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Introduction To increase CO.sub.2 elimination and to reduce work of breathing in hypercapnic patients, non-invasive ventilation (NIV) can be applied via mask either with non-vented CO.sub.2 exhalation systems or with vented systems with leak port. The effect of the exhalation system on CO.sub.2 rebreathing in the mask and total gas exchange remains widely unknown. Aim of this study was to compare the exhalation systems in terms of inspiratory O.sub.2 and CO.sub.2 concentrations, breathing patterns and gas exchange. Methods We prospectively examined 10 healthy subjects and 10 hypercapnic patients with both exhalation systems. O.sub.2 and CO.sub.2 were measured in the nose, in the mask, and in the ventilation circuit, and respiratory rate, tidal volume, and transcutaneous capnometry (PtcCO.sub.2) were recorded during the experiments. Results Using the non-vented system, CO.sub.2 concentrations in the mask were significantly higher in both subject groups, and PtcCO.sub.2 values in the patient group increased up to 3.6 mmHg compared to the vented system (p = 0.011). O.sub.2 concentrations increased with higher O.sub.2 flow rates, but were significantly lower in the vented settings in both groups. No effect in breathing pattern could be demonstrated during the measurement time. Conclusion Using NIV, the chosen exhalation system influences CO.sub.2 and O.sub.2 concentrations under the mask, CO.sub.2 rebreathing from the mask and could influence the effectiveness of the ventilation support with regards to hypercapnia treatment. To compensate for relevant hypoxia, the O.sub.2 supplementation must be set up to a sufficient level under a vented system., Author(s): Karl-Josef Franke [sup.1] [sup.3] , Maik Schroeder [sup.2] , Ulrike Domanski [sup.2] , Barbara Dewald [sup.1] , Georg Nilius [sup.1] [sup.2] Author Affiliations: (1) grid.412581.b, 0000 0000 9024 6397, [...]

Purpose Increasingly frequent, it is clinically indicated to obtain tissue from a peripheral lung lesion (PLL) to yield a pathological diagnosis. The aim of the present study was to evaluate the diagnostic sensitivity of transbronchial needle aspiration (TBNA) and transbronchial catheter aspiration (TBCA) in addition to transbronchial forceps biopsy (TBB) at conventional bronchoscopy. Methods Eligible patients showing a PLL on computed tomography scans were included in the study. In all patients, following TBB, TBNA and TBCA were employed in randomised order under fluoroscopy. Results Fourty-eight patients were enrolled, of whom 46 patients with 46 PLLs were included in the analysis. The mean ± SD diameter of the PLL was 27.0 ± 13.3 mm. The overall sensitivity for all modalities was 69.6 %; PLL [less than or equal to]20 or >20 and [less than or equal to]30 mm in diameter showed a sensitivity of 60.0 and 72.2 %, respectively. For malignant PLL (n = 33), the combined sensitivity of TBNA + TBCA versus TBB was significantly higher (63.6 vs. 33.3 %, p [less than or equal to] 0.05), and could not further be improved by TBB. For benign PLL, TBB was superior to TBNA + TBCA (76.9 vs. 38.5 %). Conclusions TBB, TBNA and TBCA are complementary to one another. Combining the three techniques, even allows transbronchial specimen collection of PLL, Author(s): Karl-Josef Franke[sup.1] , Melanie Hein[sup.1] , Ulrike Domanski[sup.1] , Georg Nilius[sup.1] , Maik Schroeder[sup.1] , Jeremias Wohlschlaeger[sup.2] [sup.3] , Dirk Theegarten[sup.2] Author Affiliations: (1) Department of Pneumology and Critical [...]

