Assisted Cough, Abdominal Compression, and Severe Kyphoscoliosis

Importance of noninvasively measured respiratory muscle overload among the causes of hospital readmission of COPD patients.

To evaluate the influence of respiratory muscle overload and right cardiac overload among the possible risk factors of hospital readmission in a 1-year follow-up of a cohort of patients with moderate-to-severe COPD.A total of 112 COPD patients who were admitted consecutively to the hospital for acute exacerbation. At hospital discharge, we evaluated the conventional clinical and functional determinations in addition to the pressure-time index (PTI), which is obtained using the equation PTI = (Pawo/Pimax) x (Ti/Ttot) x 100, where Pawo represents the mean airway pressure measured at the mouth during spontaneous breathing, Pimax is the maximal inspiratory pressure, Ti is the inspiratory time, …

Neumólogos, ventilación mecánica y técnicas complementarias

Comparison of Peak Cough Flows Measured by Pneumotachograph and a Portable Peak Flow Meter

To compare peak cough flows (PCF) obtained with a pneumotachograph (PCFp) with those measured using a portable peak flow meter (PCFm) in a population of healthy subjects and patients with neuromuscular disease.A total of 30 healthy subjects and 32 medically stable patients with neuromuscular diseases were studied. Using an oronasal mask connected, in a randomized order, to a pneumotachograph and to a portable peak flow meter, PCFp and PCFm were measured as every subject performed maximal cough efforts from total lung capacity.PCFp measurements were 377.70 +/-179.28 liters/min and PCFm measurements were 377.50 +/- 172.98 liters/min (not significant). The two measurements were correlated (r =…

Punciones arteriales: ¿siempre la radial y siempre con anestesia?

[Respiratory muscle aids during an episode of aspiration in a patient with Duchenne muscular dystrophy].

We report the case of a Duchenne muscular dystrophy patient with good bulbar function but severely decreased forced vital capacity (9%) and spontaneous peak cough flow (PCF) (2.35 L/s). The patient needed continuous noninvasive ventilation (NIV) consisting of a volumetric ventilator with a nighttime nasal mask and a daytime mouthpiece. He also required application of manually assisted coughing techniques by insufflation with a resuscitation bag and chest thrust (manually assisted PCF after maximum insufflation capacity of 4.33 L/s). An episode of serious food aspiration was resolved by his main caregiver through NIV and manually assisted coughing. Bronchoscopy under sedation using NIV with …

Critical role of fractalkine (CX3CL1) in cigarette smoke-induced mononuclear cell adhesion to the arterial endothelium.

Background Cigarette smoking is an important risk factor for the development of cardiovascular disease, yet the pathways through which this may operate are poorly understood. Therefore, the mechanism underlying cigarette smoke (CS)-induced arterial endothelial dysfunction and the potential link with fractalkine/CX3CL1 upregulation were investigated. Methods and results Stimulation of human arterial umbilical endothelial cells (HUAECs) with pathophysiological concentrations of CS extract (1% CSE) increased CX3CL1 expression. Neutralisation of CX3CL1 activity under dynamic flow conditions significantly inhibited CSE-induced mononuclear cell adhesion to HUAECs (67%). The use of small interferi…

Mechanical insufflation-exsufflation vs. tracheal suctioning via tracheostomy tubes for patients with amyotrophic lateral sclerosis: a pilot study.

