NIV feasibility during PEG tube placement in bulbar ALS patients: our experience

Background: Percutaneous Endoscopic Gastrostomy (PEG) is the most widely used procedure for feeding dysphagia in ALS patients with respiratory muscle impairment (RMI). Several studies show that it improves survival. NIV may reduce respiratory complications in ALS patients with forced vital capacity (FVC) less than 50% predicted. Moreover, patients and caregiver’s psychological well-being could decline and some distressing symptoms could occur. Aim: We report our experience of PEG tube placement (PEGTP) with NIV in patients with ALS.Methods: This prospective study was performed between December 2012 and September 2014 in our HD Respiratory Rehabilitation Unit. Data was also retrieved through validated questionnaires considering the following psychological factors: anxiety, depression and Quality of Life. PEGTP was performed during pressure-support/assist-control mode NIV through a nasal mask (nNIV) by a Respiratory Therapist (RT). Mechanical Insufflation-Exsufflation (MI-E) was applied before PEGTP if needed. The RT performed trainings before the PEGTP, with nNIV in patients who were not ventilated at home and who were already ventilated via oronasal mask; The effectiveness of nNIV was checked through patient subjective tolerance, for example, through clinical and gasometric response. In the Endoscopy Unit, sedoanalgesia with midazolam was initiated and biological variables (SpO2, heart rate, respiratory rate, and blood pressure) were monitored continuously.Results:nNIV training required a mean of 3.56 days. Two patients (8%) presented a desaturation during PEGTP. After two months of PEGTP, one patient (4%) died. Conclusions:Our results support the mandatory use of NIV during PEGTP in ALS bulbar onset patients and RMI, and it is associated with minimal peri and post-procedural complications. Therefore, we can conclude that PEGTP in patients with ALS and RMI is safe for the management of NIV and MI-E before PEGTP,with RT support.