Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration, 2014; 15: 154
LETTER TO THE EDITOR
Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration Downloaded from informahealthcare.com by University of Bristol on 03/05/15 For personal use only.
Non-invasive ventilation in amyotrophic lateral sclerosis. Hypoventilation and oxygen desaturation: two faces of the same coin?
ANTONIO M. ESQUINAS Intensive Care Unit and Non-Invasive Ventilatory Unit, Hospital Morales Meseguer Murcia, Spain
Dear Sir Amyotrophic lateral sclerosis (ALS) is a disease of poor prognosis and rapid deterioration culminating in respiratory failure in most cases (1). Non-invasive ventilation (NIV) provides symptomatic relief; however, a greater understanding of alterations in gas exchange in the later stages of NIV treated ALS is required (2). Gonzalez-Bermejo et al. describe factors that influence NIV adherence and effectiveness in ALS after NIV initiation and concluded that correction of nocturnal oxygen desaturation is an independent prognostic factor at first month of NIV (3). This is of practical implication for NIV and long-term outcome. However, the effectiveness of NIV is determined by a variety of factors that can lead to hypoventilation that may influence NIV effectiveness. While SpO2 is an appropriate measure, analysis of the implications of additional nocturnal measurement of carbon dioxide is also of benefit (4). This is relevant because Gonzalez-Bermejo et al. enrolled symptomatic ALS patients with chronic hypercapnic respiratory failure (PaCO2 mmHg. 49.1 (45.1–57.2) and 51.4 (48–58.3), groups 1 and 2, respectively) (3). Additional monitoring of carbon dioxide can help to differentiate between hypoxaemia related to ventilation/perfusion mismatch and hypoventilation, and is also useful in determining the degree of compliance with NIV (5). Carbon dioxide monitoring can also help to differentiate between true respiratory decline and leaking of the NIV apparatus (6). These are important practical aspects, especially at the beginning of NIV. Moreover, it would be useful to have further information regarding patient synchronization during NIV, as this has implications for nocturnal oxygen and hypoventilation (7).
Further prospective large clinical trials will encourage establishing risk factors for NIV adherence in ALS.4. Declaration of interest: The author reports no confl icts of interest. The author alone is responsible for the content and writing of the paper. References 1. Carratù P, Cassano A, Gadaleta F, Tedone M, Dongiovanni S, Fanfulla F, Resta O. Association between low sniff nasalinspiratory pressure (SNIP) and sleep disordered breathing in amyotrophic lateral sclerosis: preliminary results. Amyotroph Lateral Scler. 2011;12:458–63. 2. Farrero E, Prats E, Povedano M, Martinez-Matos JA, Manresa F, Escarrabill J. Survival in amyotrophic lateral sclerosis with home mechanical ventilation: the impact of systematic respiratory assessment and bulbar involvement. Chest. 2005;127:2132–8. 3. Gonzalez-Bermejo J, Morelot-Panzini C, Arnol N, Meininger V, Kraoua S, Salachas F, Similowski T. Prognostic value of efficiently correcting nocturnal desaturations after one month of non-invasive ventilation in amyotrophic lateral sclerosis: a retrospective monocentre observational cohort study. Amyotroph Lateral Scler Frontotemporal Degener. 2013 Mar 26. [Epub ahead of print] PubMed PMID: 23527531. 4. Kim SM, Park KS, Nam H, Ahn SW, Kim S, Sung JJ, Lee KW. Capnography for assessing nocturnal hypoventilation and predicting compliance with subsequent non-invasive ventilation in patients with ALS. PLoS One. 2011 Mar Berry RB, Sriram P. Evaluation of hypoventilation. Semin Respir Crit Care Med. 2009;30:303–14. 5. Nardi J, Prigent H, Adala A, Bohic M, Lebargy F, Quera-Salva MA, et al. Nocturnal oximetry and transcutaneous carbon dioxide in home-ventilated neuromuscular patients. Respir Care. 2012;57:1425–30. 6. Janssens JP, Borel JC, Pépin JL, SomnoNIV Group. Nocturnal monitoring of home non-invasive ventilation: the contribution of simple tools such as pulse oximetry, capnography, built-in ventilator software and autonomic markers of sleep fragmentation. Thorax. 2011;66:438–45. 7. Atkeson AD, RoyChoudhury A, Harrington-Moroney G, Shah B, Mitsumoto H, Basner RC. Patient-ventilator asynchrony with nocturnal non-invasive ventilation in ALS. Neurology. 2011;77:549–55.
Correspondence: A. M. Esquinas, Avenida Marques Velez s/n, Murcia, Spain 30.008. Fax: 34 968232484. E-mail: [email protected] (Received 5 July 2013 ; accepted 20 August 2013) ISSN 2167-8421 print/ISSN 2167-9223 online © 2014 Informa Healthcare DOI: 10.3109/21678421.2013.837932
LETTER TO THE EDITOR
Amyotrophic Lateral Sclerosis and Frontotemporal Degeneration Downloaded from informahealthcare.com by University of Bristol on 03/05/15 For personal use only.