To compare the effects of mechanical insufflation-exsufflation vs. suctioning via tracheostomy tubes on respiratory variables for six amyotrophic lateral sclerosis patients.In this prospective crossover study, six consecutive patients with amyotrophic lateral sclerosis who required continuous mechanical ventilation via tracheostomy tubes and developed chest infections underwent measurement of pulse oxyhemoglobin saturation (SpO2), peak inspiratory pressure (PIP), mean airway pressure (Pawm), and work of breathing performed by the ventilator (WOBv) at baseline and 5 and 30 min after tracheal suctioning and 5 min after mechanical insufflation-exsufflation.The baseline values were 93.50 +/- 2.…

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

In patients with neuromuscular diseases, a chest infection is associated with a reduction in respiratory muscle function that may result in decreased cough effectiveness.To determine if a clinical or functional parameter in patients with amyotrophic lateral sclerosis (ALS) in a stable condition could predict spontaneous cough ineffectiveness during a respiratory tract infection.Forty consecutive patients with ALS referred to our Respiratory Care Unit were studied during a one-year follow-up.FEV(1), FVC, FEV(1)/FVC, peak cough flow (PCF), peak velocity time (PVT), maximum inspiratory and expiratory pressures, and bulbar dysfunction evaluation using the Norris scale bulbar subscore (NBS). A t…

Free Radicals and Antioxidants in Physical Exercise

The beneficial effects of exercise are well documented. Indeed, it ameliorates diabetes mellitus, improves the plasma lipid profile, increases bone density and may help to lose weight. However, as stated in the old medical saying “the beneficial effects of exercise are lost with exhaustion”. It has been known for some time that exhaustive exercise causes muscle soreness, induces an elevation of cytosolic enzyme activities in blood plasma and may be harmful. In the last decade a considerable amount of information concerning production of free radicals in exhaustive exercise has been obtained. An international symposium took place in Valencia, Spain in 1993 and a book was published on the sub…

Relationship Between Cognitive-Behavioral Impairment and Clinical and Functional Parameters in ALS and Reliability of the Edinburgh Cognitive and Behavioural ALS Screen to Assess ALS: Preliminary Findings

Background Although it is widely recognized that a high percentage of individuals with amyotrophic lateral sclerosis (ALS) have cognitive and behavioral impairment, the associated clinical and functional parameters remain unknown. ALS is typically assessed via screening tests, such as the Edinburgh Cognitive and Behavioural ALS Screen (ECAS). Objective To investigate the relationship between cognitive-behavioral impairment and other clinical and functional parameters and to compare the assessment results from a set of standardized neuropsychological tests with those from the ECAS. Methods Forty individuals with ALS participated in the study. We assessed attention, memory and learning abilit…

Home Mechanical Ventilation in Amyotrophic Lateral Sclerosis Patients Is Not Always a Problem

A simple noninvasive pressure–time index at the mouth to measure respiratory load during acute exacerbation of COPD A comparison with normal volunteers

We assessed the validity of the pressure-time index (PTI) measured at the mouth as a noninvasive and simplified alternative to conventional tension-time index for assessing respiratory load and inspiratory muscle force reserve. PTI was measured within 48 h of hospital admission and at 24 h before discharge in 37 consecutive patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) using the equation PTI = (P(awo)/MIP)(T(I)/T(T)) 100, where P(awo) is the mean airway pressure measured at the mouth, MIP the maximal inspiratory pressure, and T(I)/T(T) the inspiratory time (T(I)) to total cycle length (T(T)) ratio. Controls were 30 normal volunteers with similar anthropome…

Predictors for early readmission after COPD exacerbation

Aim: Identify predictors for early readmission in patients with COPD and severe exacerbation. Material and methods: Prospective study (July 2017-June 2018) that included all patients hospitalized for an acute exacerbations of COPD. Demographic date, clinical and spirometric parameters, arterial blood gases, length of stay, and evolutive parameters were collected. We used univariate and multivariate statistical techniques to identify risks for readmission. Results: 278 consecutive patients were enrolled. During the follow-up 31 (11%) patients were admitted within 30 days of discharge (early readmission). Univariate analysis showed that FEV1 (p=0.02), FEV1 (%) (p=0.01), total dose of steroids…

Ventricular structural changes in patients with sleep-disordered breathing (SDB) and myocardial infarction

Obstructive sleep apnea (OSA) is associated with cardiovascular diseases. Aim: To analyze structural parameters of myocardial damage in patients presenting with acute coronary syndrome (ACS) and its relationship with OSA severity. Method: This is a prospective, observational study in patients with a first acute myocardial infarction (MI) treated by percutaneous coronary intervention (PCI). Cardiovascular magnetic resonance (CMR) studies were performed at 3 days and 6 months. Eligible patients underwent a polysomnography within 30 days after PCI. Quantitative data were expressed as mean±SD. Linear regression analysis was used to describe associations between infarct characteristics and OSA. …

Endurance training in patients with chronic obstructive pulmonary disease: a comparison of high versus moderate intensity.

