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Riva N, Domi T, Pozzi L, Lunetta C, Schito P, Spinelli EG, Cabras S, Matteoni E, Consonni M, Bella ED, Agosta F, Filippi M, Calvo A, Quattrini A. Update on recent advances in amyotrophic lateral sclerosis. J Neurol 2024; 271:4693-4723. [PMID: 38802624 PMCID: PMC11233360 DOI: 10.1007/s00415-024-12435-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/07/2024] [Accepted: 05/09/2024] [Indexed: 05/29/2024]
Abstract
In the last few years, our understanding of disease molecular mechanisms underpinning ALS has advanced greatly, allowing the first steps in translating into clinical practice novel research findings, including gene therapy approaches. Similarly, the recent advent of assistive technologies has greatly improved the possibility of a more personalized approach to supportive and symptomatic care, in the context of an increasingly complex multidisciplinary line of actions, which remains the cornerstone of ALS management. Against this rapidly growing background, here we provide an comprehensive update on the most recent studies that have contributed towards our understanding of ALS pathogenesis, the latest results from clinical trials as well as the future directions for improving the clinical management of ALS patients.
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Affiliation(s)
- Nilo Riva
- 3Rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS "Carlo Besta" Neurological Insitute, Milan, Italy.
| | - Teuta Domi
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Pozzi
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Christian Lunetta
- Istituti Clinici Scientifici Maugeri IRCCS, Neurorehabilitation Unit of Milan Institute, 20138, Milan, Italy
| | - Paride Schito
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edoardo Gioele Spinelli
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Cabras
- ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin; SC Neurologia 1U, AOU città della Salute e della Scienza di Torino, Turin, Italy
| | - Enrico Matteoni
- ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin; SC Neurologia 1U, AOU città della Salute e della Scienza di Torino, Turin, Italy
| | - Monica Consonni
- 3Rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS "Carlo Besta" Neurological Insitute, Milan, Italy
| | - Eleonora Dalla Bella
- 3Rd Neurology Unit and Motor Neuron Disease Centre, Fondazione IRCCS "Carlo Besta" Neurological Insitute, Milan, Italy
| | - Federica Agosta
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute Huniversity, Milan, Italy
| | - Massimo Filippi
- Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neuroimaging Research Unit, Department of Neurology, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute Huniversity, Milan, Italy
| | - Andrea Calvo
- ALS Centre, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin; SC Neurologia 1U, AOU città della Salute e della Scienza di Torino, Turin, Italy
| | - Angelo Quattrini
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Sheers NL, Howard ME, Rochford PD, Rautela L, Chao C, McKim DA, Berlowitz DJ. A Randomized Controlled Clinical Trial of Lung Volume Recruitment in Adults with Neuromuscular Disease. Ann Am Thorac Soc 2023; 20:1445-1455. [PMID: 37390359 PMCID: PMC10559144 DOI: 10.1513/annalsats.202212-1062oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 06/30/2023] [Indexed: 07/02/2023] Open
Abstract
Rationale: Clinical care guidelines advise that lung volume recruitment (LVR) be performed routinely by people with neuromuscular disease (NMD) to maintain lung and chest wall flexibility and slow lung function decline. However, the evidence base is limited, and no randomized controlled trials of regular LVR in adults have been published. Objectives: To evaluate the effect of regular LVR on respiratory function and quality of life in adults with NMD. Methods: A randomized controlled trial with assessor blinding was conducted between September 2015 and May 2019. People (>14 years old) with NMD and vital capacity <80% predicted were eligible, stratified by disease subgroup (amyotrophic lateral sclerosis/motor neuron disease or other NMDs), and randomized to 3 months of twice-daily LVR or breathing exercises. The primary outcome was change in maximum insufflation capacity (MIC) from baseline to 3 months, analyzed using a linear mixed model approach. Results: Seventy-six participants (47% woman; median age, 57 [31-68] years; mean baseline vital capacity, 40 ± 18% predicted) were randomized (LVR, n = 37). Seventy-three participants completed the study. There was a statistically significant difference in MIC between groups (linear model interaction effect P = 0.002, observed mean difference, 0.19 [0.00-0.39] L). MIC increased by 0.13 (0.01-0.25) L in the LVR group, predominantly within the first month. No interaction or treatment effects were observed in secondary outcomes of lung volumes, respiratory system compliance, and quality of life. No adverse events were reported. Conclusions: Regular LVR increased MIC in a sample of LVR-naive participants with NMD. We found no direct evidence that regular LVR modifies respiratory mechanics or slows the rate of lung volume decline. The implications of increasing MIC are unclear, and the change in MIC may represent practice. Prospective long-term clinical cohorts with comprehensive follow-up, objective LVR use, and clinically meaningful outcome data are needed. Clinical trial registered with anzctr.org.au (ACTRN12615000565549).
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Affiliation(s)
- Nicole L. Sheers
- Department of Respiratory and Sleep Medicine and
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
| | - Mark E. Howard
- Department of Respiratory and Sleep Medicine and
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
- Turner Institute of Brain and Mental Health, Monash University, Clayton, Victoria, Australia
| | | | - Linda Rautela
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Caroline Chao
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Douglas A. McKim
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; and
- CANVent Respiratory Rehabilitation Services, Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
| | - David J. Berlowitz
- Department of Respiratory and Sleep Medicine and
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
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Khan A, Frazer-Green L, Amin R, Wolfe L, Faulkner G, Casey K, Sharma G, Selim B, Zielinski D, Aboussouan LS, McKim D, Gay P. Respiratory Management of Patients With Neuromuscular Weakness: An American College of Chest Physicians Clinical Practice Guideline and Expert Panel Report. Chest 2023; 164:394-413. [PMID: 36921894 DOI: 10.1016/j.chest.2023.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/27/2023] [Accepted: 03/05/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Respiratory failure is a significant concern in neuromuscular diseases (NMDs). This CHEST guideline examines the literature on the respiratory management of patients with NMD to provide evidence-based recommendations. STUDY DESIGN AND METHODS An expert panel conducted a systematic review addressing the respiratory management of NMD and applied the Grading of Recommendations, Assessment, Development, and Evaluations approach for assessing the certainty of the evidence and formulating and grading recommendations. A modified Delphi technique was used to reach a consensus on the recommendations. RESULTS Based on 128 studies, the panel generated 15 graded recommendations, one good practice statement, and one consensus-based statement. INTERPRETATION Evidence of best practices for respiratory management in NMD is limited and is based primarily on observational data in amyotrophic lateral sclerosis. The panel found that pulmonary function testing every 6 months may be beneficial and may be used to initiate noninvasive ventilation (NIV) when clinically indicated. An individualized approach to NIV settings may benefit patients with chronic respiratory failure and sleep-disordered breathing related to NMD. When resources allow, polysomnography or overnight oximetry can help to guide the initiation of NIV. The panel provided guidelines for mouthpiece ventilation, transition to home mechanical ventilation, salivary secretion management, and airway clearance therapies. The guideline panel emphasizes that NMD pathologic characteristics represent a diverse group of disorders with differing rates of decline in lung function. The clinician's role is to add evaluation at the bedside to shared decision-making with patients and families, including respect for patient preferences and treatment goals, considerations of quality of life, and appropriate use of available resources in decision-making.
