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Basis powerpointpresentaties
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In the Netherlands, ALS patients are seen by a multidisciplinary ALS
care teams. Every three months, patients are invited for a consultation
to monitor their disease progression, in particular their respiratory
functions and complaints of hypoventilation. When it is indicated, they
are referred to a Home Ventilatory Services clinic, where their
respiratory function is monitored more closely. Criteria are a pCO2
larger than 45 millimeter of mercury, FVC lower than 70%predictive
value, symptoms of nocturnal hypercapnia, (such as morning headache,
dyspnoea or orthopnea) or signs of increased breathing activity. At the
first assessment at the HVS, the capillary pCO2 is measured and the
patients are given advice about their treatment options: Non-invasive
ventilation, Invasive ventilation or palliative comfort care. Once again,
the patient is monitored every three months and when respiratory
failure occurs, the patient will receive the ventilatory support.
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There are four HVS clinics in the Netherlands: Utrecht, Rotterdam,
Maastricht and Groningen. Patients of the Radboud UMC are mostly
referred to Utrecht.
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Ideally, patients are referred to the HVS clinic before respiratory failure
occurs. Therefore, they can make a considered choice about their
treatment options. Unfortunately, a recent observational study of
Raaphorst et al. showed that 30% of the ALS patients are referred to
the HVS after already develloping respiratory failure, which means
daytime hypercapnia or urge start of NIV. The referral is mostly based
on the criterion FVC lower than 70%. This causes multiple problems:
-Patients received ventilatory support without the chance to consider
this decision
-An urgent start of NIV was needed, which means starting the
ventilatory support within 48 hours
-16% had an ICU admission
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Clearly, improvement of the palliative care in ALS is needed.
The more intensive use of other measures could be a solution. At the
radboud, for the past 10 years, the physical therapist Jessica has
measured lung function parameters such as FVC, PCF, MIP, MEP and
SNIP. We hypothesized that these measures would better predict the
need for ventilation in the following three months. This study aimed to
map serial data of the five respiratory tests before receiving a NIV
indication at the HVS, in order to detect the test that best predicts the
need for NIV in the following three months.
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Therefore, data of the trimonthly consultation at the Radboud umc and
Home ventilation services were retrieved and the measurements of the
five respiratory tests were analysed.
As you can see, 78 Patients from Radboud UMC fulfilled our criteria.
52 had multiple measurements at the Radboud, before referred to the
HVS. Form the other 53 patients, data were retrieved at the HVS in
Utrecht. In total, 110 patients were included in the study, of whom 87
received an NIV indication.
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The data were assessed by multiple analysis.
First we evaluated the decline of the five tests by a time-curve of all
patients with two or more consecutive measurements
Then, we looked at the two groups of Radboud patients only, stratified
by NIV indication at the first HVS visit
As a starting point for further research, we determined cut-off values at
a value where 85% of the patients received an NIV indication three
months later.
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Basis powerpointpresentaties
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Then we compared the two groups. There were 57 patients with
measurements at the radboud, who were divided into a ‘no NIV’ group
of 35, compared to 22 in the ‘NIV’ group. The analysis shows that FVC
does not differ between the two groups. Consistent with other previous
studies, we may once again conclude that FVC is not an ideal test for a
referral indication.
As for the other tests, the PCF significantly discriminates No NIV
patients from NIV patients.
Also, the difference of 12% predicitive value of SNIP is remarkably
high, but not statistically significant, probably due to power issues.
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Our conclusion: although the FVC is the most frequently used
respiratory function test to monitor ALS patients in the Netherlands,
current study shows a restricted value in determining respiratory
insufficiency timely.
The PCF and SNIP show promosing results and should be further
investigated.
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To determine optimal cut-off values as starting point for further
research, the five respiratory tests were plotted the cumulative percent of patients with an NIV indication within the following three months .
We calculated the cut off values were 85% of the patients are referred
to an HVS in time, which means three months before they receive NIV.
This leaves 15% with untimely referral, which is a reduction by half
compared to the 37% we found in our previous study.
