaesthesia and Intensive Care, Division of Paediatric Intensive Care Unit, Alessandria General Hospital, Alessandria, Italy
| | - Renato Cutrera
- Pulmonology Unit, Academic Paediatric Department, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Martino Pavone
- Pediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Department of Pediatrics, Bambino Gesù Children’s Research Hospital, Rome, Italy
| | - Marina Pedemonte
- Pediatric Neurology and Muscle Diseases Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Matteo Schisano
- Respiratory Medicine Unit, AOU “Policlinico-San Marco”, Catania, Italy
| | - Stefania Pedroni
- Neurorehabilitation Unit, the NEMO Clinical Center in Milan, University of Milan, Italy
| | - Jacopo Casiraghi
- Neurorehabilitation Unit, the NEMO Clinical Center in Milan, University of Milan, Italy
| | - Andrea Vianello
- Respiratory Pathophysiology Division, Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Italy
| | - Valeria A Sansone
- Neurorehabilitation Unit, the NEMO Clinical Center in Milan, University of Milan, Italy
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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Beatmung bei neuromuskulären Erkrankungen. NEUROLOGISCHE BEATMUNGSMEDIZIN 2020. [PMCID: PMC7236064 DOI: 10.1007/978-3-662-59014-0_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Neuromuskuläre Erkrankungen betreffen das erste und zweite Motoneuron, die peripheren Nerven, die neuromuskulären Übertragung und die Muskelzelle. Es handelt sich um eine heterogene Gruppe von erblichen, degenerativen und autoimmunen Erkrankungen. Eine korrekte diagnostische Einordnung ist erforderlich, da zentralnervöse, kardiale, endokrine und weitere Begleitsymptome vorliegen können und für einige Erkrankungen bereits medikamentöse Therapien zur Verfügung stehen. Neuromuskuläre Erkrankungen haben eine große Bedeutung in der neuromuskulären Beatmungsmedizin. Die respiratorische Symptomatik resultiert in der Regel aus Paresen der am Atmen, Schlucken oder Husten beteiligten Muskulatur mit konsekutiver ventilatorischer Insuffienz, Dysphagie bis hin zur Speichelaspiration und Sekretretention. Mittels eines strukturierte Sekretmanagements und einer effektive nichtinvasive oder invasive Beatmungstherapie können neuromuskuläre Patienten viele Jahre mit guter Lebensqualität überleben. Themen dieses Kapitels sind ein Überblick über die neuromuskulären Erkrankungen, die Indikationen und Strategien der nichtinvasiven und der invasiven Beatmung und eine ausführliche Darstellung beatmungsmedizinisch besonders relevanter neuromuskulärer Erkrankungen wie der amyotrophe Lateralsklerose, des Guillain-Barré-Syndroms, der Myasthenia gravis und der Critical-Illness-Polyneuropathie/-Myopathie.
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Is "Noninvasive Ventilation" the Way to Prevent Respiratory Failure in Amyotrophic Lateral Sclerosis? Chest 2019; 156:189. [PMID: 31279372 DOI: 10.1016/j.chest.2019.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 11/21/2022] Open
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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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Braun AT, Caballero-Eraso C, Lechtzin N. Amyotrophic Lateral Sclerosis and the Respiratory System. Clin Chest Med 2019; 39:391-400. [PMID: 29779597 DOI: 10.1016/j.ccm.2018.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder that always affects the respiratory muscles. It is characterized by degeneration of motor neurons in the brain and spinal cord. Respiratory complications are the most common causes of death in ALS and typically occur within 3 to 5 years of diagnosis. Because ALS affects both upper and lower motor neurons, it causes hyperreflexia, spasticity, muscle fasciculations, muscle atrophy, and weakness. It ultimately progresses to functional quadriplegia. ALS most commonly begins in the limbs, but in about one-third of cases it begins in the bulbar muscles responsible for speech and swallowing.
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Affiliation(s)
- Andrew T Braun
- Division of Pulmonary and Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, MD 21205, USA; Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison, WI 53792, USA
| | - Candelaria Caballero-Eraso
- Division of Pulmonary and Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, MD 21205, USA; Medical-Surgical Unit of Respiratory Diseases, Institute of Biomedicine of Seville (IBiS), Centre for Biomedical Research in Respiratory Diseases Network (CIBERES), University Hospital Virgen del Rocío, University of Seville, Avenida Dr. Fedriani, 41009 Sevilla, Spain
| | - Noah Lechtzin
- Division of Pulmonary and Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Baltimore, MD 21205, USA.
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Mechanical In-exsufflation-Expiratory Flows as Indication for Tracheostomy Tube Decannulation. Am J Phys Med Rehabil 2019; 98:e18-e20. [DOI: 10.1097/phm.0000000000000999] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Association of Need for Tracheotomy With Decreasing Mechanical In-Exsufflation Flows in Amyotrophic Lateral Sclerosis. Am J Phys Med Rehabil 2019; 97:e20-e22. [PMID: 28410251 DOI: 10.1097/phm.0000000000000755] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Although patients with lower motor neuron and myopathic disorders can prolong their lives by depending on continuous noninvasive ventilatory support, most patients with amyotrophic lateral sclerosis (ALS) cannot and must use tracheostomy mechanical ventilation to prolong survival. This case demonstrates that this occurs because amyotrophic lateral sclerosis patients' upper motor neuron reflex laryngeal closure and stridor cause upper airway collapse that renders mechanical insufflation-exsufflation (MIE) ineffective in expulsing airway secretions as well as for permitting continuous noninvasive ventilatory support. A decrease in MIE-exsufflation flows is a marker for a decrease in upper airway patency that renders MIE ineffective. As airway secretions accumulate and baseline oxyhemoglobin saturation decreases, tracheotomy becomes necessary for further survival. This case demonstrates an association between diminishing MIE-exsufflation flow and need to resort to tracheotomy.
