Polysomnographic Titration of Non-invasive Ventilation in Motor Neurone Disease (3TLA)

A Multi-centre Randomised Controlled Trial of Polysomnographic Titration of Non-invasive Ventilation in Motor Neurone Disease (PSG4NIVinMND; 3, Three Letter Acronyms [3TLA])

A two-arm, individual participant randomised controlled, assessor-blinded trial in 7 MND care centres across Australia will be undertaken.

Study Overview

• Status: Recruiting
• Conditions: Motor Neuron Disease / Amyotrophic Lateral Sclerosis
• Intervention / Treatment: Other: Intervention polysomnography; Other: Sham polysomnography

Detailed Description

Non-invasive ventilation (NIV) is a treatment that uses positive pressure delivered via a face mask or mouthpiece to assist a person to breathe. It can be used as a long-term treatment for people whose breathing is failing - usually due to chronic conditions that produce weakness of the respiratory muscles such as motor neurone disease / amyotrophic lateral sclerosis [MND/ALS]chronic obstructive pulmonary disease). Most people with MND/ALS use NIV at night initially. Even though NIV may improve survival and function, many are unable to use it for more than 4 hours per day (which is considered a threshold amount of use in order to gain a benefit) and many others are unable to tolerate it at all. Our team has recently provided evidence that specific and individualised titration of NIV leads to better outcomes in people with MND. This previous trial determined that the use of a sleep study (also called 'polysomnography') can improve the way people are initially set up with NIV. This study will replicate and extend the single site study in a large, multi-centre randomised controlled trial (RCT) across multiple sites This multi-centre RCT will also include a 12-month follow-up period to evaluate longer-term outcomes.

• Study Type: Interventional
• Enrollment (Anticipated): 244
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: David Berlowitz, PhD; Phone Number: +613 9496 3871; Email: david.berlowitz@austin.org.au

Study Locations

• Australia
  • Adelaide, Australia
    • Not yet recruiting
    • Flinders Medical Centre
    • Contact: Dr Vinod Aiyappan
  • Brisbane, Australia
    • Not yet recruiting
    • The Prince Charles Hospital
    • Contact: Dr Deanne Curtin
  • Canberra, Australia
    • Not yet recruiting
    • Motor Neurone Disease Australia
    • Contact: Dr Gethin Thomas
  • Melbourne, Australia
    • Recruiting
    • Austin Health
    • Contact: Associate Professor Mark Howard
  • Melbourne, Australia
    • Not yet recruiting
    • Monash University
    • Contact: Professor Natasha Lannin
  • Melbourne, Australia
    • Not yet recruiting
    • Australian MND Registry
    • Contact: A/Professor Paul Talman
  • Melbourne, Australia
    • Not yet recruiting
    • FightMND
    • Contact: Dr Bec Sheean
  • Melbourne, Australia
    • Not yet recruiting
    • Institute for Breathing and Sleep
    • Contact: Associate Professor Mark Howard
  • Melbourne, Australia
    • Not yet recruiting
    • University of Melbourne
    • Contact: Professor David Berlowitz
  • Perth, Australia
    • Not yet recruiting
    • Sir Charles Gairdner Hospital
    • Contact: Dr Bhajan Singh
  • Sydney, Australia
    • Not yet recruiting
    • Macquarie University
    • Contact: Professor Dominic Rowe
  • Sydney, Australia
    • Not yet recruiting
    • Royal Prince Alfred Hospital
    • Contact: Dr Amanda Piper
  • Sydney, Australia
    • Not yet recruiting
    • Westmead Hospital
    • Contact: Dr John Wheatley

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Age >18 years
• Clinical indication to commence long term NIV
• Confirmed clinical diagnosis of underlying condition

Exclusion Criteria:

• Medically unstable
• Hypoventilation attributable to medications with sedative/respiratory depressant side- effects
• Use of NIV for more than 1 month in the previous 3 months
• Inability to provide informed consent
• Previous intolerance of NIV

Study Plan

How is the study designed?

