Breathing Issues

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Breathing Issues

Respiratory problems are, unarguably, the most serious of medical complications in ALS. Breathing difficulties occur from the gradual deterioration of breathing muscles, i.e. the diaphragm and the intercostals. The course is as shown below.

Signs of Respiratory Insufficiency

General fatigue, drowsiness, lethargy.
Sleep disturbances such as nightmares, night terrors, sleep apnoea (interrupted breathing during sleep) or sudden awakening.
Morning headaches.
Daytime sleepiness.
Confusion, disorientation, anxiety.
Poor appetite, weight loss.
Excessive yawning or hiccups.
More laboured breathing, especially when lying down.
Rapid, shallow respirations with increased heart rate.
Weakened or softened voice; speaking in short phrases; inability to sing or shout.
Difficulty coughing and clearing the throat (weakened abdominal and throat muscles also contribute to this)

Signs of Respiratory Insufficiency:

Monitoring for respiratory problems:

Managing Breathing Problems

Breathing Exercises:

Medications:

Bronchodilators: Dilate the airway to help breathing, but otherwise ineffective due to muscle weakness. This can be used by nebulization.
Expectorants: To thin out the secretions and make them easier to cough out.
Saliva management: Weakened breathing muscles and weaker muscles of the mouth can cause drooling. Medications can be prescribed by the physician to control drooling (glycopyrolate).
Supportive medications: The physician may prescribe other drugs for symptomatic relief such as for pain, depression, sleep disturbances, constipation, etc.

Medications:

Chest physiotherapy:

Cough Assist Device:

Automatic Mechanical cough assist devices such as the Philips Cough assist or Hillrom Vital cough helps those with an ineffective cough by breathing through a mouthpiece or masks
The device gradually applies positive pressure to insure a deep breath, then shifts to negative pressure to assist with pulling secretions upward, simulating a deep natural cough.
High frequency chest wall oscillation involves an inflatable vest that is attached to a machine.
The machine mechanically vibrates at a high frequency. This helps to loosen and thin mucus and clear the airway.

Cough Assist Device:

Noninvasive Breathing Support:

A BiPAP Machine:

This is often prescribed in ALS.

C Pap Machine

Pressure-cycled vent machines

C Pap Machine

Pressure-cycled vent machines

Noninvasive Breathing Support:

A BiPAP Machine:

This is often prescribed in ALS.

Advanced respiratory care in ALS:

As ALS progresses, the person living with the disease may become increasingly dependent on ventilation and ultimately, will require invasive ventilation with tracheostomy. This will provide more efficient ventilation and better control of the upper airway and secretions
Ventilation through tracheostomy
A tracheostomy is a surgically created hole in the trachea (windpipe) through which air is forced. The tube through which the air is delivered also is called a tracheostomy (trach) tube.

Advanced respiratory care in ALS:

Caring for the Tracheostomy

Its normal for the patient to have small amount of mucus around the tube
Hole in the neck should be pink and painless.
It’s always beneficial to carry an extra tube in case of plugging of the tube.
Hold a tissue or cloth to catch the mucus coming from the tube.
Consult a doctor to know how to prevent the plugs in the tube as the patients’ nose will no longer keep the air moist.
One of the strategies to keep the breathing air moist is to put a wet gauze or cloth outside the tube.
A few drops of salt water (saline) will loosen a plug of thick mucus. Putting a few drops in the tube and windpipe, then taking a deep breath and coughing will help bring up the mucus.
Protect the hole in the neck with a cloth or tracheostomy cover when outside. These covers can also help make the breathing sounds quieter.
During showers, cover the hole with a tracheostomy cover. No swimming is allowed with a tracheostomy tube.
To speak, the patient will need to cover the hole with a finger, a cap, or a speaking valve.
Once the hole in the neck is not sore from the surgery, clean the hole with a cotton swab or a cotton ball at least once a day to prevent infection.
The bandage (gauze dressing) between the tube and neck helps catch mucus. It also keeps the tube from rubbing on the neck. Change the bandage when it is dirty, at least once a day.
Change the ribbons (trach ties) that keep the tube in place if they get dirty. Make sure the tube is held in place while changing the ribbon. Two fingers should be fit under the ribbon to make sure it is not too tight.

Caring for the Tracheostomy:

LTV® 1150 ventilator:

Advantages of invasive ventilation:

Decision making regarding invasive care:

So, in making the decision, one should consider his family support, level of independence and financial resources.

Breathing Issues