Abstract Gimenez M, Servera E, Vergara P, Bach JR, Polu J-M. Endurance training in patients with chronic obstructive pulmonary disease: a comparison of high versus moderate intensity. Arch Phys Med Rehabil 2000;81:102-9. Purpose: To create a maximum tolerated 45-minute aerobic training program for patients with chronic obstructive pulmonary disease (COPD) and to compare its outcomes with those of commonly prescribed moderate exercise. Design: Prospective, randomized trial. Setting: A work physiology laboratory. Patients and Methods: The maximum exercise intensities that 7 COPD patients could sustain for 45 minutes were determined on a bilevel exercise ergometer. The patients then exercised …

Pulmonologists, Mechanical Ventilation and Complementary Techniques

Usefulness of Oscillations Added to Mechanical In-Exsufflation in Amyotrophic Lateral Sclerosis.

BACKGROUND: Assisted coughing via mechanical in-exsufflation (MI-E) is a first-line treatment for secretion management in patients with amyotrophic lateral sclerosis (ALS) with unassisted CPF METHODS: We conducted a 12-month, prospective, randomized follow-up study of subjects with ALS for whom assisted coughing techniques were indicated. One group was treated with oscillations in addition to MI-E (MI-E+O), and the other group was treated with conventional MI-E. RESULTS: 29 subjects were included in the MI-E group and 27 subjects were included in the MI-E+O group. Five subjects (8.9%) required invasive techniques for secretion management (3 in the MI-E group and 2 in the MI-E+O group, P = .…

Hypoxic burden and angiogenic factors in patients with myocardial infarction and obstructive sleep apnea

Introduction: The amount and severity of hypoxia have been related to risk of cardiovascular events. Aim: To determine the relationship between nocturnal hypoxic burden and pro- angiogenic factors in patients with obstructive sleep apnea (OSA) and myocardial infarction (MI). Method: A prospective, observational study in patients with a first acute MI. Eligible patients underwent a polysomnography within 30 days after MI, and a serum blood sample was drawn in order to measure a panel of angiogenic factors by Luminex technology. A hypoxic burden index (HBI) was calculated as the integral area under the desaturation curve (obtained by calculating the integral of the oxygen saturation reduction…

Non-invasive management of an acute chest infection for a patient with ALS.

We describe a man diagnosed with non-bulbar amyotrophic lateral sclerosis (ALS) who uses 24-h non-invasive ventilator at home, and assisted cough through the use of the mechanical insufflation-exsufflation (MAC) device (CoughAssist, J.H. Emerson). This was essential for the removal of bronchial secretions in order to provide successful non-invasive management (and indeed less suffering for the patient) during an acute respiratory tract infection with hypoxemia and failure of manually assisted cough.

Bulbar impairment score predicts noninvasive volume-cycled ventilation failure during an acute lower respiratory tract infection in ALS.