Design Details

• Primary Purpose: TREATMENT
• Allocation: RANDOMIZED
• Interventional Model: PARALLEL
• Masking: QUADRUPLE

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
EXPERIMENTAL: Intervention; This trial of PSG-assisted commencement of non-invasive ventilation (NIV) in motor neurone disease (MND) follows the methodology of our previous single-site study (Hannan et al 2019 ERJ), with the addition of an open label cohort that extends until (the earlier of) 12 months or death. After empirical NIV set-up and an acclimatisation period (3 weeks), participants will undergo single night in-laboratory polysomnography (PSG). The PSG will be performed and supervised by a sleep scientist. In the intervention group, the "intervention" PSG results will be used to adjust/titrate NIV settings to optimize ventilation and improve synchrony between the patient and the NIV device. Participants will be asked to continue to use NIV as prescribed for the subsequent 7 week intervention period.	Other: Intervention polysomnography; Please refer to 'Arms: Intervention' section.
PLACEBO_COMPARATOR: Control; The participants allocated to the control group will also be asked to attend a single night in-laboratory PSG. The NIV settings will not be adjusted throughout the PSG ("sham" PSG). Participants in the control group will retain their original settings after the sham PSG, and will be asked to continue to use NIV in this manner for the subsequent 7 week intervention period.	Other: Sham polysomnography; Please refer to 'Arms: Control' section.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Adherence with NIV	Defined as using NIV > 4 hours/day during the NIV treatment period.	Change during the acclimatization period (~3 weeks) and during the NIV treatment period (~7-8 weeks) (approx. 10 weeks total per participant).

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Intolerance of NIV	Defined as cessation of NIV during the NIV treatment period and/or < 4 hours.	Change during the acclimatization period (~ 3 weeks) and during the NIV treatment period (~7-8 weeks) (approx. 10 weeks total per participant).
Respiratory function	Forced expiratory volume in 1 second [FEV1], forced vital capacity [FVC]	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement as able.
Maximal inspiratory/expiratory pressure	'MIPs/MEPs'.	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement as able.
Sniff nasal pressure	'SNIP'.	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement as able.
Arousal index (during polysomnography)	Defined as the number of electroencephalogram (EEG) arousals observed per hour of total sleep time (TST).	During the baseline (following the ~3 week acclimatisation period) and during the follow-up assessment (~ week 3 + 7). Cohort: Not Collected.
Asynchrony index (during polysomnography)	Defined as the number of asynchrony events per hour of sleep.	During the baseline (following the ~3 week acclimatisation period) and during the follow-up assessment (~ week 3 + 7). Cohort: Not Collected.
Oxygen indices (during polysomnography)	Multiple measures to summarise oxygenation as one single outcome including oxygen desaturation index (defined as the total number of oxygen desaturation episodes [= 4%] per hour of total), sleep time, nadir SpO2, and time with SpO2 < 90%, area under the curve and others.	During the baseline (following the ~3 week acclimatisation period) and during the follow-up assessment (~ week 3 + 7). Cohort: Not Collected.
Total sleep time (during polysomnography)	Total amount of time asleep in minutes.	During the baseline (following the ~3 week acclimatisation period) and during the follow-up assessment (~ week 3 + 7). Cohort: Not Collected.
% rapid eye movement (REM) sleep (during polysomnography)	Percentage of sleep characterised by eye movement, relaxation of the body, faster. respiration, and increased brain activity	During the baseline (following the ~3 week acclimatisation period) and during the follow-up assessment (~ week 3 + 7). Cohort: Not Collected.
% slow wave sleep (SWS) (during polysomnography)	Percentage of 'deep sleep'.	During the baseline (following the ~3 week acclimatisation period) and during the follow-up assessment (~ week 3 + 7). Cohort: Not Collected.
Asynchrony sub-indices (during polysomnography)	Ineffective efforts, double-trigger etc.	During the baseline (following the ~3 week acclimatisation period) and during the follow-up assessment (~ week 3 + 7). Cohort: Not Collected.
Dyspnoea Amyotrophic Lateral Sclerosis (DALS-15)	A measure of breathlessness in people with ALS/MND.	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement.
Health-related quality of life - Severe Respiratory Insufficient Questionnaire (SRI)	A measure of health-related quality of life.	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement.
Health-related quality of life - Assessment of Quality of Life (8-Dimension-AQoL)	A measure of health-related quality of life.	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement.
Health-related quality of life - Calgary Sleep Apnoea Quality of Life Index (SAQLI)	A measure of health-related quality of life.	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement.
Functional rating - Amyotrophic Lateral Sclerosis Functional Rating Scale (Revised) (ALSFRS)	A clinical measure of functional rating in people with ALS/MND. Minimum score: 0, maximum score: 40. The higher the score the more function is retained.	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement.
Sleep quality - Pittsburgh Sleep Quality Index (PSQI)	A measure of sleep quality.	RCT: During the baseline and during the follow-up assessment. Cohort: At 3, 6 and 12 months following RCT commencement.
Daytime somnolence - Epworth Sleepiness Scale (ESS)	A measure of daytime sleepiness.	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement.
Daytime somnolence - Karolinska Sleepiness Scales (KSS)	The KSS is rating of the current daytime sleepiness state using a 9-point scale (1 = very alert to 9 = very sleepy, fighting sleep).	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement.
Carer burden - Caregiver Burden Scale (CBS)	A measure of caregiver burden. Rated ona scale from 0 (never) to 4 (nearly always), with higher scores indicating greater carer burden.	During the baseline (~week 0) and during the follow-up assessment (~ week 3 + 7). Cohort: At 3, 6 and 12 months following RCT commencement.
Cost effectiveness of the intervention	Economic evaluation using MBS/PBS data.	Throughout the trial period (approx. 5 years) (retrospective analysis).
Usual clinical care practices	Multidisciplinary clinician surveys at each recruitment site.	At trial commencement and trial end.
Usual care and the barriers and enablers to undertaking the intervention	Multidisciplinary clinician focus groups at each recruitment site.	At trial commencement (start of RCT) and trial end (end of RCT; approx. 4 to 5 years).
Experience of receiving the intervention and the barriers and enablers to the PSG and NIV usage	Participant semi-structured interviews.	At trial end (end of RCT; approx. 4 to 5 years)
Experience of the person they are caring for receiving the intervention and the barriers and enablers to the PSG and NIV usage	Caregiver semi-structured interviews.	At trial end (end of RCT; approx. 4 to 5 years).

