Noninvasive mechanical ventilation in patients with neuromuscular diseases and in patients with chest restriction

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Pontificia Universidad Católica de Chile. Santiago. Chile." "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Departamento de Neurología. Pontificia Universidad Católica de Chile. Santiago. Chile" "etiqueta" => "b" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ventilación mecánica no invasiva en pacientes con enfermedades neuromusculares y en pacientes con alteraciones de la caja torácica" ] ] "textoCompleto" => "Introduction Noninvasive mechanical ventilation (NIV), defined as the use of a mechanical ventilation technique that does not require tracheal intubation, has been applied for several decades in patients with neurological diseases. In fact, most published reports of sustained clinical use of NIV involve such patients1-3, and NIV from negative pressure ventilators was widely used to treat respiratory insufficiency in patients with poliomyelitis between 1930 and 1960, leading to dramatic decreases in mortality. The publication of various noncontrolled trials describing cases successfully treated with NIV4-9 has meant that, for ethical reasons, hardly any controlled trials have been designed. Available reports indicate that NIV is able to reverse alveolar hypoventilation, improve quality of life and prolong survival in neurological patients, as well as provide other benefits. Nevertheless, it may be that such findings overestimate the benefits of NIV, given that negative results are seldom reported. The only controlled studies of NIV are those of Vianello et al10 and Shonhofer et al11. The former observed clinical and functional benefits in patients with Duchenne muscular dystrophy and the latter reported positive results in patients with chest restriction.In this review, we discuss the underlying pathophysiology of NIV use in patients with neurological diseases, the general mechanisms of action of the technique and its indications and complications. We also analyze the mechanisms involved and results obtained with NIV in two neuromuscular diseases.Pathophysiology of NIV in patients with neuromuscular diseases and in patients with chest restrictionNeuromuscular diseasesThe alteration common to neuromuscular disease patients is respiratory muscle weakness, which varies highly according to the underlying disease. Differences arise because a) muscles are not affected to the same degree; b) respiratory muscle involvement may appear early or late; c) illness may be acute or may progress slowly; and d) muscle involvement may be reversible or recurrent. When respiratory muscle dysfunction is severe, respiratory insufficiency invariably develops and support ventilation becomes necessary. Weakness may affect three main muscle groups: inspiratory muscles (diaphragm, parasternal, scalene and accessory muscles); expiratory muscles (external intercostal and abdominal muscles); and muscles that innervate the upper airways (palatine, pharyngeal and genioglossal muscles)12 (Fig. 1).<img src="260v39n07-13046507tab01.gif"></img> Fig. 1. Physiological and clinical effects of weakness in respiratory muscles. PImax: maximal inspiratory pressure; PEmax: maximal expiratory pressure; ERV: expiratory reserve volume.The end result of inspiratory muscle impairment is alveolar hypoventilation, with corresponding hypercapnia and hypoxemia. Expiratory muscle impairment, in turn, leads to an inefficient cough and retention of secretions. Finally, upper airway muscle impairment affects swallowing, leading to aspiration of saliva and food particles in the presence of an ineffective cough, a clinical picture that leads to recurrent respiratory infections. Such infections increase work of breathing, overloading inspiratory muscles that are already weakened by the underlying disease and triggering acute respiratory failure. However, the mechanisms that lead to chronic, progressive respiratory insufficiency in some neuromuscular diseases have not been clearly established. Two possible overlapping mechanisms have been suggested: 1. Inspiratory muscle fatigue, a result of increased work of breathing arising from diminished pulmonary distensibility due to microatelectasis and decreased distensibility of the thorax due to deformities secondary to muscle weakness. As a result, the load that must be borne by the muscles and their ability to bear it are imbalanced, such that the patient must develop greater pleural pressures (Ppl) to generate flow volume, given a diminished ability to generate maximal inspiratory pressure (PImax), with an increased Ppl/PImax ratio13-15. Decreased respiratory muscle strength in these patients has been clearly demonstrated by the reduction in both PImax and maximal expiratory pressure (PEmax). Less information is available on diaphragm function, however12,16. 2. Decreased respiratory muscle response. Neuromuscular disease patients experience frequent apneas and hypopneas during sleep due to the combination of respiratory muscle weakness and upper airway obstruction14. As a result, nocturnal hypoventilation leads to increased PaCO2 and CO2 retention, which in turn lead to decreased central respiratory drive. It has therefore been suggested that hypoventilation constitutes an adaptive mechanism aimed at decreasing effort of breathing, thereby preventing the development of inspiratory muscle fatigue17. The characteristic respiratory pattern of these patients is of rapid, superficial breathing. Figure 2 shows the mechanisms that have been said to be involved in hypercapnia in neuromuscular diseases.<img src="260v39n07-13046507tab02.gif"></img>Fig. 2. Mechanisms involved in respiratory failure in neuromuscular diseases. PImax: maximal inspiratory pressure; Ppl: pleural pressure; VT: tidal volume.Chest restriction Although neuromuscular diseases lead to structural changes in the thorax as a result of muscle weakness, primary deformities are also present in the chest, such as can be seen in idiopathic kyphoscoliosis or in the presence of thoracoplasty performed after lobectomy or pneumonectomy in tuberculosis. Such primary deformities may lead to respiratory failure if they are sufficiently pronounced.In respiratory insufficiency due to severe kyphoscoliosis, a concomitant increase in thoracic impedance may contribute to greater respiratory loading and weakened respiratory muscles. Muscle weakness may be a sequela of poliomyelitis or a consequence of anomalous muscle insertion caused by thoracic deformity. Increased loading and decreased ability to generate force can lead to respiratory muscle fatigue. We observed severely reduced maximal transdiaphragmatic pressure (Pdimax) when we studied the relation between inspiratory muscle function and respiratory failure in a group of patients with severe kyphoscoliosis in comparison with an age-matched group of normal subjects13. In addition to lower PImax, we observed an increase in Ppl and Pdi deflections during relaxed breathing. Those increases led to higher Ppl/PImax and Pdi/Pdimax ratios, which approached figures that reflect respiratory fatigue. Pdimax correlated significantly with PaO2 (r=0.63) and PaCO2 (r=-0.76), and PImax was related to PaO2 (r=0.79) and PaC02 (r=-0.86). We also saw that Pimax rose in the six patients who underwent inspiratory muscle training for 12 months, with improvement coming after two months of training; moreover, hypercapnia was corrected in those