Abstract
Background: Although noninvasive ventilation (NIV) improves survival and quality of life (QOL) in ALS, use of NIV is suboptimal. Objective: To determine compliance with “early” NIV initiation, requisite for the feasibility of a large study of early NIV initiation, and examine factors impacting compliance. Methods: Seventy-three ALS participants with forced vital capacities (FVC) >50% were enrolled. Participants with FVC over 80% (Group 1) were initiated on NIV early (FVC between 80 and 85%). Participants with FVC between 50 and 80% (Group 2) started NIV at FVC between 50 and 55%. Symptom surveys, QOL scores, and NIV compliance (machine download documenting use ≥4 hours/night >60% of time) were collected following NIV initiation. Results: 53.6% of Group 1 and 50% of Group 2 were compliant 28 days following NIV initiation, with increased compliance over time. Participants who were unmarried, had lower income, lower educational attainment, or limited caregiver availability were less likely to be compliant. Bothersome symptoms in non-compliant participants included facial air pressure, frequent arousals with difficulty returning to sleep, and claustrophobia. Both compliant and noncompliant participants felt improved QOL with NIV; improvement was significantly greater in compliant participants. Conclusions: These data suggest ALS patients can comply with NIV early in their disease, and potentially benefit as evidenced by improved QOL scores, supporting both feasibility and need for a study comparing early versus late NIV initiation. Moreover, modifiable symptoms were identified that could be optimized to improve compliance. Further studies are needed to determine the impact of “early” intervention on survival and QOL.
Introduction
Respiratory failure is the leading cause of mortality in ALS patients and the majority of patients in North America opt against tracheostomy (Citation1,Citation2). Noninvasive ventilation (NIV) has been shown to extend median survival by 205 days, maintain quality of life measures significantly longer, and result in improvements in the SF-36, Chronic Respiratory Questionnaire, and the Sleep Apnea quality of life (QOL) index (Citation3). NIV has also shown to relieve symptoms of chronic hypoventilation and improve QOL (Citation4). Based upon an evidence-based review of the subject in 2009, the American Academy of Neurology published recommendations to initiate NIV when symptoms of orthopnea occur, or when the the individual cannot reach either a pressure of −60 cm H2O on maximal inspiratory pressure measurement (MIP) or a forced vital capacity (FVC) of 50% predicted on spirometry. (Citation5). There remains, however, no concensus on the ideal measure to use (Citation6) or on the optimal indication or timing of NIV (Citation7). Some agencies recommend NIV at a liberal FVC% threshold of 80% or less if there are symptoms of hypoventilation (Citation8).
Despite the impressive data regarding extension in survival with NIV, analysis of the ALS CARE Database showed that in patients with a FVC <50%, only 36% of patients used NIV (Citation9). Compliance was strongly correlated with symptoms of orthopnea and dyspnea, use of PEG tubes, riluzole, augmentative speech devices, male gender, and household income >$80,000. In a review of the Pooled Resource Open Access ALS Clinical Trials database published in 2019, only 33.9% of patients reported NIV use (Citation10).
A large retrospective study (Citation11) and three small series have demonstrated an improvement in survival for patients initiating NIV with a FVC >80% (Citation12–14) have demonstrated an improvement in survival for patients initiating NIV with VC >80% predicted, although this effect was not confirmed when sam NIV was used in the control group (Citation14). Jacobs et al. reported an adherence of about 3 hours per day with early NIV (Citation14). A large randomized controlled trial on this subject (Citation15) was terminated due to insufficient recruitment.
The objective of this study was to determine if NIV would be accepted earlier in disease when the FVC was still relatively normal in order to examine the feasibility of a study that examines early versus standard initiation of NIV (at FVC of <50%). Our secondary objective was to examine factors that influence NIV compliance in order to determine how to maximize compliance.
Methods
Seventy-three ALS participants were enrolled in the multicenter pilot study of Nutrition and NIV in ALS which has been previously described (Citation16). All activities were reviewed by the local IRBs of the participating sites and all subjects signed IRB approved consents. Inclusion criteria included participants aged 18–80 with a diagnosis of possible, definite or probable, sporadic or familial ALS, onset of weakness within 60 months, and best sitting FVC between 50% and 95%. Participants were excluded if they had a history of asthma or COPD, were currently using NIV or did not have a reliable caregiver. Baseline demographic data including the date of onset, site of onset, gender, race, marital status, BMI, years of education, household income, military service, and other health conditions were collected. Differences between groups was assessed by Wilcoxan signed rank test.
