Science News: Amyotrophic Lateral Sclerosis and Noninvasive Positive Pressure Ventilatory Support: "Nasal Noninvasive Ventilation" or "Noninvasive Ventilatory Support"?

Submitted by: Rebecca O'Bryan, MD
Edited by: Nakul Katyal, MD

Bach JR, Pham H. Amyotrophic lateral sclerosis and noninvasive positive pressure ventilatory support: "Nasal noninvasive ventilation" or "noninvasive ventilatory support"?. Am J Phys Med Rehabil. 2022;101(4):400-404. doi:10.1097/PHM.0000000000001905

Summary: This article proposes a trial of noninvasive ventilatory support as an alternative to tracheostomy in patients with amyotrophic lateral sclerosis (ALS). Studies have shown brief statistical benefit of nasal noninvasive ventilation; however, this strategy may not be able to normalize carbon dioxide (CO2), leading to hypercapnia and therefore eventually to CO2 narcosis, intubation, and tracheostomy. 
 
Noninvasive ventilatory support provides continuous ventilatory support and can be maintained in ALS patients without resorting to tracheotomies. The authors propose the alternative of continuous noninvasive ventilatory support with mechanical insufflation-exsufflation to nasal noninvasive ventilation. Nineteen centers reported 335 ALS patients using this method for up to 12 years, for an average of 14 months.

Comments: This article is interesting in terms of offering patients some extension in time prior to tracheostomy. This approach is not one to which I had been exposed previously. There is not a large body of literature on this, and more research is needed to determine how this would stack up to other options, but in the case of many of my ALS patients who opt not to choose tracheostomy, I see a very low downside to trialing this method.