who retained CO218. Such observations confirm the role of inspiratory muscle dysfunction in the development of respiratory insufficiency in these patients. Increased respiratory loading and decreased muscle strength may also be the mechanisms responsible for chronic respiratory insufficiency after thoracoplasty. Apart from altered respiratory mechanics, another mechanism involved in respiratory insufficiency in kyphoscoliosis patients is hypoventilation and central or obstructive apneas during sleep14.Mechanisms of action in NIVThe mechanisms by which NIV produces beneficial effects are not fully understood, although the following factors have been proposed to explain them15,17: a) respiratory muscle rest; b) improved central respiratory response to CO2; c) changes in pulmonary mechanics; and d) improved sleep architecture.As previously mentioned, the first mechanism assumes that inspiratory muscles are in a state of "chronic" fatigue. Intermittent nocturnal ventilation allows muscles to rest and recover, with a consequent improvement in inspiratory muscle function, ventilation and arterial blood gases during the day. Although some authors19,20 have shown that muscles rest during NIV, others have nevertheless observed increased inspiratory muscle effort in patients whose alveolar hypoventilation has been corrected by NIV21,22.The second mechanism of action postulates that nocturnal NIV prevents hypoventilation during sleep, resetting central response to CO2 and improving ventilation and gas exchange during the day22.NIV has also been said to improve pulmonary function by recruiting atelectasic zones, increasing pulmonary distensibility and improving ventilation-perfusion ratios. None of these mechanisms has been shown to be uniquely responsible for improving respiratory insufficiency during the day, and therefore part of the improvement has been attributed to the beneficial effects of NIV on sleep architecture and fragmentation. Disordered sleep associated with central and mechanical respiratory dysfunction aggravates changes in arterial blood gases, particularly during rapid eye movement (REM) sleep14. Moreover, the symptoms most commonly reported by these patients are daytime sleepiness, fatigue, morning headache, cognitive dysfunctions and dyspnea, mainly related to sleep fragmentation secondary to apneas. NIV largely corrects these problems, such that this mechanism of action would also be implicated in producing treatment benefits. Results from the few studies evaluating the effect of withdrawing NIV from patients in whom the treatment has corrected hypoventilation support this hypothesis. Thus, one week after withdrawal of NIV, nocturnal hypoventilation became aggravated and symptoms recurred, in the absence of lung function changes21. Similarly, Masa et al23 showed that suspending NIV for 15 days produced no changes in arterial blood gases, spirometry, lung volumes or maximal respiratory pressures measured during the day, even though there was severe deterioration in gas exchange during REM sleep a long with polysomnographic changes.Clinical and functional effects of NIV Table 1 summarizes the features of some of the most important studies published on the clinical and functional effects of NIV; among them, only that of Schonhofer et al11 included a control group. Many studies enrolled patients with both neuromuscular diseases and thoracic restriction, and most reported beneficial effects on both clinical and functional variables. Among the clinical gains were decreased daytime sleepiness, increased ability to perform activities of daily living, greater sense of well-being, a reduction in the number of hospitalizations and prolonged survival. The main functional benefits were improved or corrected diurnal hypoxemia and hypercapnia, improvement in nocturnal hypoventilation, and in come cases increases in maximal respiratory pressures.<img src="260v39n07-13046507tab03.gif"></img>Indications for NIV in neuromuscular diseasesNIV is prescribed mainly to treat increasing daytime hypercapnia in neuromuscular disease patients. Temporary application during respiratory infections or in patients who are frequently admitted for episodes of respiratory insufficiency have also been suggested. No benefit has been demonstrated for the prophylactic use of NIV, however, in patients without diurnal hypercapnia. Indications for using NIV in patients with chronic respiratory insufficiency take into consideration the clinical and pathophysiologic characteristics1,3,17,25 shown in Table 2. Table 3 shows contraindications.<img src="260v39n07-13046507tab04.gif"></img><img src="260v39n07-13046507tab05.gif"></img>Complications of NIVThe complications of positive pressure NIV are usually mild, are generally related to the interface (air leaks, nasal pressure sores, nasal dryness and eye irritation) and can usually be overcome by changing the interface or undertaking fairly simple interventions. Less frequent complications are aspiration, pneumothorax and an inability to tolerate ventilation.It is important to point out that one death due to respirator failure has been reported in a patient receiving NIV26, underlining the need to check respirators periodically. Domiciliary NIV has been increasingly prescribed. A recent article on the current status of this procedure in Spain found that over 1,800 patients are ventilated at home27. We found no reports in the literature on the prevalence of domiciliary NIV in Latin America.NIV in specific neuromuscular diseasesThe two most prevalent nervous system diseases that give rise to respiratory insufficiency susceptible to treatment with NIV are amyotrophic lateral sclerosis (ALS), which affects motor neurons, and Duchenne muscular dystrophy, which affects the muscle.Motor neuron diseases Motor neuron loss in ALS leads to atrophy of the corresponding muscle, with consequent weakening of respiratory muscles. Early stages of disease are therefore generally asymptomatic and respiratory insufficiency usually manifests late, although it is the presenting symptom in approximately 5% of cases23,28,29. Muscle weakness becomes more marked as ALS progresses and degree of muscle involvement is the only parameter able to predict survival. Moreover, when muscle function becomes pronounced, the patient feels impending ventilatory failure. Although respiratory muscle deficits may manifest only during sleep initially, respiratory insufficiency invariably develops. At first, when symptoms are the result of changes in sleep architecture or nocturnal CO2 retention, the symptoms will be daytime somnolence, problems with concentration and morning headache in the absence of dyspnea. When respiratory insufficiency is present, however, dyspnea is usually among the symptoms and is due to marked diaphragm dysfunction30. If respiratory muscle impairment is the suspected cause of any of the aforementioned symptoms, that possibility should be carefully investigated. Although some authors have advised that assessment should include the measurement of respiratory muscle strength, particularly by means of tests that do not require volitional participation from the patient, such testing can be difficult to carry out and great variability has been observed in patients with established diaphragm muscle impairment31. Therefore, assessment will depend on the stage of disease. Early sleep disorders, once suspected, should be assessed by polysomnography to determine whether changes in gas exchange