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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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Vianello A, Arcaro G, Molena B, Iovino S, Gallan F, Turato C, Marchese-Ragona R. Effect of a passive exhalation port on tracheostomy ventilation in amyotrophic lateral sclerosis patients: a randomized controlled trial. J Thorac Dis 2018; 10:1007-1014. [PMID: 29607174 DOI: 10.21037/jtd.2018.01.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Amyotrophic lateral sclerosis (ALS) patients often require long-term tracheostomy ventilation (LT-TV) because of progressive ventilatory failure. Although widely used for non-invasive ventilation (NIV), passive exhalation port systems have not been gaining popularity for TV because of the possibility of carbon dioxide (CO2) rebreathing. The current study set out to investigate the effect of a Whisper Swivel connector in comparison to an active exhalation valve on gas exchange and symptoms in ALS patients requiring LT-TV. Methods A prospective randomized controlled trial was carried out to compare the clinical outcome of ten ALS patients receiving LT-TV by means of a Trilogy 100 ventilator with a Whisper Swivel passive exhalation port (group A) and of 10 ALS patients connected to an Airox Legendair ventilator with an active exhalation valve (group B). The study's main outcome measure was CO2 retention at the 30-day follow-up assessment. Results One patient in each of the two cohorts showed significant CO2 retention. At the 30-day assessment, scores on the following measures were not significantly different in the two groups: the Borg dyspnea scale {2 [1-3] vs. 1 [1-3]; P=0.2891}, the visual analogue scale (VAS) dyspnea {20 [10-85] vs. 20 [0-50]; P=0.8571}, the Epworth sleepiness scale (ESS) {8 [4-10] vs. 5.5 [0-12]; P=0.1443}, the EuroQol-VAS (EQ-VAS) {55 [50-80] vs. 50 [30-80]; P=0.4593} and the relative stress scale (RSS) {49 [30-65] vs. 52 [25-64]; P=0.8650}. At the 3-month follow-up assessment, the numbers of hospitalizations and deaths were likewise similar in the two groups. Conclusions The efficacy of the Whisper Swivel connector is similar to that of an active exhalation valve in ALS patients undergoing LT-TV.
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Affiliation(s)
- Andrea Vianello
- Respiratory Pathophysiology and Intensive Care Unit, Department of Cardio-Thoracic, University-City Hospital of Padova, Padova, Italy
| | - Giovanna Arcaro
- Respiratory Pathophysiology and Intensive Care Unit, Department of Cardio-Thoracic, University-City Hospital of Padova, Padova, Italy
| | - Beatrice Molena
- Respiratory Pathophysiology and Intensive Care Unit, Department of Cardio-Thoracic, University-City Hospital of Padova, Padova, Italy
| | - Silvia Iovino
- Respiratory Pathophysiology and Intensive Care Unit, Department of Cardio-Thoracic, University-City Hospital of Padova, Padova, Italy
| | - Federico Gallan
- Respiratory Pathophysiology and Intensive Care Unit, Department of Cardio-Thoracic, University-City Hospital of Padova, Padova, Italy
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Lechtzin N, Cudkowicz ME, de Carvalho M, Genge A, Hardiman O, Mitsumoto H, Mora JS, Shefner J, Van den Berg LH, Andrews JA. Respiratory measures in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2018; 19:321-330. [PMID: 29566571 DOI: 10.1080/21678421.2018.1452945] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease that causes skeletal muscle weakness, including muscles involved with respiration. Death often results from respiratory failure within 3-5 years. Monitoring respiratory status is therefore critical to ALS management, as respiratory/pulmonary function tests (PFTs) are used to make decisions including when to initiate noninvasive ventilation. Understanding the different respiratory and PFTs as they relate to disease progression and survival may help determine which tests are most suitable. METHODS This review describes the tests used to assess respiratory muscle and pulmonary function in patients with ALS and the correlations between different respiratory measures and clinical outcomes measures. RESULTS The most commonly used measurement, forced vital capacity (VC), has been shown to correlate with clinical milestones including survival, but also requires good motor coordination and facial strength to form a tight seal around a mouthpiece. Other tests such as slow VC, sniff inspiratory pressure, or transdiaphragmatic pressure with magnetic stimulation are also associated with distinct advantages and disadvantages. CONCLUSIONS Therefore, how and when to use different tests remains unclear. Understanding how each test relates to disease progression and survival may help determine which is best suited for specific clinical decisions.
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Affiliation(s)
- Noah Lechtzin
- a Johns Hopkins University School of Medicine , Baltimore , MD , USA
| | | | - Mamede de Carvalho
- c Faculty of Medicine, IMM, University of Lisbon , Department of Neurosciences-CHLN , Lisbon , Portugal
| | - Angela Genge
- d Montreal Neurological Institute , Montreal , Canada
| | - Orla Hardiman
- e Trinity Biomedical Sciences Institute, Trinity College , Dublin , Ireland
| | - Hiroshi Mitsumoto
- f Eleanor and Lou Gehrig ALS Center, The Neurological Institute, Columbia University , New York , NY , USA
| | - Jesus S Mora
- g Unidad de ELA-Hospital Universitario La Paz-Hospital Carlos III , Madrid , Spain
| | - Jeremy Shefner
- h Department of Neurology , Barrow Neurological Institute , Phoenix , AZ , USA
| | - Leonard H Van den Berg
- i Department of Neurology , Brain Centre Rudolf Magnus, University Medical Centre Utrecht , Utrecht , The Netherlands
| | - Jinsy A Andrews
- f Eleanor and Lou Gehrig ALS Center, The Neurological Institute, Columbia University , New York , NY , USA
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Dias A, Faria I, Santos AC, Bárbara C. Thinking outside the thorax for patients difficult to wean from non-invasive ventilation: amyotrophic lateral sclerosis diagnosis and management in a Respiratory Intermediate Care Unit. Pulmonology 2017; 24:S2173-5115(17)30161-6. [PMID: 29290577 DOI: 10.1016/j.rppnen.2017.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/20/2017] [Accepted: 11/05/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- A Dias
- Chest Department, Centro Hospitalar Lisboa Norte, Lisboa, Portugal.
