ORIGINAL ARTICLE Percutaneous Radiologic Gastrostomy in Patients With Amyotrophic Lateral Sclerosis on Noninvasive Ventilation Jung Hyun Park, MD, Seong-Woong Kang, MD, PhD ABSTRACT. Park JH, Kang S-W. Percutaneous radiologic gastrostomy in patients with amyotrophic lateral sclerosis on noninvasive ventilation. Arch Phys Med Rehabil 2009;90: 1026-9. Objective: To determine the safety and feasibility of percu- taneous radiologic gastrostomy (PRG) tube placement in pa- tients with amyotrophic lateral sclerosis (ALS) with too low a vital capacity to be weaned off noninvasive positive pressure ventilation (NPPV). Design: Five-year follow-up cohort study. Setting: Inpatient pulmonary rehabilitation hospital. Participants: Patients with ALS (N=25) with dysphagia on NPPV. Interventions: PRG tube placement was performed. During the procedure, all subjects used NPPV via nasal masks. No sedatives or narcotics were administered for premedication. Main Outcome Measures: Success and complication rates after PRG tube placement, and mean survival after the procedure. Results: For the 25 patients enrolled, mean percent forced vital capacity (FVC) was 33.317.8% seated (n=19) and 25.312.0% supine (n=18). FVCs could not be measured in patients who could not tolerate being off NPPV. PRG place- ment was 100% successful technically. Mean survival for the 25 patients was 32.1 months. Conclusions: The application of NPPV during PRG was found to be a successful, safe means of providing nutritional care for patients with ALS with too low an FVC to be off NPPV. We advocate that PRG be considered the treatment of choice for nutritional care in patients with ALS on NPPV. Key Words: Amyotrophic lateral sclerosis; Gastrostomy; Rehabilitation; Respiratory insufficiency; Respiratory therapy. © 2009 by the American Congress of Rehabilitation Medicine M OST PATIENTS WITH amyotrophic lateral sclerosis develop swallowing difficulties, which lead to malnutri- tion and weight loss. Nutritional status is a risk factor for survival and an important contributor to quality of life. 1,2 The American Academy of Neurology ALS Practice Param- eters suggest PEG tube insertion when FVC in a seated erect position is 50% of normal predicted value or greater. 3 How- ever, if bulbar dysfunction appears later than limb or respira- tory muscle weakness, patients do not show weight loss or severe malnutrition when FVC falls to less than 50% of the normal value, 4,5 and thus, many patients miss the opportunity to have nutritional tubes inserted. In general, PEG is a relatively safe procedure, but morbidity and mortality rise as the FVC falls. 5,6 When performing PEG, mild sedation is needed, which might introduce the risk of respiratory compromise in patients with an FVC less than 50%, and the risk of aspiration, because the pharynx is transiently anesthetized. 7,8 On the other hand, PRG does not require se- dation or an endoscopic tube, and has the advantages of a high success rate and a low risk of aspiration. 9,10 However, perform- ing PRG in patients with low FCV is problematic. In the present study, we discuss the safety and feasibility of PRG placement in patients with ALS with too low a vital capacity for NPPV. METHODS Subjects Twenty-five patients with probable or definitive ALS ac- cording to El Escorial criteria were recruited for this study. 11 All patients had dysphagia symptoms, had weight loss (10% of usual weight), had an FVC below 5% of pre- dicted, and used an NPPV. They were referred to our De- partment of Interventional Radiology for PRG placement between August 2001 and March 2003. The institutional review boards approved this study, and informed consent was obtained from all 25 patients. Respiratory Function Evaluation Respiratory functions were evaluated in all cases just before the PRG procedure as follows. Forced vital capacity. FVCs were measured in sitting and supine positions using a spirometer. a This process was repeated at least 3 times, and the highest value achieved was defined as the FVC. We calculated FVC predicted values based on ages, heights, and weights of subjects. 12 Relative FVC values (%) are presented as FVC/FVC pre- dicted values (%). Peak cough flow. PCF was measured by using a peak flow-meter. b Unassisted PCF was measured by having the patient cough as much as possible through the peak flow- meter. The highest value recorded during at least 3 tests was used. From the Department of Rehabilitation Medicine, Eulji University College of Medicine, Daejeon, Korea (Park); and the Department of Rehabilitation Medicine and Rehabilitation Institute of Muscular Disease, Yonsei University College of Medicine, Seoul, Korea (Kang). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organi- zation with which the authors are associated. Correspondence to Seong-Woong Kang, MD, PhD, Department of Rehabilitation Medicine, Gangnam Severance Hospital, Yonsei University, 612 Eonjuro, Gangnam- gu, Seoul, Korea, 135-720, e-mail: kswoong@yuhs.ac. Reprints are not available from the author. 0003-9993/09/9006-00785$36.00/0 doi:10.1016/j.apmr.2008.12.006 List of Abbreviations ALS amyotrophic lateral sclerosis FVC forced vital capacity NPPV noninvasive positive-pressure ventilation PCF peak cough flow PEG percutaneous endoscopic gastrostomy PRG percutaneous radiologic gastrostomy 1026 Arch Phys Med Rehabil Vol 90, June 2009