Survival in amyotrophic lateral sclerosis with home mechanical ventilation: the impact of systematic respiratory assessment and bulbar involvement.
OBJECTIVE
To analyze (1) the impact of a protocol of early respiratory evaluation of the indications for home mechanical ventilation (HMV) in patients with amyotrophic lateral sclerosis (ALS), and (2) the effects of the protocol and of bulbar involvement on the survival of patients receiving noninvasive ventilation (NIV).


METHODS
Retrospective study in a tertiary care referral center.


METHODS
HMV was indicated in 86 patients with ALS, with 22 patients (25%) presenting with intolerance to treatment associated with bulbar involvement. Treatment with HMV had been initiated in 15 of 64 patients prior to initiating the protocol (group A) and in the remaining 49 patients after protocol initiation (group B).


RESULTS
In group A, the majority of patients began treatment with HMV during an acute episode requiring ICU admission (p = 0.001) and tracheal ventilation (p = 0.025), with a lower percentage of patients beginning HMV treatment without respiratory insufficiency (p = 0.013). No significant differences in survival rates were found between groups A and B among patients treated with NIV. Greater survival was observed in group B (p = 0.03) when patients with bulbar involvement were excluded (96%). Patients without bulbar involvement at the start of therapy with NIV presented a significantly better survival rate (p = 0.03). Multivariate analysis showed bulbar involvement to be an independent prognostic factor for survival (relative risk, 1.6; 95% confidence interval, 1.01 to 2.54; p = 0.04). No significant differences in survival were observed between patients with bulbar involvement following treatment with NIV and those with intolerance, except for the subgroup of patients who began NIV treatment with hypercapnia (p = 0.0002).


CONCLUSIONS
Early systematic respiratory evaluation in patients with ALS is necessary to improve the results of HMV. Further studies are required to confirm the benefits of NIV treatment in patients with bulbar involvement, especially in the early stages.
Farrero
Eva
E
Pulmonary Department, Hospital Universitari de Bellvitge, Feixa Llarga s/n, 08907 L'Hospitalet, Barcelona, Spain. efarrero@csub.scs.es
Prats
Enric
E
Povedano
Mónica
M
Martinez-Matos
J Antonio
JA
Manresa
Frederic
F
Escarrabill
Joan
J
D000328:Adult; D000690:Amyotrophic Lateral Sclerosis / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D010244:Bulbar Palsy, Progressive / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D015331:Cohort Studies; D005260:Female; D006699:Home Care Services; D006801:Humans; D008297:Male; D008875:Middle Aged; D011336:Probability; D011379:Prognosis; D016016:Proportional Hazards Models; D011665:Pulmonary Valve Insufficiency / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D012121:Respiration, Artificial / Q000379:methods*; D012129:Respiratory Function Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D016896:Treatment Outcome