Amyotrophic lateral sclerosis (ALS) patients can suffer episodes of lower respiratory tract infections (LRTI) leading to an acute respiratory failure (ARF) requiring noninvasive ventilation (NIV).To determine whether clinical or functional parameters can predict noninvasive management failure during LRTI causing ARF in ALS.A prospective study involving all ALS patients with ARF requiring NIV in a Respiratory Care Unit. NIV was provided with volume-cycled ventilators.63 ALS patients were included (APACHE II: 14.93±3.56, Norris bulbar subscore (NBS): 18.78±9.68, ALSFRS-R: 19.90±6.98, %FVC: 40.01±18.07%, MIC: 1.62±0.74L, PCF 2.51±1.15L/s, PImax -34.90±19.44cmH2O, PEmax 51.20±28.84cmH2O). In 73…

Contestación a la carta de los Dres. F. Barbé, B. Togores y A.G.N. Agustí

Effect of High-Frequency Oscillations on Cough Peak Flows Generated by Mechanical In-Exsufflation in Medically Stable Subjects With Amyotrophic Lateral Sclerosis.

BACKGROUND: Mechanically assisted coughing with mechanical in-exsufflation (MI-E) is recommended for noninvasive management of respiratory secretions in amyotrophic lateral sclerosis (ALS). To improve the effectiveness of the technique, a new device combining MI-E with high-frequency oscillations (HFO) has been developed. This work aimed to assess the effect of HFO on the cough peak flow generated by MI-E in medically stable subjects with ALS. METHODS: This was a prospective study that included subjects with ALS in a medically stable condition. Cough peak flow generated by MI-E was measured in 4 situations: without HFO, with HFO during insufflation, with HFO during exsufflation, and with HF…

Performance of a Highly Sensitive Mycobacterium tuberculosis Complex Real-Time PCR Assay for Diagnosis of Pulmonary Tuberculosis in a Low-Prevalence Setting: a Prospective Intervention Study

ABSTRACT The potential impact of routine real-time PCR testing of respiratory specimens from patients with presumptive tuberculosis in terms of diagnostic accuracy and time to tuberculosis treatment inception in low-prevalence settings remains largely unexplored. We conducted a prospective intervention cohort study. Respiratory specimens from 1,020 patients were examined by acid-fast bacillus smear microscopy, tested by a real-time Mycobacterium tuberculosis complex PCR assay (Abbott RealTi me MTB PCR), and cultured in mycobacterial media. Seventeen patients tested positive by PCR (5 were acid-fast bacillus smear positive and 12 acid-fast bacillus smear negative), and Mycobacterium tubercul…

Non-invasive ventilation effectiveness and the effect of ventilatory mode on survival in ALS patients.

Non-invasive ventilation (NIV) prolongs survival in amyotrophic lateral sclerosis (ALS), but there are no data with which to compare the effectiveness of the different ventilator modes – volume (Vol-NIV) or pressure-cycled (Pres-NIV) ventilation – in ALS. We aimed to determine whether the ventilatory mode has an effect on ventilation effectiveness and survival of ALS patients using NIV. We used a retrospective study that included all ALS patients for whom NIV was indicated in two referral units: one using Vol-NIV and the other using Pres-NIV. Demographic, functional and nocturnal gas exchange parameters at NIV initiation were recorded. Eighty-two ALS patients ventilated using Pres-NIV and 6…

Traqueotomía en enfermos con ELA: pro

Effect of lung mechanics on mechanically assisted flows and volumes.

To correlate the air flows generated by mechanical insufflation-exsufflation as a function of pressure delivery in a lung model at two pulmonary compliance and three airway resistance settings.With each combination of pulmonary compliances of 25 and 50 ml/cm H2O and airway resistances of 6, 11, and 17 cm H2O/liter/sec, ten cycles of mechanical insufflation-exsufflation were applied using pressure deliveries of 40 to -40, 50 to -50, 60 to -60, and 70 to -70 cm H2O. The resulting peak exsufflation flows and volumes were recorded.In a multivariate analysis, the pulmonary compliance, airway resistance, and pressure delivery were all found to significantly affect exsufflation flows and volumes s…

