title: A risk stratifying tool to facilitate safe late-stage percutaneous endoscopic gastrostomy in ALS.
abstract: The safety of percutaneous endoscopic gastrostomy (PEG) insertion in amyotrophic lateral sclerosis (ALS) patients with significant respiratory compromise has been questioned.
  
  
  
  To review the characteristics of an ALS clinic patient cohort undergoing PEG, and the introduction of a risk stratification tool with procedural adaptations for higher-risk individuals.
  
  
  
  Patients undergoing PEG insertion were analysed (n = 107). Cases stratified as higher-risk underwent insertion in a semi-recumbent position, minimising sedation, with the option of nasal non-invasive ventilation.
  
  
  
  All underwent successful PEG. One-third had pre-procedure FVC ≤50% (mean, 64 ± 22%). Of those who underwent PEG insertion after introduction of risk stratification (n = 58), 39 (67%) met criteria for being higher risk, 16 (41%) of whom had FVC ≤50% (p = 0.005). High-risk patients received lower sedative doses vs. the low-risk group (midazolam 2.1 ± 1.1 vs.2.8 ± 0.95mg, p = 0.021; fentanyl 42 ± 16 vs. 60 ± 21μg, p = 0.015). Four deaths occurred within one month of insertion (attributable to the natural disease course).
  
  
  
  Risk stratification identified a greater number of patients with evidence of respiratory compromise than using the sole criterion of FVC ≤50%. A modified PEG procedure enabled safe insertion despite respiratory compromise, in those who might not have tolerated attempted insertion by alternative means such as radiologically-inserted gastrostomy.
authors.affiliation: a Nuffield Department of Clinical Neurosciences , University of Oxford , Oxford , UK.
authors.forename: Alexander G
authors.initials: AG
authors.lastname: Thompson
authors.affiliation: b Translational Gastroenterology Unit, Nuffield Department of Medicine , University of Oxford , Oxford , UK.
authors.forename: Victoria
authors.initials: V
authors.lastname: Blackwell
authors.affiliation: a Nuffield Department of Clinical Neurosciences , University of Oxford , Oxford , UK.
authors.forename: Rachael
authors.initials: R
authors.lastname: Marsden
authors.affiliation: c Department of Nutrition and Dietetics , Oxford Health NHS Foundation Trust , Oxford , UK , and.
authors.forename: Emma
authors.initials: E
authors.lastname: Millard
authors.affiliation: b Translational Gastroenterology Unit, Nuffield Department of Medicine , University of Oxford , Oxford , UK.
authors.forename: Clare
authors.initials: C
authors.lastname: Lawson
authors.affiliation: d Department of Chest Medicine , Oxford University Hospitals NHS Trust , Oxford , UK.
authors.forename: Annabel H
authors.initials: AH
authors.lastname: Nickol
authors.affiliation: b Translational Gastroenterology Unit, Nuffield Department of Medicine , University of Oxford , Oxford , UK.
authors.forename: James E
authors.initials: JE
authors.lastname: East
authors.affiliation: a Nuffield Department of Clinical Neurosciences , University of Oxford , Oxford , UK.
authors.forename: Kevin
authors.initials: K
authors.lastname: Talbot
authors.affiliation: b Translational Gastroenterology Unit, Nuffield Department of Medicine , University of Oxford , Oxford , UK.
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Allan
authors.affiliation: a Nuffield Department of Clinical Neurosciences , University of Oxford , Oxford , UK.
authors.forename: Martin R
authors.initials: MR
authors.lastname: Turner
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000690:Amyotrophic Lateral Sclerosis / Q000453:epidemiology* / Q000601:surgery*; D015331:Cohort Studies; D018450:Disease Progression; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D004750:Enteral Nutrition; D005260:Female; D005774:Gastrostomy / Q000379:methods*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage / Q000627:therapeutic use; D008297:Male; D018529:Nutritional Support; D012129:Respiratory Function Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D014797:Vital Capacity
chemical_list: D006993:Hypnotics and Sedatives
keywords: Nutrition; PEG; gastrostomy; management; treatment