| | - I Faria
- Chest Department, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - A C Santos
- Chest Department, Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - C Bárbara
- Chest Department, Centro Hospitalar Lisboa Norte, Lisboa, Portugal; Institute of Environmental Health (ISAMB), Faculty of Medicine, University of Lisbon, Portugal
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15
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Bach JR. Noninvasive Respiratory Management of Patients With Neuromuscular Disease. Ann Rehabil Med 2017; 41:519-538. [PMID: 28971036 PMCID: PMC5608659 DOI: 10.5535/arm.2017.41.4.519] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/19/2017] [Indexed: 12/14/2022] Open
Abstract
This review article describes definitive noninvasive respiratory management of respiratory muscle dysfunction to eliminate need to resort to tracheotomy. In 2010 clinicians from 22 centers in 18 countries reported 1,623 spinal muscular atrophy type 1 (SMA1), Duchenne muscular dystrophy (DMD), and amyotrophic lateral sclerosis users of noninvasive ventilatory support (NVS) of whom 760 required it continuously (CNVS). The CNVS sustained their lives by over 3,000 patient-years without resort to indwelling tracheostomy tubes. These centers have now extubated at least 74 consecutive ventilator unweanable patients with DMD, over 95% of CNVS-dependent patients with SMA1, and hundreds of others with advanced neuromuscular disorders (NMDs) without resort to tracheotomy. Two centers reported a 99% success rate at extubating 258 ventilator unweanable patients without resort to tracheotomy. Patients with myopathic or lower motor neuron disorders can be managed noninvasively by up to CNVS, indefinitely, despite having little or no measurable vital capacity, with the use of physical medicine respiratory muscle aids. Ventilator-dependent patients can be decannulated of their tracheostomy tubes.
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Affiliation(s)
- John R Bach
- Department of Physical Medicine and Rehabilitation for Rutgers New Jersey Medical School & Center for Ventilator Management Alternatives at University Hospital, Newark, NJ, USA
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Enache I, Pistea C, Fleury M, Schaeffer M, Oswald-Mammosser M, Echaniz-Laguna A, Tranchant C, Meyer N, Charloux A. Ability of pulmonary function decline to predict death in amyotrophic lateral sclerosis patients. Amyotroph Lateral Scler Frontotemporal Degener 2017; 18:511-518. [DOI: 10.1080/21678421.2017.1353097] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Irina Enache
- Department of Physiology and Pulmonary Function Tests, Chest diseases, University Hospital of Strasbourg and EA 3072, Federation of Translational Medicine, Strasbourg University, Strasbourg Cedex, France,
| | - Cristina Pistea
- Department of Physiology and Pulmonary Function Tests, Chest diseases, University Hospital of Strasbourg and EA 3072, Federation of Translational Medicine, Strasbourg University, Strasbourg Cedex, France,
| | - Marie Fleury
- Department of Neurology, University Hospital of Strasbourg, Strasbourg Cedex, France, and
| | - Mickael Schaeffer
- Department of Public Health, Biostatistic and Methodology Service, University Hospital of Strasbourg, Strasbourg Cedex, France
| | - Monique Oswald-Mammosser
- Department of Physiology and Pulmonary Function Tests, Chest diseases, University Hospital of Strasbourg and EA 3072, Federation of Translational Medicine, Strasbourg University, Strasbourg Cedex, France,
| | - Andoni Echaniz-Laguna
- Department of Neurology, University Hospital of Strasbourg, Strasbourg Cedex, France, and
| | - Christine Tranchant
- Department of Neurology, University Hospital of Strasbourg, Strasbourg Cedex, France, and
| | - Nicolas Meyer
- Department of Public Health, Biostatistic and Methodology Service, University Hospital of Strasbourg, Strasbourg Cedex, France
| | - Anne Charloux
- Department of Physiology and Pulmonary Function Tests, Chest diseases, University Hospital of Strasbourg and EA 3072, Federation of Translational Medicine, Strasbourg University, Strasbourg Cedex, France,
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Sancho J, Servera E, Bañuls P, Marín J. Effectiveness of assisted and unassisted cough capacity in amyotrophic lateral sclerosis patients. Amyotroph Lateral Scler Frontotemporal Degener 2017; 18:498-504. [DOI: 10.1080/21678421.2017.1335324] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jesús Sancho
- Respiratory Care Unit, Respiratory Medicine Department, Hospital Clínico Universitario,
- Research Group for Respiratory Problems in Neuromuscular Diseases, Institute of Health Research INCLIVA, and
| | - Emilio Servera
- Respiratory Care Unit, Respiratory Medicine Department, Hospital Clínico Universitario,
- Research Group for Respiratory Problems in Neuromuscular Diseases, Institute of Health Research INCLIVA, and
- Universitat de Valencia, Valencia, Spain
| | - Pilar Bañuls
- Respiratory Care Unit, Respiratory Medicine Department, Hospital Clínico Universitario,
- Research Group for Respiratory Problems in Neuromuscular Diseases, Institute of Health Research INCLIVA, and
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18
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De Mattia E, Iatomasi M, Garabelli B, Lunetta C, Sansone VA, Rao F. Use of the Intermittent Abdominal Pressure Ventilation to guarantee speech in a tracheostomized Amyotrophic Lateral Sclerosis patient. REVISTA PORTUGUESA DE PNEUMOLOGIA 2017; 23:236-239. [PMID: 28579222 DOI: 10.1016/j.rppnen.2017.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 02/03/2017] [Accepted: 03/19/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- E De Mattia
- NEuroMuscular Omnicentre (NEMO), Fondazione Serena Onlus, Milano, Italy.