during sleep are due to obstructive apneas, which need only continuous positive airway pressure (CPAP) treatment, or to episodes of hypoventilation, which require NIV support. Polysomnography gives additional information on disease progression, as abnormalities only occur during REM sleep in early stages. When dyspnea is present, diurnal arterial blood gas measurement is imperative and either clinical or laboratory assessment of diaphragmatic function is advised30-32. The possibility that breathless patients should begin receiving ventilatory support without further examination has also been proposed17. Although NIV has been shown to prolong survival in ALS patients until advanced stages of the disease, when patients begin to feel extremely "locked in", contradictory reports of the effects of ventilatory support on quality of life have been made. While some authors have observed improved quality of life33-35, a study by Pinto et al36, comparing patients receiving NIV with a control group of patients who did not receive ventilation, found no evidence of quality of life gains, only longer survival in NIV patients who retained CO2. Those findings were confirmed by later studies37-39. Unfortunately, adherence to NIV treatment is not good. Aboussouan et al39 observed that only 46% (18/39) of their patients with ALS tolerated treatment, with tolerance defined as the ability to use NIV at least 4 h without interruption during sleep. Bulbar symptoms, such as dysphagia, decreased the likelihood of tolerating NIV by half. The results of that study also demonstrated, moreover, that the risk of death was reduced 3-fold if NIV was tolerated.It is important to point out that when respiratory failure presents in ALS, there is rapid overall deterioration, such that it is ethically necessary to discuss in a timely way the meaning of such deterioration and the therapeutic options available. A study of 38 patients with ALS found that most wanted as much information as possible about mechanical ventilation40 options. Nevertheless, the same study also demonstrated that opinions about resuscitation changed as the disease progressed, such that periodic review of the topic with patients is necessary. Moss et al41 studied 99 patients with ALS who had respiratory failure, finding that only 10% wanted invasive mechanical ventilation. Ninety percent of those who chose support ventilation, however, were satisfied with their decision.Muscular dystrophies Respiratory muscle impairment in Duchenne muscular dystrophy diminishes forced vital capacity. Alterations are evident in patients at an early age, generally at around age 12. Progression leads to diurnal CO2 retention between 18 and 20 years of age and the appearance of this sign is associated with approaching death from respiratory failure. NIV is recommended when patients report symptoms of respiratory insufficiency and daytime CO2 retention17, given that attempts to change the natural course of the disease by starting NIV when the patient has no respiratory symptoms have not produced benefits42,43. Measuring forced expiratory volume in one second has been suggested for monitoring muscular dystrophy patients but it seems more reasonable to use variables related to the restrictive nature of lung impairment and to decreased inspiratory muscle force, as has recently been demonstrated by Raggette et al44 in a study of 42 patients with primary myopathies. Those authors found that measuring inspiratory vital capacity (IVC) and PImax gives valuable insight into disease progression from the onset of sleep disorders until the appearance of diurnal respiratory insufficiency. According to their results, IVC less than 60% of the predicted value and a PImax less than 4.5 kPa predict the onset of sleep disorders, while an IVC less than 25% of the predicted value and a PImax less than 3.5 kPa predict the appearance of diurnal respiratory insufficiency44. Just as in ALS, early functional changes in breathing may manifest only during sleep, such that the patient should be asked about symptoms of nocturnal hypoventilation, morning headache, frequent awakening and daytime sleepiness. A base excess greater than 4 mm/l in arterial blood predicts significant nocturnal desaturation45. Some patients with Duchenne disease may present obstructive sleep apneas before developing hypoventilation due to respiratory muscle failure, and in them CPAP may be temporarily effective46. However, progression is inevitable and NIV will become necessary.NIV will probably prolong survival in Duchenne disease patients who develop hypoventilation. Prospective controlled trials are lacking because of ethical constraints that prevent us from acquiring objective evidence. Nevertheless, the hypothesis of prolonged survival is supported by the findings of Vianello et al10; in their study 5 patients with Duchenne disease who accepted ventilation were alive after 2 years, whereas only one of 5 patients who refused ventilation was alive.The efficacy of NIV varies in different studies. Leger et al8 described a series of 16 patients in whom one third continued to receive NIV while another third advanced to ventilation through a tracheostomy. A more recent study of patients receiving NIV, on the other hand, reported a one-year survival rate of 85% and a 5-year survival rate of 73%, suggesting that the progression to invasive ventilation may not be inevitable47. It may be that tracheostomy prolongs survival more than NIV once an ineffective cough develops and severe quadriplegia is present. Robert et al48 described a mean survival of 7 years in such circumstances. On the other hand, the number of hospitalizations due to pulmonary complications in Duchenne disease patients is lower in those receiving NIV than in those with tracheostomies49.The quality of life of patients with Duchenne disease who receive NIV is not different from that of other age-matched controls who have other non-progressive diseases requiring NIV50, but the literature contains no studies comparing quality of life in these patients before and after initiating NIV. Most patients in these circumstances describe their quality of life as satisfactory50,51. Caregivers who work with such patients usually underestimate patient satisfaction with quality of life, and that is often given as the explanation for why some physicians do not propose NIV to Duchenne disease patients whose quality of life they assume will be unsatisfactory52.In summary, even though most information on NIV in patients with neuromuscular or thoracic cavity diseases are based on uncontrolled studies, the many reports of beneficial effects and of improvement in the underlying pathophysiology support the use of NIV. Nevertheless, contraindications must be taken into account and invasive ventilation considered on an individual basis.<hr></hr>Correspondence: Dr. C. Lisboa. Departamento de Enfermedades Respiratorias. Pontificia Universidad Católica de Chile. Marcoleta, 345, piso 4. Santiago. Chile. E-mail: <a href="mailto:clisboa@med.puc.cl" class="elsevierStyleCrossRefs"> clisboa@med.puc.cl</a>Manuscript received 30 January 2003. Accepted for publication 30 January 2003." 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Ventilación mecánica no invasiva en pacientes con enfermedades neuromusculares y en pacientes con alteraciones de la caja torácica

C. Lisboaa, O. Díaza, R. Fadicb

a Departamento de Enfermedades Respiratorias. Pontificia Universidad Católica de Chile. Santiago. Chile.