Purpose Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a standard procedure for intrathoracic lymph node biopsies. The newly developed cryo-needle operates in a similar way to the EBUS-TBNA but is able to obtain specimens for histological evaluation. The purpose of this animal study was to evaluate the feasibility, effect, and safety of the cryo-needle biopsies. Methods Four EBUS-guided cryo-needle biopsies were obtained from a mediastinal lymph node of a healthy pig. In an open surgery approach, cryo-needle biopsies using activation times of 1, 2, and 3 s (A1/A2/A3) and needle biopsies using a 21-gauge EBUS-TBNA needle were obtained from mesenteric lymph nodes. Cryo-needle biopsies A2 were performed with (A2+) and without (A2-) an oversheath. The size, weight, percentage of lymphatic tissue and artefact-free area of each cryobiopsy were evaluated. Smears were made with the TBNA-needle aspirates to determine the number of lymphocytes per high-power field (HPF). The bleeding duration was measured. Results We successfully obtained EBUS-guided cryo-needle biopsies. The area and weight of the biopsies A3 and A2+ were significantly larger compared with A1 (1.7 ± 0.8 and 1.4 ± 0.3 vs. 0.9 ± 0.4 mm.sup.2; 5.2 ± 2.4 and 3.4 ± 1.8 vs. 1.5 ± 0.7 mg). The percentage of lymphatic tissue of the cryobiopsies was 90 ± 25 and 98 % of samples were artefact-free. The number of lymphocytes/HPF of TBNA-needle smears was 128 ± 54.3. There was no difference in bleeding duration between the techniques. Conclusions The cryo-needle yields large histological specimens of high quality., Author(s): Karl-Josef Franke[sup.1] , Georg Nilius[sup.1] , Karl-Heinz Ruehle[sup.1] , Markus D. Enderle[sup.2] , Walter Linzenbold[sup.2] , Claus Hann von Weyhern[sup.3] Author Affiliations: (1) Department of Pneumology and Critical Care [...]

Introduction: To increase CO2 elimination and to reduce work of breathing in hypercapnic patients, non-invasive ventilation (NIV) can be applied via mask either with non-vented CO2 exhalation systems or with vented systems with leak port. The effect of the exhalation system on CO2 rebreathing in the mask and total gas exchange remains widely unknown. Aim of this study was to compare the exhalation systems in terms of inspiratory O2 and CO2 concentrations, breathing patterns and gas exchange. Methods: We prospectively examined 10 healthy subjects and 10 hypercapnic patients with both exhalation systems. O2 and CO2 were measured in the nose, in the mask, and in the ventilation circuit, and respiratory rate, tidal volume, and transcutaneous capnometry (PtcCO2) were recorded during the experiments. Results: Using the non-vented system, CO2 concentrations in the mask were significantly higher in both subject groups, and PtcCO2 values in the patient group increased up to 3.6 mmHg compared to the vented system (p = 0.011). O2 concentrations increased with higher O2 flow rates, but were significantly lower in the vented settings in both groups. No effect in breathing pattern could be demonstrated during the measurement time. Conclusion: Using NIV, the chosen exhalation system influences CO2 and O2 concentrations under the mask, CO2 rebreathing from the mask and could influence the effectiveness of the ventilation support with regards to hypercapnia treatment. To compensate for relevant hypoxia, the O2 supplementation must be set up to a sufficient level under a vented system. [ABSTRACT FROM AUTHOR]