| | - M Iatomasi
- NEuroMuscular Omnicentre (NEMO), Fondazione Serena Onlus, Milano, Italy
| | - B Garabelli
- NEuroMuscular Omnicentre (NEMO), Fondazione Serena Onlus, Milano, Italy
| | - C Lunetta
- NEuroMuscular Omnicentre (NEMO), Fondazione Serena Onlus, Milano, Italy
| | - V A Sansone
- NEuroMuscular Omnicentre (NEMO), Fondazione Serena Onlus, Milano, Italy; Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
| | - F Rao
- NEuroMuscular Omnicentre (NEMO), Fondazione Serena Onlus, Milano, Italy
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19
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Pinto T, Chatwin M, Banfi P, Winck JC, Nicolini A. Mouthpiece ventilation and complementary techniques in patients with neuromuscular disease: A brief clinical review and update. Chron Respir Dis 2017; 14:187-193. [PMID: 27932555 DOI: 10.1177/1479972316674411] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Noninvasive ventilatory support (NVS) is sometimes reported as suboptimal in patients with neuromuscular disease (NMD). The reasons for this include inadequate ventilator settings and/or lack of interface tolerance. NVS has been used for many years in patients with NMD disorders as a viable alternative to continuous ventilatory support via a tracheostomy tube. The mouthpiece ventilation (MPV) is a ventilatory mode that is used as daytime ventilatory support in combination with other ventilatory modalities and interfaces for nocturnal NVS. However, there is still a poor understanding of this method's benefits compared with other modalities. This review aims to highlight the indications and advantages along with the disadvantages of MPV.
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Affiliation(s)
- Tiago Pinto
- 1 Lung Function and Ventilation Unit, Department of Pulmonary Medicine, Porto, Portugal
| | - Michelle Chatwin
- 2 Clinical and Academic Department of Sleep and Breathing, Royal Brompton Hospital, London, UK
| | - Paolo Banfi
- 3 Don Gnocchi Foundation IRCSS, Milan, Italy
| | | | - Antonello Nicolini
- 5 Respiratory Diseases Unit and ALS Centre, Hospital of Sestri Levante, Italy
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Schenk P, Eber E, Funk GC, Fritz W, Hartl S, Heininger P, Kink E, Kühteubl G, Oberwaldner B, Pachernigg U, Pfleger A, Schandl P, Schmidt I, Stein M. [Non-invasive and invasive out of hospital ventilation in chronic respiratory failure : Consensus report of the working group on ventilation and intensive care medicine of the Austrian Society of Pneumology]. Wien Klin Wochenschr 2016; 128 Suppl 1:S1-36. [PMID: 26837865 DOI: 10.1007/s00508-015-0899-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The current consensus report was compiled under the patronage of the Austrian Society of Pneumology (Österreichischen Gesellschaft für Pneumologie, ÖGP) with the intention of providing practical guidelines for out-of-hospital ventilation that are in accordance with specific Austrian framework parameters and legal foundations. The guidelines are oriented toward a 2004 consensus ÖGP recommendation concerning the setup of long-term ventilated patients and the 2010 German Respiratory Society S2 guidelines on noninvasive and invasive ventilation of chronic respiratory insufficiency, adapted to national experiences and updated according to recent literature. In 11 chapters, the initiation, adjustment, and monitoring of out-of-hospital ventilation is described, as is the technical equipment and airway access. Additionally, the different indications-such as chronic obstructive pulmonary diseases, thoracic restrictive and neuromuscular diseases, obesity hypoventilation syndrome, and pediatric diseases-are discussed. Furthermore, the respiratory physiotherapy of adults and children on invasive and noninvasive long-term ventilation is addressed in detail.
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Affiliation(s)
- Peter Schenk
- Abteilung für Pulmologie, Landesklinikum Hochegg, Hocheggerstraße 88, 2840, Grimmenstein, Österreich.
| | - Ernst Eber
- Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Georg-Christian Funk
- I. Interne Lungenabteilung, Pulmologisches Zentrum, Sozialmedizinisches Zentrum Baumgartner Höhe, Otto Wagner Spital, Wien, Österreich
| | - Wilfried Fritz
- Klinische Abteilung für Lungenkrankheiten, Universitätsklinik für Innere Medizin, Universitätsklinikum Graz, Graz, Österreich
| | - Sylvia Hartl
- I. Interne Lungenabteilung, Pulmologisches Zentrum, Sozialmedizinisches Zentrum Baumgartner Höhe, Otto Wagner Spital, Wien, Österreich
| | | | - Eveline Kink
- Abteilung für Lungenkrankheiten, Landeskrankenhaus Hörgas-Enzenbach, Eisbach, Österreich
| | - Gernot Kühteubl
- Abteilung für Pulmologie, Landesklinikum Hochegg, Hocheggerstraße 88, 2840, Grimmenstein, Österreich
| | | | - Ulrike Pachernigg
- Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Andreas Pfleger
- Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Petra Schandl
- 1. Allgemeine Intensivstation, Wilhelminenspital, Wien, Österreich
| | - Ingrid Schmidt
- I. Interne Lungenabteilung, Pulmologisches Zentrum, Sozialmedizinisches Zentrum Baumgartner Höhe, Otto Wagner Spital, Wien, Österreich
| | - Markus Stein
- Abteilung für Pneumologie, Landeskrankenhaus Hochzirl-Natters, Standort Natters, Natters, Österreich
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Affiliation(s)
- J.R. Bach
- Department of Physical Medicine and Rehabilitation, University Hospital B-403, 150 Bergen Street, Newark, NJ, USA,
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22
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Kang SW, Choi WA, Cho HE, Lee JW, Park JH. Management of Ventilatory Insufficiency in Neuromuscular Patients Using Mechanical Ventilator Supported by the Korean Government. J Korean Med Sci 2016; 31:976-82. [PMID: 27247509 PMCID: PMC4853679 DOI: 10.3346/jkms.2016.31.6.976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 03/17/2016] [Indexed: 11/20/2022] Open
Abstract
Since 2001, financial support has been provided for all patients with neuromuscular disease (NMD) who require ventilatory support due to the paralysis of respiratory muscles in Korea. The purpose of this study was to identify ventilator usage status and appropriateness in these patients. We included 992 subjects with rare and incurable NMD registered for ventilator rental fee support. From 21 February 2011 to 17 January 2013, ventilator usage information, regular follow-up observation, and symptoms of chronic hypoventilation were surveyed by phone. Home visits were conducted for patients judged by an expert medical team to require medical examination. Abnormal ventilatory status was assessed by respiratory evaluation. Chronic respiratory insufficiency symptoms were reported by 169 of 992 subjects (17%), while 565 subjects (57%) did not receive regular respiratory evaluation. Ventilatory status was abnormal in 102 of 343 home-visit subjects (29.7%). Although 556 subjects (56%) reported 24-hour ventilator use, only 458 (46%) had an oxygen saturation monitoring device, and 305 (31%) performed an airstacking exercise. A management system that integrates ventilator usage monitoring, counselling and advice, and home visits for patients who receive ventilator support could improve the efficiency of the ventilator support project.
