Reference Range of Respiratory Muscle Strength and Its Clinical Application in Amyotrophic Lateral Sclerosis: A Single-Center Study

Initiation of noninvasive ventilation in patients with amyotrophic lateral sclerosis

INTRODUCTION/AIMS

Noninvasive ventilation (NIV) has been shown to improve survival and symptom burden in patients with amyotrophic lateral sclerosis (ALS). However, limited data exist regarding the clinical and physiological parameters at the time of NIV initiation. This study aimed to describe the clinical characteristics and respiratory physiological markers in a cohort of ALS patients with chronic respiratory failure.

METHODS

This is a single-center retrospective cohort study of patients with ALS assessed for NIV initiation between February 2012 and January 2021. NIV was initiated based on insurance eligibility criteria: daytime hypercapnia, defined by partial pressure of carbon dioxide (PaCO2) >45 mm Hg using diurnal transcutaneous CO2 (TcCO2) as a surrogate, a maximal inspiratory pressure (MIP) <60 cmH2O or forced vital capacity (FVC) <50% predicted normal.

RESULTS

We identified 335 patients with ALS and chronic respiratory failure referred to an outpatient home ventilation clinic for NIV initiation. The mean age was 64 years ±11; 151 (45%) were female, 326 (97%) were white, and 100 (29%) had bulbar-onset ALS. At the time of NIV initiation, the mean FVC was 64% ± 19%, the mean MIP; 41 cmH2O ± 17, and diurnal TcCO2; 40 ± 6 mmHg. The most common reasons for NIV initiation were MIP <60 cmH2O (58%) and multiple concomitant indications (28%). Within 1 year of NIV initiation, 126 (37%) patients were deceased.

DISCUSSION

We found that impairment in inspiratory force was the most common reason for NIV initiation and often preceded significant declines in FVC.

Maximal respiratory pressures: Measurements at functional residual capacity in individuals with different health conditions using a digital manometer

BACKGROUND

Measuring maximal respiratory pressure is a widely used method of investigating the strength of inspiratory and expiratory muscles.

OBJECTIVES

To compare inspiratory pressures obtained at functional residual capacity (FRC) with measures at residual volume (RV), and expiratory pressures obtained at FRC with measures at total lung capacity (TLC) in individuals with different health conditions: post-COVID-19, COPD, idiopathic pulmonary fibrosis (IPF), heart failure (CHF), and stroke; and to compare the mean differences between measurements at FRC and RV/TLC among the groups.

METHODS

Inspiratory and expiratory pressures were obtained randomly at different lung volumes. Mixed factorial analysis of covariance with repeated measures was used to compare measurements at different lung volumes within and among groups.

RESULTS

Seventy-five individuals were included in the final analyses (15 individuals with each health condition). Maximal inspiratory pressures at FRC were lower than RV [mean difference (95% CI): 11.3 (5.8, 16.8); 8.4 (2.3, 14.5); 11.1 (5.5, 16.7); 12.8 (7.1, 18.4); 8.0 (2.6, 13.4) for COVID-19, COPD, IPF, CHF, and stroke, respectively] and maximal expiratory pressures at FRC were lower than TLC [mean difference (95% CI): 51.9 (37.4, 55.5); 60.9 (44.2, 77.7); 62.9 (48.1, 77.8); 58.0 (43.9, 73.8); 57.2 (42.9, 71.6) for COVID-19, COPD, IPF, CHF, and stroke, respectively]. All mean differences were similar among groups.

CONCLUSION

Although inspiratory and expiratory pressures at FRC were lower than measures obtained at RV/TLC for the five groups of health conditions, the mean differences between measurements at different lung volumes were similar among groups, which raises the discussion about the influence of the viscoelastic properties of the lungs on maximal respiratory pressure.

Associations between pulmonary function and cognitive decline in the middle-aged and older adults: evidence from the China Health and Retirement Longitudinal Study

BACKGROUND

Studies observing the relationship between pulmonary function and the risk of cognitive impairment in middle-aged and older adults was increasing, but the results were inconsistent. To date, evidence from longitudinal data is scarce and further research is urgently needed.

METHODS

We used data from the China Health and Retirement Longitudinal Study. Participants were enrolled in 2011/2013 and followed up in 2013, 2015 and 2018. Pulmonary function was assessed via peak expiratory flow (PEF). Cognitive function, measured by episodic memory and mental status, was assessed through a face-to-face interview in each survey.

RESULTS

A total of 8,274 participants (52.86% males; mean age, 56.44 years) were included. The scores of global cognition (12.46 versus 11.51, P < 0.001) of men were significantly higher than women at baseline, with a total of 5096 participants (61.59%) declining during the follow-up. Higher baseline PEF was associated with lower absolute decline in global cognition (OR per 1-SD difference 0.921; P = 0.031) and mental status (OR per 1-SD difference 0.9889; P = 0.002) during follow-up in men, and significant associations between higher baseline PEF and a lower absolute decline in the episodic memory were both found in men (OR per 1-SD difference 0.907; P = 0.006) and women (OR per 1-SD difference 0.915; P = 0.022). Second analysis showed that the significant associations between positive PEF variation and a lower rate of 4-year decline in global cognition, mental status and episodic memory were all only found in men. In subgroup analyses, higher PEF at baseline was significantly associated with a lower absolute decline of global cognition among male individuals >60 years. Significant associations between higher PEF at baseline and lower absolute decline in global cognition and episodic memory during follow-up were only found in never-smokers, while higher PEF was related to lower absolute decline in mental status among non-smoking and smoking males.