Non-invasive ventilation in amyotrophic lateral sclerosis. Hypoventilation and oxygen desaturation: two faces of the same coin?
ANTONIO M. ESQUINAS Intensive Care Unit and Non-Invasive Ventilatory Unit, Hospital Morales Meseguer Murcia, Spain
Dear Sir Amyotrophic lateral sclerosis (ALS) is a disease of poor prognosis and rapid deterioration culminating in respiratory failure in most cases (1). Non-invasive ventilation (NIV) provides symptomatic relief; however, a greater understanding of alterations in gas exchange in the later stages of NIV treated ALS is required (2). Gonzalez-Bermejo et al. describe factors that influence NIV adherence and effectiveness in ALS after NIV initiation and concluded that correction of nocturnal oxygen desaturation is an independent prognostic factor at first month of NIV (3). This is of practical implication for NIV and long-term outcome. However, the effectiveness of NIV is determined by a variety of factors that can lead to hypoventilation that may influence NIV effectiveness. While SpO2 is an appropriate measure, analysis of the implications of additional nocturnal measurement of carbon dioxide is also of benefit (4). This is relevant because Gonzalez-Bermejo et al. enrolled symptomatic ALS patients with chronic hypercapnic respiratory failure (PaCO2 mmHg. 49.1 (45.1–57.2) and 51.4 (48–58.3), groups 1 and 2, respectively) (3). Additional monitoring of carbon dioxide can help to differentiate between hypoxaemia related to ventilation/perfusion mismatch and hypoventilation, and is also useful in determining the degree of compliance with NIV (5). Carbon dioxide monitoring can also help to differentiate between true respiratory decline and leaking of the NIV apparatus (6). These are important practical aspects, especially at the beginning of NIV. Moreover, it would be useful to have further information regarding patient synchronization during NIV, as this has implications for nocturnal oxygen and hypoventilation (7).
Further prospective large clinical trials will encourage establishing risk factors for NIV adherence in ALS.4. Declaration of interest: The author reports no confl icts of interest. The author alone is responsible for the content and writing of the paper. References 1. Carratù P, Cassano A, Gadaleta F, Tedone M, Dongiovanni S, Fanfulla F, Resta O. Association between low sniff nasalinspiratory pressure (SNIP) and sleep disordered breathing in amyotrophic lateral sclerosis: preliminary results. Amyotroph Lateral Scler. 2011;12:458–63. 2. Farrero E, Prats E, Povedano M, Martinez-Matos JA, Manresa F, Escarrabill J. Survival in amyotrophic lateral sclerosis with home mechanical ventilation: the impact of systematic respiratory assessment and bulbar involvement. Chest. 2005;127:2132–8. 3. Gonzalez-Bermejo J, Morelot-Panzini C, Arnol N, Meininger V, Kraoua S, Salachas F, Similowski T. Prognostic value of efficiently correcting nocturnal desaturations after one month of non-invasive ventilation in amyotrophic lateral sclerosis: a retrospective monocentre observational cohort study. Amyotroph Lateral Scler Frontotemporal Degener. 2013 Mar 26. [Epub ahead of print] PubMed PMID: 23527531. 4. Kim SM, Park KS, Nam H, Ahn SW, Kim S, Sung JJ, Lee KW. Capnography for assessing nocturnal hypoventilation and predicting compliance with subsequent non-invasive ventilation in patients with ALS. PLoS One. 2011 Mar Berry RB, Sriram P. Evaluation of hypoventilation. Semin Respir Crit Care Med. 2009;30:303–14. 5. Nardi J, Prigent H, Adala A, Bohic M, Lebargy F, Quera-Salva MA, et al. Nocturnal oximetry and transcutaneous carbon dioxide in home-ventilated neuromuscular patients. Respir Care. 2012;57:1425–30. 6. Janssens JP, Borel JC, Pépin JL, SomnoNIV Group. Nocturnal monitoring of home non-invasive ventilation: the contribution of simple tools such as pulse oximetry, capnography, built-in ventilator software and autonomic markers of sleep fragmentation. Thorax. 2011;66:438–45. 7. Atkeson AD, RoyChoudhury A, Harrington-Moroney G, Shah B, Mitsumoto H, Basner RC. Patient-ventilator asynchrony with nocturnal non-invasive ventilation in ALS. Neurology. 2011;77:549–55.
Correspondence: A. M. Esquinas, Avenida Marques Velez s/n, Murcia, Spain 30.008. Fax: 34 968232484. E-mail: [email protected] (Received 5 July 2013 ; accepted 20 August 2013) ISSN 2167-8421 print/ISSN 2167-9223 online © 2014 Informa Healthcare DOI: 10.3109/21678421.2013.837932