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Affiliation(s)
- Seong-Woong Kang
- Department of Rehabilitation Medicine, Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Won Ah Choi
- Department of Rehabilitation Medicine, Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Han Eol Cho
- Department of Rehabilitation Medicine, Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Jang Woo Lee
- Department of Rehabilitation Medicine, Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hyun Park
- Department of Rehabilitation Medicine, Pulmonary Rehabilitation Center, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Korea
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23
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Herrero MV, Bach JR. Uninformed guidelines for mechanical in-exsufflation. Amyotroph Lateral Scler Frontotemporal Degener 2016; 17:304. [DOI: 10.3109/21678421.2015.1137948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- María V. Herrero
- Petrona Villegas de Cordero Hospital, San Fernando, Argentina and
| | - J. R. Bach
- Rutgers Biomedical and Health Sciences New Jersey Medical School, USA
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24
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Servera E, Sancho J, Bañuls P, Marín J. Bulbar impairment score predicts noninvasive volume-cycled ventilation failure during an acute lower respiratory tract infection in ALS. J Neurol Sci 2015; 358:87-91. [DOI: 10.1016/j.jns.2015.08.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 08/14/2015] [Accepted: 08/18/2015] [Indexed: 11/30/2022]
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25
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Rafiq MK, Bradburn M, Proctor AR, Billings CG, Bianchi S, McDermott CJ, Shaw PJ. A preliminary randomized trial of the mechanical insufflator-exsufflator versus breath-stacking technique in patients with amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2015; 16:448-55. [DOI: 10.3109/21678421.2015.1051992] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Muhammad K. Rafiq
- Academic Neurology Unit, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Michael Bradburn
- Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alison R. Proctor
- Academic Neurology Unit, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Catherine G. Billings
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Stephen Bianchi
- Academic Directorate of Respiratory Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Christopher J. McDermott
- Academic Neurology Unit, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Pamela J. Shaw
- Academic Neurology Unit, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
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26
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Bach JR, Takyi SL. Physical Medicine Interventions to Avoid Acute Respiratory Failure and Invasive Airway Tubes. PM R 2015; 7:871-877. [DOI: 10.1016/j.pmrj.2015.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/10/2015] [Accepted: 03/07/2015] [Indexed: 12/14/2022]
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Servera E, Sancho J. Pulmonologists, mechanical ventilation and complementary techniques. Arch Bronconeumol 2014; 50:505-6. [PMID: 25145321 DOI: 10.1016/j.arbres.2014.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Revised: 07/08/2014] [Accepted: 07/09/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Emilio Servera
- Unidad de Cuidados Respiratorios, Servicio de Neumología, Hospital Clínico Universitario y Grupo de Investigación en Problemas Respiratorios en las enfermedades Neuromusculares, INCLIVA, Valencia, España; Universidad de Valencia, Valencia, España.
| | - Jesús Sancho
- Unidad de Cuidados Respiratorios, Servicio de Neumología, Hospital Clínico Universitario y Grupo de Investigación en Problemas Respiratorios en las enfermedades Neuromusculares, INCLIVA, Valencia, España
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Pilot study for home monitoring of cough capacity in amyotrophic lateral sclerosis: A case series. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:181-7. [DOI: 10.1016/j.rppneu.2013.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 10/25/2013] [Accepted: 11/19/2013] [Indexed: 11/21/2022] Open
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Open circuit mouthpiece ventilation: Concise clinical review. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:211-8. [PMID: 24841239 DOI: 10.1016/j.rppneu.2014.03.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/16/2014] [Accepted: 03/24/2014] [Indexed: 11/22/2022] Open
Abstract
In 2013 new "mouthpiece ventilation" modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece. Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via "mask" interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22mm angled mouthpieces and straw-type mouthpieces are the most commonly used. NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates "air-stacking" to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.
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31
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Tamplin J, Berlowitz DJ. A systematic review and meta-analysis of the effects of respiratory muscle training on pulmonary function in tetraplegia. Spinal Cord 2014; 52:175-80. [DOI: 10.1038/sc.2013.162] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 12/02/2013] [Accepted: 12/09/2013] [Indexed: 01/25/2023]
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Goyal NA, Mozaffar T. Respiratory and Nutritional Support in Amyotrophic Lateral Sclerosis. Curr Treat Options Neurol 2014; 16:270. [DOI: 10.1007/s11940-013-0270-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Yamauchi R, Imai T, Tsuda E, Hozuki T, Yamamoto D, Shimohama S. Respiratory insufficiency with preserved diaphragmatic function in amyotrophic lateral sclerosis. Intern Med 2014; 53:1325-31. [PMID: 24930652 DOI: 10.2169/internalmedicine.53.2326] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE We performed a longitudinal study to elucidate the correlation between respiratory insufficiency and respiratory biomarkers, including diaphragmatic compound muscle action potential (DCMAP), at the initiation of noninvasive ventilation (NIV) in patients with amyotrophic lateral sclerosis (ALS). METHODS The patients were assessed at least every six months. Additional assessments were performed at the start of respiratory therapy when the patients met the criteria for the initiation of NIV. Each assessment consisted of a full neurological examination, a phrenic nerve conduction study, respiratory function tests, and nocturnal pulsed oximetry. PATIENTS We enrolled 43 patients with either definite or probable ALS as defined by the revised El Escorial criteria. RESULTS The patients were divided into two groups according to the timing of the initiation of respiratory therapy. Seventeen patients (group A) met the criteria for NIV initiation when their DCMAP remained normal. Twenty-six patients (group B) met the criteria when their DCMAP decreased below normal limits. Although respiratory function parameters were significantly worse in group B compared with group A at NIV initiation, more than 80% of the patients in both groups developed nocturnal desaturation during sleep. CONCLUSION DCMAP is not always a reliable indicator for determining the optimal timing for NIV initiation during the progression of respiratory insufficiency in ALS. Physicians should be aware of the risk of respiratory insufficiency during sleep in patients with ALS.
