Gastrostomy in amyotrophic lateral sclerosis: effects of non-invasive ventilation

Abstract

Although the optimum method and timing for gastrostomy insertion in patients with amyotrophic lateral sclerosis are not entirely clear, feeding through a gastrostomy tube is often used to support these patients.1Miller RG Jackson CE Kasarskis EJ et al.Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.Neurology. 2009; 73: 1218-1226Crossref PubMed Scopus (576) Google Scholar In The Lancet Neurology, members of the ProGas Study Group2ProGas Study GroupGastrostomy in patients with amyotrophic lateral sclerosis (ProGas): a prospective cohort study.Lancet Neurol. 2015; 14: 702-709Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar recently set out to compare three gastrostomy insertion approaches (percutaneous endoscopic gastrostomy, radiologically inserted gastrostomy, and per-oral image-guided gastrostomy) in a large population of patients with amyotrophic lateral sclerosis who agreed with their treating clinicians to undergo gastrostomy at 24 motor neuron disease care centres or clinics in the UK. At study end, the researchers concluded that the procedure risk did not differ significantly in the three groups; rather, the survival rate was significantly affected by age at disease onset and the percentage of bodyweight lost from diagnosis to gastrostomy.2ProGas Study GroupGastrostomy in patients with amyotrophic lateral sclerosis (ProGas): a prospective cohort study.Lancet Neurol. 2015; 14: 702-709Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar We would like to take objection to the fact that non-invasive ventilation, which is known to reduce mortality and to enhance quality of life in patients with amyotrophic lateral sclerosis, was not taken into adequate consideration by the ProGas Study Group. The authors made no mention of respiratory support provided by non-invasive ventilation during tube placement, despite reports that it enables successful percutaneous endoscopic gastrostomy placement in most patients with amyotrophic lateral sclerosis.3Sancho J Servera E Chiner E et al.Noninvasive respiratory muscle aids during PEG placement in ALS patients with severe ventilatory impairment.J Neurol Sci. 2010; 297: 55-59Summary Full Text Full Text PDF PubMed Scopus (36) Google Scholar It could be argued that, although the 30-day mortality was similar across the three groups, this result could have been different if ventilatory support had been provided. Additionally, use of non-invasive ventilation was not included in the regression model constructed to assess the effect of relevant variables affecting patient survival during the post-procedure period. Improved survival is a well established benefit of non-invasive ventilation in patients with amyotrophic lateral sclerosis, both when initiation of this ventilation is late (hypercapnia and forced vital capacity 38–45% of predicted at initiation) and when it is early (forced vital capacity 49–56% of predicted at initiation, which was probably the case in the per-oral image-guided gastrostomy group).4Qureshi M Schoenfeld DA Paliwal Y Shui A Cudkowicz ME The natural history of ALS is changing: improved survival.Amyotroph Lateral Scler. 2009; 10: 324-331Crossref PubMed Scopus (55) Google Scholar In our opinion, failure to include non-invasive ventilation in the regression model could have led to a misidentification of predictors of post-procedure survival. To conclude, our opinion is that, in view of its important and established positive effects on patient survival and wellbeing, non-invasive ventilation should be a key consideration when gastrostomy insertion in patients with amyotrophic lateral sclerosis is being assessed. We declare no competing interests. Gastrostomy in patients with amyotrophic lateral sclerosis (ProGas): a prospective cohort studyThe three methods of gastrostomy seemed to be as safe as each other in relation to survival and procedural complications. In the absence of data from randomised trials, our findings could inform clinicians and patients in reaching decisions about gastrostomy and will stimulate further research into the nutritional management in patients with amyotrophic lateral sclerosis. Full-Text PDF Open AccessGastrostomy in amyotrophic lateral sclerosis: effects of non-invasive ventilation – Authors' replyWe have read with interest the letters by Andrea Vianello and colleagues, and Paolo Innocente Banfi and colleagues about the findings of the ProGas study. In response, we would like to make two comments. Full-Text PDF