b Departamento de Neurología. Pontificia Universidad Católica de Chile. Santiago. Chile

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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara"> Noninvasive mechanical ventilation &#40;NIV&#41;&#44; defined as the use of a mechanical ventilation technique that does not require tracheal intubation&#44; has been applied for several decades in patients with neurological diseases&#46; In fact&#44; most published reports of sustained clinical use of NIV involve such patients<span class="elsevierStyleSup">1-3</span>&#44; and NIV from negative pressure ventilators was widely used to treat respiratory insufficiency in patients with poliomyelitis between 1930 and 1960&#44; leading to dramatic decreases in mortality&#46; The publication of various noncontrolled trials describing cases successfully treated with NIV<span class="elsevierStyleSup">4-9</span> has meant that&#44; for ethical reasons&#44; hardly any controlled trials have been designed&#46; Available reports indicate that NIV is able to reverse alveolar hypoventilation&#44; improve quality of life and prolong survival in neurological patients&#44; as well as provide other benefits&#46; Nevertheless&#44; it may be that such findings overestimate the benefits of NIV&#44; given that negative results are seldom reported&#46; The only controlled studies of NIV are those of Vianello et al<span class="elsevierStyleSup">10</span> and Shonhofer et al<span class="elsevierStyleSup">11</span>&#46; The former observed clinical and functional benefits in patients with Duchenne muscular dystrophy and the latter reported positive results in patients with chest restriction&#46;</p><p class="elsevierStylePara">In this review&#44; we discuss the underlying pathophysiology of NIV use in patients with neurological diseases&#44; the general mechanisms of action of the technique and its indications and complications&#46; We also analyze the mechanisms involved and results obtained with NIV in two neuromuscular diseases&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Pathophysiology of NIV in patients with neuromuscular diseases and in patients with chest restriction</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Neuromuscular diseases</span></p><p class="elsevierStylePara">The alteration common to neuromuscular disease patients is respiratory muscle weakness&#44; which varies highly according to the underlying disease&#46; Differences arise because <span class="elsevierStyleItalic">a&#41;</span> muscles are not affected to the same degree&#59; <span class="elsevierStyleItalic">b&#41;</span> respiratory muscle involvement may appear early or late&#59; <span class="elsevierStyleItalic">c&#41;</span> illness may be acute or may progress slowly&#59; and <span class="elsevierStyleItalic">d&#41;</span> muscle involvement may be reversible or recurrent&#46; When respiratory muscle dysfunction is severe&#44; respiratory insufficiency invariably develops and support ventilation becomes necessary&#46;</p><p class="elsevierStylePara"> Weakness may affect three main muscle groups&#58; inspiratory muscles &#40;diaphragm&#44; parasternal&#44; scalene and accessory muscles&#41;&#59; expiratory muscles &#40;external intercostal and abdominal muscles&#41;&#59; and muscles that innervate the upper airways &#40;palatine&#44; pharyngeal and genioglossal muscles&#41;<span class="elsevierStyleSup">12</span> &#40;Fig&#46; 1&#41;&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046507tab01.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold"> Fig&#46; 1&#46; Physiological and clinical effects of weakness in respiratory muscles&#46; PI<span class="elsevierStyleInf">max</span>&#58; maximal inspiratory pressure&#59; PE<span class="elsevierStyleInf">max</span>&#58; maximal expiratory pressure&#59; ERV&#58; expiratory reserve volume&#46;</span></p><p class="elsevierStylePara">The end result of inspiratory muscle impairment is alveolar hypoventilation&#44; with corresponding hypercapnia and hypoxemia&#46; Expiratory muscle impairment&#44; in turn&#44; leads to an inefficient cough and retention of secretions&#46; Finally&#44; upper airway muscle impairment affects swallowing&#44; leading to aspiration of saliva and food particles in the presence of an ineffective cough&#44; a clinical picture that leads to recurrent respiratory infections&#46; Such infections increase work of breathing&#44; overloading inspiratory muscles that are already weakened by the underlying disease and triggering acute respiratory failure&#46; However&#44; the mechanisms that lead to chronic&#44; progressive respiratory insufficiency in some neuromuscular diseases have not been clearly established&#46; Two possible overlapping mechanisms have been suggested&#58;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 1&#46;</span> Inspiratory muscle fatigue&#44; a result of increased work of breathing arising from diminished pulmonary distensibility due to microatelectasis and decreased distensibility of the thorax due to deformities secondary to muscle weakness&#46; As a result&#44; the load that must be borne by the muscles and their ability to bear it are imbalanced&#44; such that the patient must develop greater pleural pressures &#40;Ppl&#41; to generate flow volume&#44; given a diminished ability to generate maximal inspiratory pressure &#40;PI<span class="elsevierStyleInf">max</span>&#41;&#44; with an increased Ppl&#47;PI<span class="elsevierStyleInf">max</span> ratio<span class="elsevierStyleSup">13-15</span>&#46; Decreased respiratory muscle strength in these patients has been clearly demonstrated by the reduction in both PI<span class="elsevierStyleInf">max</span> and maximal expiratory pressure &#40;PE<span class="elsevierStyleInf">max</span>&#41;&#46; Less information is available on diaphragm function&#44; however<span class="elsevierStyleSup">12&#44;16</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic"> 2&#46;</span> Decreased respiratory muscle response&#46; Neuromuscular disease patients experience frequent apneas and hypopneas during sleep due to the combination of respiratory muscle weakness and upper airway obstruction<span class="elsevierStyleSup">14</span>&#46; As a result&#44; nocturnal hypoventilation leads to increased PaCO<span class="elsevierStyleInf">2</span> and CO<span class="elsevierStyleInf">2</span> retention&#44; which in turn lead to decreased central respiratory drive&#46; It has therefore been suggested that hypoventilation constitutes an adaptive mechanism aimed at decreasing effort of breathing&#44; thereby preventing the development of inspiratory muscle fatigue<span class="elsevierStyleSup">17</span>&#46; The characteristic respiratory pattern of these patients is of rapid&#44; superficial breathing&#46;</p><p class="elsevierStylePara"> Figure 2 shows the mechanisms that have been said to be involved in hypercapnia in neuromuscular diseases&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046507tab02.