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Affiliation(s)
- Akram Khan
- Division of Pulmonary Allergy and Critical Care Medicine, Oregon Health and Science University, Portland, OR.
| | | | - Reshma Amin
- Department of Respiratory Medicine, The Hospital for Sick Kids, Toronto
| | - Lisa Wolfe
- Department of Medicine, Northwestern University, Chicago, IL
| | | | - Kenneth Casey
- Department of Sleep Medicine, William S. Middleton Memorial Veterans Hospital, Shorewood Hills, WI
| | - Girish Sharma
- Department of Pediatrics, Rush University Medical Center, Chicago, IL
| | - Bernardo Selim
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
| | - David Zielinski
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | | | - Douglas McKim
- Department of Medicine, The Ottawa Hospital Research Institute, Ottawa, ON
| | - Peter Gay
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN
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Sheers NL, O’Sullivan R, Howard ME, Berlowitz DJ. The role of lung volume recruitment therapy in neuromuscular disease: a narrative review. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1164628. [PMID: 37565183 PMCID: PMC10410160 DOI: 10.3389/fresc.2023.1164628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 06/16/2023] [Indexed: 08/12/2023]
Abstract
Respiratory muscle weakness results in substantial discomfort, disability, and ultimately death in many neuromuscular diseases. Respiratory system impairment manifests as shallow breathing, poor cough and associated difficulty clearing mucus, respiratory tract infections, hypoventilation, sleep-disordered breathing, and chronic ventilatory failure. Ventilatory support (i.e., non-invasive ventilation) is an established and key treatment for the latter. As survival outcomes improve for people living with many neuromuscular diseases, there is a shift towards more proactive and preventative chronic disease multidisciplinary care models that aim to manage symptoms, improve morbidity, and reduce mortality. Clinical care guidelines typically recommend therapies to improve cough effectiveness and mobilise mucus, with the aim of averting acute respiratory compromise or respiratory tract infections. Moreover, preventing recurrent infective episodes may prevent secondary parenchymal pathology and further lung function decline. Regular use of techniques that augment lung volume has similarly been recommended (volume recruitment). It has been speculated that enhancing lung inflation in people with respiratory muscle weakness when well may improve respiratory system "flexibility", mitigate restrictive chest wall disease, and slow lung volume decline. Unfortunately, clinical care guidelines are based largely on clinical rationale and consensus opinion rather than level A evidence. This narrative review outlines the physiological changes that occur in people with neuromuscular disease and how these changes impact on breathing, cough, and respiratory tract infections. The biological rationale for lung volume recruitment is provided, and the clinical trials that examine the immediate, short-term, and longer-term outcomes of lung volume recruitment in paediatric and adult neuromuscular diseases are presented and the results synthesised.
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Affiliation(s)
- Nicole L. Sheers
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
- Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Rachel O’Sullivan
- Department of Physiotherapy, Christchurch Hospital, Canterbury, New Zealand
| | - Mark E. Howard
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
- Department of Medicine, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Turner Institute of Brain and Mental Health, Monash University, Clayton, VIC, Australia
| | - David J. Berlowitz
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, VIC, Australia
- Institute for Breathing and Sleep, Heidelberg, VIC, Australia
- Department of Physiotherapy, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, VIC, Australia
- Department of Physiotherapy, Austin Health, Heidelberg, VIC, Australia
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Katz SL, Mah JK, McMillan HJ, Campbell C, Bijelić V, Barrowman N, Momoli F, Blinder H, Aaron SD, McAdam LC, Nguyen TTD, Tarnopolsky M, Wensley DF, Zielinski D, Rose L, Sheers N, Berlowitz DJ, Wolfe L, McKim D. Routine lung volume recruitment in boys with Duchenne muscular dystrophy: a randomised clinical trial. Thorax 2022; 77:805-811. [PMID: 35236763 PMCID: PMC9340020 DOI: 10.1136/thoraxjnl-2021-218196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/25/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Impaired cough results in airway secretion retention, atelectasis and pneumonia in individuals with Duchenne muscular dystrophy (DMD). Lung volume recruitment (LVR) stacks breaths to inflate the lungs to greater volumes than spontaneous effort. LVR is recommended in DMD clinical care guidelines but is not well studied. We aimed to determine whether twice-daily LVR, compared with standard of care alone, attenuates the decline in FVC at 2 years in boys with DMD. METHODS In this multicentre, assessor-blinded, randomised controlled trial, boys with DMD, aged 6-16 years with FVC >30% predicted, were randomised to receive conventional treatment or conventional treatment plus manual LVR twice daily for 2 years. The primary outcome was FVC % predicted at 2 years, adjusted for baseline FVC % predicted, age and ambulatory status. Secondary outcomes included change in chest wall distensibility (maximal insufflation capacity minus FVC) and peak cough flow. RESULTS Sixty-six boys (36 in LVR group, 30 in control) were evaluated (median age (IQR): 11.5 years (9.5-13.5), median baseline FVC (IQR): 85% predicted (73-96)). Adjusted mean difference in FVC between groups at 2 years was 1.9% predicted (95% CI -6.9% to 10.7%; p=0.68) in the direction of treatment benefit. We found no differences in secondary outcomes. CONCLUSION There was no difference in decline in FVC % predicted with use of twice-daily LVR for boys with DMD and relatively normal lung function. The burden associated with routine LVR may outweigh the benefit. Benefits of LVR to maintain lung health in boys with worse baseline lung function still need to be clarified. TRIAL REGISTRATION NUMBER NCT01999075.
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Affiliation(s)
- Sherri L Katz
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean K Mah
- Division of Pediatric Neurology, Alberta Children's Hospital, Calgary, Alberta, Canada
- Department of Pediatric and Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Hugh J McMillan
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Craig Campbell
- Department of Pediatrics, Epidemiology and Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada
- Department of Pediatrics, London Health Sciences Centre Children's Hospital, London, Ontario, Canada
| | - Vid Bijelić
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Nick Barrowman
- CHEO Research Institute, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Shawn D Aaron
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Respirology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Laura C McAdam
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - The Thanh Diem Nguyen
- Department of Respiratory Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Mark Tarnopolsky
- Division of Neuromuscular and Neurometabolic Disease, McMaster University, Hamilton, Ontario, Canada
| | - David F Wensley
- Division of Pediatric Respirology, Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada
- Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - David Zielinski
- Division of Pediatric Respirology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada
- Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Louise Rose
- Department of Midwifery and Palliative Care, King's College London Florence Nightingale School of Nursing and Midwifery, London, London, UK
- Critical Care Directorate and Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, London, London, UK
| | - Nicole Sheers
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - David J Berlowitz
- Department of Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lisa Wolfe
- Department of Medicine and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Respiratory Care, Shirley Ryan AbilityLab, Chicago, Illinois, USA
| | - Doug McKim
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- CANVent Respiratory Rehabilitation Services, Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
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Fernandes DDL, Righi NC, Rubin LJ, Bellé JM, Pippi CM, Ribas CZDM, Nichele LDFI, Signori LU, da Silva AMV. Effects of the breath stacking technique after upper abdominal surgery: a randomized clinical trial. J Bras Pneumol 2022; 48:e20210280. [PMID: 35293484 PMCID: PMC8964306 DOI: 10.36416/1806-3756/e20210280] [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] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/24/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate the effect of the association of the breath stacking (BS) technique associated with routine physiotherapy on pulmonary function, lung volumes, maximum respiratory pressures, vital signs, peripheral oxygenation, thoracoabdominal mobility, and pain in the surgical incision in patients submitted to upper abdominal surgery during the postoperative period, as well as to analyze BS safety. METHODS This was a randomized clinical trial involving 34 patients divided into a control group (CG; n = 16), who underwent conventional physiotherapy only, and the BS group (BSG; n = 18), who underwent conventional physiotherapy and BS. Both groups performed two daily sessions from postoperative day 2 until hospital discharge. The primary outcomes were FVC and Vt. The safety of BS was assessed by the incidence of gastrointestinal, hemodynamic, and respiratory repercussions. RESULTS Although FVC significantly increased at hospital discharge in both groups, the effect was greater on the BSG. Significant increases in FEV1, FEV1/FVC ratio, PEF, and FEF25-75% occurred only in the BSG. There were also significant increases in Ve and Vt in the BSG, but not when compared with the CG values at discharge. MIP and MEP significantly increased in both groups, with a greater effect on the BSG. There was a significant decrease in RR, as well as a significant increase in SpO2 only in the BSG. SpO2 acutely increased after BS; however, no changes were observed in the degree of dyspnea, vital signs, or signs of respiratory distress, and no gastrointestinal and hemodynamic repercussions were observed. CONCLUSIONS BS has proven to be safe and effective for recovering pulmonary function; improving lung volumes, maximum respiratory pressures, and peripheral oxygenation; and reducing respiratory work during the postoperative period after upper abdominal surgery.