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Arterial Blood Gas (ABG) (during polysomnography)	Arterial Blood Gas	RCT: During the baseline (following the acclimatisation period) and during the follow-up assessment. Cohort: Not Collected.

Collaborators and Investigators

• Sponsor: University of Melbourne
• Collaborators: Monash University; Western Sydney Local Health District; Royal Prince Alfred Hospital, Sydney, Australia; The Prince Charles Hospital; Flinders Medical Centre; Macquarie University, Australia; Sir Charles Gairdner Hospital; Austin Hospital, Melbourne Australia; FightMND; Institute for Breathing and Sleep, Australia; Macquarie Health; Motor Neurone Disease Australia; Australian Motor Neurone Disease Registry; Calvary Bethlehem; Perron Institute for Neurological and Translational Science
• Investigators: Study Chair: Abbey Sawyer, PhD, University of Melbourne

Study record dates

Study Major Dates

• Study Start (ACTUAL): December 15, 2021
• Primary Completion (ANTICIPATED): February 28, 2026
• Study Completion (ANTICIPATED): February 28, 2028

Study Registration Dates

• First Submitted: October 21, 2021
• First Submitted That Met QC Criteria: November 25, 2021
• First Posted (ACTUAL): November 29, 2021

Study Record Updates

• Last Update Posted (ACTUAL): June 23, 2022
• Last Update Submitted That Met QC Criteria: June 19, 2022
• Last Verified: June 1, 2022

More Information

Terms related to this study

• Keywords: Polysomnography; Non-invasive ventilation; Amyotrophic lateral sclerosis; Sleep study; Chronic respiratory failure
• Additional Relevant MeSH Terms: Pathologic Processes; Metabolic Diseases; Central Nervous System Diseases; Nervous System Diseases; Neuromuscular Diseases; Neurodegenerative Diseases; Spinal Cord Diseases; TDP-43 Proteinopathies; Proteostasis Deficiencies; Sclerosis; Motor Neuron Disease; Amyotrophic Lateral Sclerosis
• Other Study ID Numbers: CT20020

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Dataset in de-identified form will be shared on request to corresponding author.
• IPD Sharing Time Frame: 5 years from study completion.

IPD Sharing Access Criteria

Subject to optional consent, where participants give permission for data to be used for the purpose of:

1. The ethically approved research project only.
2. This ethically approved research project and any closely related future research projects.
3. This ethically approved research project and any future research projects that may or may not be related to this project.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No