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Clinical Trial Details — Status: Not yet recruiting

Administrative data

NCT number NCT06119087
Other study ID # 854981
Secondary ID
Status Not yet recruiting
Phase N/A
First received
Last updated
Start date June 1, 2024
Est. completion date December 31, 2025

Study information

Verified date April 2024
Source University of Pennsylvania
Contact Jason Ackrivo, MD
Phone 2156623202
Email jason.ackrivo@pennmedicine.upenn.edu
Is FDA regulated No
Health authority
Study type Interventional

Clinical Trial Summary

The goal of this clinical trial is to learn how doing mechanical insufflation (MI) using a mechanical insufflator-exsufflator (MI-E) device affects breathing in early amyotrophic lateral sclerosis (ALS). This will be a single-center, single-arm study of MI in 20 patients with ALS at Penn. Based on prior research, we believe that 6-months of MI may slow decline in cough strength, measured as peak cough flow (PCF). Participants will perform MI using a device designed for mechanical insufflation-exsufflation (MI-E) known as the BiWaze Cough system. The BiWaze Cough is used for mucus clearance . It is connected to tubing and mouthpiece (or mask). The device will use programmed pressure and timing settings. An insufflation includes inflating the lungs for a maximal size inhalation before exhaling. The daily routine for the device includes 5 sets of 5 insufflations twice daily. Researchers will compare how use of MI in early ALS affects peak cough flow compared to 20 subjects who did not use MI in early ALS.


Recruitment information / eligibility

Status Not yet recruiting
Enrollment 20
Est. completion date December 31, 2025
Est. primary completion date September 8, 2025
Accepts healthy volunteers No
Gender All
Age group 18 Years and older
Eligibility Inclusion Criteria: 1. Provision of signed and dated informed consent form. 2. Stated willingness to comply with all study procedures and availability for the duration of the study. 3. Age =18 years. 4. Diagnosed with amyotrophic lateral sclerosis using the Gold Coast Criteria. 5. Have an able and willing caregiver to assist with mechanical insufflation on a daily basis. 6. Willingness and ability to participate in study procedures. Exclusion Criteria: 1. Age <18 years old. 2. Inability to perform a cough peak flow or spirometry manuever 3. Current use of non-invasive ventilation (NIV), bi-level positive pressure ventilation, or "Bi-PAP" or physician prescribing NIV on day of potential enrollment. 4. Current use of MI-E (also known as a "cough assist device") for airway clearance. Please note that patients can start use of a MI-E device subsequent to enrollment while currently being followed for the study. 5. Active enrollment in hospice. 6. Current tracheostomy. 7. Presence of cognitive dysfunction that would impair ability to complete study procedures, as determined by neurology attending physician. 8. Absence of an able and willing caregiver to assist with MI twice daily as specified in the protocol. 9. Pregnancy 10. Medical history of any of the following: 1. Recent hemoptysis 2. Recent barotrauma 3. History of emphysema of any kind (including bullous emphysema) 4. History of or known susceptibility to pneumothorax 5. History of or known susceptibility to pneumomediastinum 6. Chronic obstructive pulmonary disease 7. Uncontrolled asthma (defined as recent exacerbation requiring corticosteroids in the previous 30 days) 8. Symptomatic cardiomyopathy (heart failure) with left ventricular ejection fraction less than 50% 9. History of right heart failure or pulmonary hypertension 11. Current smoker or tobacco use within the last 30 days.

Study Design


Intervention

Device:
Mechanical insufflation
Mechanical insufflation (MI) is a chest physiotherapy exercise that will be performed using a type of mechanical insufflator-exsufflator (MI-E) known as the BiWaze Cough device. The device connects to a tube that can interface with a patient using either a facemask or mouthpiece. Mechanical insufflation is a chest physiotherapy exercise that passively inflates the chest with positive pressure that is delivered in coordination with the patient's own inspiratory timing until maximal inflation capacity (MIC), determined by the patient or maximal chest rise on visual inspection. At MIC, the patient passively exhales, which completes one "cycle". Prior literature has used a "dose" of 5 sets of 5 cycles once or twice daily. The maneuver is usually performed with assistance of a caregiver to hold the mask or mouthpiece in place.

Locations

Country Name City State
United States University of Pennsylvania Philadelphia Pennsylvania

Sponsors (1)

Lead Sponsor Collaborator
University of Pennsylvania

Country where clinical trial is conducted

United States, 

References & Publications (32)

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Kaminska M, Browman F, Trojan DA, Genge A, Benedetti A, Petrof BJ. Feasibility of Lung Volume Recruitment in Early Neuromuscular Weakness: A Comparison Between Amyotrophic Lateral Sclerosis, Myotonic Dystrophy, and Postpolio Syndrome. PM R. 2015 Jul;7(7):677-684. doi: 10.1016/j.pmrj.2015.04.001. Epub 2015 Apr 3. — View Citation

Katz SL, Barrowman N, Monsour A, Su S, Hoey L, McKim D. Long-Term Effects of Lung Volume Recruitment on Maximal Inspiratory Capacity and Vital Capacity in Duchenne Muscular Dystrophy. Ann Am Thorac Soc. 2016 Feb;13(2):217-22. doi: 10.1513/AnnalsATS.201507-475BC. — View Citation