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Affiliation(s)
- Débora da Luz Fernandes
- . Programa de Pós-Graduação em Reabilitação Funcional, Universidade Federal de Santa Maria, Santa Maria (RS) Brasil
| | - Natiele Camponogara Righi
- . Programa de Pós-Graduação em Reabilitação Funcional, Universidade Federal de Santa Maria, Santa Maria (RS) Brasil
| | - Léo José Rubin
- . Curso de Fisioterapia, Universidade Federal de Santa Maria, Santa Maria (RS) Brasil
| | | | | | | | - Lidiane de Fátima Ilha Nichele
- . Programa de Residência Multiprofissional em Saúde, Hospital Universitário de Santa Maria, Universidade Federal de Santa Maria, Santa Maria (RS) Brasil
| | - Luis Ulisses Signori
- . Departamento de Fisioterapia e Reabilitação, Centro de Ciências de Saúde, Universidade Federal de Santa Maria, Santa Maria (RS) Brasil
| | - Antônio Marcos Vargas da Silva
- . Departamento de Fisioterapia e Reabilitação, Centro de Ciências de Saúde, Universidade Federal de Santa Maria, Santa Maria (RS) Brasil
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Veldhoen ES, Vercoelen F, Ros L, Verweij-van den Oudenrijn LP, Wösten-van Asperen RM, Hulzebos EH, Bartels B, Gaytant MA, van der Ent K, Ludo van der Pol W. Short-term effect of air stacking and mechanical insufflation-exsufflation on lung function in patients with neuromuscular diseases. Chron Respir Dis 2022; 19:14799731221094619. [PMID: 35442817 PMCID: PMC9024083 DOI: 10.1177/14799731221094619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Air stacking (AS) and mechanical insufflation-exsufflation (MI-E) aim to increase cough efficacy by augmenting inspiratory lung volumes in patients with neuromuscular diseases (NMDs). We studied the short-term effect of AS and MI-E on lung function. We prospectively included NMD patients familiar with daily AS or MI-E use. Studied outcomes were forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and peak expiratory flow (PEF) prior to, immediately after, and up to 2 h after treatment. Paired sample T-test and Wilcoxon signed-rank test was used. Sixty-seven patients participated. We observed increased FVC and FEV1 immediately after AS with a mean difference of respectively 0.090 L (95% CI 0.045; 0.135, p < .001) and 0.073 L (95% CI 0.017; 0.128, p = .012). Increased FVC immediately after MI-E (mean difference 0.059 L (95% CI 0.010; 0.109, p = .021) persisted 1 hour (mean difference 0.079 L (95% CI 0.034; 0.125, p = .003). The effect of treatment was more pronounced in patients diagnosed with Spinal Muscular Atrophy, compared to patients with Duchenne muscular dystrophy. AS and MI-E improved FVC immediately after treatment, which persisted 1 h after MI-E. There is insufficient evidence that short-lasting increases in FVC would explain the possible beneficial effect of AS and MI-E.
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Affiliation(s)
- Esther S Veldhoen
- Pediatric Intensive Care Unit and Center of Home Mechanical Ventilation, Wilhelmina Children's Hospital
- 89098University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Femke Vercoelen
- Pediatric Intensive Care Unit and Center of Home Mechanical Ventilation, Wilhelmina Children's Hospital
- 89098University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Leandra Ros
- Department of Neurology, Brain Centre Rudolf Magnus, 89098University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Laura P Verweij-van den Oudenrijn
- Pediatric Intensive Care Unit and Center of Home Mechanical Ventilation, Wilhelmina Children's Hospital
- 89098University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roelie M Wösten-van Asperen
- Pediatric Intensive Care Unit, Wilhelmina Children's Hospital, 89098University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erik Hj Hulzebos
- Child Development and Exercise Center, Wilhelmina Children's Hospital, 89098University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Bart Bartels
- Child Development and Exercise Center, Wilhelmina Children's Hospital, 89098University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Michael A Gaytant
- Center of Home Mechanical Ventilation, Department of Pulmonology, 89098University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kors van der Ent
- Department of Pediatric Pulmonology, Wilhelmina Children's Hospital, 89098University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - W Ludo van der Pol
- Department of Neurology, Brain Centre Rudolf Magnus, 89098University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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8
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Murray D, Rooney J, Al-Chalabi A, Bunte T, Chiwera T, Choudhury M, Chio A, Fenton L, Fortune J, Maidment L, Manera U, Mcdermott C, Meldrum D, Meyjes M, Tattersall R, Torrieri MC, Van Damme P, Vanderlinden E, Wood C, Van Den Berg LH, Hardiman O. Correlations between measures of ALS respiratory function: is there an alternative to FVC? Amyotroph Lateral Scler Frontotemporal Degener 2021; 22:495-504. [PMID: 34590504 DOI: 10.1080/21678421.2021.1908362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background: An ongoing longitudinal study in six European sites includes a 3-monthly assessment of forced vital capacity (FVC), slow vital capacity (SVC), peak cough flow (PCF), and Sniff nasal inspiratory pressure (SNIP). The aim of this interim analysis was to assess the potential for SNIP to be a surrogate for aerosol generating procedures given COVID-19 related restrictions. Methods: This was a prospective observational study. Patients attending six study sites with King's Stage 2 or 3 ALS completed baseline FVC/SVC/SNIP/PCF and repeated assessments 3 monthly. Data were collected from March 2018 to March 2020, after which a COVID-19 related study suspension was imposed. Correlations between the measures were calculated. A Bayesian multiple outcomes random-effects model was constructed to investigate rates of decline across measures. Results: In total, 270 cases and 828 assessments were included (Mean age 65.2 ± 15.4 years; 32.6% Female; 60% Kings stage 2; 81.1% spinal onset). FVC and SVC were the most closely correlated outcomes (0.95). SNIP showed the least correlation with other metrics 0.53 (FVC), 0.54 (SVC), 0.60 (PCF). All four measures significantly declined over time. SNIP in the bulbar onset group showed the fastest rate of decline. Discussion: SNIP was not well correlated with FVC and SVC, probably because it examines a different aspect of respiratory function. Respiratory measures declined over time, but differentially according to the site of onset. SNIP is not a surrogate for FVC and SVC, but is a complementary measure, declining linearly and differentiating spinal and bulbar onset patients.
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Affiliation(s)
- Deirdre Murray
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Neurocent Directorate, Beaumont Hospital, Dublin, Ireland
| | - James Rooney
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Amar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Tommy Bunte
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Theresa Chiwera
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Mutahhara Choudhury
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | - Adriano Chio
- ALS Center, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy.,Neurology 1, Azienda Ospedale Università Città della Salute e della Scienza, Turin, Italy
| | - Lauren Fenton
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | - Jennifer Fortune
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | - Lindsay Maidment
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Umberto Manera
- ALS Center, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Chris Mcdermott
- Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK.,Sheffield Institute for Translational Neuroscience, Department of Neuroscience, University of Sheffield, Sheffield, UK
| | - Dara Meldrum
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
| | - Myrte Meyjes
- Department of Neurology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rachel Tattersall
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Neurocent Directorate, Beaumont Hospital, Dublin, Ireland
| | - Maria Claudia Torrieri
- ALS Center, 'Rita Levi Montalcini' Department of Neuroscience, University of Turin, Turin, Italy
| | - Philip Van Damme
- Neurology Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and.,KU Leuven, Department of Neuroscience, Leuven Brain Institute and VIB Center for Brain & Disease Research, Leuven, Belgium
| | - Elien Vanderlinden
- Neurology Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium, and
| | - Claire Wood
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK.,Department of Neurology, King's College Hospital, London, UK
| | | | - Orla Hardiman
- Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland.,Neurocent Directorate, Beaumont Hospital, Dublin, Ireland
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9
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Cleary S, Misiaszek JE, Wheeler S, Kalra S, Genuis SK, Johnston WS. Lung volume recruitment improves volitional airway clearance in amyotrophic lateral sclerosis. Muscle Nerve 2021; 64:676-682. [PMID: 34505708 PMCID: PMC9293446 DOI: 10.1002/mus.27417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/11/2022]
Abstract
Introduction/Aims In this study we evaluated the effects of lung volume recruitment treatment (LVR), a low‐tech, low‐cost, manual “breath‐stacking” technique used to help people cough with enough force to clear their airways, thereby reducing the risk of aspiration and choking, on five volitional airway clearance and protection behaviors used by people living with amyotrophic lateral sclerosis (PwALS). Methods Using a repeated‐measures cross‐over design, 29 PwALS performed five volitional airway clearance and protection behaviors in LVR treatment and in no‐treatment, control conditions. Peak cough flow (PCF) was used to measure maximum expiratory rate during forced expiration, throat clearing, hawking, post‐swallow coughing, and the supraglottic swallowing maneuver. Comparisons were made as a function of condition (treatment or control) and three time‐points (pretreatment, and 15 and 30 minutes posttreatment). Results LVR treatment had a significant positive effect on maximum expiratory rates during all tested airway clearance and protection behaviors. Increased PCF values lasted for up to 30 minutes post‐LVR for all tested behaviors in the treatment condition. Discussion We found that LVR treatment could increase control over airway clearance in PwALS, as well as provide improved airway protection for up to 30 minutes, the duration of a typical meal. This study has implications for patient care. These include offering patients control over some of the most feared symptoms of ALS, particularly choking during activities of daily living, and enhanced ALS respiratory care in low‐resource settings. Findings may have implications for other neurodegenerative disorders in which dysphagia occurs with retained sensory function.
