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To the Editor:
We read the article by Boitano et al,1 in which five patients with advanced ALS had percutaneous endoscopic gastrostomy (PEG) tube placement for enteral feeding while being supported by noninvasive positive pressure ventilation (NIPPV). No respiratory complications occurred during the PEG placement procedure. Based on this experience, the authors conclude that support by NIPPV during PEG placement in ALS may reduce the ventilatory complications during the procedure. We disagree with the authors’ premise that patients with advanced ALS—i.e., patients with a forced vital capacity (FVC) < 50% predicted—have a high risk of ventilatory complications primarily or solely due to the placement of the PEG or the sedation used during the PEG placement procedure. Intuitively, it makes sense that this population will be at increased risk of ventilatory or respiratory complications during the procedure. However, based on the existing literature, this risk appears to be small. Mathus–Vliegen et al.2 used an inclusion criterion cutoff of FVC of 1 liter or greater (mean FVC was 45.8% predicted) for their ALS patients’ PEG placement and had a procedure-related mortality rate of 1.8% and in-hospital mortality rate of 3.6%. Mazzini et al.3 reported six cases (of 31 patients) of tube site infection or hemorrhage but no procedurally related respiratory complications in their ALS population with a mean FVC of 30.6%. Chio et al.4 also reported no surgical complications, even in patients with FVC < 65%. PEG appears to be a well-tolerated and safe procedure with a very low acute and long-term morbidity and …
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