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Fig&#46; 2&#46; Mechanisms involved in respiratory failure in neuromuscular diseases&#46; PI<span class="elsevierStyleInf">max</span>&#58; maximal inspiratory pressure&#59; Ppl&#58; pleural pressure&#59; V<span class="elsevierStyleInf">T</span>&#58; tidal volume</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Chest restriction</span></p><p class="elsevierStylePara"> Although neuromuscular diseases lead to structural changes in the thorax as a result of muscle weakness&#44; primary deformities are also present in the chest&#44; such as can be seen in idiopathic kyphoscoliosis or in the presence of thoracoplasty performed after lobectomy or pneumonectomy in tuberculosis&#46; Such primary deformities may lead to respiratory failure if they are sufficiently pronounced&#46;</p><p class="elsevierStylePara">In respiratory insufficiency due to severe kyphoscoliosis&#44; a concomitant increase in thoracic impedance may contribute to greater respiratory loading and weakened respiratory muscles&#46; Muscle weakness may be a sequela of poliomyelitis or a consequence of anomalous muscle insertion caused by thoracic deformity&#46; Increased loading and decreased ability to generate force can lead to respiratory muscle fatigue&#46; We observed severely reduced maximal transdiaphragmatic pressure &#40;Pdi<span class="elsevierStyleInf">max</span>&#41; when we studied the relation between inspiratory muscle function and respiratory failure in a group of patients with severe kyphoscoliosis in comparison with an age-matched group of normal subjects<span class="elsevierStyleSup">13</span>&#46; In addition to lower PI<span class="elsevierStyleInf">max</span>&#44; we observed an increase in Ppl and Pdi deflections during relaxed breathing&#46; Those increases led to higher Ppl&#47;PI<span class="elsevierStyleInf">max</span> and Pdi&#47;Pdi<span class="elsevierStyleInf">max</span> ratios&#44; which approached figures that reflect respiratory fatigue&#46; Pdi<span class="elsevierStyleInf">max</span> correlated significantly with PaO<span class="elsevierStyleInf">2</span> &#40;r&#61;0&#46;63&#41; and PaCO<span class="elsevierStyleInf">2</span> &#40;r&#61;&#173;-0&#46;76&#41;&#44; and PI<span class="elsevierStyleInf">max</span> was related to PaO<span class="elsevierStyleInf">2</span> &#40;r&#61;0&#46;79&#41; and PaC0<span class="elsevierStyleInf">2</span> &#40;r&#61;-&#173;0&#46;86&#41;&#46; We also saw that Pi<span class="elsevierStyleInf">max</span> rose in the six patients who underwent inspiratory muscle training for 12 months&#44; with improvement coming after two months of training&#59; moreover&#44; hypercapnia was corrected in those who retained CO<span class="elsevierStyleInf">2</span><span class="elsevierStyleSup">18</span>&#46; Such observations confirm the role of inspiratory muscle dysfunction in the development of respiratory insufficiency in these patients&#46; Increased respiratory loading and decreased muscle strength may also be the mechanisms responsible for chronic respiratory insufficiency after thoracoplasty&#46;</p><p class="elsevierStylePara"> Apart from altered respiratory mechanics&#44; another mechanism involved in respiratory insufficiency in kyphoscoliosis patients is hypoventilation and central or obstructive apneas during sleep<span class="elsevierStyleSup">14</span>&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Mechanisms of action in NIV</span></p><p class="elsevierStylePara">The mechanisms by which NIV produces beneficial effects are not fully understood&#44; although the following factors have been proposed to explain them<span class="elsevierStyleSup">15&#44;17</span>&#58; <span class="elsevierStyleItalic">a&#41;</span> respiratory muscle rest&#59; <span class="elsevierStyleItalic">b&#41;</span> improved central respiratory response to CO<span class="elsevierStyleInf">2</span>&#59; <span class="elsevierStyleItalic">c&#41;</span> changes in pulmonary mechanics&#59; and <span class="elsevierStyleItalic">d&#41;</span> improved sleep architecture&#46;</p><p class="elsevierStylePara">As previously mentioned&#44; the first mechanism assumes that inspiratory muscles are in a state of &#34;chronic&#34; fatigue&#46; Intermittent nocturnal ventilation allows muscles to rest and recover&#44; with a consequent improvement in inspiratory muscle function&#44; ventilation and arterial blood gases during the day&#46; Although some authors<span class="elsevierStyleSup">19&#44;20</span> have shown that muscles rest during NIV&#44; others have nevertheless observed increased inspiratory muscle effort in patients whose alveolar hypoventilation has been corrected by NIV<span class="elsevierStyleSup">21&#44;22</span>&#46;</p><p class="elsevierStylePara">The second mechanism of action postulates that nocturnal NIV prevents hypoventilation during sleep&#44; resetting central response to CO<span class="elsevierStyleInf">2</span> and improving ventilation and gas exchange during the day<span class="elsevierStyleSup">22</span>&#46;</p><p class="elsevierStylePara">NIV has also been said to improve pulmonary function by recruiting atelectasic zones&#44; increasing pulmonary distensibility and improving ventilation-perfusion ratios&#46;</p><p class="elsevierStylePara"> None of these mechanisms has been shown to be uniquely responsible for improving respiratory insufficiency during the day&#44; and therefore part of the improvement has been attributed to the beneficial effects of NIV on sleep architecture and fragmentation&#46; Disordered sleep associated with central and mechanical respiratory dysfunction aggravates changes in arterial