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Affiliation(s)
- Stuart Cleary
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - John E Misiaszek
- Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sonya Wheeler
- Misericordia Hospital, Covenant Health Group, Edmonton, Alberta, Canada
| | - Sanjay Kalra
- Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Shelagh K Genuis
- Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Wendy S Johnston
- Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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10
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Naughton PE, Sheers N, Berlowitz DJ, Howard ME, McKim DA, Katz SL. Objective measurement of lung volume recruitment therapy: laboratory and clinical validation. BMJ Open Respir Res 2021; 8:8/1/e000918. [PMID: 34326156 PMCID: PMC8323364 DOI: 10.1136/bmjresp-2021-000918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/11/2021] [Indexed: 11/29/2022] Open
Abstract
Lung volume recruitment manoeuvres are often prescribed to maintain respiratory health in neuromuscular disease. Unfortunately, no current system accurately records delivered dose. This study determined the performance characteristics of a novel, objective, manual lung volume recruitment bag counter (‘the counter’) with bench and healthy volunteer testing, as well as in individuals with neuromuscular disease. We undertook (1) bench test determination of activation threshold, (2) bench and healthy volunteer fidelity testing during simulated patient interface leak and different pressure compressions and (3) comparisons with self-report in individuals with neuromuscular disease. The data are reported as summary statistics, compression counts, percentage of recorded versus delivered compressions and concordance (Cohen’s kappa (K) and absolute agreement).
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Affiliation(s)
- Phoebe E Naughton
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
| | - Nicole Sheers
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - David J Berlowitz
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia .,Physiotherapy, Austin Health, Heidelberg, Victoria, Australia.,Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia.,Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Mark E Howard
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Douglas A McKim
- Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Respiratory Medicine, Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sherri L Katz
- Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Respiratory Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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11
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Hadda V, Suri TM, Pahuja S, El-Khatib M, Ciobanu LD, Cabrita B, Karim HMR, Barjaktarevic I, Crimi C, Garuti G, Mittal S, Tiwari P, Madan K, Mohan A, Karakurt Z, Esquinas A. Secretion management in patients with ineffective airway clearance with non-invasive mechanical ventilation use: Expert guidance for clinical practice. Monaldi Arch Chest Dis 2021; 91. [PMID: 34121373 DOI: 10.4081/monaldi.2021.1499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 04/17/2021] [Indexed: 11/23/2022] Open
Abstract
Non-invasive ventilation (NIV) is a mainstay of management of chronic respiratory failure in many disorders which are known to cause abnormal airway secretion clearance. Currently, there is no guidance regarding either the secretion handling during NIV use or the role of NIV in secretion management in these patients. The aim of this document was to provide an overview of the various techniques available in the management of respiratory secretions and their use in conjunction with NIV. Literature search was performed using the keywords, "(secretion OR secretions) AND (noninvasive ventilation OR NIV)" on PubMed and EMBASE. The search yielded 1681 and 509 titles from PubMed and EMBASE, respectively. After screening, 19 articles were included in this review. Suggestions of the expert panel were formulated by mutual consensus after reviewing the relevant literature. The draft of the expert panel's suggestions was circulated among all authors via electronic mail for comments. Any conflicts were resolved by mutual discussion to achieve agreement. The final document was approved by all. This document by the International Network for Airway Secretions Management in NIV describes various airway secretion clearance techniques. It provides the expert panel's suggestions for the use of these techniques in conjunction with NIV for patients with muco-obstructive and neuromuscular disorders.
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Affiliation(s)
- Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute Of Medical Sciences, New Delhi.
| | - Tejas Menon Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute Of Medical Sciences, New Delhi.
| | - Sourabh Pahuja
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute Of Medical Sciences, New Delhi.
| | - Mohamad El-Khatib
- Department of Respiratory Therapy, American University of Beirut Medical Center, Beirut.
| | - Laura D Ciobanu
- Department of Internal Medicine, University of Medicine and Pharmacy "Grigore T. Popa", Iasi.
| | - Bruno Cabrita
- Pulmonology Department, Hospital Pedro Hispano, Matosinhos.
| | - Habib Md Reazaul Karim
- Department of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur.
| | - Igor Barjaktarevic
- Division of Pulmonary and Critical Care, David Geffen School of Medicine at University of California, Los Angeles, CA.
| | - Claudia Crimi
- Respiratory Medicine Unit, A.O.U. "Policlinico-Vittorio Emanuele", Catania.
| | | | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute Of Medical Sciences, New Delhi.
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute Of Medical Sciences, New Delhi.
| | - Karan Madan
- All India Institute of Medical Sciences, New Delhi.
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute Of Medical Sciences, New Delhi.
| | - Zuhal Karakurt
- Respiratory Intensive Care Unit, Sureyyapasa Chest Diseases and Surgery Hospital, Istanbul.
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12
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Comparison between breath stacking technique associated with expiratory muscle training and breath stacking technique in amyotrophic lateral sclerosis patients: Protocol for randomized single blind trial. Contemp Clin Trials Commun 2020; 19:100647. [PMID: 33005816 PMCID: PMC7511726 DOI: 10.1016/j.conctc.2020.100647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/31/2020] [Accepted: 08/16/2020] [Indexed: 12/12/2022] Open
Abstract
Introduction Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease affecting both upper and lower motor neurons, and lead to respiratory failure. Strategies are suggested to respiratory management in ALS patients, as the breath stacking and Expiratory muscle training (EMT), which have been used as aid to assist cough in neuromuscular disorders. However, the randomized controlled trials performed in ALS patients have not investigated the addiction of EMT together breath stacking in this population. This trial aims to determine if breath stacking plus EMT is more effective than breath stacking alone to decrease the decline rate on the inspiratory/expiratory muscle strength, FVC and voluntary PCF in ALS patients. Methods This parallel-group, assessor-blinded randomized controlled trial, powered for superiority, aims to assess pulmonary function, respiratory muscle strength, peak cough flow as primary outcomes. Forty-two participants are being recruited referral neuromuscular disease center at Brasilia, Brazil. Following baseline testing, participants are randomized using concealed allocation, to receive either: a) breath stacking technique alone or b) breath stacking technique plus EMT. Conclusion There is a lack of evidence regarding the benefit of EMT plus breath stacking in ALS patients. This trial will contribute to evidence currently being generated in national and international trials by implementing and evaluating a respiratory therapy program including two components not yet combined in previous research, for people with ALS involving longer-term follow-up of outcomes. This trial is ongoing and currently recruiting. Trial registration This trial was prospectively registered on the Clinical Trials Registry NCT04226144.
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13
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Chicayban LM, Hemétrio AC, Azevedo LTR. Comparison of the effects of voluntary and involuntary breath stacking techniques on respiratory mechanics and lung function patterns in tracheostomized patients: a randomized crossover clinical trial. J Bras Pneumol 2020; 46:e20190295. [PMID: 32696839 PMCID: PMC7567629 DOI: 10.36416/1806-3756/e20190295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 10/29/2019] [Indexed: 11/30/2022] Open
Abstract
Objective: To compare the effects of voluntary breath stacking (VBS) and involuntary breath stacking (IBS) techniques on respiratory mechanics, lung function patterns, and inspiratory capacity in tracheostomized patients. Methods: This was a randomized crossover clinical trial involving 20 tracheostomized patients admitted to the ICU and submitted to the VBS and IBS techniques, in random order, with an interval of 5 h between each. Ten cycles of each technique were performed with an interval of 30 s between each cycle. In VBS, patients performed successive inspirations for up to 30 s through a one-way valve, whereas in IBS, successive slow insufflations were performed with a resuscitator bag until the pressure reached 40 cmH2O. Respiratory mechanics, inspiratory capacity, and the lung function pattern were evaluated before and after the interventions. Results: After IBS, there was an increase in static compliance (p = 0.007), which was also higher after IBS than after VBS (p = 0.03). There was no significant difference between the pre-VBS and post-VBS evaluations in terms of static compliance (p = 0.42). Inspiratory capacity was also greater after IBS than after VBS (2,420.7 ± 480.9 mL vs. 1,211.3 ± 562.8 mL; p < 0.001), as was airway pressure (38.3 ± 2.6 cmH2O vs. 25.8 ± 5.5 cmH2O; p < 0.001). There were no changes in resistance or lung function pattern after the application of either technique. Conclusions: In comparison with VBS, IBS promoted greater inspiratory capacity and higher airway pressure, resulting in an increase in static compliance.
