Independent brokers providing members and non-members of Canadian Automobile Association (CAA) with auto, home, health, travel and medical insurance. Includes FAQs and articles. Skyline Homes now produces factory-built Canadian housing that are built to CSAZ240 code and are A277 Certified. About 4 months ago when we were setting up our mortgage with CIBC they offered us a home warranty, which was free for 5 months and then $15.95 per. Ford Ford Motor Company of Canada 1-800-565-3673 The Canadian Rd, Oakville, ON L6J 5E4 U.S. General Motors General Motors of Canada 1-800-263-3777 (English) 1-800-263. Trade association is the voice of the residential construction industry in Canada. Includes advice for new home buyers and for those considering renovating an existing home. Purchase Plus Improvements We can help qualified home buyers tailor improvements immediately after taking possession, to make their new home just right for them. All this can be done with one manageable mortgage and 5% down payment. To Sign Up for gentecdirect.com – our B2B Site – please email us at [email protected] with your Gentec account number, contact, address and valid e-mail address, and we will assist you with a login and password. Click here to return to Gentec International. Builders are responsible for partnering with a warranty provider, becoming an authorized user of the online home registry, and entering all new construction projects into the registry. They are your primary point of contact during the construction of your home. CAMVAP Is Fair You will receive a fair hearing before an impartial arbitrator. Consumers with vehicle problems or warranty concerns like yours have used CAMVAP since 1994 and have given CAMVAP arbitrators high ratings for being courteous, professional and fair. Thank you for purchasing a dependable Rheem heating and cooling product, and for taking the time to complete your warranty registration online. Please select the type of product registration you will be entering from the drop-down list below, and then click the 'Add. A Canadian Thoracic Society clinical practice guideline. Introduction. ALS is a neurodegenerative disorder involving both upper and lower motor neurons that results in the progressive weakness of skeletal muscles. Death usually occurs as a result of progressive respiratory muscle involvement, with 5. The rapid progression to death separates ALS from most other NMDs for which NIV and tracheostomy ventilation is considered. ALS is also distinct from other ventilated medical conditions, including other NMDs, by virtue of having the poorest survival on ventilation (2). As a result, authors have tried to address the question of benefit of NIV in this disease. In reviewing the evidence, consideration was given to the type and magnitude of benefit of NIV in ALS, monitoring required in this population, and timing or parameters for initiation of ventilation to obtain any significant benefit. The committee also attempted to find evidence for the specific manner in which ventilation should be performed in this population. Key evidence. Compared with other disease groups, there is a relatively large volume of literature that attempts to answer the questions posed above. However, despite suggesting benefit for ventilation in ALS, the available information is not definitive and is of low quality in many instances. There is only a single RCT, and the remainder of the literature consists of prospective and retrospective studies or series. Control groups are present in many of the prospective studies; however, they often consist of historical controls, patients declining or unable to tolerate treatment, or patients with similar disease severity without respiratory involvement. One small RCT (3), nine prospective studies (4–1. NIV or timing of initiation of NIV in patients with ALS. In these studies, outcomes of interest included survival, health- related Qo. L (HRQo. L), pulmonary function, gas exchange, sleep parameters, cognition and timing of initiation of NIV. One RCT (3), four prospective studies (4,5,8,1. NIV. They all reported a survival benefit; however, the magnitude of the survival benefit was modest. Subset analysis of the bulbar- predominant patients in the RCT (3) did not show a survival benefit in the patients with severe bulbar dysfunction. Seven studies, including the single RCT, reported Qo. L measures (3,4,6,7–1. All showed improvement in Qo. L in some domains, with these improvements persisting in spite of disease progression. The improvement in Qo. L was still found in the more severe bulbar population in the RCT, although gains were not as significant (3). Another study examined cognitive function before and after ventilation (6), and showed improvement following initiation of NIV that was assumed to be secondary to treatment of sleep disordered breathing. Some studies identified other benefits, including a slowing of decline in VC (1. ABGs) (6,9,1. 9) following initiation of ventilation. Indications for the initiation of ventilation in studies showing benefit have not been consistent, making it difficult to answer the questions of how to monitor patients and when to initiate ventilation. Earlier literature focused on measures of lung function that predict daytime hypercapnia or a short time to death because these were frequently used criteria to initiate mechanical ventilation. More recently, the focus has been on predicting nocturnal hypoventilation to initiate ventilation earlier. A sitting VC of < 5. Sniff nasal pressure (SNP), a noninvasive measure of respiratory muscle strength, was shown to better predict daytime hypercapnia than VC and maximal inspiratory pressure (MIP) (2. MIP in advanced disease, particularly when there is bulbar weakness. Bulbar weakness often leads to difficulty in maintaining an adequate oral seal and, hence, obtaining reliable measurements. An SNP of < 4. MIP is also a sensitive test of muscle function and can be used late in the disease to predict survival, although it also requires the patient to be able to form a seal around a mouthpiece for reliable measurements. A reduction in VC on assuming the supine position is frequently associated with the symptom of orthopnea (2. One author found a Borg dyspnea scale of . Symptom improvement was reported in four studies in which documented sleep disordered breathing was treated with NIV (1. Orthopnea is a frequent indication for initiation of ventilation in the studies reported (4,5,8,1. One study (1. 