Katz SL, Mah JK, McMillan HJ, Campbell C, Bijelic V, Barrowman N, Momoli F, Blinder H, Aaron SD, McAdam LC, Nguyen TTD, Tarnopolsky M, Wensley DF, Zielinski D, Rose L, Sheers N, Berlowitz DJ, Wolfe L, McKim D. Routine lung volume recruitment in boys with Duchenne muscular dystrophy: a randomised clinical trial. Thorax. 2022 Aug;77(8):805-811. doi: 10.1136/thoraxjnl-2021-218196. Epub 2022 Mar 2. — View Citation

Lechtzin N, Shade D, Clawson L, Wiener CM. Supramaximal inflation improves lung compliance in subjects with amyotrophic lateral sclerosis. Chest. 2006 May;129(5):1322-9. doi: 10.1378/chest.129.5.1322. — View Citation

McDonald LA, Berlowitz DJ, Howard ME, Rautela L, Chao C, Sheers N. Pneumothorax in neuromuscular disease associated with lung volume recruitment and mechanical insufflation-exsufflation. Respirol Case Rep. 2019 Jun 13;7(6):e00447. doi: 10.1002/rcr2.447. eCollection 2019 Aug. — View Citation

McKim DA, Katz SL, Barrowman N, Ni A, LeBlanc C. Lung volume recruitment slows pulmonary function decline in Duchenne muscular dystrophy. Arch Phys Med Rehabil. 2012 Jul;93(7):1117-22. doi: 10.1016/j.apmr.2012.02.024. Epub 2012 Mar 12. — View Citation

Miller RG, Jackson CE, Kasarskis EJ, England JD, Forshew D, Johnston W, Kalra S, Katz JS, Mitsumoto H, Rosenfeld J, Shoesmith C, Strong MJ, Woolley SC; Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter update: the care of the patient with amyotrophic lateral sclerosis: drug, nutritional, and respiratory therapies (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2009 Oct 13;73(15):1218-26. doi: 10.1212/WNL.0b013e3181bc0141. Erratum In: Neurology. 2009 Dec 15;73(24):2134. Neurology. 2010 Mar 2;74(9):781. — View Citation

Miske LJ, Hickey EM, Kolb SM, Weiner DJ, Panitch HB. Use of the mechanical in-exsufflator in pediatric patients with neuromuscular disease and impaired cough. Chest. 2004 Apr;125(4):1406-12. doi: 10.1378/chest.125.4.1406. — View Citation

Molgat-Seon Y, Hannan LM, Dominelli PB, Peters CM, Fougere RJ, McKim DA, Sheel AW, Road JD. Lung volume recruitment acutely increases respiratory system compliance in individuals with severe respiratory muscle weakness. ERJ Open Res. 2017 Mar 14;3(1):00135-2016. doi: 10.1183/23120541.00135-2016. eCollection 2017 Jan. — View Citation

Mustfa N, Aiello M, Lyall RA, Nikoletou D, Olivieri D, Leigh PN, Davidson AC, Polkey MI, Moxham J. Cough augmentation in amyotrophic lateral sclerosis. Neurology. 2003 Nov 11;61(9):1285-7. doi: 10.1212/01.wnl.0000092018.56823.02. — View Citation

Sawnani H, Mayer OH, Modi AC, Pascoe JE, McConnell K, McDonough JM, Rutkowski AM, Hossain MM, Szczesniak R, Tadesse DG, Schuler CL, Amin R. Randomized trial of lung hyperinflation therapy in children with congenital muscular dystrophy. Pediatr Pulmonol. 2020 Sep;55(9):2471-2478. doi: 10.1002/ppul.24954. Epub 2020 Jul 20. — View Citation

Shefner JM, Al-Chalabi A, Baker MR, Cui LY, de Carvalho M, Eisen A, Grosskreutz J, Hardiman O, Henderson R, Matamala JM, Mitsumoto H, Paulus W, Simon N, Swash M, Talbot K, Turner MR, Ugawa Y, van den Berg LH, Verdugo R, Vucic S, Kaji R, Burke D, Kiernan MC. A proposal for new diagnostic criteria for ALS. Clin Neurophysiol. 2020 Aug;131(8):1975-1978. doi: 10.1016/j.clinph.2020.04.005. Epub 2020 Apr 19. No abstract available. — View Citation

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Stanojevic S, Kaminsky DA, Miller MR, Thompson B, Aliverti A, Barjaktarevic I, Cooper BG, Culver B, Derom E, Hall GL, Hallstrand TS, Leuppi JD, MacIntyre N, McCormack M, Rosenfeld M, Swenson ER. ERS/ATS technical standard on interpretive strategies for routine lung function tests. Eur Respir J. 2022 Jul 13;60(1):2101499. doi: 10.1183/13993003.01499-2021. Print 2022 Jul. — View Citation