blood gases&#44; particularly during rapid eye movement &#40;REM&#41; sleep<span class="elsevierStyleSup">14</span>&#46; Moreover&#44; the symptoms most commonly reported by these patients are daytime sleepiness&#44; fatigue&#44; morning headache&#44; cognitive dysfunctions and dyspnea&#44; mainly related to sleep fragmentation secondary to apneas&#46; NIV largely corrects these problems&#44; such that this mechanism of action would also be implicated in producing treatment benefits&#46; Results from the few studies evaluating the effect of withdrawing NIV from patients in whom the treatment has corrected hypoventilation support this hypothesis&#46; Thus&#44; one week after withdrawal of NIV&#44; nocturnal hypoventilation became aggravated and symptoms recurred&#44; in the absence of lung function changes<span class="elsevierStyleSup">21</span>&#46; Similarly&#44; Masa et al<span class="elsevierStyleSup">23</span> showed that suspending NIV for 15 days produced no changes in arterial blood gases&#44; spirometry&#44; lung volumes or maximal respiratory pressures measured during the day&#44; even though there was severe deterioration in gas exchange during REM sleep a long with polysomnographic changes&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical and functional effects of NIV</span></p><p class="elsevierStylePara"> Table 1 summarizes the features of some of the most important studies published on the clinical and functional effects of NIV&#59; among them&#44; only that of Schonhofer et al<span class="elsevierStyleSup">11</span> included a control group&#46; Many studies enrolled patients with both neuromuscular diseases and thoracic restriction&#44; and most reported beneficial effects on both clinical and functional variables&#46; Among the clinical gains were decreased daytime sleepiness&#44; increased ability to perform activities of daily living&#44; greater sense of well-being&#44; a reduction in the number of hospitalizations and prolonged survival&#46; The main functional benefits were improved or corrected diurnal hypoxemia and hypercapnia&#44; improvement in nocturnal hypoventilation&#44; and in come cases increases in maximal respiratory pressures&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046507tab03.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Indications for NIV in neuromuscular diseases</span></p><p class="elsevierStylePara">NIV is prescribed mainly to treat increasing daytime hypercapnia in neuromuscular disease patients&#46; Temporary application during respiratory infections or in patients who are frequently admitted for episodes of respiratory insufficiency have also been suggested&#46; No benefit has been demonstrated for the prophylactic use of NIV&#44; however&#44; in patients without diurnal hypercapnia&#46;</p><p class="elsevierStylePara"> Indications for using NIV in patients with chronic respiratory insufficiency take into consideration the clinical and pathophysiologic characteristics<span class="elsevierStyleSup">1&#44;3&#44;17&#44;25</span> shown in Table 2&#46; Table 3 shows contraindications&#46;</p><p class="elsevierStylePara"><img src="260v39n07-13046507tab04.gif"></img></p><p class="elsevierStylePara"><img src="260v39n07-13046507tab05.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Complications of NIV</span></p><p class="elsevierStylePara">The complications of positive pressure NIV are usually mild&#44; are generally related to the interface &#40;air leaks&#44; nasal pressure sores&#44; nasal dryness and eye irritation&#41; and can usually be overcome by changing the interface or undertaking fairly simple interventions&#46; Less frequent complications are aspiration&#44; pneumothorax and an inability to tolerate ventilation&#46;</p><p class="elsevierStylePara">It is important to point out that one death due to respirator failure has been reported in a patient receiving NIV<span class="elsevierStyleSup">26</span>&#44; underlining the need to check respirators periodically&#46;</p><p class="elsevierStylePara"> Domiciliary NIV has been increasingly prescribed&#46; A recent article on the current status of this procedure in Spain found that over 1&#44;800 patients are ventilated at home<span class="elsevierStyleSup">27</span>&#46; We found no reports in the literature on the prevalence of domiciliary NIV in Latin America&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">NIV in specific neuromuscular diseases</span></p><p class="elsevierStylePara">The two most prevalent nervous system diseases that give rise to respiratory insufficiency susceptible to treatment with NIV are amyotrophic lateral sclerosis &#40;ALS&#41;&#44; which affects motor neurons&#44; and Duchenne muscular dystrophy&#44; which affects the muscle&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Motor neuron diseases</span></p><p class="elsevierStylePara"> Motor neuron loss in ALS leads to atrophy of the corresponding muscle&#44; with consequent weakening of respiratory muscles&#46; Early stages of disease are therefore generally asymptomatic and respiratory insufficiency usually manifests late&#44; although it is the presenting symptom in approximately 5&#37; of cases<span class="elsevierStyleSup">23&#44;28&#44;29</span>&#46; Muscle weakness becomes more marked as ALS progresses and degree of muscle involvement is the only parameter able to predict survival&#46; Moreover&#44; when muscle function becomes pronounced&#44; the patient feels impending ventilatory failure&#46; Although respiratory muscle deficits may manifest only during sleep initially&#44; respiratory insufficiency invariably develops&#46; At first&#44; when symptoms are the result of changes in sleep architecture or nocturnal CO<span class="elsevierStyleInf">2</span> retention&#44; the symptoms will be daytime somnolence&#44; problems with concentration and morning headache in the absence of dyspnea&#46; When respiratory insufficiency is present&#44; however&#44; dyspnea is usually among the symptoms and is due to marked diaphragm dysfunction<span class="elsevierStyleSup">30</span>&#46; If respiratory muscle impairment is the suspected cause of any of the aforementioned symptoms&#44; that possibility should be carefully investigated&#46; Although some authors have advised that assessment should include the measurement of respiratory