An example of the plot of the PCF is displayed on the screen. The
lower the value is, the higher the chance become to receive a NIV
indication. As for PCF, at a value of 386, 85% of the patient will be
referred in time.
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These cut-off values could be used to select patient for additional
diagnostics, such as a transcutaneous carbon dioxided monitor. This a
non-invasive method of measuring arterial carbon dioxide levels. This
gives a simple and efficient screening for respiratory failure in home
setting and may detect early nocturnal hypercapnia.
Also, ultrasonography of the diafragma is a possible additional
assessment, which evaluates the thickness of the diaphragm. It gives an
indication of the strength of the diafragmic muscle.
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That brings us to the end of our presentation. Thank you for listening.
I’d be glad to answer any questions you may have.
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Basis powerpointpresentaties
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Ervaring in het doen en interpreteren van spirometrie.
Scholingen: focusgroep richtlijn fysiotherapie, CTB scholing
airstacken, Npi Airway clearance technieken, informatieavond met
CTB, werkgroep FT bij ALS
Intern: scholing fysiotherapeuten en artsen die betrokken zijn bij
andere doelgroepen (NMA, orthopedie, CVA, critical illness)
Mantelzorg: airstacken voor betrokkenen, verdacht zijn op symptomen
1e lijn-en thuiszorg: scholen in airstacken en evt manuele compressie
Landelijke scholing: Spirometrie en airstacken bij ALS, ALS-centrum
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Hoe vaak?
Wat zegt de richtlijn?
Verschillende periodieken afhankelijk van beloop
Sinds kort geïntroduceerde meetcaroussel
Daarnaast variabele periodieken
Hoe lang?
Afhankelijk van FT/medisch handelen kun je nog iets in je
behandelstrategie? Zijn alle mogelijkheden besproken? PEG/PRG-
plaatsing? Wil de patiënt het nog?
Onderzoek: verzamelen data
Heeft het CTB de patiënt in beeld?
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FVC: Sufficiëntie van de longen; indicatie voor fysiotherapeutisch
handelen; CTB
FEV1: Aandacht voor COPD (Tiffenau index); invloed op handelen
PCF: hoestkracht; indicatie voor fysiotherapeutisch handelen; CTB
MIP: om IMT te indiceren
Gezien het beperkte bewijs voor IMT training bij ALS, doen we niet
standaard de MIP.
Indien er motivatie is vanuit patiënt om te trainen en de
beweegmogelijkheden te beperkt zijn nemen we de MIP af om IMT te
indiceren en evt in te stellen
MEP: wij denken dat het uitvoeren van de MEP naast de PCF geen
duidelijke meerwaarde heeft voor ons fysiotherapeutisch handelen
SNIP: Tot nu toe blijkt de SNIP voor ons niet makkelijk bruikbaar. Wij
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hebben ermee geoefend en de uitkomsten waren niet betrouwbaar. Mogelijk is de
uitkomst afhankelijk van de “neus” van de patiënt?
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Doornemen van de informatie bij de verschillende metingen.
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MIP: om IMT te indiceren
Gezien het beperkte bewijs voor IMT training bij ALS, doen we niet
standaard de MIP.
Indien er motivatie is vanuit patiënt om te trainen en de
beweegmogelijkheden te beperkt zijn nemen we de MIP af om IMT te
indiceren en evt in te stellen
MEP: wij denken dat het uitvoeren van de MEP naast de PCF geen
duidelijke meerwaarde heeft voor ons fysiotherapeutisch handelen, al
zegt de richtlijn wel dat de meting als geheel betrouwbaarder wordt als
beide testen afgenomen worden.
SNIP: volgens de literatuur zou de SNIP een betrouwbaarder middel
moeten zijn om de achteruitgang van de respiratoire functie in kaart te
brengen dan de FVC. In onze praktijk blijkt de SNIP niet makkelijk
bruikbaar. Wij hebben ermee geoefend en de uitkomsten waren niet
betrouwbaar. Mogelijk is de uitkomst afhankelijk van de “neus” van de
patiënt.
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Basis powerpointpresentaties
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Basis powerpointpresentaties