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

Abstract Although no clear recommendations are given about when percutaneous endoscopic gastrostomy (PEG) should be placed in amyotrophic lateral sclerosis (ALS) patients, some experts underline the risk of respiratory complications when patients had severe ventilatory muscle impairment (SVMI). Aim To evaluate the efficacy of noninvasive ventilation (NIV) and mechanically assisted cough (MAC) to avoid respiratory complications related to PEG placement in ALS patients with SVMI. Material and methods Prospective study including ALS patients who had chosen to have PEG placement timed by swallowing dysfunction with the aid of NIV and MAC if needed. PEG was carried out under volume-cycled NIV th…

Efficacy of Mechanical Insufflation-Exsufflation in Medically Stable Patients With Amyotrophic Lateral Sclerosis

Objective: To determine under what circumstances the use of mechanical insufflation-exsufflation (MI-E) can generate clinically effective expiratory flows for airway clearance (> 2.7 L/s) for clinically stable patients with amyotrophic lateral sclerosis (ALS). Materials and method: Twenty-six consecutive patients with ALS were studied, 15 with severe bulbar dysfunction. Using a pneumotachograph and with the aid of an oronasal mask, we measured FVC, FEV1, peak cough flow (PCF), maximum insufflation capacity (MIC), PCF generated from a maximum insufflation MIC (PCFMIC), and PCF generated by MI-E (PCFMI-E). MI-E was delivered at 40 cm H2O. Maximum inspiratory pressure (PImax) and maximum expir…

Exercise causes blood glutathione oxidation in chronic obstructive pulmonary disease: prevention by O2 therapy

Viña, José, Emilio Servera, Miguel Asensi, Juan Sastre, Federico V. Pallardó, José A. Ferrero, JoséGarcı́a-de-la-Asunción, Vicente Antón, and Julio Marı́n. Exercise causes blood glutathione oxidation in chronic obstructive pulmonary disease: prevention by O2therapy. J. Appl. Physiol. 81(5): 2199–2202, 1996.—The aim of the present study was to determine whether glutathione oxidation occurs in chronic obstructive pulmonary disease (COPD) patients who perform exercise and whether this could be prevented. Blood glutathione red-ox ratio [oxidized-to-reduced glutathione (GSSG/GSH)] was significantly increased when patients performed exercise for a short period of time until exhaustion. Their res…

Secretion Management Must Be Considered When Reporting Success or Failure of Noninvasive Ventilation

Ayudas a los músculos respiratorios durante un episodio de aspiración en un enfermo con distrofia muscular de Duchenne

Presentamos el caso de un enfermo afectado de distrofia muscular de Duchenne con buena funcion bulbar, pero con disminucion importante de la capacidad vital forzada (9%) y del pico de flujo de tos espontaneo (2,35 l/s) que le obligaba a mantener ventilacion no invasiva (VNI) continua (ventilador volumetrico, mascarilla nasal nocturna y pieza bucal en vigilia) y a utilizar ayudas manuales para la tos mediante insuflaciones con ambu y compresion toracica espiratoria (pico de flujo de tos asistida tras maxima capacidad de insuflacion de 4,33 l/s). El paciente presento una aspiracion importante de material digestivo que se resolvio gracias a la asociacion de las ayudas manuales para la tos prop…

Factores predictivos de reingreso hospitalario en la agudización de la EPOC moderada-grave

Objetivos: Conocer los factores asociados a la exacerbacion de la enfermedad pulmonar obstructiva (EPOC) es importante para mejorar la supervivencia de los pacientes y conseguir mayor efectividad en su tratamiento. El objetivo de este estudio es identificar las variables asociadas con el reingreso hospitalario en la agudizacion de la EPOC moderada-grave. Pacientes y metodos: Se estudio de forma prospectiva a 90 pacientes con EPOC moderada-grave ingresados de manera consecutiva en nuestro Servicio de Neumologia por exacerbacion de su enfermedad. En el momento del alta se evaluaron las variables clinicas, espirometricas y gasometricas, asi como el estado muscular, mediante medidas no invasiva…

[Risk factors of readmission in acute exacerbation of moderate-to-severe chronic obstructive pulmonary disease].

