Randomized cross‐over trial of ventilator modes during non‐invasive ventilation titration in amyotrophic lateral sclerosis

Background and objective Non‐invasive ventilation ( NIV ) improves survival, quality of life and sleep in patients with amyotrophic lateral sclerosis ( ALS ). Nevertheless, NIV titration is conducted in different ways. We aim to provide more insight into NIV titration by comparing the effects of a spontaneous (S) and spontaneous‐timed (ST) modes on gas exchange, sleep architecture and patient‐ventilator asynchronies ( PVAs ). Methods After an initial night of NIV titration, patients were randomized to S or ST mode in a cross‐over design. NIV was titrated using polysomnography, oximetry (oxygen saturation, SpO 2 %) and transcutaneous carbon dioxide ( PtcCO 2 ) measurement. PVAs were analysed breath‐by‐breath. Results Thirteen patients were analysed after inclusion. ST mode showed better results in gas exchange (minimal SpO 2 %: 83 (80–89)% vs 87 (84–89)%; oxygen desaturation index: 15 (5–28)/h sleep vs 7 (3–9)/h sleep; PtcCO 2 >55 mm Hg : 20 (0–59)% vs 0 (0–27)% total sleep time for S and ST mode, respectively, all P  < 0.05) and respiratory events (obstructive: 8.9 (1.2–18.3)/h sleep vs 1.8 (0.3–4.9)/h sleep and central: 2.6 (0.4–14.1)/h sleep vs 0.2 (0.0–1.1)/h sleep for S and ST mode, respectively, both P  < 0.01). No differences in sleep architecture were found. Ineffective efforts and respiratory events were more frequently present in S mode. Nevertheless, four patients were discharged on S mode as these patients showed clinically better results for sleep architecture and PVA during the night on S mode. Conclusion ST mode shows better results in gas exchange, respiratory events and PVA . Nevertheless, accurate NIV titration remains necessary as some patients show equal or better results when using the S mode.