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

• Published in: Chest Vol. 125; no. 4; pp. 1400 - 1405
• Main Authors: Sancho, Jesús, Servera, Emilio, Díaz, Juan, Marín, Julio
• Format: Journal Article
• Language: English
• Published: Northbrook, IL Elsevier Inc 01.04.2004; American College of Chest Physicians
• Subjects: Amyotrophic lateral sclerosis; Amyotrophic Lateral Sclerosis - therapy; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Cardiology. Vascular system; Cough - therapy; cough capacity; Degenerative and inherited degenerative diseases of the nervous system. Leukodystrophies. Prion diseases; Disease; Evaluation Studies as Topic; Exhalation - physiology; Female; Humans; Insufflation - methods; lung function test; Male; Masks; mechanical insufflation-exsufflation; Medical sciences; Middle Aged; Neurology; neuromuscular disease; Neuromuscular diseases; noninvasive respiratory aids; noninvasive ventilation; Ostomy; peak cough flow; Pneumology; Positive-Pressure Respiration - methods; Respiratory Insufficiency - etiology; Respiratory Insufficiency - therapy; Respiratory system : syndromes and miscellaneous diseases; Tracheotomy; Madrid Spain; Spain; peak cough flow; PCFmic; mechanical insufflation-exsufflation; MIC; noninvasive ventilation; ROC; ALS; neuromuscular disease; amyotrophic lateral sclerosis; lung function test; MI-E; cough capacity; PCF; PCFmi-e; Pimax; noninvasive respiratory aids; NEP; Pemax; Motor neuron disease; mechanical insufflation-exsufflation. neuromuscular disease; Respiratory system; Respiratory tract; Lung function; Capacity; Efficiency; Anesthesia; Degenerative disease; Peak; Cardiology; Human; Immunopathology; Nervous system diseases; Neuromuscular diseases; AIDS; Amyotrophic lateral sclerosis; Immune deficiency; Cough; Infection; Viral disease; Central nervous system disease; Ventilation; Circulatory system; Spinal cord disease
• ISSN: 0012-3692; 1931-3543
• DOI: 10.1378/chest.125.4.1400

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). 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 expiratory pressure (Pemax) at the mouth were also measured. Although both groups had a similar time from ALS symptom onset to diagnosis, statistical differences (p < 0.05) were found between nonbulbar and bulbar patients in lung function and cough capacity parameters: FVC, 2.58 ± 1.24 L vs 1.62 ± 0.74 L; FEV1, 2.26 ± 1.18 L vs 1.54 ± 0.69 L; Pimax, – 93.45 ± 47.47 cm H2O vs − 3.64 ± 25.07 cm H2O; Pemax, 140.45 ± 75.98 cm H2O vs 69.93 ± 32.14 cm H2O; MIC, 3.02 ± 1.22 L vs 1.97 ± 0.75 L; PCF, 5.91 ± 2.55 L/s vs 3.42 ± 1.44 L/s; PCFmic, 6.68 ± 2.71 L/s vs 4.00 ± 1.48 L/s; and PCFmi-e, 4.34 ± 0.82 L/s vs 3.35 ± 0.77 L/s. Four patients with bulbar dysfunction and MIC > 1 L had PCFmi-e < 2.7 L/s. The receiver operating characteristic (ROC) curve analysis showed PCFmic of ≤ 2.7 L/s predicting those patients with PCFmi-e < 2.7 L/s. The ROC curve analysis showed PCFmic > 4 L/s predicting those patients with PCFmic greater than PCFmi-e. MI-E is able to generate clinically effective PCFmi-e (> 2.7 L/s) for stable patients with ALS, except for those with bulbar dysfunction who also have a MIC > 1 L and PCFmic <2.7 L/s who probably have severe dynamic collapse of the upper airways during the exsufflation cycle. Clinically stable patients with mild respiratory dysfunction and PCFmic > 4 L/s might not benefit from MI-E except during an acute respiratory illness.