In order to study the feasibility of early initiation of NIV, we wanted to study whether participants who were earlier in their disease course would be compliant. To do this, we stratified participants into an “early intervention” group and a standard of care group. Participants with a FVC >80% of predicted at baseline were initiated on NIV when their FVC was 75–85% predicted (Group 1–Early intervention). Participants with an FVC between 50 and 80% were started on NIV when their FVC was 45–55% (Group 2–Standard of Care). Participants were evaluated every 8 weeks for 48 weeks. Additional study visits at 4 week intervals were scheduled if a participant was within 5% of the FVC that would trigger initiation of NIV. Respiratory assessments including supine/sitting forced vital capacity (FVC), Maximal Inspiratory Pressure (MIP), and Maximal Expiratory Pressure (MEP), and the ALS Functional Rating Score-Revised (ALSFRS-R) were collected at each study visit. Sleep scales including the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Scale (PSQI) were also completed. We evaluated 17 symptoms that might impact on a subjects use of NIV in order to examine what symptoms were overall most bothersome in NIV users and which symptoms were most likely to impact compliance. Subjects scored each symptom from 1 (mild symptoms) to 10 (severe) with 0 indicating they did not have the symptom. We calculated the percent of subjects with each symptom (total population of NIV users, overall compliant (average of >4 hours use for more than 60% of the time), and the noncompliant (average of <4 hours of use 60% of the time) in order to examine what symptoms were most common. A Chi square analysis was used to determine whether the differences in percent of subjects with the symptom was different between compliant and noncompliant participants.
For each symptom, we also analyzed differences in the severity of the symptoms when present (scale of 1–10). To do this we calculated the mean scores for the total group of NIV users and also the overall compliant and overall noncompliant NIV users. We examined for differences in the mean symptom severity scores between compliant and noncompliant subjects utilizing a t test with assumed unequal variance between the compliant and noncompliant groups.
Finally, we enquired if the NIV user believed that there had been an overall improvement in the quality of life since initiating NIV and if so how much of an impact there had been on a scale of 0 (none) to 10 (maximal effect).
At the time of NIV initiation, participants were given an educational DVD to review. All participants received treatment with a Bipap ST Synchrony device (Phillips Respironics) with a heated humidifier and gel nasal mask. The initial settings were an IPAP of 6 cm and EPAP of 4 cm, back up rate of 12 breaths/min, rise time of 2, and time in IPAP mode = 33%. Participants were encouraged to use the device for short periods of the day until they became tolerant, and then to initiate treatment overnight.
A respiratory therapist went to the participant’s home three times the first week, two times the second week, weekly for 2 weeks, then monthly. The respiratory therapist educated both the participant and the caregiver about the NIV device and its use, how to record meter readings, adjust pressures, and addressed issues leading to intolerance (). If the patient had problems with the mask due to leakage, they were offered a different interface.
Table 1 Addressing the issues leading to intolerance.
The initial treatment goals specified that participants were to use NIV for >4 hours/night at least 60% of nights within the first 28 days. NIV compliance assessments were performed at each study visit and included a NIV tolerance questionnaire (self-report), download of compliance information from the NIV device using Encore Pro software (average daily use, and % of nights with use >4 hours), and meter readings from the device. In addition overall compliance was determined by examining compliance for each visit by the same criteria of use of the NIV for >4 hours for 60% or greater of the days between visits. If the participant was compliant for 60% of all their study visits, they were determined to be overall compliant.
Data were expressed as counts and percentages for categorical variables and median (range or interquartile range) for continuous variables overall as well as by disease or compliance group. Given that many variables (e.g. most of pulmonary function measures) were not normally distributed, we used non-parametric tests such as the Wilcoxon rank sum test to compare between compliance groups. For each measure we obtained the subject-specific slope by using the best fitted line of all the longitudinal values for that subject. Rate of decline of each pulmonary function parameter was then estimated using the median of subject-specific slopes for the absolute drops over time and correlated with participant’s compliance status. Multiple testing adjustments were not made due to the exploratory nature of this study. p-values less than 0.05 were considered statistically significant. SAS version 9.4 (SAS Institute Inc., Cary, NC) was used for all the data analyses.
Results
Seventy three subjects were enrolled in the study, and based on baseline %FVC, 47 participants were assigned to Group 1 and 26 patients to Group 2. There were no significant differences in baseline demongraphics, PQSI, and ESS, although there was a difference in FVC as planned (). In addition, for subjects with >3 visits, the slope of change in FVC and ALSFRS-R was calculated. There were no significant differences between Group 1 and 2 for median slope of decline for ALSFRS-R (–1.13 (range −2.54 to 0.2) points/month Group 1 vs −1.13 (–2.54, −0.30) points/month in Group 2. Similarly the changes in the sitting FVC showed no significant difference (–1.97 (–8.91, 2.28) %/month in Group 1 vs −2.32 (–10.85, 0.34)%/month in Group 2).