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Affiliation(s)
- Rika Yamauchi
- Department of Neurology, Sapporo Medical University School of Medicine, Japan
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Abstract
Respiratory failure (RF) can be attributed to a plethora of neuromuscular diseases (NMDs) and manifests clinically in a multitude of overt or more subtle ways. The basic principles of pathophysiology, diagnosis and treatment of neurologic diseases and of RF apply concomitantly to this subset of patients. Various entities should be approached according to the latest evidence-based recommendations. Treatment follows the natural disease progression, from minimal respiratory assistance to mechanical ventilation (MV). A comprehensive treatment plan has to be formulated that takes into consideration the patient's wishes.
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35
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Affiliation(s)
- John R Bach
- Department of Physical Medicine & Rehabilitation, University Hospital, Newark, NJ, USA
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36
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Park SY, Kim SM, Sung JJ, Lee KM, Park KS, Kim SY, Nam HW, Lee KW. Nocturnal hypoxia in ALS is related to cognitive dysfunction and can occur as clusters of desaturations. PLoS One 2013; 8:e75324. [PMID: 24058674 PMCID: PMC3776791 DOI: 10.1371/journal.pone.0075324] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 08/12/2013] [Indexed: 02/05/2023] Open
Abstract
Background Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that leads to progressive weakness of the respiratory and limb muscles. Consequently, most patients with ALS exhibit progressive hypoventilation, which worsens during sleep. The aim of this study was to evaluate the relationship between nocturnal hypoxia and cognitive dysfunction and to assess the pattern of nocturnal hypoxia in patients with ALS. Method Twenty-five patients with definite or probable ALS underwent neuropsychologic testing, nocturnal pulse oximetry, and capnography. Patients were grouped according to the presence of nocturnal hypoxia (SpO2<95% for ≥10% of the night) and their clinical characteristics and cognitive function were compared. Results Compared to patients without nocturnal hypoxia, those with nocturnal hypoxia (n = 10, 40%) had poor memory retention (p = 0.039) and retrieval efficiency (p = 0.045). A cluster-of-desaturation pattern was identified in 7 patients (70%) in the Hypoxia Group. Conclusions These results suggest that nocturnal hypoxia can be related to cognitive dysfunction in ALS. In addition, a considerable number of patients with ALS may be exposed to repeated episodes of deoxygenation–reoxygenation (a cluster-of-desaturation pattern) during sleep, which could be associated with the generation of reactive oxygen species. Further studies are required to define the exact causal relationships between these phenomena, the exact manifestations of nocturnal cluster-of-desaturation patterns, and the effect of clusters of desaturation on ALS progression.
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Affiliation(s)
- Su-Yeon Park
- Department of Neurology, Korea Cancer Center Hospital, Seoul, Korea
| | - Sung-Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- * E-mail: (SMK); (JJS)
| | - Jung-Joon Sung
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- * E-mail: (SMK); (JJS)
| | - Kyung-Min Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Kyung-Seok Park
- Department of Neurology, Seoul National University, Bundang Hospital, Gyeonggi, Korea
| | - Sang-Yun Kim
- Department of Neurology, Seoul National University, Bundang Hospital, Gyeonggi, Korea
| | - Hyun-woo Nam
- Department of Neurology, Boramae Hospital, Seoul, Korea
| | - Kwang-Woo Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
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Spataro R, Marchese S, La Bella V. Tracheostomy mechanical ventilation in amyotrophic lateral sclerosis. J Neurol Sci 2013; 328:103-4. [PMID: 23428210 DOI: 10.1016/j.jns.2013.01.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 01/22/2013] [Indexed: 11/25/2022]
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Non-tracheostomy ventilatory support: Clinical features and survival analysis. J Neurol Sci 2013; 328:102. [DOI: 10.1016/j.jns.2013.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 01/22/2013] [Indexed: 12/14/2022]
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Bach JR. Noninvasive respiratory management and diaphragm and electrophrenic pacing in neuromuscular disease and spinal cord injury. Muscle Nerve 2013; 47:297-305. [PMID: 23349084 DOI: 10.1002/mus.23646] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/21/2012] [Indexed: 11/07/2022]
Abstract
The purpose of this monograph is to describe noninvasive management of respiratory muscle weakness/paralysis for patients with neuromuscular disease (NMD) and spinal cord injury (SCI). Noninvasive ventilation (NIV) assists and supports inspiratory muscles, whereas mechanically assisted coughing (MAC) simulates an effective cough. Long-term outcomes will be reviewed as well as the use of NIV, MAC, and electrophrenic pacing (EPP) and diaphragm pacing (DP) to facilitate extubation and decannulation. Although EPP and DP can facilitate decannulation and maintain alveolar ventilation for high-level SCI patients when they cannot use NIV because of lack of access to oral interfaces, there is no evidence that they have any place in the management of NMD.
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Affiliation(s)
- John R Bach
- Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, B403, 150 Bergen Street, Newark, New Jersey 07103, USA.
