The Utility of Non-invasive Positive Pressure Ventilation Support during the Procedure of Percutaneous Gastrostomyin Amyotrophic Lateral Sclerosis

OBJECTIVE: To consider the utility of non-invasive positive pressure ventilation (NIPPV) support during percutaneous gastrostomy procedure in amyotrophic lateral sclerosis (ALS) patients with severe respiratory insufficiency and weight loss. METHOD: Percutaneous gastrostomy was performed in 25 ALS patients with forced vital capacity (FVC) below 50% of predicted normal value. NIPPV was applied to all these patients during the procedure. To estimate the utility of NIPPV application during gasrtostomy tube placement, safety and procedure related complications were investigated. RESULTS: Percutaneous endoscopic gastrostomy (PEG) was performed successfully in 21/25 patients (84%). Percutaneous radiologic gastrostomy (PRG) was performed to the rest. FVCP (predicted value of FVC) in seated position were 1,239.1 ml (32.1%) in PEG-successful group and 1,065.0 ml (26.8%) in PEG-failed group, respectively. All the patients tolerated the use of NIPPV successfully and there were no respiratory complications with the procedure. There were no major complications and procedure-related mortality in all the patients. CONCLUSION: NIPPV support during percutaneous gastrostomy tube placement could make the procedure possible in ALS patients with very low vital capacities.

Non-invasive Mechanical Ventilator Care for the Patients with Advanced Neuromuscular Disease

OBJECTIVE: The usage of mechanical ventilator has been an issue in advanced stage of most neuromuscular diseases. The patients experience hypoventilation symptoms and usually die from pulmonary complications at last. Besides traditional invasive mechanical ventilation, non-invasive intermittent positive pressure ventilation (NIPPV) has provided an alternative treatment option. We evaluated the effects of NIPPV. METHOD: We applied NIPPV method to the patients with advanced neuromuscular disease who were hospitalized due to ventilatory failure, who visit our outpatient clinic due to hypercapnic symptoms, or who showed hypercapnia on a routine follow-up. To evaluate ventilatory status, blood gas tensions were analyzed by the arterial blood gas analysis and/or pulse-oxymeter and capnometer. Overnight pulse-oxymeter monitorings were done whenever necessary. RESULTS: Thirty patients were managed with NIPPV successfully. In five cases, invasive IPPV with tracheostomy at admission was switched to NIPPV. Three patients who had been intubated to receive IPPV were transferred to NIPPV without being tracheostomized. CONCLUSION: NIPPV can be used safely and effectively as an alternative method of ventilatory support for the patients with advanced neuromuscular disease who show ventilatory failure. It would relieve symptoms and signs of hypoventilation and prevent the acute respiratory muscle decompensation, if applied before overt ventilatory failure.

Clinical Influence of Emotional Depression on Chronic Low Back Pain

OBJECTIVE: To compare the patients of chronic low back pain with and without emotional depression in terms of psychosomatic aspect and clinical outcome by cross-sectional and prospective study. METHOD: We evaluated 100 patients who were admitted due to chronic low back pain. The patients were classified into three groups (moderately depressed, mild depressed, non-depressed) by the score of Beck Depression Inventory (BDI). And three groups were compared by Pain Disability Index (PDI), Visual Analogue Scale (VAS), Pain Rating Score (PRS) and special diagnostic studies such as MRI and EMG. All subjects took the same conservative treatments for 4 weeks and then, they were re-evaluated by PDI, VAS and PRS. RESULTS: BDI score was positively correlated with VAS and PRS significantly. All groups were not different with respect to functional limitation (measured by PDI) and organic lesion (measured by MRI and EMG study). But, subjective pain (measured by VAS, PRS) were severe in depressed group. All groups showed improvement in PDI, VAS and PRS after 4 weeks of treatment. But, the amount of improvement was greater in non-depressed group. CONCLUSION: The clinician treating chronic low back pain should be familiar with depression and prepare for screening on that.

Analysis of Pulmonary Mechanics and the Factors for Coughing in Duchenne Muscular Dystrophy

OBJECTIVE: To investigate the pathologic pulmonary mechanics and analyze the factors affecting cough ability in patients with Duchenne muscular dystrophy (DMD). METHOD: Thirty-one patients with DMD were investigated. The vital capacity (VC), maximum insufflation capacity (MIC), maximal inspiratory (MIP), and expiratory pressure (MEP) were measured. Unassisted peak cough flow (UPCF) and assisted PCF at three different conditions were evaluated. RESULTS: The mean value of MICs (1, 873 +/- 644 cc) was higher than that of VCs (1, 509 +/- 640 cc). MIP and MEP were 48.8 +/- 21.4% and 29.5 +/- 19.5% of predicted normal value respectively. MIP was correlated with UPCFs as well as MEP. All of three assisted cough methods showed significantly higher value than unassisted method (p<0.01). The manual assisted PCFs at MIC significantly exceeded those produced by manual assisted or PCFs at MIC. The positive correlation between the MIC-VC difference and PCF at MIC-UPCF difference was seen (p<0.01). CONCLUSION: Inspiratory muscle strength and the preservation of pulmonary compliance is important for the development of effective cough as well as expiratory muscle power. Thus, the clinical implication of the inspiratory phase in assisting a cough should be emphasized.

The Relationships of Coughing to the Respiratory Muscle Strength and Pulmonary Compliance in Tetraplegic Patients

OBJECTIVE: To analyze the factors influencing the capacity of cough, the relationships between maximal respiratory pressure, lung compliance, capacity of cough, and assisted cough techniques were evaluated in tetraplegics. METHOD: The vital capacity (VC) in seated and supine position, maximum insufflation capacity (MIC), maximum inspiratory (MIP) and expiratory (MEP) pressure in seated position were measured. Unassisted and assisted peak cough flow (PCF) at two different conditions (a volume assisted method by the mechanical insufflation [PCFmic] and the manual assistance by abdominal compression [MPCF]) were evaluated in 44 tetraplegic patients. RESULTS: The mean value of VC in supine was greater than that of seated position (p<0.01). The MICs of the subjects were significantly higher than VCs in a same position (<0.01). Both volume and manual assisted method showed significantly higher PCF than unassisted PCF (p<0.01). MIP (r=0.53) correlated with UPCF as well as MEP (r=0.68), although MEP was better correlated with UPCF. CONCLUSION: Generally the therapists apply manual pressure only to increase capacity of cough, which assist the expulsive phase. The results of this study showed that both inspiratory and expulsive phases should be assisted to enhance the effectiveness of cough.