25!Gennaio!2020!

“Lung sonography in the choise of the best mask for NIV in ALS patient“
A.  Longoni*/** , P. Pozzi **, A. Paddeu**
* S.R.R.F. - ** Cardio-Respiratory Rehabilitation Center “Paola Giancola Foundation”, S. Anthony Abate Hospital Cantù, ASST Lariana, Italy

angelo.longoni@asst-lariana.it

Case history Investigations

E.R. a 77 year-old woman suffering from ALS with tetraparesis
at lower limbs was hospitalized to start non invasive
mechanical ventilation (NIMV). The basal pulmonary function
testings (PFT) were compatible with a severe reduction of the
forced vital capacity (FVC) as well as of the maximum
inspiratory and expiratory pressures (Mip=32, Mep=28,
FVC=69%,Fev1=83%, Fev1/FVC=131%, Pef=67%), PCEF=
380 lt/m.
The Niv treatment
The patient has performed NIMV (Amstral 150) with a
integrated hot humidifier and different masks (Fig.2-7-12). The
parameters were: S/T mode, Avaps on, VT= 400 ml, Ipap
max= 20, Ipap min=16, Epap=6, FR=10, Ti =1.2. The
Ultrasound (US) were performed at the admission and at the
discharge with patient in 45° lying down position (Fig.1) with
normal and forced breathing (Fig.6-11), in M-mode with a
convex probe 1-5 MgHz. We have studied the diaphragmatic
excursion in anterior subcostal view and the presence of A line
in upper right thoracic position.
We have
! !studied
! the ventilator index, mask leaks and the problems
and sensations reported by the patient during NIMV with the
different masks compared with US parameters:
1)  The oronasal mask was the first choice but gave it problems of
eyes for heigh leaks due to the thin shape of the cheeks. The
ventilator had high leaks and lower tidal volume values ( Fig.5) ,
lower US diaphragmatic excursion (Fig. 3) and lower presence of
A lines ( Fig.4) .
2)  The nasal mask was most comfortable for the cheeks and nose
and had less ventilator leaks (Fig.10). It had created problems
related to the opening of the mouth during sleep even if it had the
maximum value of diaphragmatic excursion (Fig.8), but low tidal
volume ( Fig.10) and a good presence of A lines ( Fig. 9).
3)  The total face mask was the most comfortable. A smaller
diaphragmatic excursion ( Fig.13) than the second mask but an
higher tidal volume ( Fig.15), an alveolar recruitment linked to
the high number of lines A (Fig.14), a reduced mask leaks ( Fig.
15) and elimination of the psychological problems due to
opening mouth.

Fig.1 Fig.2 Fig.3 Fig.4 Fig.5

Fig.6 Fig.7 Fig.8 Fig.9 Fig.10

Fig.11 Fig.12 Fig.13 Fig.14 Fig.15

Masks! Oronasale! Nasale! Facciale!

Conclusion:
+!confort! 0! 1! 2!
At the discharge (31/07 to 21/08/2018) the patient was able to carry the NIMV all night long 0!problems! 0! 1! 2!
and she had a satisfactory diaphragmatic excursion with 1,1 cm to 3 cm in normal and 0!Skin!lesions! 0! 1! 2!
3,8 cm to 5,2 cm in forced breathing. Mip=33, Mep=25, PCEF= 360 lt/m, 0!Mask!!!leak!(L/min)! 0! 1! 2!
FVC=76%,Fev1=88%, Fev1/FVC=127%, Pef=66%). During NIMV she had 1,2 cm, 4,6 +!Vte!!ml! 0! 1! 2!
!!cm, 3 cm in ventilation with oronasal, nasal and facial mask ( Fig. 8-9-10) respect to
+!Diaphragmatic!
normal ventilation (Fig.6) and recruitment of 3,5,9 A lines (Fig. 13-14-15). Diaphragmatic excursion!(cm)!
0! 2! 1!
Sonography can be an excellent verification tool, safe, fast, not expensive method to be +!Alveolar!
performed, at the patient's bed, to choose the most suitable mask for the needs and recruitment!(A0lines)!
0! 1! 2!
patient’s face during non invasive ventilation. Total! 0! 8! 13!