Table 2 Baseline demographics and disease characteristics for the entire population overall and by group.
A total of 58 participants were initiated on NIV. In Group 1, 35 patients were initiated on NIV; 7 refused and 5 never met the target FVC of <80% predicted during the study period. In Group 2, 23 patients were initiated on NIV and 3 never met the target FVC of <50% during the study period. Downloads were available on 44 of the participants followed over time. Compliance at 28 days was not significantly different between groups, at 52.3% overall, with 53.6% of subjects compliant in Group 1 and 50% compliant in Group 2 (). In addition, at the first visit following NIV initiation, we compared the participant reported NIV use and compliance with the downloads and meter readings from the NIV machine. We found that downloaded data and meter readings were consistent with participant reports of compliance in only 23/42 (55%) of patients.
Table 3 Compliance over time overall and by group.
Forty-seven of the subjects placed on NIV had 3 or more follow up visits, with 44 of these participants providing downloads that could be used to evaluate compliance over time (). Overall compliance did increase over time with a maximum overall of 74% in the total population. Group 2, who were more advanced when starting NIV, reached compliance rates of 87.5% although the numbers of subjects surviving and on NIV were small. In Group 1, the maximum compliance reached 68.4%.
Overall, participants who were compliant were more likely to be married, had more years of education, and had higher household annual income than noncompliant participants. There was no difference in compliance based on site of disease onset or the ALSFRS-R subscores. While the numbers were small in this pilot study, we examined the slope of change in the sitting FVC, MIP, and ALSFRS-R over the course of the study in compliant and noncompliant subjects. There was no difference in these slopes (). Despite the small numbers, we were able to demonstrate an improvement in the PSQI that was significant with compliant participants demonstrating a decrease (improvement) in their score while noncompliant participants had an increase in score. This demonstrates an improved quality of sleep among compliant participants. The Epworth Sleepiness Scale did not demonstrate a significant difference over time.
Table 4 Variables associated with long term compliance.
presents our findings for percentage of symptoms and the mean value of severity for the total group in compliant as well as noncompliant participants. In addition it presents the data regarding the overall positive impact on QOL improvement including the overall percent of participants who felt a positive impact along with the mean value of the perceived impact on a scale of 1–10.
Table 5 Symptoms associated with NIV use (scale of 0–10) and perceived impact on QOL.
The most common symptoms were excessive dryness of the throat and nasal passages, followed by air leakage, frequent night arousals, stuffy nose, and mask discomfort occurring in more than 50% of the NIV users. There was a significantly increased percentage of compliant subjects who complained of eye irritation, marks on their faces from the mask, complaints from their spouses and bloating while there was a significantly higher percentage of non-compliant subjects who complained about the pressure of air on their face. In terms of the severity of the symptoms, overall severity was greatest for excessive dryness of the nasal and oral passages and rash or marks on the face. In considering compliant vs non-compliant participants, significant differences were seen in the severity of four symptoms: Difficulty getting back to sleep, difficulties with the pressure of air on the face, difficulties having caregiver available and a sense of suffocation. In each case, the symptom was more severe in the non-compliant NIV users. Trends toward higher symptom scores for frequent arousals and excessive dryness in the nasal and oral passages were also noted in the non-compliant group which did not meet significance with p = 0.06)
It is of interest that more than 70% of NIV users, both compliant and non-compliant, felt that NIV improved their quality of life. However there was a statistical difference between the magnitude of the impact with compliant NIV users having a significantly greater effect (20% higher QOL score) on their quality of life.
Discussion
Our findings demonstrate that Group 1 participants with normal respiratory function were equally adherent to NIV as were Group 2 participants. Furthermore, in both groups there is a general trend for compliance to increase over time. This may reflect increasing respiratory difficulties over the course of the illness impacting use or, alternatively, that the participants who were still alive were those who were more compliant. In addition, in judging compliance, it was clear that self reported use is inaccurate and it is important to utilize data directly obtained from the ventilator to determine compliance. The high level of complance in participants early in the disease sets the stage to examine the effects of early intervention on survival and quality of life compared to the present AAN-recommended and Medicare-directed practice of initiating NIV at an FVC of <50% expected or NIF of <60 cmH20.
While the number of participants in this pilot study were not powered to answer the questions regarding efficacy of NIV use, there were some suggestive findings. Sleep quality was improved in compliant participants when compared to noncompliant participants. Furthermore, there was a subjective impact on the quality of life in all NIV users but the impact was significantly greater in the compliant participants. Future studies should include a more formal assessment of quality of life.
