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

Although no clear recommendations are given about when percutaneous endoscopic gastrostomy (PEG) should be placed in amyotrophic lateral sclerosis (ALS) patients, some experts underline the risk of respiratory complications when patients had severe ventilatory muscle impairment (SVMI). Aim: To evaluate the efficacy of noninvasive ventilation (NIV) and mechanically assisted cough (MAC) to avoid respiratory complications related to PEG placement in ALS patients with SVMI. Material and methods: Prospective study including ALS patients who had chosen to have PEG placement timed by swallowing dysfunction with the aid of MV and MAC if needed. PEG was carried out under volume-cycled NIV through a nasal mask. MAC was applied prior to and at the end of the procedure. Results: Thirty ALS patients (60.43 +/- 12.03 years) were included. Prior to PEG placement: BMI 25.0 +/- 4.6 kg/m(2), ALSRFS-R 19.5 +/- 5.0, Norris bulbar sub-score 15.1 +/- 6.6, %FVC 35.9 +/- 18.1%, PCF 23 +/- 1.2 L/s, Plmax -35.6 +/- 24.6 cm H2O, and PEmax 40.5 +/- 23.9 cm H2O. Three patients had PEG placement under tracheotomy ventilation because NIV SpO(2) was below 88%. No patient died during the procedure nor did any have respiratory complications. Survival at 1 month was 100%. Conclusion: Respiratory support provided by volume-cycled NIV and MAC permits successful PEG placement in most ALS patients with SVMI. (C) 2010 Elsevier B.V. All rights reserved.