Suri P, Burns SP, Bach JR. Pneumothorax associated with mechanical insufflation-exsufflation and related factors. Am J Phys Med Rehabil. 2008 Nov;87(11):951-5. doi: 10.1097/PHM.0b013e31817c181e. — View Citation

Tzeng AC, Bach JR. Prevention of pulmonary morbidity for patients with neuromuscular disease. Chest. 2000 Nov;118(5):1390-6. doi: 10.1378/chest.118.5.1390. — View Citation

Vianello A, Corrado A, Arcaro G, Gallan F, Ori C, Minuzzo M, Bevilacqua M. Mechanical insufflation-exsufflation improves outcomes for neuromuscular disease patients with respiratory tract infections. Am J Phys Med Rehabil. 2005 Feb;84(2):83-8; discussion 89-91. doi: 10.1097/01.phm.0000151941.97266.96. — View Citation

Vitacca M, Paneroni M, Trainini D, Bianchi L, Assoni G, Saleri M, Gile S, Winck JC, Goncalves MR. At home and on demand mechanical cough assistance program for patients with amyotrophic lateral sclerosis. Am J Phys Med Rehabil. 2010 May;89(5):401-6. doi: 10.1097/PHM.0b013e3181d89760. — View Citation

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Winck JC, Goncalves MR, Lourenco C, Viana P, Almeida J, Bach JR. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance. Chest. 2004 Sep;126(3):774-80. doi: 10.1378/chest.126.3.774. — View Citation

* Note: There are 32 references in allClick here to view all references

Outcome

Type Measure Description Time frame Safety issue
Other Time to start of non-invasive ventilation Defined by the time period between enrollment for the MI trial and date of prescription for non-invasive ventilation
Non-invasive ventilation start date will be defined by date of prescription for non-invasive ventilation as recorded in the medical record or patient-reported date if a prescription is not recorded in the medical record.
1 year
Other Tracheostomy free survival time Defined by the time period between enrollment for the MI trial and death as long as the subject never had a tracheostomy placed.
Death date will be determined by family report, electronic medical record review, or publicly available obituaries.
Tracheostomy placement will be determined by patient or family report; or as documented in the electronic medical record.
1 year
Primary peak cough flow (PCF) PCF in liters/minute as measured by use of a peak flow meter while the patient is in a seated upright position. An alternative device for measuring PCF can be the use of a handheld spirometer and using the measured peak expiratory flow by multiplying by 60 to convert from liters/second to liters/minute.
The subject must be seated in an upright position and the interface must include a mouthpiece or an oronasal mask. Subjects are asked to perform a deep inhalation followed by a maximal cough.
6 months
Secondary Forced vital capacity (FVC) Defined as maximal volume, in liters, that a person can exhale forcefully after a complete inhalation.
Measured using a spirometer connected to a face mask or mouthpiece in the sitting and upright position.
6 months
Secondary Maximal inspiratory pressure (MIP) Defined as the maximum pressure, in cmH2O, generated when the subject exhales as much air as possible and then immediately inhales as forcefully as possible. 6 months
Secondary Maximal expiratory pressure (MEP) Defined as the maximum pressure, in cmH2O, generated when the subject inhales as much air as possible and then immediately exhales as forcefully as possible.
Measured using a hand-held manual or digital manometer connected to a mouthpiece or mask in the sitting and upright position.
6 months
Secondary Maximum insufflation capacity (MIC) Defined as exhaled volume, in liters, immediately following a MI maneuver to maximum insufflation capacity.
Measured using a spirometer connected to a face mask or mouthpiece, in the sitting and upright position.
6 months
Secondary Maximum insufflation capacity assisted peak cough flow Defined as the peak cough flow generated from MIC.
Lungs are inflated to MIC using MI and before the subject exhales they insert a peak flow meter in their mouth and follow with a peak cough flow as described above.
6 months
Secondary MIC-FVC difference defined by subtracting the FVC from the MIC 6 months
Secondary Transcutaneous carbon dioxide Defined as the average value in mmHg from a daytime in-clinic measurement over a 15-minute transcutaneous recording.
Measured using a Sentec transcutaneous digital monitoring system while the subject is sitting upright in a chair or wheelchair. The transcutaneous sensor can be placed on the subject forehead, cheek, or earlobe.
6 months
Secondary ALS Functional Rating Scale - Revised (ALSFRS-R) dyspnea and orthopnea scores The ALSFRS-R is a 12-item standardized questionnaire to assess the motor function status of an individual with ALS. The ALSFRS-R is assessed by a research staff member who has been certified for performance of the ALSFRS-R.
The dyspnea score is one of the questions focusing on level of shortness of breath, scored on a scale of 0 to 4, with 4 being no symptoms at all and 0 being severely symptomatic with consideration of mechanical respiratory support.
The orthopnea score is one of the questions focused on breathing symptoms and difficulty sleeping while lying supine, scored on a scale of 0 to 4, with 4 being no symptoms at all and 0 being severely symptomatic with inability to sleep.
6 months
Secondary Global rate of change score for peak cough flow The global rate of change score for the peak cough flow will ask patients how effective they think their cough is today by rating it on a Likert scale from -7 (extremely impaired) to +7 (extremely strong). 6 months
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