More effective management of chronic obstructive pulmonary disease (COPD) and improved survival of COPD patients requires a better understanding of the risk factors for exacerbation. The aim of this study was to identify factors related to readmission in patients with moderate-to-severe COPD.Ninety patients with moderate-to-severe COPD hospitalized consecutively for acute exacerbation were studied prospectively. At discharge, the following potential predictors were assessed: clinical and spirometric variables, arterial blood gases, and respiratory muscle strength determined noninvasively. The patients were followed for a period of 3 months. Readmission for exacerbation and time intervals fr…

[Recommendations for end-of-life care in patients with chronic obstructive pulmonary disease].

Over the last 20 years, advances in the treatment of patients with chronic obstructive pulmonary disease (COPD) have improved survival even among patients in the most advanced stages of the disease, such as those requiring domiciliary oxygen therapy.1,2 This improvement—in principle a positive development—has given rise to considerable clinical problems associated with the establishment of a therapeutic ceiling and the difficulty of determining prognosis in some of these patients. In this situation, the clinician should consider introducing palliative care, that is, care aimed at improving symptom control, communication, physical activity, and emotional support, in order to achieve the best…

Cigarette Smoke Increases Endothelial CXCL16-Leukocyte CXCR6 Adhesion In Vitro and In Vivo. Potential Consequences in Chronic Obstructive Pulmonary Disease

Cardiovascular disease (CVD) is a major comorbidity in chronic obstructive pulmonary disease (COPD). Although the mechanism of its development remains largely unknown, it appears to be associated with cigarette consumption and reduced lung function. Therefore, the aim of this study was to investigate the potential link between water-soluble cigarette smoke extract (CSE)-induced endothelial dysfunction and the function of CXCL16/CXCR6 axis on the initial attachment of leukocytes, in addition to its possible impact on COPD-associated systemic inflammation. To do this, we employed several experimental approaches, including RNA silencing and flow cytometry analysis, the dynamic flow chamber tec…

Effectiveness of assisted and unassisted cough capacity in amyotrophic lateral sclerosis patients.

Decreased cough capacity during a respiratory infection is one of the main causes of acute respiratory failure and hospitalisation in amyotrophic lateral sclerosis (ALS).To determine whether a respiratory measurement could identify the effectiveness of cough capacity in ALS during a respiratory infection.This was a prospective study of all ALS patients who were treated at a respiratory care unit due to a respiratory infection from 2012 to 2016. The effectiveness of unassisted and assisted coughing was evaluated and respiratory function tests were performed during the acute episode.Forty-eight ALS patients were enrolled, with only four having an effective unassisted cough. The variable which…

Exercise induces oxidative stress in healthy subjects and in chronic obstructive pulmonary disease patients

Entrenamiento de los músculos ventilatorios

Ventilación asistida vía máscara nasal en pacientes hospitalizados en una sala de neumología por descompensación de su obstrucción crónica al flujo aéreo

Our aim was to evaluate the efficacy of assisted ventilation through a nasal mask (AVN) in treating chronic obstructive pulmonary disease (COPD) patients who were admitted to a pneumology ward due to decompensation, with PaCO2 > 60 mmHg and pH < 7.35. We studied 13 COPD patients who were first observed for 1-2 days until adaptation and then given 2 daily sessions of AVN lasting 4 hours with double positive pressure (DP90) devices through Sullivan mask with a cannula for hyperoxia. Gasometric readings were recorded, along with subjective assessment of condition and problems with the mask. Gasometric readings were taken as follows: the first upon admission to the ward (AW), the second with AV…

Alternatives to Endotracheal Intubation for Patients with Neuromuscular Diseases

To evaluate the usefulness of continuous noninvasive mechanical ventilation and mechanical coughing aids to avoid endotracheal intubation and tracheostomy during episodes of acute respiratory failure in patients with neuromuscular disease.We conducted a prospective cohort study at the respiratory medicine ward of a university hospital to study the success rate of the use of continuous noninvasive mechanical ventilation and manually and mechanically (CoughAssist) assisted coughing to avert endotracheal intubation in 24 consecutive episodes of acute respiratory failure for 17 patients with neuromuscular disease. The noninvasive mechanical ventilation and coughing aids were used to reverse dec…