muscle strength&#44; particularly by means of tests that do not require volitional participation from the patient&#44; such testing can be difficult to carry out and great variability has been observed in patients with established diaphragm muscle impairment<span class="elsevierStyleSup">31</span>&#46; Therefore&#44; assessment will depend on the stage of disease&#46; Early sleep disorders&#44; once suspected&#44; should be assessed by polysomnography to determine whether changes in gas exchange during sleep are due to obstructive apneas&#44; which need only continuous positive airway pressure &#40;CPAP&#41; treatment&#44; or to episodes of hypoventilation&#44; which require NIV support&#46; Polysomnography gives additional information on disease progression&#44; as abnormalities only occur during REM sleep in early stages&#46; When dyspnea is present&#44; diurnal arterial blood gas measurement is imperative and either clinical or laboratory assessment of diaphragmatic function is advised<span class="elsevierStyleSup">30-32</span>&#46; The possibility that breathless patients should begin receiving ventilatory support without further examination has also been proposed<span class="elsevierStyleSup">17</span>&#46; Although NIV has been shown to prolong survival in ALS patients until advanced stages of the disease&#44; when patients begin to feel extremely &#34;locked in&#34;&#44; contradictory reports of the effects of ventilatory support on quality of life have been made&#46; While some authors have observed improved quality of life<span class="elsevierStyleSup">33-35</span>&#44; a study by Pinto et al<span class="elsevierStyleSup">36</span>&#44; comparing patients receiving NIV with a control group of patients who did not receive ventilation&#44; found no evidence of quality of life gains&#44; only longer survival in NIV patients who retained CO<span class="elsevierStyleInf">2&#46;</span> Those findings were confirmed by later studies<span class="elsevierStyleSup">37-39</span>&#46;</p><p class="elsevierStylePara"> Unfortunately&#44; adherence to NIV treatment is not good&#46; Aboussouan et al<span class="elsevierStyleSup">39</span> observed that only 46&#37; &#40;18&#47;39&#41; of their patients with ALS tolerated treatment&#44; with tolerance defined as the ability to use NIV at least 4 h without interruption during sleep&#46; Bulbar symptoms&#44; such as dysphagia&#44; decreased the likelihood of tolerating NIV by half&#46; The results of that study also demonstrated&#44; moreover&#44; that the risk of death was reduced 3-fold if NIV was tolerated&#46;</p><p class="elsevierStylePara">It is important to point out that when respiratory failure presents in ALS&#44; there is rapid overall deterioration&#44; such that it is ethically necessary to discuss in a timely way the meaning of such deterioration and the therapeutic options available&#46; A study of 38 patients with ALS found that most wanted as much information as possible about mechanical ventilation<span class="elsevierStyleSup">40</span> options&#46; Nevertheless&#44; the same study also demonstrated that opinions about resuscitation changed as the disease progressed&#44; such that periodic review of the topic with patients is necessary&#46; Moss et al<span class="elsevierStyleSup">41</span> studied 99 patients with ALS who had respiratory failure&#44; finding that only 10&#37; wanted invasive mechanical ventilation&#46; Ninety percent of those who chose support ventilation&#44; however&#44; were satisfied with their decision&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Muscular dystrophies</span></p><p class="elsevierStylePara"> Respiratory muscle impairment in Duchenne muscular dystrophy diminishes forced vital capacity&#46; Alterations are evident in patients at an early age&#44; generally at around age 12&#46; Progression leads to diurnal CO<span class="elsevierStyleInf">2</span> retention between 18 and 20 years of age and the appearance of this sign is associated with approaching death from respiratory failure&#46; NIV is recommended when patients report symptoms of respiratory insufficiency and daytime CO<span class="elsevierStyleInf">2</span> retention<span class="elsevierStyleSup">17</span>&#44; given that attempts to change the natural course of the disease by starting NIV when the patient has no respiratory symptoms have not produced benefits<span class="elsevierStyleSup">42&#44;43</span>&#46; Measuring forced expiratory volume in one second has been suggested for monitoring muscular dystrophy patients but it seems more reasonable to use variables related to the restrictive nature of lung impairment and to decreased inspiratory muscle force&#44; as has recently been demonstrated by Raggette et al<span class="elsevierStyleSup">44</span> in a study of 42 patients with primary myopathies&#46; Those authors found that measuring inspiratory vital capacity &#40;IVC&#41; and PI<span class="elsevierStyleInf">max</span> gives valuable insight into disease progression from the onset of sleep disorders until the appearance of diurnal respiratory insufficiency&#46; According to their results&#44; IVC less than 60&#37; of the predicted value and a PI<span class="elsevierStyleInf">max</span> less than 4&#46;5 kPa predict the onset of sleep disorders&#44; while an IVC less than 25&#37; of the predicted value and a PI<span class="elsevierStyleInf">max</span> less than 3&#46;5 kPa predict the appearance of diurnal respiratory insufficiency<span class="elsevierStyleSup">44</span>&#46; Just as in ALS&#44; early functional changes in breathing may manifest only during sleep&#44; such that the patient should be asked about symptoms of nocturnal hypoventilation&#44; morning headache&#44; frequent awakening and daytime sleepiness&#46; A base excess greater than 4 mm&#47;l in arterial blood predicts significant nocturnal desaturation<span class="elsevierStyleSup">45</span>&#46; Some patients with Duchenne disease may present obstructive sleep apneas before developing hypoventilation due to respiratory muscle failure&#44; and in them CPAP may be temporarily effective<span class="elsevierStyleSup">46</span>&#46; However&#44; progression is inevitable and NIV will become necessary&#46;</p><p class="elsevierStylePara">NIV will probably prolong survival in Duchenne disease patients who develop