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Affiliation(s)
- Luciano Matos Chicayban
- Laboratório de Pesquisa em Fisioterapia Pneumofuncional e Intensiva, Institutos Superiores de Ensino do Centro Educacional Nossa Senhora Auxiliadora, Campos dos Goytacazes, RJ, Brasil
| | - Alice Campos Hemétrio
- Institutos Superiores de Ensino do Centro Educacional Nossa Senhora Auxiliadora, Campos dos Goytacazes, RJ, Brasil
| | - Liz Tavares Rangel Azevedo
- Institutos Superiores de Ensino do Centro Educacional Nossa Senhora Auxiliadora, Campos dos Goytacazes, RJ, Brasil
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14
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Spinou A. A Review on Cough Augmentation Techniques: Assisted Inspiration, Assisted Expiration and Their Combination. Physiol Res 2020; 69:S93-S103. [DOI: 10.33549/physiolres.934407] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Cough is an important mechanism of airway clearance. In patients who present weak and ineffective cough, augmentation techniques aim to assist or simulate the maneuver. These techniques target different phases of the cough cycle, mainly the inspiratory and expiratory phases, through assisted inspiration, assisted expiration and their combination. They include the manual hyperinflation, ventilator hyperinflation, glossopharyngeal breathing, manually assisted cough and mechanical insufflator-exsufflator, each applied individually or in different combinations. The aim of this review is to investigate the effectiveness and safety of cough augmentation techniques. Findings support that all commonly used techniques can theoretically improve airway clearance, as they generate higher cough peak flows compared to unassisted cough. Still, the studies assessing cough augmentation present considerable limitations and the direct comparison of different techniques is challenging. Current evidence indicate that cough peak flow shows higher increase with the combination of assisted inspiration and expiration, and improvement is greater in patients with lower unassisted values. Associated adverse events are infrequent.
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Affiliation(s)
- A. Spinou
- Population Health Sciences, Faculty of Life Sciences and Medicine, King’s College London, United Kingdom.
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15
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Scala R, Ciarleglio G, Maccari U, Granese V, Salerno L, Madioni C. Ventilator Support and Oxygen Therapy in Palliative and End-of-Life Care in the Elderly. Turk Thorac J 2020; 21:54-60. [PMID: 32163365 DOI: 10.5152/turkthoracj.2020.201401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022]
Abstract
Elderly patients suffering from chronic cardio-pulmonary diseases commonly experience acute respiratory failure. As in younger patients, a well-known therapeutic approach of noninvasive mechanical ventilation is able to prevent orotracheal intubation in a large number of severe scenarios in elderly patients. In addition, this type of ventilation is frequently applied in elderly patients who refuse intubation for invasive mechanical ventilation. The rate of failure of noninvasive ventilation may be reduced by means of the integration of new technological devices (i.e., high-flow nasal cannula, extracorporeal CO2 removal, cough assistance and high-frequency chest wall oscillation, and fiberoptic bronchoscopy). Ethical issues with end-of-life decisions and the choice of the environment are not clearly defined in the treatment of elderly with acute respiratory insufficiency.
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Affiliation(s)
- Raffaele Scala
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Giuseppina Ciarleglio
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Uberto Maccari
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Valentina Granese
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Laura Salerno
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
| | - Chiara Madioni
- Division of Pulmonology and Respiratory Intensive Care Unit, San Donato Hospital, Arezzo, Italy
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16
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Veldhoen ES, Verweij‐van den Oudenrijn LP, Ros LA, Hulzebos EH, Papazova DA, van der Ent CK, van der Pol LW, Nijman J, Wösten‐van Asperen RM. Effect of mechanical insufflation-exsufflation in children with neuromuscular weakness. Pediatr Pulmonol 2020; 55:510-513. [PMID: 31909568 PMCID: PMC7004176 DOI: 10.1002/ppul.24614] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 12/14/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Children with neuromuscular diseases develop cough impairment. Airway clearance techniques (ACTs) may help to prevent recurrent respiratory tract infections (RTIs). A commonly used ACT is mechanical insufflation-exsufflation (MI-E), but evidence for efficacy is limited. We hypothesize that MI-E has beneficial effect on RTI related hospital admission rate. METHODS In this single-center retrospective study, we reviewed all children who used daily MI-E between 2005 till June 2019. Primary outcome studied was the number of RTIs requiring hospital admission. Patient satisfaction and burden experienced by MI-E use were explored by questionnaires using a Likert scale. The relative number of RTIs requiring admission and the number of admission days per eligible period before and after the introduction of MI-E were compared using the Friedman test and the Wilcoxon signed-rank test. RESULTS Thirty-seven children were included. The median number of RTI related hospital admissions per 1000 eligible days after the introduction of MI-E was 0.9 (interquartile range [IQR] 0.0-3.1) compared to the 3 preceding years (median 3.7; IQR 1.4-5.9; P = .006). The median number of RTI related admission days per 1000 eligible days after the introduction of MI-E was significantly lower with a median of 2.7 (IQR 0.0-17.4) compared to the 3 preceding years (median 33.6; IQR 15.0-51.1; P = .001). Patient satisfaction was high with low burden, even in patients who discontinued treatment. CONCLUSION A significantly lower number of RTIs requiring hospital admission and shorter admission duration after the introduction of MI-E was found, with high patient satisfaction and low burden.
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Affiliation(s)
- Esther S. Veldhoen
- Pediatric Intensive Care Unit and Center of Home Mechanical Ventilation, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Laura P. Verweij‐van den Oudenrijn
- Pediatric Intensive Care Unit and Center of Home Mechanical Ventilation, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Leandra A. Ros
- Pediatric Intensive Care Unit, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Erik H. Hulzebos
- Child Development and Exercise Center, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Diana A. Papazova
- Pediatric Intensive Care Unit, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Cornelis K. van der Ent
- Department of Pediatric Pulmonology, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Ludo W. van der Pol
- Department of Neurology, Brain Center Rudolf MagnusUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Joppe Nijman
- Pediatric Intensive Care Unit, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Roelie M. Wösten‐van Asperen
- Pediatric Intensive Care Unit, Wilhelmina Children's HospitalUniversity Medical Center UtrechtUtrechtThe Netherlands
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17
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Tattersall R, Murray D, Heverin M, Rooney J, Tobin K, Vance R, Hardiman O, Meldrum D. Respiratory measurements and airway clearance device prescription over one year in amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2019; 21:70-77. [PMID: 31823661 DOI: 10.1080/21678421.2019.1697887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Objective: The rates of decline in respiratory measurements, including Peak Cough Flow (PCF) have not been established in Amyotrophic Lateral Sclerosis (ALS). Additionally, optimal prescription of cough adjuncts which aim to increase cough strength are unknown. The primary aim of this study was to quantify declines in respiratory function in ALS using PCF, Sniff Nasal Inspiratory Pressure (SNIP) and Slow Vital Capacity (SVC). Secondary aims were to measure respiratory morbidity, audit the characteristics of those prescribed cough adjuncts, and compare outcomes between treated and untreated cohorts. Methods: A prospective, longitudinal, observational, cohort study evaluated respiratory measures, morbidity, and physical function in ALS patients at three monthly intervals, over one year. Patient and disease characteristics of those prescribed cough adjuncts were profiled at the time of device prescription. Results: one hundred and eight participants with mean age 62.1 ± 11.5 years participated. PCF declined rapidly at a rate of 124.8L/min/year (p < 0.001). SNIP, SVC (%predicted), and ALSFRS-R also declined significantly at rates of 18.72cmH2O, 17.49%, and 9.62 units per year respectively (p < 0.001). Thirty-two (29.6%) patients reported 56 incidences of chest infection and 21 died. Patients prescribed a cough adjunct (44.4%) had significantly lower average PCF, SNIP, SVC percent predicted, and ALSFRS-R (p < 0.001). Conclusions: This study identified a rapid rate of decline in PCF, a similar decline in SNIP, and slower declines in SVC and ALSFRS-R. Cough adjunct prescription was triggered by declining respiratory measures and recommended PCF thresholds, but also by respiratory symptoms. Chest infections were common in patients regardless of cough adjunct prescription and should be closely monitored.