Effect of a short-term psychological intervention on the anxiety and depression of amyotrophic lateral sclerosis patients

This study evaluated the effectiveness of a psychological intervention in amyotrophic lateral sclerosis patients, consisting of four semi-structured sessions of cognitive behavioural therapy combined with counselling techniques. An intervention group and a control group were established. The Hospital Anxiety and Depression Scale was used to assess levels of anxiety and depression. In total, fifty-four patients took part. Prior to the intervention, the intervention group displayed rates of 63.3 and 36.7 per cent for anxiety and depression, respectively, falling to 16.7 and 10.0 per cent afterwards. The psychological intervention demonstrated potential for the reduction of levels of anxiety …

Non-invasive ventilation in amyotrophic lateral sclerosis.

Tos asistida, presión abdominal y cifoscoliosis grave

Noninvasive ventilation during the weaning process in chronically critically ill patients.

Chronically critically ill patients often undergo prolonged mechanical ventilation. The role of noninvasive ventilation (NIV) during weaning of these patients remains unclear. The aim of this study was to determine the value of NIV and whether a parameter can predict the need for NIV in chronically critically ill patients during the weaning process. We conducted a prospective study that included chronically critically ill patients admitted to Spanish respiratory care units. The weaning method used consisted of progressive periods of spontaneous breathing trials. Patients were transferred to NIV when it proved impossible to increase the duration of spontaneous breathing trials beyond 18 h. 2…

Tolerance of Volume Control Noninvasive Ventilation in Subjects With Amyotrophic Lateral Sclerosis.

BACKGROUND: Noninvasive ventilation (NIV) tolerance has been identified as an independent predictor of survival in amyotrophic lateral sclerosis (ALS). Volume control continuous mandatory ventilation (VC-CMV) NIV has been associated with poor tolerance. The aim of this study was to determine the tolerance of subjects with ALS to VC-CMV NIV. METHODS: This was a prospective study involving subjects with ALS who were treated with VC-CMV NIV. Respiratory and functional parameters were recorded when the subjects began ventilatory support. NIV tolerance was evaluated after 3 months. RESULTS: Eighty-seven subjects with ALS were included. After 3 months, 80 subjects (92%) remained tolerant of NIV. …

Unstable control of breathing can lead to ineffective noninvasive ventilation in amyotrophic lateral sclerosis

Upper airway obstruction with decreased central drive (ODCD) is one of the causes of ineffective noninvasive ventilation (NIV) in amyotrophic lateral sclerosis (ALS). The aim of this study is to determine the mechanism responsible for ODCD in ALS patients using NIV. This is a prospective study that included ALS patients with home NIV. Severity of bulbar dysfunction was assessed with the Norris scale bulbar subscore; data on upper or lower bulbar motor neuron predominant dysfunction on physical examination were collected. Polysomnography was performed on every patient while using NIV and the ODCD index (ODCDI: number of ODCD events/total sleep time) was calculated. To determine the possible …

Noninvasive Ventilatory Assistance During Exercise for Patients with Kyphoscoliosis

The goal was to determine whether noninvasive ventilatory assistance (NIV) could facilitate exercise performance and benefit physiologic parameters for eight hypercapnic kyphoscoliosis patients using a cycloergometer for 6-min periods at a constant power (20 W). The exercise protocols were performed in random order while breathing unaided (spontaneous breathing test or SBT) and also while receiving NIV (NIV test or NIVT). The NIV was pressure support (15 cm H2O) plus positive end expiratory pressure (PEEP) (4 cm H2O) via a nasal mask. Of the compared parameters, heart rate was not significantly different, but acidosis (pH = 7.32 +/- 0.04 vs. 7.36 +/- 0.04), hypoxia (PaO2 = 61.5 +/- 15.9 vs.…

