Enteral and parenteral nutrition in the later stages of ALS: An observational study

Abstract

Current practice guidelines state that enteral feeding should be proposed and provided whenever ALS patients show significant dysphagia and/or weight loss. Percutaneous endoscopic gastrostomy (PEG) is usually available at ALS centres, but this method is not indicated in the case of patients with severe respiratory impairment. We undertook a study to assess the feasibility of applying home parenteral nutrition (PN) to ALS patients with respiratory insufficiency, to assess the complications and survival times after the procedure. PN was provided, via an implanted port, to 30 ALS patients with respiratory insufficiency requiring nutritional support. Nutritional and neurological follow-up were carried out. The results were compared with those obtained on a group of 35 patients who underwent PEG, who were subdivided into patients with respiratory insufficiency and those without respiratory insufficiency at the time of the PEG. Post-procedure survival of PEG patients with respiratory insufficiency was similar to those of the PN group. The results of the study suggest that PN is a safe and effective method, which improves the patients' nutritional status and stabilizes their weight in most cases. Home PN could be applied to patients with advanced ALS and poor respiratory function as an alternative to enteral feeding.

Nutrition Management of Amyotrophic Lateral Sclerosis

“…Diaphragmatic weakness causes a “high‐riding” stomach, in which the stomach lies under the ribs, which can increase the difficulty of PEG placement 37 . Nasogastric tube feedings are indicated only for short‐term nutrition support due to the high risk of aspiration and because of their uncomfortable and embarrassing nature 48 . Nasogastric tubes increase oropharyngeal secretions and can cause nasopharyngeal discomfort or even ulceration 48 , 49 .…”

“…Nasogastric tube feedings are indicated only for short‐term nutrition support due to the high risk of aspiration and because of their uncomfortable and embarrassing nature 48 . Nasogastric tubes increase oropharyngeal secretions and can cause nasopharyngeal discomfort or even ulceration 48 , 49 . Postpyloric feeding tubes may be indicated if intolerance is present with gastric feedings, such as in the presence of severe gastroesophageal reflux disease, gastroparesis, or gastrectomy 50 …”

“…Syringe bolus feeds seem to be the preferred method of administration, followed by gravity bag, nocturnal, and, last, continuous. Of caution, 1 study indicates bolus feedings may be contraindicated in those with ventilatory dysfunction due to increased work of breathing 48 . At this time, there is no disease‐specific enteral formula for ALS patients.…”

“…Lack of access to the gastrointestinal tract with dysphagia, and conditions such as malabsorption, dysmotility, and enterocutaneous fistula are contraindications of EN. Verschueren et al 48 compared 35 ALS patients who underwent PEG with 30 patients who received PN. All of the patients had a 5%–10% weight loss during the previous 6 months, severe dysphagia with evidence of aspiration, and BMI <18 m/kg 2 .…”

Clinical Outcomes Comparing Parenteral and Nasogastric Tube Nutrition After Laryngeal and Pharyngeal Cancer Surgery

“…Recent studies have shown, however, that parenteral nutrition is superior in specific circumstances and for the intensive supply of specific micronutrients [4]. Although several clinical trials have compared the nutritional and clinical aspects of enteral versus parenteral nutrition in various clinical settings [5,6], these modalities have not been compared in the postoperative care of patients after laryngeal or pharyngeal cancer surgery. Surgery for these cancers involves extensive resection and surgical damage to tissues critical in the normal swallowing mechanism, making postoperative swallowing rehabilitation inevitable and causing the requirement for alternative nutritional support for a certain period of time.…”