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Affiliation(s)
- R Tattersall
- Physiotherapy Department, Beaumont Hospital, Dublin 9, Ireland.,Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - D Murray
- Physiotherapy Department, Beaumont Hospital, Dublin 9, Ireland.,Academic Unit of Neurology, School of Medicine, Trinity Biomedical Sciences Institute, Trinity College, Dublin 2, Ireland
| | - M Heverin
- Academic Unit of Neurology, School of Medicine, Trinity Biomedical Sciences Institute, Trinity College, Dublin 2, Ireland
| | - J Rooney
- Academic Unit of Neurology, School of Medicine, Trinity Biomedical Sciences Institute, Trinity College, Dublin 2, Ireland
| | - K Tobin
- School of Medicine, Trinity College Dublin, Dublin 2, Ireland
| | - R Vance
- Physiotherapy Department, Beaumont Hospital, Dublin 9, Ireland
| | - O Hardiman
- Academic Unit of Neurology, School of Medicine, Trinity Biomedical Sciences Institute, Trinity College, Dublin 2, Ireland.,Department of Neurology, Beaumont Hospital, Dublin 9, Ireland
| | - D Meldrum
- Academic Unit of Neurology, School of Medicine, Trinity Biomedical Sciences Institute, Trinity College, Dublin 2, Ireland
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18
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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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19
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An SK, Shin WS. Effect of air stacking training on pulmonary function, respiratory strength and peak cough flow in persons with cervical spinal cord injury. ACTA ACUST UNITED AC 2018. [DOI: 10.14474/ptrs.2018.7.4.147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Sang-Kyun An
- Department of Physical Therapy, Graduate School of Daejeon University, Daejeon, Republic of Korea
| | - Won-Seob Shin
- Department of Physical Therapy, College of Health and Medical Science, Daejeon University, Daejeon, Republic of Korea
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20
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Sheers N, Howard ME, Berlowitz DJ. Respiratory adjuncts to NIV in neuromuscular disease. Respirology 2018; 24:512-520. [DOI: 10.1111/resp.13431] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 09/19/2018] [Accepted: 10/01/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Nicole Sheers
- Department of Respiratory and Sleep MedicineAustin Health Melbourne VIC Australia
- Institute for Breathing and Sleep Melbourne VIC Australia
- The University of Melbourne Melbourne VIC Australia
| | - Mark E. Howard
- Department of Respiratory and Sleep MedicineAustin Health Melbourne VIC Australia
- Institute for Breathing and Sleep Melbourne VIC Australia
- The University of Melbourne Melbourne VIC Australia
| | - David J. Berlowitz
- Department of Respiratory and Sleep MedicineAustin Health Melbourne VIC Australia
- Institute for Breathing and Sleep Melbourne VIC Australia
- The University of Melbourne Melbourne VIC Australia
- Department of PhysiotherapyAustin Health Melbourne VIC Australia
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21
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Talbot K, Feneberg E, Scaber J, Thompson AG, Turner MR. Amyotrophic lateral sclerosis: the complex path to precision medicine. J Neurol 2018; 265:2454-2462. [PMID: 30054789 PMCID: PMC6182683 DOI: 10.1007/s00415-018-8983-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/19/2018] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease of the corticomotorneuronal network responsible for voluntary movement. There are well-established clinical, genetic and pathological overlaps between ALS and frontotemporal dementia (FTD), which together constitute the 'TDP-43 proteinopathies'. An ever-expanding list of genes in which mutation leads to typical ALS have implicated abnormalities in RNA processing, protein homoeostasis and axonal transport. How these apparently distinct pathways converge to cause the characteristic clinical syndrome of ALS remains unclear. Although there are major gaps in our understanding of the essential nature of ALS pathophysiology, the identification of genetic causes in up to 15% of ALS patients, coupled with advances in biotechnology and biomarker research provide a foundation for approaches to treatment based on 'precision medicine', and even prevention of the disease in pre-symptomatic mutation carriers in the future. Currently, multidisciplinary care remains the bedrock of management and this is increasingly being put onto an evidence-based footing.
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Affiliation(s)
- Kevin Talbot
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK.
| | - Emily Feneberg
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Jakub Scaber
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Alexander G Thompson
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
| | - Martin R Turner
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, OX3 9DU, UK
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22
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Bello-Haas VD. Physical therapy for individuals with amyotrophic lateral sclerosis: current insights. Degener Neurol Neuromuscul Dis 2018; 8:45-54. [PMID: 30890895 PMCID: PMC6065609 DOI: 10.2147/dnnd.s146949] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive, neurodegenerative, and inevitably fatal disease. There is no cure for ALS and life expectancy is typically 2–5 years after symptom onset. Despite the lack of a cure and the rapidly progressive nature of the disease, ALS is considered a “treatable disease” and rehabilitation is integral to optimal, comprehensive care. In addition to the other health care professions making up the health care team, physical therapy provides a critical role in the overall management in individuals with ALS. Physical therapy that is tailored to the individual’s needs and goals and focused on addressing symptoms and maximizing function and participation enables people with ALS to live their lives to the fullest and with quality. The purpose of this paper is to review some of the recent ALS research findings that have implications for physical therapy practice.
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Affiliation(s)
- Vanina Dal Bello-Haas
- Physiotherapy Program, School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada,
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23
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Khamankar N, Coan G, Weaver B, Mitchell CS. Associative Increases in Amyotrophic Lateral Sclerosis Survival Duration With Non-invasive Ventilation Initiation and Usage Protocols. Front Neurol 2018; 9:578. [PMID: 30050497 PMCID: PMC6052254 DOI: 10.3389/fneur.2018.00578] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 06/26/2018] [Indexed: 12/11/2022] Open
Abstract
Objective: It is hypothesized earlier non-invasive (NIV) ventilation benefits Amyotrophic Lateral Sclerosis (ALS) patients. NIV typically consists of the removable bi-level positive airway pressure (Bi-PAP) for adjunctive respiratory support and/or the cough assist intervention for secretion clearance. Historical international standards and current USA insurance standards often delay NIV until percent predicted forced vital capacity (FVC %predict) is <50. We identify the optimal point for Bi-PAP initiation and the synergistic benefit of daily Bi-PAP and cough assist on associative increases in survival duration. Methods: Study population consisted of a retrospective ALS cohort (Emory University, Atlanta, GA, USA). Primary analysis included 474 patients (403 Bi-PAP users, 71 non-users). Survival duration (time elapsed from baseline onset until death) is compared on the basis of Bi-PAP initiation threshold (FVC %predict); daily Bi-PAP usage protocol (hours/day); daily cough assist usage (users or non-users); ALS onset type; ALSFRS-R score; and time elapsed from baseline onset until Bi-PAP initiation, using Kruskal-Wallis one-way analysis of variance and Kaplan Meier. Results: Bi-PAP users' median survival (21.03 months, IQR = 23.97, N = 403) is significantly longer (p < 0.001) than non-users (13.84 months, IQR = 11.97, N = 71). Survival consistently increases (p < 0.01) with FVC %predict Bi-PAP initiation threshold: <50% (20.3 months); ≥50% (23.60 months); ≥80% (25.36 months). Bi-PAP usage >8 hours/day (23.20 months) or any daily Bi-PAP usage with cough assist (25.73 months) significantly (p < 0.001) extends survival compared to Bi-PAP alone (15.0 months). Cough assist without Bi-PAP has insignificant impact (14.17 months) over no intervention (13.68 months). Except for bulbar onset Bi-PAP users, higher ALSFRS-R total scores at Bi-PAP initiation significantly correlate with higher initiation FVC %predict and longer survival duration. Time elapsed since ALS onset is not a good predictor of when NIV should be initiated. Conclusions: The “optimized” NIV protocol (Bi-PAP initiation while FVC %predict ≥80, Bi-PAP usage >8 h/day, daily cough assist usage) has a 30. 8 month survival median, which is double that of a “standard” NIV protocol (initiation FVC %predict <50, usage >4 h/day, no cough assist). Earlier access to Bi-PAP and cough assist, prior to precipitous respiratory decline, is needed to maximize NIV synergy and associative survival benefit.