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Bach JR, Gonçalves MR, Hon A, Ishikawa Y, De Vito EL, Prado F, Dominguez ME. Changing Trends in the Management of End-Stage Neuromuscular Respiratory Muscle Failure. Am J Phys Med Rehabil 2013; 92:267-77. [DOI: 10.1097/phm.0b013e31826edcf1] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Moran FCE, Spittle A, Delany C, Robertson CF, Massie J. Effect of home mechanical in-exsufflation on hospitalisation and life-style in neuromuscular disease: a pilot study. J Paediatr Child Health 2013; 49:233-7. [PMID: 23438093 DOI: 10.1111/jpc.12111] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2012] [Indexed: 01/29/2023]
Abstract
AIM Mechanical in-exsufflation (MI-E) augments the weakened cough of patients with neuromuscular disease (NMD), clearing secretions and overcoming atelectasis. Little has been published on the impact of MI-E alone on rates of hospitalisation and quality of life (QOL). The aim of this study was to assess the impact of home MI-E on hospital admissions and life-style in children with NMD. METHODS A retrospective chart review was performed on children using MI-E, including data on the number of admissions to hospital, length of stay and hours of ventilation. A parental survey was used to gather information on the impact of MI-E on life-style for the child and family. RESULTS Ten children with NMD (seven spinal muscular atrophy, two Duchenne muscular dystrophy and one centronuclear myopathy) using MI-E at home were identified. MI-E use commenced at mean age of 8.5 years (range 1.1-16.9) with 1.4 years of use (range 0.3-3.8). MI-E pressures ranged from +/-30 to 40 cmH2 O with no complications reported. There was a significant reduction in hospital days at 6 (P = 0.036) and 12 (P = 0.028) months following commencement of home MI-E compared with the same period preceding MI-E use. The survey highlighted positive benefits of MI-E use, in particular the ability to treat many pulmonary exacerbations at home. CONCLUSIONS Home MI-E use by children with NMD can reduce hospitalisation and benefit families by maintaining their child at home.
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Affiliation(s)
- Fiona C E Moran
- Department of Physiotherapy, Royal Children's Hospital, Melbourne, Victoria, Australia.
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Vrijsen B, Testelmans D, Belge C, Robberecht W, Van Damme P, Buyse B. Non-invasive ventilation in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2013; 14:85-95. [DOI: 10.3109/21678421.2012.745568] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Gruis KL, Lechtzin N. Respiratory therapies for amyotrophic lateral sclerosis: a primer. Muscle Nerve 2012; 46:313-31. [PMID: 22907221 DOI: 10.1002/mus.23282] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Respiratory complications are a common cause of morbidity and mortality in amyotrophic lateral sclerosis (ALS). Treatment of respiratory insufficiency with noninvasive ventilation (NIV) improves ALS patients' quality of life and survival. Evidence-based practice guidelines for the management of ALS patients recommend treatment of respiratory insufficiency with NIV as well as consideration of insufflation/exsufflation to improve clearance of airway secretions. Despite these recommendations respiratory therapies remain underused. In this review we provide a practical guide for the clinician to prescribe and manage respiratory therapies for the patient with ALS.
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Affiliation(s)
- Kirsten L Gruis
- Department of Neurology, University of Michigan, 1C327 UH, EMG Lab, SPC 5036, 1500 E. Medical Center Drive, Ann Arbor, Michigan 48109, USA.
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Muir JF, Lamia B, Molano C, Declercq PL, Cuvelier A. [Non-invasive ventilation era: is there still a place for long-term tracheostomy?]. Rev Mal Respir 2012; 29:994-1006. [PMID: 23101641 DOI: 10.1016/j.rmr.2012.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 04/23/2012] [Indexed: 11/26/2022]
Abstract
INTRODUCTION At a time when non-invasive ventilation (NIV) is commonly used in acute as well as chronic respiratory failure, it is important to consider the current place, if any, of long-term tracheostomy. BACKGROUND Except in emergency situations where tracheostomy is mandatory to ensure safe access to the airway, long-term ventilation with tracheostomy (LTVT) is generally considered in the case of inability to wean from NIV after an episode of acute respiratory failure requiring endotracheal ventilation or because of the development of bulbar signs (swallowing, phonation) in advanced neuromuscular disease. It is also appropriate when ventilatory dependence on NIV exceeds 20 hours per day. Historical retrospective studies confirmed the feasibility of LTVT, but this has to be seen in perspective with the results obtained 20 years later with NIV. VIEWPOINT AND CONCLUSION Even if the indications for LTVT have diminished considerably since the emergence of NIV, tracheostomy remains mandatory in some situations of respiratory distress and it should be considered as a potential resource, possibly temporary in some cases in the light of recent work on the possibility of decanulation after LTVT.
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Affiliation(s)
- J-F Muir
- UPRES EA 3830, unité de soins intensifs respiratoires, service de pneumologie, institut hospitalo-universitaire de recherche biomédicale et d'innovation, université de Rouen, CHU de Rouen, 76031 Rouen cedex, France.
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Mahajan KR, Bach JR, Saporito L, Perez N. Diaphragm pacing and noninvasive respiratory management of amyotrophic lateral sclerosis/motor neuron disease. Muscle Nerve 2012; 46:851-5. [DOI: 10.1002/mus.23663] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2012] [Indexed: 11/08/2022]
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Tracheostomy Decannulation and Cough Peak Flows in Patients with Neuromuscular Weakness. Am J Phys Med Rehabil 2012; 91:666-70. [DOI: 10.1097/phm.0b013e31825597b8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bolikal P, Bach JR, Goncalves M. Electrophrenic pacing and decannulation for high-level spinal cord injury: a case series. J Spinal Cord Med 2012; 35:170-4. [PMID: 22333657 PMCID: PMC3324834 DOI: 10.1179/2045772311y.0000000056] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND In 1997, guidelines were developed for the management of high-level ventilator-dependent patients with spinal cord injury who had little or no ventilator-free breathing ability (VFBA). This article describes the three categories of patients, the decannulation criteria, and the successful decannulation of four patients with no VFBA and electrophrenic/diaphragm pacing, using these criteria. METHOD Case series. CONCLUSION Lack of VFBA in patients with high-level spinal cord injury does not mandate tracheostomy or electrophrenic/diaphragm pacing.
