Safety of Gastrostomy Tube Placement in Patients with Advanced Amyotrophic Lateral Sclerosis With Noninvasive Ventilation

Abstract

Background In patients with amyotrophic lateral sclerosis (ALS), bulbar muscle dysfunction can occur, which eventually requires the initiation of enteral tube feeding. However, there is no consensus on the optimal timing for the gastrostomy or the proper ventilator support method during the procedure. We aimed to investigate the safe range of gastrostomy according to respiratory support status and forced vital capacity (FVC) % of predicted values classification and to compare the safety of noninvasive and invasive mechanical ventilation during the procedure in ALS patients with FVC < 30% of predicted. Methods A total of 477 patients diagnosed with ALS at our institution from January 1, 2009, to December 31, 2018, were evaluated, and 105 patients were enrolled in this study. All medical records covering ventilation status and complications within 6 months to 1 year after the initial gastrostomy were gathered and reviewed. Results The gastrostomy procedure was considered safe regardless of FVC status or modality of respiratory support. There were complications related to the gastrostomy procedure in 6 of 105 patients and all were managed through conservative care. The incidence of complications, including respiratory ones, for noninvasive and invasive positive pressure ventilation was 5.5% and 9.6%, respectively, which were not statistically significantly different (P = .294). Conclusion The procedure and tube placement of a gastrostomy can be safely performed in ALS patients with minimal FVC regardless of ventilation invasiveness. We suggest that there should be a new standard for FVC % of predicted to facilitate performing gastrostomy in ALS patients.

Non-invasive ventilation support for people with amyotrophic lateral sclerosis: multidisciplinary team management

“…The notion of determining suitability for gastrostomy on a pulmonary function threshold alone is coming into question. Whilst the NICE guidance is clear that FVC should be >50% of predicted to perform the procedure safely [9], Kim et al reported outcomes suggesting that gastrostomy insertion can be performed safely in patients with a FVC <30%, irrespective of ventilatory support [14 ▪ ]. These findings may be interpreted with caution given contradictory findings about mortality risk in NIV dependent individuals observed in contemporaneous studies, but does suggest that the relationship between NIV use, pulmonary function and survival post gastrostomy may not be as linear as initially thought.…”