Evaluation of a Mechanical Device During Acute Respiratory Failure in Patients With Neuromuscular Disorders (Nemucough)

Evaluation of a Mechanical Insufflation-exsufflation Device During Acute Respiratory Failure in Patients With Neuromuscular Disorders: a Prospective, Randomized, Controlled, Multicenter Study

The hypothesis is that a mechanical insufflation-exsufflation (MI-E) is associated with a decrease in the number of intubations and more rapid clinical improvement in children and adults with neuromuscular disease who are admitted for an acute respiratory exacerbation.In this prospective, randomised, multicenter study, 55 patients will be treated with standard treatment and a MI-E, and 55 patients with standard treatment and standard respiratory physiotherapy. The primary objective is the reduction of the number of patients requiring invasive ventilatory support (endotracheal intubation or tracheotomy) in the group treated with MI-E (MI-E group). The main secondary objectives are a reduction in hospital stay and an improvement in clinical condition, dyspnea and respiratory muscle function.

Study Overview

• Status: Terminated
• Conditions: Neuromuscular Diseases; Amyotrophic Lateral Sclerosis; Duchenne Muscular Dystrophy
• Intervention / Treatment: Device: mechanical insufflation - exsufflation; Device: Standard respiratory physiotherapy

Detailed Description

Justification Respiratory muscle weakness reduces the efficacy of the cough reflex in patients with neuromuscular disorders and exposes them to the risk of acute respiratory failure. Mechanical insufflation-exsufflation devices assist cough and have been shown to be efficient in increasing the cough expiratory flow in children and adults with neuromuscular disease and decreasing the risk of intubation in a limited population of hospitalized adults with acute respiratory failure.

Primary objective The goal is to record the efficacy of mechanical insufflation-exsufflation (MI-E) during acute respiratory failure in patients with neuromuscular disorders.The primary objective is the reduction of the number of patients requiring invasive ventilatory support (endotracheal intubation or tracheotomy) in the group treated with MI-E (MI-E group) compared to the group treated with traditional chest physiotherapy without MI-E (Control group).

Secondary objectives

In the MI-E group, compared to the Control group:

1. Decrease in the length of hospitalization in the intensive care unit (ICU)
2. Decrease in the total length of hospitalization
3. Decrease in the incidence of bronchoscopy-assisted aspiration
4. Decrease in the duration of oxygen therapy
5. Decrease in the daily length of noninvasive positive pressure ventilation (NPPV)
6. Improvement in blood gases on room air during hospitalization
7. Improvement of the peak cough flow (PCF)
8. Improvement of the vital capacity (VC), maximal inspiratory (PImax) and expiratory (PEmax) pressures, sniff nasal inspiratory pressure (SNIP), peak expiratory flow (PEF) and dyspnea during hospitalization.
9. Decrease in the number of secondary tracheotomies (for weaning of ventilatory support)

Type of study Prospective, randomized, controlled, multicenter study

Number of subjects The calculation of the number of subjects is based on two retrospective studies. In the study by VIANELLO, which included 11 adults hospitalized in the ICU for respiratory failure, the number of therapeutic failures, defined as the need for a "mini" tracheotomy or intubation, was significantly less in the group using MI-E than in a group of 16 historical control patients [2 failures in the MI-E group (18%) versus 10 failures in the control group (63%), p<0.05] (1). Another study reported 19 successes (80%) versus 5 failures on MI-E (2).

• Study Type: Interventional
• Enrollment (Actual): 14
• Phase: Phase 3

Contacts and Locations

Study Locations

• France
  • Paris, France, 75012
    • Hospital Armand Trousseau, Pediatric Pulmonology Department and INSERM UMR S-893

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 4 years and older (Child, Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

Pediatric or adult patients with chronic neuromuscular disorders, such as spinal muscular atrophy, Duchenne muscular dystrophy, other congenital myopathy, or amyotrophic lateral sclerosis (ALS), hospitalized for acute respiratory failure, as defined by:

• Persistent bronchial encumbrance (> 2 days) despite regular treatment in the homecare setting, associated with-Oxygen desaturation on room air, defined by a pulse oximetry (SaO2) <95%) or
• In patients not receiving long-term NPPV: the need to institute NPPV-In patients receiving long-term NPPV: the need to increase the daily length of NPPV by at least 25%.

