Nutrition in Clinical Practice

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Sedation During Noninvasive Mechanical Ventilation and Percutaneous Endoscopic Gastrostomy in Advanced Amyotrophic Lateral Sclerosis : You Can't Compare Apples With Pears! Andrea Vianello, Domenico Barrile and Antonio M. Esquinas Nutr Clin Pract 2013 28: 142 DOI: 10.1177/0884533612470698 The online version of this article can be found at: http://ncp.sagepub.com/content/28/1/142

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470698 98Nutrition in Clinical PracticeVianello et al 2012

NCPXXX10.1177/08845336124706

Letter to the Editor

Sedation During Noninvasive Mechanical Ventilation and Percutaneous Endoscopic Gastrostomy in Advanced Amyotrophic Lateral Sclerosis:  You Can’t Compare Apples With Pears!

Percutaneous endoscopic gastrostomy (PEG) is the treatment of choice for long-term enteral feeding in patients with amyotrophic lateral sclerosis (ALS) and severe swallowing impairment, to reduce the risk of inhalation and the stress of achieving adequate intake in individuals with feeding difficulties. Other neurological conditions are commonly associated with such disability and constitute a common indication for PEG, including stroke (usually the most common indication for PEG and often vertebrobasilar strokes), multiple sclerosis, Parkinson disease, brain tumors, dementia, and head injury.1 In recent years, the use of intravenous (IV) propofol, either alone or with concomitant benzodiazepines or opioids, has gained great popularity as a form of sedation for gastrointestinal endoscopy due to the drug’s known pharmacological properties, allowing for better quality of sedation and shorter recovery time after the procedure.2 However, critical questions involving the use of propofol remain open, particularly the prevention of cardiopulmonary complications. In fact, although propofol has proved safe for mainly diagnostic endoscopic procedures, there is evidence that cardiorespiratory side effects may occur more frequently and that assisted ventilation may be necessary if propofol sedation is performed for interventional endoscopic procedures.3 On the basis of these preliminary considerations, we read with great interest the article by Kawa et al4 in Nutrition in Clinical Practice concerning the administration of nurseassisted propofol sedation (NAPS) for the placement of PEG in patients with ALS and severe ventilatory impairment. The finding that standardized use of NAPS is as safe and effective as using combined IV midazolam and fentanyl (MF) is of critical importance, supporting the argument that this treatment strategy should be preferred for ALS patients undergoing PEG, since it also allows for reduction of anxiety related to the impending procedure and can lower hospital cost. However, we feel that the conclusion from Kawa et al is overenthusiastic since their study suffers from a serious methodological error: in fact, the proportion of individuals treated by noninvasive ventilation (NIV) during the procedure was much higher in the NAPS group (62%) than in the MF group (19%). Considering that provision of noninvasive respiratory support facilitates successful PEG placement in ALS patients with severe respiratory muscle impairment,5 the patients’ outcome in the NAPS group could have been positively influenced by the more aggressive ventilatory approach, making comparison

Nutrition in Clinical Practice Volume 28 Number 1 February 2013 142-143 © 2013 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533612470698 ncp.sagepub.com hosted at online.sagepub.com

between the 2 treatment groups really difficult. Although the authors suggest that the application of NIV “does not play a large role in the superiority of NAPS vs M/F,” the importance of NIV in the study population is confirmed by data in Table 2 showing a clear trend for the association of a greater number of episodes of severe oxygen desaturation with lack of NIV use, regardless of the type of sedation. This said, we believe that the key message from the study by Kawa et al4 should be quite different, underlining that support by NIV during PEG placement may reduce ventilatory complications and recommending its use when deciding to submit ALS patients to insertion of a gastrostomy tube. We agree with the authors that forced vital capacity (FVC) may not be a good predictor of oxygen desaturation during sedation with either NAPS or MF: this is in accord with previous experiences reporting no procedurally related respiratory complications in ALS patients submitted to PEG, despite a severe reduction of FVC.6,7 In our opinion, this can be explained by the fact that the course of FVC does not strictly reflect the loss of ability to handle oropharyngeal secretion and effectively cough, which is the major factor contributing to increased risk of aspiration and acute oxygen desaturation under sedation in ALS individuals. For this reason, we believe that evaluation of cough ability by measuring peak cough flow should be recommended as a standard procedure when ALS patients undergo sedation and that assisted coughing techniques should be offered in any case where clearance of the airways is compromised. Andrea Vianello, MD

Domenico Barrile, MD Hospital of Padova, Padova, Italy Antonio M. Esquinas, MD, PhD, FCCP Hospital Morales Meseguer, Murcia, Spain References 1. Nicholson FB, Korman MG, Richardson MA. Percutaneous endoscopic gastrostomy: a review of indications, complications and outcome. J Gastroenterol Hepatol. 2000;15(1):21-25. 2. Lazzaroni M, Bianchi Porro G. Preparation, premedication and surveillance. Endoscopy. 2003;35(2):103-111. 3. Wehrmann T, Riphaus A. Sedation with propofol for interventional endoscopic procedures: a risk factor analysis. Scand J Gastroenterol. 2008;43(3):368-374.

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