CONCLUSIONS

Pulmonary function correlates with cognitive functions in middle-aged and older people, especially males. Additional studies characterizing early and long-term PEF changes are needed.

Handgrip Force and Maximum Inspiratory and Expiratory Pressures in Critically Ill Patients With a Tracheostomy

BACKGROUND

The association between peripheral striated muscle strength and respiratory muscle strength has been confirmed in a number of disorders. However, this association is unknown in intensive care unit patients with tracheostomies.

OBJECTIVE

To examine correlations between handgrip force, maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP) in intensive care unit patients with tracheostomies.

METHODS

Twenty patients (7 women, 13 men) with tracheostomies, in the intensive care unit longer than 11 days, in stable condition, with functional limbs, and with Glasgow Coma Scale scores of 15 were recruited. Both MIP and MEP were measured with a membrane manometer; handgrip force was measured with a hydraulic hand dynamometer.

RESULTS

Handgrip force was significantly correlated with MIP (r = 0.45, P = .04) and MEP (r = 0.78, P = .001). Handgrip force was significantly predicted by MIP and MEP when the effect of sex was controlled for (P < .05). However, when MIP and MEP were included as predictors in a regression model, MEP was the only significant predictor (R = 0.80, R2 = 0.63, adjusted R2 = 0.57).

CONCLUSIONS

Strength of the hand flexors and strength of the expiratory muscles (abdominal) were significantly correlated in intensive care unit patients. Handgrip strength appears to be an easy, fast way to evaluate expiratory muscle strength by using a simple handhold command without special equipment. A strong handhold may also correspond to strong expiratory muscles. ClinicalTrials.gov: NCT03457376.

Split hand muscle echo intensity index as a reliable imaging marker for differential diagnosis of amyotrophic lateral sclerosis

OBJECTIVE

The objective of this study was to investigate the usefulness of muscle ultrasound in evaluating dissociated small hand muscle atrophy, termed 'split hand', and its feasibility in the diagnosis of amyotrophic lateral sclerosis (ALS).

METHODS

Forty-four patients with ALS, 18 normal subjects and 9 patients with other neuromuscular disorders were included in this study. The hand muscles were divided into three regions, the median-innervated lateral hand muscle group (ML), the ulnar-innervated lateral hand muscle (UL) and the ulnar-innervated medial hand muscle (UM), and the muscle echo intensity (EI) and compound muscle action potential (CMAP) were measured. We calculated the split hand index (SHI) using muscle EI (SHI_mEI) and CMAP (SHI_CMAP) for comparison among groups. The SHI was derived by dividing muscle EI (or CMAP) measured at the ML and UL by that measured at the UM.

RESULTS

The SHI_mEI was significantly higher in patients with ALS (51.7±28.3) than in normal controls (29.7±9.9) and disease controls with other neuromuscular disorders (36.5±7.3; P<0.001), particularly in upper limb-onset ALS (66.5±34.0; P<0.001). Receiver operating characteristic curve analysis indicated that the SHI_mEI had significantly better diagnostic accuracy than the SHI_CMAP.

CONCLUSIONS

The SHI_mEI was more sensitive in evaluating dissociated small hand muscle atrophy compared with the SHI_CMAP and may be a reliable diagnostic marker for differentiating ALS from other neuromuscular disorders and healthy controls.

Respiratory involvement in neuromuscular disorders

PURPOSE OF REVIEW

In numerous neuromuscular disorders (NMDs), respiratory muscle weakness is present, and acute or chronic respiratory failure may evolve. Very often, respiratory involvement substantially adds to the burden of disease, impairs quality of life, or reduces life expectancy. This article summarizes new aspects of both diagnosis and management of respiratory muscle weakness in patients with NMDs.

RECENT FINDINGS

Drugs like deflazacort, ataluren, eteplirsen, and nusinersen are now approved treatments for Duchenne Muscular Dystrophy and Spinal Muscular Atrophy, and others are on their way in NMDs. Although observing how innovative drugs will change the natural history of these diseases, including respiratory function over time, adequate symptomatic treatment remains meaningful and is strongly recommended. Physicians should systematically take respiratory involvement into account to improve patients' quality of life and prognosis.

SUMMARY

First, it is outlined in which subtypes of NMD respiratory muscle dysfunction is particularly relevant. Second, new developments regarding diagnostic procedures, including respiratory muscle strength testing, spirometry, and sleep studies, are covered. Third, this article gives an overview on current concepts of ventilatory support and management of secretions in patients with NMD.

Respiratory measures in amyotrophic lateral sclerosis

OBJECTIVE

Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease that causes skeletal muscle weakness, including muscles involved with respiration. Death often results from respiratory failure within 3-5 years. Monitoring respiratory status is therefore critical to ALS management, as respiratory/pulmonary function tests (PFTs) are used to make decisions including when to initiate noninvasive ventilation. Understanding the different respiratory and PFTs as they relate to disease progression and survival may help determine which tests are most suitable.

METHODS

This review describes the tests used to assess respiratory muscle and pulmonary function in patients with ALS and the correlations between different respiratory measures and clinical outcomes measures.

RESULTS

The most commonly used measurement, forced vital capacity (VC), has been shown to correlate with clinical milestones including survival, but also requires good motor coordination and facial strength to form a tight seal around a mouthpiece. Other tests such as slow VC, sniff inspiratory pressure, or transdiaphragmatic pressure with magnetic stimulation are also associated with distinct advantages and disadvantages.

CONCLUSIONS

Therefore, how and when to use different tests remains unclear. Understanding how each test relates to disease progression and survival may help determine which is best suited for specific clinical decisions.