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Affiliation(s)
- Nishad Khamankar
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
| | - Grant Coan
- School of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States
| | - Barry Weaver
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
| | - Cassie S Mitchell
- Laboratory for Pathology Dynamics, Biomedical Engineering, Georgia Institute of Technology and Emory University School of Medicine, Atlanta, GA, United States
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24
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Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure: which recipe for success? Eur Respir Rev 2018; 27:27/149/180029. [DOI: 10.1183/16000617.0029-2018] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/16/2018] [Indexed: 12/12/2022] Open
Abstract
Noninvasive positive-pressure ventilation (NPPV) to treat acute respiratory failure has expanded tremendously over the world in terms of the spectrum of diseases that can be successfully managed, the locations of its application and achievable goals.The turning point for the successful expansion of NPPV is its ability to achieve the same physiological effects as invasive mechanical ventilation with the avoidance of the life-threatening risks correlated with the use of an artificial airway.Cardiorespiratory arrest, extreme psychomotor agitation, severe haemodynamic instability, nonhypercapnic coma and multiple organ failure are absolute contraindications for NPPV. Moreover, pitfalls of NPPV reduce its rate of success; consistently, a clear plan of what to do in case of NPPV failure should be considered, especially for patients managed in unprotected setting. NPPV failure is likely to be reduced by the application of integrated therapeutic tools in selected patients handled by expert teams.In conclusion, NPPV has to be considered as a rational art and not just as an application of science, which requires the ability of clinicians to both choose case-by-case the best “ingredients” for a “successful recipe” (i.e.patient selection, interface, ventilator, interface,etc.) and to avoid a delayed intubation if the ventilation attempt fails.
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25
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Chatwin M, Toussaint M, Gonçalves MR, Sheers N, Mellies U, Gonzales-Bermejo J, Sancho J, Fauroux B, Andersen T, Hov B, Nygren-Bonnier M, Lacombe M, Pernet K, Kampelmacher M, Devaux C, Kinnett K, Sheehan D, Rao F, Villanova M, Berlowitz D, Morrow BM. Airway clearance techniques in neuromuscular disorders: A state of the art review. Respir Med 2018; 136:98-110. [PMID: 29501255 DOI: 10.1016/j.rmed.2018.01.012] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 01/20/2018] [Accepted: 01/22/2018] [Indexed: 12/13/2022]
Abstract
This is a unique state of the art review written by a group of 21 international recognized experts in the field that gathered during a meeting organized by the European Neuromuscular Centre (ENMC) in Naarden, March 2017. It systematically reports the entire evidence base for airway clearance techniques (ACTs) in both adults and children with neuromuscular disorders (NMD). We not only report randomised controlled trials, which in other systematic reviews conclude that there is a lack of evidence base to give an opinion, but also include case series and retrospective reviews of practice. For this review, we have classified ACTs as either proximal (cough augmentation) or peripheral (secretion mobilization). The review presents descriptions; standard definitions; the supporting evidence for and limitations of proximal and peripheral ACTs that are used in patients with NMD; as well as providing recommendations for objective measurements of efficacy, specifically for proximal ACTs. This state of the art review also highlights how ACTs may be adapted or modified for specific contexts (e.g. in people with bulbar insufficiency; children and infants) and recommends when and how each technique should be applied.
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Affiliation(s)
- Michelle Chatwin
- Academic and Clinical Department of Sleep and Breathing and NIHR Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, Sydney Street, London, UK.
| | - Michel Toussaint
- Centre for Home Mechanical Ventilation and Specialized Centre for Neuromuscular Diseases, Inkendaal Rehabilitation Hospital, Vlezenbeek, Belgium
| | - Miguel R Gonçalves
- Noninvasive Ventilatory Support Unit, Pulmonology Department, Emergency and Intensive Care Medicine Department, São João University Hospital, Faculty of Medicine, University of Porto, Portugal
| | - Nicole Sheers
- Institute for Breathing and Sleep and Victorian Respiratory Support Service, Austin Health, Melbourne, Australia
| | - Uwe Mellies
- Departement of Pediatric Pulmonology and Sleep Medicine, Cystic Fibrosis Center Essen, University of Essen, Germany
| | - Jesus Gonzales-Bermejo
- Sorbonne Université, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Jesus Sancho
- Respiratory Care Unit, Respiratory Medicine Department, Hospital Clinico Universitario, Valencia, Institute of Health Research INCLIVA, Valencia, Spain
| | - Brigitte Fauroux
- Pediatric Noninvasive Ventilation and Sleep Unit, Necker University Hospital, Paris, Paris Descartes University, Paris Research Unit INSERM U 955, Team 13, Creteil, France
| | - Tiina Andersen
- Norwegian Centre of Excellence for Home Mechanical Ventilation, Thoracic Department and Department of Physiotherapy, Haukeland University Hospital, Bergen Norway, Department of Clinical Science, Medical Faculty, University of Bergen, Bergen, Norway
| | - Brit Hov
- Dept of Peadiatric Medicine, Oslo University Hospital, Oslo, Norway and Norwegian Centre of Excellence for Home Mechanical Ventilation, Haukeland University Hospital, Bergen, Norway
| | - Malin Nygren-Bonnier
- Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Functional Area Occupational Therapy and Physiotherapy, Allied Health Professionals Function, Karolinska University Hospital, Stockholm, Sweden
| | - Matthieu Lacombe
- Adult Intensive Care Unit, Raymond Poincaré Hospital (AP-HP) Garches, France
| | - Kurt Pernet
- Centre for Home Mechanical Ventilation and Specialized Centre for Neuromuscular Diseases, Inkendaal Rehabilitation Hospital, Vlezenbeek, Belgium
| | - Mike Kampelmacher
- Home Ventilation Service, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Christian Devaux
- Direction des Actions Médicales, Paramédicales et Psychologiques, Association Française Contre Les Myopathies-Téléthon, 91000 EVRY, France
| | - Kathy Kinnett
- Parent Project Muscular Dystrophy, 401 Hackensack Ave 9th Floor, Hackensack, NJ 07601, United States
| | - Daniel Sheehan
- Assisted Breathing Center, Women and Children's Hospital of Buffalo Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, The State University of New York, United States
| | - Fabrizio Rao
- Respiratory Unit, Neuromuscular OmniCentre (NeMO), Neurorehabilitation, University of Milan, Niguarda Hospital, Milan, Italy
| | - Marcello Villanova
- Neuromuscular Rehabilitation Unit, Nigrisoli Hospital, Viale Ercolani 7/b - 40125, Bologna, Italy
| | - David Berlowitz
- Institute for Breathing and Sleep and Victorian Respiratory Support Service, Austin Health, Melbourne, Australia
| | - Brenda M Morrow
- Department of Paediatrics and Child Health, University of Cape Town, Klipfontein Rd, Rondebosch, Cape Town, South Africa
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26
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Hardiman O, Al-Chalabi A, Chio A, Corr EM, Logroscino G, Robberecht W, Shaw PJ, Simmons Z, van den Berg LH. Amyotrophic lateral sclerosis. Nat Rev Dis Primers 2017; 3:17071. [PMID: 28980624 DOI: 10.1038/nrdp.2017.71] [Citation(s) in RCA: 820] [Impact Index Per Article: 117.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Amyotrophic lateral sclerosis (ALS), also known as motor neuron disease, is characterized by the degeneration of both upper and lower motor neurons, which leads to muscle weakness and eventual paralysis. Until recently, ALS was classified primarily within the neuromuscular domain, although new imaging and neuropathological data have indicated the involvement of the non-motor neuraxis in disease pathology. In most patients, the mechanisms underlying the development of ALS are poorly understood, although a subset of patients have familial disease and harbour mutations in genes that have various roles in neuronal function. Two possible disease-modifying therapies that can slow disease progression are available for ALS, but patient management is largely mediated by symptomatic therapies, such as the use of muscle relaxants for spasticity and speech therapy for dysarthria.