Lung volume reduction therapy is an established treatment for patients with severe emphysema of the lung. In Germany, the treatment with nitinol coils is the only method for endoscopic lung volume reduction in patients with positive collateral ventilation approved by the Gemeinsamer Bundesausschuss. Therefore this procedure can be performed as standard-of-care and has assured reimbursement. After the production of the initial coils was stopped for years, when the only manufacturer had been bought by a large corporation, by the end of 2022 there was a new nitinol-coil, the so called Coil #4, becme available in the European market. The new Coil #4 has a different shape, different application catheter and the implantation procedure differs from that of the original product. We report our experience in endoscopic lung volume reduction with the new Coil #4 in three patients with emphysema. The procedure was performed without complications. All three of them showed improvement in lung function parameters meeting minimal clinically important differences. In two of three patients, we also saw clinically relevant improvement in the 6MWT distance und improvements in SGRQ und CAT-Score. In our opinion, this case series is just a prospect of the possibilities that come with the Coil #4. With due caution, we will continue to offer the Coil #4 as a treatment for selected patients under constant evaluation of the outcome until more data is available., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction: Endoscopic lung volume reduction (ELVR) with one-way valves produces beneficial outcomes in patients with severe emphysema. Evidence on the efficacy remains unclear in patients with a very low forced expiratory volume in 1 s (FEV 1 ) (≤20% predicted). We aim to compare clinical outcomes of ELVR, in relation to the FEV 1 restriction., Methods: All data originated from the German Lung Emphysema Registry (Lungenemphysem Register), which is a prospective multicentric observational study for patients with severe emphysema after lung volume reduction. Two groups were formed at baseline: FEV 1 ≤20% pred and FEV 1 21-45% pred. Pulmonary function tests (FEV 1 , residual volume, partial pressure of carbon dioxide), training capacity (6-min walk distance (6MWD)), quality of life (modified Medical Research Council dyspnoea scale (mMRC), COPD Assessment Test (CAT), St George's Respiratory Questionnaire (SGRQ)) and adverse events were assessed and compared at baseline and after 3 and 6 months., Results: 33 patients with FEV 1 ≤20% pred and 265 patients with FEV 1 21-45% pred were analysed. After ELVR, an increase in FEV 1 was observed in both groups (both p<0.001). The mMRC and CAT scores, and 6MWD improved in both groups (all p<0.05). The SGRQ score improved significantly in the FEV 1 21-45% pred group, and by trend in the FEV 1 ≤20% pred group. Pneumothorax was the most frequent complication within the first 90 days in both groups (FEV 1 ≤20% pred: 7.7% versus FEV 1 21-45% pred: 22.1%; p=0.624). No deaths occurred in the FEV 1 ≤20% pred group up to 6 months., Conclusion: Our study highlights the potential efficacy of one-way valves, even in patients with very low FEV 1 , as these patients experienced significant improvements in FEV 1 , 6MWD and quality of life. No death was reported, suggesting a good safety profile, even in these high-risk patients., Competing Interests: Conflict of interest: S. Eisenmann reports receiving grants or contracts from DFG, outside the submitted work; consulting fees from Acceleron, AstraZeneca and Sanofi Genzyme, outside the submitted work; payment for expert testimony for Nanovation, outside the submitted work; support for attending meetings and/or travel from Boehringer Ingelheim and Sanofi Genzyme, outside the submitted work. Conflict of interest: M. Witzenrath reports grants or contracts from Deutsche Forschungsgemeinschaft, Bundesministerium für Bildung und Forschung, Deutsche Gesellschaft für Pneumologie, European Respiratory Society, Marie Curie Foundation, Else Kröner Fresenius Stiftung, Capnetz Stiftung, Bayer Health Care, Biotest and Pantherna, outside the submitted work; consulting fees from Insmed, Pantherna, Pherecydes, Aptarion, GlaxoSmithKline, Inflarx and Biotest, outside the submitted work; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from AstraZeneca, Insmed, Chiesi, Novartis, Teva, Actelion, Boehringer Ingelheim, GlaxoSmithKline, Biotest and Bayer Health Care, outside the submitted work; patents issued EPO 12181535.1 (IL-27 for modulation of immune response in acute lung injury), WO/2010/094491 (Means for inhibiting the expression of Ang-2), DE 102020116249.9 (Camostat/Niclosamide cotreatment in SARS-CoV-2 infected human lung cells) and PCT/EP2021/075627 (New medical use of cystic fibrosis transmembrane conductance regulator (CFTR) modulators), outside the submitted work. Conflict of interest: A. Holland reports being a board member of Lungenemphysemregister e.V., outside the submitted work. Conflict of interest: W. Gesierich reports lectures fees from PulmonX GmbH, outside the submitted work. Conflict of interest: R-H. Hübner reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Pulmonx, Olympus and AstraZeneca, outside the submitted work; participation on a data safety monitoring board or advisory board for Bento Study (sponsor: IHF GmbH – Institut für Herzinfarktforschung), outside the submitted work; leadership or fiduciary role in other board, society, committee or advocacy group for Head of Lungenemphysem Register e.V., outside the submitted work. Conflict of interest: The remaining authors have nothing to disclose., (Copyright ©The authors 2023.)

Objective: For transbronchial biopsy of peripheral pulmonary lesions manouevering the biopsy instrument into acutely angulated subsegmental ostia is frequently problematic. The aim of the present study was to compare the stiffness of various biopsy instruments with regard to their use in the clinical setting. -, Methods: The maximal anterograde and retrograde bending angles, were measured for various bronchoscopes and biopsy instruments. Measurement was made with the distal tip of the biopsy instrument either flush with the distal end of the bronchoscope, or extending 1.5 cm beyond it. The following scopes and biopsy instruments were investigated: 1. the 6.2 mm outside diameter (OD) bronchoscope, with the 2.4 mm OD forceps, 0.7 mm needle, 2.3 mm catheter, and the 1.9 mm cryoprobe. 2. the 5.1 mm OD bronchoscope, with the 1.8 mm forceps, 0.7 mm needle, and the 1.8 mm catheter. 3. the 3.7 mm bronchoscope, with the 1.0 mm forceps and the 0.8 mm forceps. -, Results: Maximum angulation was greater by 35.4° with the needle extended, vis-a-vis the needle "flush". Both needle and catheter were associated with a greater angulation of up to 20.5° in comparison with the forceps. With an instrument in the working channel the largest anterograde angles were measured for the 5.1 mm bronchoscope, and the largest retrograde angles for the 6.2 mm bronchoscope. -, Conclusion: When selecting the optimal instrument for transbronchial biopsy specimen collection, account must be taken of the fact that the degree of angulation will depend on the type and diameter of the instrument employed.