hypoventilation&#46; Prospective controlled trials are lacking because of ethical constraints that prevent us from acquiring objective evidence&#46; Nevertheless&#44; the hypothesis of prolonged survival is supported by the findings of Vianello et al<span class="elsevierStyleSup">10</span>&#59; in their study 5 patients with Duchenne disease who accepted ventilation were alive after 2 years&#44; whereas only one of 5 patients who refused ventilation was alive&#46;</p><p class="elsevierStylePara">The efficacy of NIV varies in different studies&#46; Leger et al<span class="elsevierStyleSup">8</span> described a series of 16 patients in whom one third continued to receive NIV while another third advanced to ventilation through a tracheostomy&#46; A more recent study of patients receiving NIV&#44; on the other hand&#44; reported a one-year survival rate of 85&#37; and a 5-year survival rate of 73&#37;&#44; suggesting that the progression to invasive ventilation may not be inevitable<span class="elsevierStyleSup">47</span>&#46; It may be that tracheostomy prolongs survival more than NIV once an ineffective cough develops and severe quadriplegia is present&#46; Robert et al<span class="elsevierStyleSup">48</span> described a mean survival of 7 years in such circumstances&#46; On the other hand&#44; the number of hospitalizations due to pulmonary complications in Duchenne disease patients is lower in those receiving NIV than in those with tracheostomies<span class="elsevierStyleSup">49</span>&#46;</p><p class="elsevierStylePara">The quality of life of patients with Duchenne disease who receive NIV is not different from that of other age-matched controls who have other non-progressive diseases requiring NIV<span class="elsevierStyleSup">50</span>&#44; but the literature contains no studies comparing quality of life in these patients before and after initiating NIV&#46; Most patients in these circumstances describe their quality of life as satisfactory<span class="elsevierStyleSup">50&#44;51</span>&#46; Caregivers who work with such patients usually underestimate patient satisfaction with quality of life&#44; and that is often given as the explanation for why some physicians do not propose NIV to Duchenne disease patients whose quality of life they assume will be unsatisfactory<span class="elsevierStyleSup">52</span>&#46;</p><p class="elsevierStylePara">In summary&#44; even though most information on NIV in patients with neuromuscular or thoracic cavity diseases are based on uncontrolled studies&#44; the many reports of beneficial effects and of improvement in the underlying pathophysiology support the use of NIV&#46; Nevertheless&#44; contraindications must be taken into account and invasive ventilation considered on an individual basis&#46;</p><hr></hr><p class="elsevierStylePara">Correspondence&#58; Dr&#46; C&#46; Lisboa&#46;<br></br> Departamento de Enfermedades Respiratorias&#46;<br></br> Pontificia Universidad Cat&#243;lica de Chile&#46;<br></br> Marcoleta&#44; 345&#44; piso 4&#46; Santiago&#46; Chile&#46;<br></br> E-mail&#58; <a href="mailto&#58;clisboa&#64;med&#46;puc&#46;cl" class="elsevierStyleCrossRefs"> clisboa&#64;med&#46;puc&#46;cl</a></p><p class="elsevierStylePara">Manuscript received 30 January 2003&#46;<br></br> Accepted for publication 30 January 2003&#46;</p>"
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Article information

ISSN: 15792129
Original language: English

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Year/Month	Html	Pdf	Total

2024 November	5	4	9
2024 October	52	32	84
2024 September	69	30	99
2024 August	67	47	114
2024 July	33	25	58
2024 June	72	40	112
2024 May	54	43	97
2024 April	43	21	64
2024 March	38	34	72
2024 February	27	40	67
2024 January	2	0	2
2023 March	8	0	8
2023 February	94	42	136
2023 January	83	28	111
2022 December	80	27	107
2022 November	88	27	115
2022 October	78	34	112
2022 September	79	29	108
2022 August	72	36	108
2022 July	61	51	112
2022 June	97	47	144
2022 May	101	43	144
2022 April	71	36	107
2022 March	83	60	143
2022 February	75	33	108
2022 January	71	27	98
2021 December	49	38	87
2021 November	70	48	118
2021 October	103	49	152
2021 September	41	51	92
2021 August	89	37	126
2021 July	78	47	125
2021 June	92	57	149
2021 May	75	53	128
2021 April	224	96	320
2021 March	123	26	149
2021 February	91	35	126
2021 January	87	25	112
2020 December	62	15	77
2020 November	78	22	100
2020 October	73	20	93
2020 September	84	20	104
2020 August	77	15	92
2020 July	88	12	100
2020 June	55	16	71
2020 May	81	37	118
2020 April	65	22	87
2020 March	70	27	97
2020 February	63	18	81
2020 January	48	34	82
2019 December	123	39	162
2019 November	163	37	200
2019 October	163	16	179
2019 September	164	21	185
2019 August	123	23	146
2019 July	99	20	119
2019 June	176	22	198
2019 May	173	45	218
2019 April	192	42	234
2019 March	181	45	226
2019 February	95	24	119
2019 January	83	21	104
2018 December	56	27	83
2018 November	67	22	89
2018 October	104	24	128
2018 September	103	22	125
2018 May	39	0	39
2018 April	95	20	115
2018 March	103	10	113
2018 February	82	10	92
2018 January	86	15	101
2017 December	87	8	95
2017 November	105	8	113
2017 October	114	17	131
2017 September	90	8	98
2017 August	151	15	166
2017 July	103	29	132
2017 June	120	12	132
2017 May	130	15	145
2017 April	134	13	147
2017 March	141	11	152
2017 February	107	12	119
2017 January	98	8	106
2016 December	96	12	108
2016 November	247	10	257
2016 October	197	22	219
2016 September	248	24	272
2016 August	192	20	212
2016 July	82	24	106
2016 June	1	0	1
2016 March	2	0	2
2016 February	1	0	1
2016 January	1	0	1
2015 December	2	0	2
2015 October	127	6	133
2015 September	127	24	151
2015 August	98	12	110
2015 July	169	22	191
2015 June	100	27	127
2015 May	143	30	173
2015 April	121	18	139
2015 March	181	13	194
2015 February	160	7	167
2015 January	80	11	91
2014 December	107	4	111
2014 November	174	12	186
2014 October	266	16	282
2014 September	171	12	183
2014 August	191	17	208
2014 July	169	16	185
2014 June	174	14	188
2014 May	168	15	183
2014 April	140	15	155
2014 March	147	17	164
2014 February	109	15	124
2014 January	102	13	115
2013 December	80	11	91
2013 November	77	20	97
2013 October	87	18	105
2013 September	78	12	90
2013 August	104	17	121
2013 July	95	31	126
2013 June	72	22	94
2013 May	57	13	70
2013 April	64	13	77
2013 March	12	5	17

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