Appropriate Management of Respiratory Problems Is of Utmost Importance in the Treatment of Patients With Amyotrophic Lateral Sclerosis

Noninvasive respiratory muscle aids during PEG placement in ALS patients with severe ventilatory impairment

Although no clear recommendations are given about when percutaneous endoscopic gastrostomy (PEG) should be placed in amyotrophic lateral sclerosis (ALS) patients, some experts underline the risk of respiratory complications when patients had severe ventilatory muscle impairment (SVMI).

AIM

To evaluate the efficacy of noninvasive ventilation (NIV) and mechanically assisted cough (MAC) to avoid respiratory complications related to PEG placement in ALS patients with SVMI.

MATERIAL AND METHODS

Prospective study including ALS patients who had chosen to have PEG placement timed by swallowing dysfunction with the aid of NIV and MAC if needed. PEG was carried out under volume-cycled NIV through a nasal mask. MAC was applied prior to and at the end of the procedure.

RESULTS

Thirty ALS patients (60.43±12.03years) were included. Prior to PEG placement: BMI 25.0±4.6kg/m(2), ALSRFS-R 19.5±5.0, Norris bulbar sub-score 15.1±6.6, %FVC 35.9±18.1%, PCF 2.3±1.2L/s, PImax -35.6±24.6cmH(2)O, and PEmax 40.5±23.9cmH(2)O. Three patients had PEG placement under tracheotomy ventilation because NIV SpO(2) was below 88%. No patient died during the procedure nor did any have respiratory complications. Survival at 1month was 100%.

CONCLUSION

Respiratory support provided by volume-cycled NIV and MAC permits successful PEG placement in most ALS patients with SVMI.

Predictors of Ineffective Cough during a Chest Infection in Patients with Stable Amyotrophic Lateral Sclerosis

RATIONALE

In patients with neuromuscular diseases, a chest infection is associated with a reduction in respiratory muscle function that may result in decreased cough effectiveness.

OBJECTIVES

To determine if a clinical or functional parameter in patients with amyotrophic lateral sclerosis (ALS) in a stable condition could predict spontaneous cough ineffectiveness during a respiratory tract infection.

METHODS

Forty consecutive patients with ALS referred to our Respiratory Care Unit were studied during a one-year follow-up.

MEASUREMENTS AND MAIN RESULTS

FEV(1), FVC, FEV(1)/FVC, peak cough flow (PCF), peak velocity time (PVT), maximum inspiratory and expiratory pressures, and bulbar dysfunction evaluation using the Norris scale bulbar subscore (NBS). A total of 26 patients (65%) had spontaneous cough ineffectiveness during a respiratory tract infection. The best variables to predict nonassisted cough during a respiratory tract infection were NBS (p < 0.01) with a cutoff point of 29 (sensitivity, 0.89; specificity, 0.90; positive predicted value, 0.88; negative predictive value, 0.87), PCF (p < 0.001) with a cutoff point of 4.25 L/s (sensitivity, 0.74; specificity, 0.85; positive predictive value, 0.71; negative predictive value, 0.85), and PCF/PVT (p < 0.001) with a cutoff point of 28.88 L/s(2) (sensitivity, 0.77; specificity, 0.96; positive predictive value, 0.91; negative predictive value, 0.89).

CONCLUSIONS

In patients with stable ALS, bulbar dysfunction (NBS < 29), PCF (< 4.25 L/s), and PCF/PVT (< 28.88 L/s(2)) could predict the risk of ineffective spontaneous cough during a respiratory tract infection.

The steady, inevitable decline of amyotrophic lateral sclerosis patients

Progressive muscle weakness and fasciculations can indicate developing amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's disease. Its treatment and prognosis have been unchanged for almost 100 years, although our understanding on a cellular level is better. All ALS patients can be expected to progress to a state that requires complete supportive care.