Whether initiating NIV in routine clinical care or for the purpose of a clinical trial, it will be important to address factors that impact NIV adherence. We found that single marital status, lower level of education and household income <$50,000 have a significant adverse effect on compliance. While these factors may not be modifiable, they do help identify a population who may require more intensive interventions to improve NIV adherence. Although all patients had to have a caregiver in order to participate in the trial, the reliability of the caregiver certainly could have influenced NIV compliance. This was confirmed based on the symptom score for “difficulty for caregiver to help due to time availability” (see ). There was a significant difference in the response between compliant and non-compliant patients (i.e. non-compliant patients had more difficulty). Symptom management may have a large impact on our ability to implement and maximize NIV use. While some complaints were significantly increased in compliant subjects (eye irritation, marks on their faces from the mask, complaints from their spouses and bloating likely related to aerophagia due to increased use of the ventilator), it is most important to focus on the symptoms that were more common in the non-compliant participants as these symptoms likely contribute to nonadherence. The non-compliant subjects more commonly complained about the pressure of air on their face. The severity of this symptom was also significantly greater in the non-compliant subjects suggesting that it may contribute to poor compliance. Other symptoms that were significantly more bothersome in non-compliant NIV users included frequent arousals with difficulty getting back to sleep, claustrophobia with the interface and caregiver availability. These findings are certainly not unexpected given our clinical experience with NIV implementation. Importantly, these are symptoms that can be treated aggressively to improve NIV compliance. Use of sleep aids, pressure adjustments or use of volume ventilators along with interface choice, air humidification and reduction where possible of anticholinergic medications could all help enhance compliance. Certainly the use of newer technology may also increase compliance rates in future trials.
In summary, our results suggest that even early asymptomatic ALS patients can adhere to NIV use and this may lead to improved quality of life. These findings set the stage for studies directed at answering questions about the optimal timing of NIV as we now primarily rely on guidelines which have not been developed in a systematic fashion in the ALS population. Our findings suggest that a study directed at the question of intervention at an earlier time in the course of disease (when FVC is over 80%) are feasible and warranted. Further, our findings support those of others that have demonstrated positive effects of NIV on quality of life. Furthermore, we have clearly identified several modifiable factors that can be addressed during routine clinical care to improve adherence and maximize the effect of NIV in our clinical population.
Acknowledgements
NIV Sites – Drexel University College of Medicine: Terry Heiman-Patterson, MD, Michael Sherman, MD, Melonie Mitchell RPT, Roseanne Sattazahn RN; Beth Israel: Stephen N. Scelsa, MD, Theresa Imperato; SUNY Upstate University: Jeremy M. Shefner, MD, Ph.D, Mary Lou Watson; University of Colorado: Yvonne Rollins, MD, John Cumming; Henry Ford Hospital: Dan Newman, MD, Helen Foley; University of Miami: Ashok Verma, MD, Donald Koggan, MD, Julie Steele; University of Texas: Carlayne Jackson, MD, Pam Kittrell, RN
Nutrition Sites – University of Kentucky: - Edward J. Kasarskis, MD, PhD – PI, Stephen Wells, Kathryn Vanderpool, RN, Christie Shrestha, MPH, Deborah Taylor, Marta Mendiondo, Ph.D, Richard Kryscio, Ph.D, Margaret Healey, Marsha Sams, Megan Thompson; Columbia: Hiroshi Mitsumoto, MD, FAAN, Daniel Bell; University of Vermont: Rup Tandan, MD, Chris Potter, Dwight Matthews; University of Utah: Mark Bromberg, MD, Summer Davis; Pennsylvania State University: Zachary Simmons, MD, FAAN, Beth Stephens, Ally Brothers
Statistics Core – Temple University Lewis Katz School of Medicine: Daohai Yu, PhD, Xiaoning Lu MS.
Declaration of interest
Dr. Jackson serves a consultant for Mitsubishi Tanabe Pharma America, Cytokinetics, and Brainstorm.
Dr. Heiman Patterson serves on the medical advisory board for Mitsubishi Tanabe Pharma America, Biogen, Samus, Cytokinetics, and Orphazyme. She has received an honorarium from IQVA and received a consulting fee from Evidera.
Dr. Yu has no relevant disclosures.
Dr. Sherman has no relevant disclosures. Content contributed by Dr. Sherman is through his affiliation with Drexel University.
Dr. Kasarskis has research support from Alexion, AB Science, Neuraltus and collaborative research support from Healey Platform trial, Amylyx, Kansas University, and Columbia University.
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References
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