Abstract
Background: The safety of percutaneous endoscopic gastrostomy (PEG) insertion in amyotrophic lateral sclerosis (ALS) patients with significant respiratory compromise has been questioned. Objectives: 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. Methods: 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. Results: 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). Conclusions: 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.
Highlights
Nutrition is an important component of optimal care in patients with amyotrophic lateral sclerosis (ALS)
A retrospective study suggested that the percutaneous endoscopic gastrostomy (PEG) procedure may carry increased risk in patients with significant respiratory weakness, as indicated by forced vital capacity (FVC) below 50% predicted (5)
Data were prospectively collected on patient age, gender, the site and date of clinical disease onset, disease progression rate (based on ALS functional rating score (ALSFRS)), FVC prior to PEG insertion and a locally-developed risk stratification tool summarised by a ‘traffic light’ score
Summary
Nutrition is an important component of optimal care in patients with amyotrophic lateral sclerosis (ALS). Gastrostomy insertion is frequently employed as a means of enteral nutritional supplementation in patients with ALS unable to meet their nutritional requirements orally. It may be associated with modestly prolonged survival (4). A retrospective study suggested that the PEG procedure may carry increased risk in patients with significant respiratory weakness, as indicated by forced vital capacity (FVC) below 50% predicted (5). This led to (Received 6 October 2016; revised 17 November 2016; accepted 10 December 2016). 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
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