Effect of one-year dextromethorphan/quinidine treatment on management of respiratory impairment in amyotrophic lateral sclerosis

Abstract Treatment with Dextromethorphan/Quinidine (DM/Q) has demonstrated benefit on pseudobulbar affect and bulbar function in amyotrophic lateral sclerosis (ALS). The aim of this study was to assess whether DM/Q could provide long-term improvement in bulbar function and thereby prolong noninvasive respiratory management in ALS. Materials and methods This prospective, case-cohort study, recruited ALS patients with bulbar dysfunction. Subjects included were compared with cross-matched historical controls. Cases received DM/Q (20/10 mg twice daily) during one-year follow-up; bulbar dysfunction was evaluated with the Norris scale bulbar subscore (NBS) and bulbar subscale of AlSFRS-R (ALSFRSb…

Mechanical Insufflation-Exsufflation With Oscillations in Amyotrophic Lateral Sclerosis With Home Ventilation via Tracheostomy

BACKGROUND: Mechanical insufflation-exsufflation (MI-E) applied via tracheostomy tubes in patients with amyotrophic lateral sclerosis (ALS) who are on home mechanical ventilation via tracheostomy is an effective procedure for respiratory secretion management. Nonetheless, tenacious secretions may remain and increase the risk of respiratory infections. The aim of this study was to determine whether adding oscillations to MI-E could reduce the rate of respiratory infections and the need for bronchoscopy to remove secretions in patients with ALS on home mechanical ventilation via tracheostomy. METHODS: This was a 2-y, prospective, crossover study. Subjects were treated with conventional MI-E a…

Bulbar impairment score and survival of stable amyotrophic lateral sclerosis patients after noninvasive ventilation initiation

There is general agreement that noninvasive ventilation (NIV) prolongs survival in amyotrophic lateral sclerosis (ALS) and that the main cause of NIV failure is the severity of bulbar dysfunction. However, there is no evidence that bulbar impairment is a contraindication for NIV. The aim of this study was to determine the effect of bulbar impairment on survival in ALS patients with NIV. ALS patients for whom NIV was indicated were included. Those patients who refused NIV were taken as the control group. 120 patients who underwent NIV and 20 who refused NIV were included. The NIV group presented longer survival (median 18.50 months, 95% CI 12.62–24.38 months) than the no-NIV group (3.00 mont…

Predictors of need for noninvasive ventilation during respiratory tract infections in medically stable, non-ventilated subjects with amyotrophic lateral sclerosis.

BACKGROUND: Acute lower respiratory infections can impair muscle strength in patients with amyotrophic lateral sclerosis (ALS). When associated with an increase in load on the respiratory system, this situation may precipitate hypercapnic respiratory failure in non-ventilated patients with ALS. The aim of this study was to determine whether a clinical or functional parameter can predict the need for noninvasive ventilation (NIV) during an acute respiratory infection for medically stable, non-ventilated patients with ALS. METHODS: This was a prospective study involving all non-ventilated subjects with ALS admitted due to an acute respiratory infection to a respiratory care unit from a tertia…

Predictors of mortality in COPD patients after hospitalization due to an exacerbation

Aim: Identify factors related to mortality at 6 months after hospitalization by an acute COPD exacerbation (AECOPD). Method: We performed a 12-month prospective, observational study (July 2017-June 2018) that included COPD patients admitted by an AECOPD. Sociodemographic data, comorbidities, functional and clinical parameters were collected. Mortality at 6 months of admission was considered the end point. Results: 278 consecutive patients were enrolled, of whom 48 (16.2%) died during 6 months after AECOPD. Univariate analysis showed that age (p Conclusions: In COPD patients, Barthel Index, grade of dyspnea and previous hospitalizations are independent risk factors for mortality at 6 months,…

Long-Term Oxygen Therapy