0) showed that the greatest benefit and adherence occurred in patients who complained of orthopnea. The same study suggested that patients treated for asymptomatic nocturnal hypoventilation were less compliant, although the numbers were very small. Evidence is lacking to inform the questions of where ventilation should be initiated and how the initial and subsequent ventilator settings should be chosen. Only eight of the 1. NIV described how the ventilator settings were determined. In spite of demonstrating successful treatment, only one study (1. Seven of the eight studies that described methods for setting the initial ventilation (3,5,8–1. Not all authors reported the type of bilevel parameter used (spontaneous versus spontaneous/ timed . Of those reporting, however, all reported the S/T mode with which a back- up rate is provided. The remainder of the studies that did not use bilevel pressure ventilation used volume- cycled ventilation, which requires specification of a respiratory rate. Because central apneas and hypoventilation figure prominently in previous descriptions of sleep disordered breathing in patients with ALS (1. Tracheostomy ventilation is an option if prolonged survival is desired and cannot be achieved with NIV. In a recent Canadian survey of ventilatory practices in ALS (3. ALS patients receive this type of ventilation. Tracheostomy ventilation is associated with a high burden of care and, although chosen by some, tracheostomy may result from an acute deterioration and intubation when a personal directive is unavailable. Following tracheostomy for acute respiratory failure, a recent Italian study (3. Only one patient was liberated from mechanical ventilation. None of the patients had their tracheostomy removed. Bach (1. 6) and Bach et al (3. ALS patients with preserved bulbar function and the ability to generate an assisted PCF of > 1. L/min. Despite these occasional reports and the possibility of an extended period of NIV after decannulation, tracheostomy will be required in the future because bulbar function deteriorates if patients choose invasive ventilation in the hope of prolonged survival. Since 2. 00. 7, diaphragm pacing has been reported in 3. ALS (3. 6), and there is an ongoing trial targeting this therapy in 1. ALS patients. The initial goal with this therapy was to reduce the rate of decline in lung function. The laparoscopic insertion of the electrodes into the diaphragm in patients with a forced vital capacity (FVC) of > 5. Applied positive airway pressure (PAP) may still be required during pacing to avoid upper airway collapse. In the small number of ALS patients reported to date, there may be a slower rate of decline in lung function, which was extrapolated to a longer ventilator- free survival rate. Report of the larger series of ALS patients is pending; however, this technology is not yet approved for ALS patients in Canada. The importance of airway clearance is highlighted in Section I (Airway Clearance). There have been studies conducted specifically in the ALS population, however, that warrant mention. One study investigated predictors of ineffective cough during chest infections in patients with stable ALS (3. They found that a Norris bulbar scale of < 2. PCF < 4. 2. 5 L/s in stable ALS patients predicted ineffective cough with a chest infection and, therefore, suggested that assisted clearance techniques be introduced when patients reach one or more of these thresholds. Another study in ALS patients (3. PCF could be dramatically increased with various assisted- cough techniques, even in patients with bulbar dysfunction, a group in whom it has been challenging to achieve good clearance of airway mucus. Finally, a study assessing the efficacy of MI- E in stable ALS patients (4. PCF in all patients but those with very severe bulbar dysfunction. Conclusion. The majority of the studies investigating outcomes of NIV use have been observational cohort studies, with only a single RCT to date. Although the evidence base is modest, it is relatively consistent in favour of benefit to patients able to tolerate NIV. In ALS patients, the survival benefit is modest compared with other diagnoses for which HMV is commonly recommended. The improvement in Qo. L, including improvements in measures of daytime fatigue and sleepiness, seems to be a more relevant end point in this patient population. Sustained improvements in Qo. L were seen in most studies. Most importantly, there was no deterioration in Qo. L with NIV use apart from the expected changes in domains related to physical functioning secondary to increasing disability. Initiation of ventilation for symptomatic daytime hypercapnia or orthopnea secondary to muscle weakness seems clear. Earlier initiation for nocturnal hypoventilation with normal daytime PCO2 or based on higher FVC may be of benefit, but the evidence to date is limited. SECTION III. RECOMMENDATIONSRegular monitoring of ALS patients is advised from the time of diagnosis every two to six months and varies with anticipated rapidity of disease progression and should include the following. Symptom review to include orthopnea, dyspnea, poor sleep, excessive daytime sleepiness, poor concentration, morning headache. ABGs and/or nocturnal oximetry and/or polysomnography are not required, but may be helpful in some circumstances. Elective tracheostomy ventilation may be considered, and is dependent on regional resources and careful discussion with the patient and caregivers. Haverkamp LJ, Appel V, Appel SH.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. Archives
December 2016
Categories |