Exclusion Criteria:

• Need for immediate intubation (alteration in consciousness, coma, hemodynamic disorders)
• Multiple organ failure (e.g., associated cardiac failure)
• In adults: respiratory rate >30/min, pH < 7.35, PaCO2 > 50 mm Hg
• Facial deformity or anomaly which prevents the use of a mouthpiece or mask
• Patients who signed a refusal to be intubated regardless of the progression of their disease
• Patients on long-term oxygen therapy
• Tracheotomized patients
• Patients requiring the use of an intrapulmonary percussive ventilation device during hospitalization
• Acute neuromuscular disorder of known or unknown etiology
• Associated lung disease such as chronic obstructive pulmonary disease (COPD)
• Refusal of patient consent and/or parental consent in the case of a minor
• Uncooperative patients
• Patients < 4 years old

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: 1; patients treated with standard treatment and a mechanical insufflation-exsufflation	Device: mechanical insufflation - exsufflation; Patients will receive MI-E treatment with the following settings: insufflation pressure of at least +30 cm H2O and an exsufflation pressure ≥ -30 cm H2O. There will be at least 6 hyperinflation/exsufflation sequences per session of chest physiotherapy. There will be at least two daily sessions done routinely by the respiratory therapist at 8 hour intervals.; Other Names: Mechanical insufflation-exsufflation devices assist cough
Active Comparator: 2; Patients with standard treatment and standard respiratory physiotherapy	Device: Standard respiratory physiotherapy; Traditional chest physiotherapy without mechanical insufflation-exsufflation

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Reduction of the number of patients requiring invasive ventilatory support in the group treated with MI-E (MI-E group) compared to the group treated with traditional chest physiotherapy without MI-E (Control group).	During the treatment phase

Secondary Outcome Measures

Outcome Measure	Time Frame
Decrease in the length of hospitalization in the intensive care unit (ICU) (if necessary)	During the treatment phase
Decrease in the total length of hospitalization	During the treatment phase
Decrease in the incidence of bronchoscopy-assisted aspiration	During the treatment phase
Decrease in the duration of oxygen therapy	During the treatment phase
Decrease in the daily length of noninvasive positive pressure ventilation (NPPV)	During the treatment phase
Improvement in blood gases on room air during hospitalization and improvement of the peak cough flow (PCF)	During the treatment phase
Improvement of the vital capacity (VC), maximal inspiratory (PImax) and expiratory (PEmax) pressures, sniff nasal inspiratory pressure (SNIP), peak expiratory flow (PEF) and dyspnea during hospitalization	During the treatment phase
Decrease in the number of secondary tracheotomies (for weaning of ventilatory support)	During the treatment phase

Collaborators and Investigators

• Sponsor: Assistance Publique - Hôpitaux de Paris
• Investigators: Principal Investigator: Brigitte FAUROUX, MD PhD, Assistance Publique - Hôpitaux de Paris

Study record dates

Study Major Dates

• Study Start: June 1, 2009
• Primary Completion (Actual): February 1, 2011
• Study Completion (Actual): December 1, 2011

Study Registration Dates

• First Submitted: February 6, 2009
• First Submitted That Met QC Criteria: February 6, 2009
• First Posted (Estimate): February 9, 2009

Study Record Updates

• Last Update Posted (Estimate): May 28, 2015
• Last Update Submitted That Met QC Criteria: May 27, 2015
• Last Verified: May 1, 2015

More Information

Terms related to this study

• Keywords: Neuromuscular disease; Chest physiotherapy; Cough assisted device; Respiratory exacerbation; Invasive ventilation,; Congenital myopathies
• Additional Relevant MeSH Terms: Metabolic Diseases; Central Nervous System Diseases; Nervous System Diseases; Respiratory Tract Diseases; Respiration Disorders; Genetic Diseases, Inborn; Genetic Diseases, X-Linked; Musculoskeletal Diseases; Muscular Diseases; Neurodegenerative Diseases; Spinal Cord Diseases; TDP-43 Proteinopathies; Proteostasis Deficiencies; Muscular Disorders, Atrophic; Respiratory Insufficiency; Motor Neuron Disease; Amyotrophic Lateral Sclerosis; Muscular Dystrophies; Muscular Dystrophy, Duchenne; Neuromuscular Diseases
• Other Study ID Numbers: P080406