Introduction:　Noninvasive positive pressure ventilation (NPPV) is used as noninvasive ventilatory support without intratracheal intubation for patients with a range of diseases. In our hospital, since 2007, we have performed safe bronchoscopic examinations with ventilatory support employing NPPV in patients with respiratory failure. Herein, we report safe performance of gastrostomy under respiratory management with NPPV in a patient with amyotrophic lateral sclerosis (ALS) complicated by type II respiratory failure.

Case:　A 67-year-old woman had suffered from ALS since 2010. She visited our hospital with a chief complaint of dyspnea in December 2011, which led to hospital admission for treatment of type II respiratory failure due to progression of respiratory muscle paralysis.

Clinical course:　On the day of hospital admission, respiratory management by NPPV was initiated. Although her respiratory failure improved rapidly, gastrostomy for tube feeding was necessitated by reduced dietary intake due to progression of bulbar paralysis and generalized muscle weakness. Percutaneous endoscopic gastrostomy (PEG) was scheduled but the operation had to be performed under ventilatory support employing NPPV because of concerns about possible worsening of respiratory failure due to intraoperative use of a sedative in addition to respiratory muscle atrophy. As for masks, we used an Endoscopy Mask^® with an endoscope insertion hole produced by Smiths Medical Japan. For NPPV, we used the Philips Respironics V60^®. After the patient had been sedated with intravenous midazolam 10 mg, PEG was performed with NPPV through the face mask. A gastric fistula could be made without worsening of her respiratory condition.

Discussion:　We consider NPPV to be among the most useful methods of respiratory support during gastrostomy in patients with poor respiratory functions. However, in our opinion, this method should be used only after careful consideration because it requires certain skills and a multidisciplinary team approach.