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Affiliation(s)
- Priya Bolikal
- Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, University Hospital, Newark, NJ 07103, USA
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McKim DA, King J, Walker K, Leblanc C, Timpson D, Wilson KG, Marks M, Curran D, Woolnough A. Formal ventilation patient education for ALS predicts real-life choices. ACTA ACUST UNITED AC 2012; 13:59-65. [PMID: 22214354 DOI: 10.3109/17482968.2011.626053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Our objective was to evaluate a single-session, hands-on education programme on mechanical ventilation for ALS patients and caregivers in terms of knowledge, change in affect and to determine whether ventilator decisions made after the education sessions predict those made later in life. Questionnaires were administered to 26 patients and 26 caregivers on four separate occasions. The questionnaires assessed knowledge of ventilatory support, feedback on the nature of the education programme, as well as self-reported emotional well-being. All patients were followed until their death or until initiation of invasive ventilation. Both groups demonstrated significant improvements in knowledge as a result of the education session which was retained after one month. There was no change in patient or caregiver reports' self-reported emotional well-being. The choices of ventilatory support expressed at one month (T4) accurately predicted the real-life clinical choices made by 76% of patients. Any difference resulted from choosing palliative care. Hands-on patient and caregiver education results in improved knowledge, assists in decision-making with respect to ventilatory support, and is not associated with a worsening of affect. It also provides for an accurate prediction of real-life choices and avoids undesired life support interventions and critical care admissions.
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Affiliation(s)
- Douglas A McKim
- Respiratory Rehabilitation Services and The Ottawa Hospital Sleep Centre, Department of Medicine, University of Ottawa, 1201-505 Smyth Road, Ottawa, Ontario, Canada.
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Abstract
This article describes noninvasive acute and long-term management of the respiratory muscle paralysis of high spinal cord injury (SCI). This includes full-setting, continuous ventilatory support by noninvasive intermittent positive pressure ventilation (NIV) to support inspiratory muscles and mechanically assisted coughing (MAC) to support inspiratory and expiratory muscles. The NIV and MAC can also be used to extubate or decannulate 'unweanable' patients with SCI, to prevent intercurrent respiratory tract infections from developing into pneumonia and acute respiratory failure (ARF), and to eliminate tracheostomy and resort to costly electrophrenic/diaphragm pacing (EPP/DP) for most ventilator users, while permitting glossopharyngeal breathing (GPB) for security in the event of ventilator failure.
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Affiliation(s)
- John R. Bach
- Department of Physical Medicine & Rehabilitation, University Hospital, NY, USA,Center for Ventilator Management Alternatives, University Hospital, NY, USA,Department of Neurosciences, UMD, New Jersey Medical School, Newark, NJ,Correspondence to: John R. Bach, Department of Physical Medicine and Rehabilitation, University Hospital B-403, 150 Bergen Street, Newark, NJ 07103, USA.
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De Vito EL, Suárez AA, Monteiro SG. The use of full-setting non-invasive ventilation in the home care of people with amyotrophic lateral sclerosis-motor neuron disease with end-stage respiratory muscle failure: a case series. J Med Case Rep 2012; 6:42. [PMID: 22289290 PMCID: PMC3295643 DOI: 10.1186/1752-1947-6-42] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2011] [Accepted: 01/30/2012] [Indexed: 12/14/2022] Open
Abstract
Introduction Little has been written about the use of non-invasive ventilation in the home care of amyotrophic lateral sclerosis-motor neuron disease patients with end-stage respiratory muscle failure. Nocturnal use of non-invasive ventilation has been reported to improve daytime blood gases but continuous non-invasive ventilation dependence has not been studied in this regard. There continues to be great variation by country, economics, physician interest and experience, local concepts of palliation, hospice requirements, and resources available for home care. We report a case series of home-based amyotrophic lateral sclerosis-motor neuron disease patients who refused tracheostomy and advanced non-invasive ventilation to full-setting, while maintaining normal alveolar ventilation and oxygenation in the course of the disease. Since this topic has been presented in only one center in the United States and nowhere else, it is appropriate to demonstrate that this can be done in other countries as well. Case presentation We present here the cases of three Caucasian patients (a 51-year-old Caucasian man, a 45-year-old Caucasian woman and a 57-year-old Caucasian woman) with amyotrophic lateral sclerosis who developed continuous non-invasive ventilation dependence for 15 to 27 months without major complications and were able to maintain normal CO2 and pulse oxyhemoglobin saturation despite a non-measurable vital capacity. All patients were wheelchair-dependent and receiving riluzole 50 mg twice a day. Patient one developed mild-to-moderate bulbar-innervated muscle weakness. He refused tracheostomy but accepted percutaneous gastrostomy. Patient two had two lung infections, acute bronchitis and pneumonia, which were treated with antibiotics and cough assistance at home. Patient three had three chest infections (bronchitis and pneumonias) and asthmatic episodes treated with antibiotics, bronchodilators and cough assistance at home. All patients had normal speech while receiving positive pressure; they died suddenly and with normal oxygen saturation. Conclusions Although warned that prognosis was poor as vital capacity diminished, our patients survived without invasive airway tubes and despite non-measurable vital capacity. No patient opted for tracheostomy. Our patients demonstrate the feasibility of resorting to full-setting non-invasive management to prolong survival, optimizing wellness and management at home, and the chance to die peacefully.
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Affiliation(s)
- Eduardo L De Vito
- Laboratorio Pulmonar de Enfermedades Neuromusculares, Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de Buenos Aires, CONICET Combatientes de Malvinas 3150, CP 1427, Buenos Aires, Argentina.
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