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Affiliation(s)
- Orla Hardiman
- Academic Unit of Neurology, Room 5.41 Trinity Biomedical Science Institute, Trinity College Dublin, Pearse Street, Dublin 2, Ireland
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Adriano Chio
- Rita Levi Montalcini Department of Neurosciences, University of Turin, Turin, Italy
| | - Emma M Corr
- Academic Unit of Neurology, Room 5.41 Trinity Biomedical Science Institute, Trinity College Dublin, Pearse Street, Dublin 2, Ireland
| | | | - Wim Robberecht
- KU Leuven-University of Leuven, University Hospitals Leuven, Department of Neurology, Leuven, Belgium
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Zachary Simmons
- Department of Neurology, Milton S. Hershey Medical Center, Penn State Health, Hershey, Pennsylvania, USA
| | - Leonard H van den Berg
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands
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27
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Challenges on non-invasive ventilation to treat acute respiratory failure in the elderly. BMC Pulm Med 2016; 16:150. [PMID: 27846872 PMCID: PMC5111281 DOI: 10.1186/s12890-016-0310-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 11/07/2016] [Indexed: 01/26/2023] Open
Abstract
Acute respiratory failure is a frequent complication in elderly patients especially if suffering from chronic cardio-pulmonary diseases. Non-invasive mechanical ventilation constitutes a successful therapeutic tool in the elderly as, like in younger patients, it is able to prevent endotracheal intubation in a wide range of acute conditions; moreover, this ventilator technique is largely applied in the elderly in whom invasive mechanical ventilation is considered not appropriated. Furthermore, the integration of new technological devices, ethical issues and environment of treatment are still largely debated in the treatment of acute respiratory failure in the elderly. This review aims at reporting and critically analyzing the peculiarities in the management of acute respiratory failure in elderly people, the role of noninvasive mechanical ventilation, the potential advantages of applying alternative or integrated therapeutic tools (i.e. high-flow nasal cannula oxygen therapy, non-invasive and invasive cough assist devices and low-flow carbon-dioxide extracorporeal systems), drawbacks in physician’s communication and “end of life” decisions. As several areas of this topic are not supported by evidence-based data, this report takes in account also “real-life” data as well as author’s experience. The choice of the setting and of the timing of non-invasive mechanical ventilation in elderly people with advanced cardiopulmonary disease should be carefully evaluated together with the chance of using integrated or alternative supportive devices. Last but not least, economic and ethical issues may often challenges the behavior of the physicians towards elderly people who are hospitalized for acute respiratory failure at the end stage of their cardiopulmonary and neoplastic diseases.
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28
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Hobson EV, McDermott CJ. Supportive and symptomatic management of amyotrophic lateral sclerosis. Nat Rev Neurol 2016; 12:526-38. [PMID: 27514291 DOI: 10.1038/nrneurol.2016.111] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The main aims in the care of individuals with amyotrophic lateral sclerosis (ALS) are to minimize morbidity and maximize quality of life. Although no cure exists for ALS, supportive and symptomatic care provided by a specialist multidisciplinary team can improve survival. The basis for supportive management is shifting from expert consensus guidelines towards an evidence-based approach, which encourages the use of effective treatments and could reduce the risk of harm caused by ineffective or unsafe interventions. For example, respiratory support using noninvasive ventilation has been demonstrated to improve survival and quality of life, whereas evidence supporting other respiratory interventions is insufficient. Increasing evidence implicates a causal role for metabolic dysfunction in ALS, suggesting that optimizing nutrition could improve quality of life and survival. The high incidence of cognitive dysfunction and its impact on prognosis is increasingly recognized, although evidence for effective treatments is lacking. A variety of strategies are used to manage the other physical and psychological symptoms, the majority of which have yet to be thoroughly evaluated. The need for specialist palliative care throughout the disease is increasingly recognized. This Review describes the current approaches to symptomatic and supportive care in ALS and outlines the current guidance and evidence for these strategies.
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Affiliation(s)
- Esther V Hobson
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385a Glossop Rd, Sheffield, S10 2HQ, UK
| | - Christopher J McDermott
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385a Glossop Rd, Sheffield, S10 2HQ, UK
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29
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Arcuri JF, Abarshi E, Preston NJ, Brine J, Pires Di Lorenzo VA. Benefits of interventions for respiratory secretion management in adult palliative care patients-a systematic review. BMC Palliat Care 2016; 15:74. [PMID: 27507303 PMCID: PMC4979117 DOI: 10.1186/s12904-016-0147-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 08/01/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Respiratory secretions impact negatively on palliative patients. Unfortunately, a gold standard therapy is not yet available. The purpose of this study was to identify which interventions are in use to control respiratory secretions in patients with chronic disease with a poor prognosis and verify their effects on outcomes relevant for palliative care patients. METHODS A systematic review of the literature with narrative summary was conducted. We searched eight electronic databases in April (6th), 2016. Citation-tracking and reference list searches were conducted. We included randomized controlled trials, crossover trials, observational and qualitative studies regarding interventions for respiratory secretion management in adult patients with chronic diseases that met inclusion criteria indicating short prognosis. RESULTS Six randomized controlled trials, 11 observational studies, ten crossover trials and one qualitative study were found. Interventions included mechanical insufflation-exsufflation (MIE), expiratory muscle training, manually-assisted cough, tracheotomy, chest physiotherapy, suctioning, air stacking, electrical stimulation of abdominal muscles, nebulized saline, positive expiratory pressure masks, percussive ventilation, high frequency chest wall oscillations. The interventions with most promising benefits to patients in palliative care were manually-assisted cough and mechanical insufflation-exsufflation to promote expectoration and percussive ventilation to improve mucous clearance. CONCLUSION Therapies, such as manually assisted cough, mechanical insufflation-exsufflation and percussive ventilation, which aim to deal with respiratory secretion, were the most promising treatment for use in palliative care for specific diseases. Nevertheless, the evidence still needs to improve in order to identify which treatment is the best.
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Affiliation(s)
- Juliano Ferreira Arcuri
- Federal University of São Carlos, Rod Washington Luiz, km 235, Monjolinho, São Carlos, SP, CEP 13565-905, Brazil.
| | - Ebun Abarshi
- International Observatory on End of Life Care, Faculty of Health and Medicine, Furness College, Lancaster University, Bailrigg, LA1 4YG, UK
| | - Nancy J Preston
- International Observatory on End of Life Care, Faculty of Health and Medicine, Furness College, Lancaster University, Bailrigg, LA1 4YG, UK
| | - Jenny Brine
- Lancaster University Library, Lancaster University, Bailrigg, LA1 4YG, UK
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Rafiq MK, Mcdermott C, Shaw P. Evidence-based or arrogance-based medicine? Amyotroph Lateral Scler Frontotemporal Degener 2016; 17:305-6. [DOI: 10.3109/21678421.2016.1140211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Muhammad Khizar Rafiq
- Sheffield Institute of Translational Neuroscience, Department of Neuroscience, University of Sheffield, UK
| | - Chris Mcdermott
- Sheffield Institute of Translational Neuroscience, Department of Neuroscience, University of Sheffield, UK
| | - Pamela Shaw
- Sheffield Institute of Translational Neuroscience, Department of Neuroscience, University of Sheffield, UK
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31
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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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32
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Elliott MW. Diaphragm pacing and motor neurone disease: lessons for all? ERJ Open Res 2015; 1:00073-2015. [PMID: 27730160 PMCID: PMC5005125 DOI: 10.1183/23120541.00073-2015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 10/17/2015] [Indexed: 11/25/2022] Open
Abstract
Respiratory muscle involvement is inevitable in motor neurone disease (MND) and most patients will die a respiratory death. Noninvasive ventilation (NIV) has been shown to prolong life and improve quality of life [1]. It is therefore important to identify patients who should be offered NIV at an early stage, as a delay may result in presentation with catastrophic respiratory failure, requiring endotracheal intubation, which almost always results in an unplanned tracheostomy. It used to be considered that respiratory muscle involvement was only a feature of advanced disease, but this is not correct; if looked for there is evidence of respiratory muscle weakness in most patients by the time the diagnosis is made [2]. In a small number, the diagnosis is made when the patient presents with hypercapnic respiratory failure. Respiratory physicians and neurologists should be cognisant of the respiratory complications of motor neurone diseasehttp://ow.ly/TIxe5
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