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Pneumonia is a common and severe disease in older people. In this group of patients pneumonia is among the four most frequent diseases leading to death. The diagnosis can often be difficult due to an atypical clinical presentation. Therefore, pneumonia should always be considered as the cause of any deterioration in an older person. Geriatric problems, such as frailty, physical and psychological limitations should be recorded as well as the social situation, as all these factors are of prognostic importance. Pneumonia acquired in a nursing home or by people in need of long-term care has a less favorable prognosis. Although this type of pneumonia is considered to be community acquired, special attenion is required. The treatment of pneumonia does not fundamentally differ from the treatment of younger patients but should take special situations into account, such as the patient's wishes documented in a living will when planning therapy. Older people in particular often show atypical clinical pictures with a coronavirus disease 2019 (COVID-19) infection. Therefore, in any acute change in the health condition of an older person COVID-19 should be considered.

Idiopathic pulmonary fibrosis (IPF) does not occur in younger persons. Therefore, it is not surprising that the nine hallmarks of biological aging can all be found in the pathomechanism of IPF. In this respect the homeostasis of cellular protein synthesis, degradation and recycling becomes unbalanced, which causes a dysregulation of repair mechanisms in the case of lung damage. Severve acute respiratory syndrome coronarvius type 2 (SARS-CoV-2) infections may also predominantyl seen in aged persons. In this situation cellular aging of the lungs also plays a role but additionally, the aging of the immune system is also of great importance. Immunosenescence is associated with a loss of naïve T‑cells. Moreover, there are gender-specific differences with a loss of B‑cells only in men but not in women, which partly explains the more severe course of COVID-19 pneumonia in older men.

Hoheres Lebensalter ist kein Argument gegen die Durchfuhrung einer Spirometrie. Die Notwendigkeit fur eine Spirometrie ergibt sich alleine aufgrund der mit uber 20 % hohen Pravalenz einer obstruktiven Ventilationsstorung bei alteren Menschen. Normwerte fur die Lungenfunktionsprufung sind bis ins hohe Lebensalter verfugbar. Erfahrung des Untersuchers und eine ruhig Umgebung beeinflussen das Messergebnis. Ausgepragte Hirnleistungsstorungen und schwere Immobilitat machen eine Lungenfunktionsprufung unmoglich. Einfache Assessments helfen dabei, diese Patienten verlasslich zu identifizieren. Fur diese Subgruppe mussen alternative Untersuchungsverfahren entwickelt und validiert werde, um diese gefahrdete und vulnerable Subgruppe adaquat behandeln zu konnen.

The SERVE-HF study revealed no benefit of adaptive servoventilation (ASV) versus guideline-based medical treatment in patients with symptomatic heart failure, an ejection fraction (EF) ≤45% and a predominance of central events (apnoea-hypopnea Index [AHI] 15/h). Because both all-cause and cardiovascular mortality were higher in the ASV group, an EF ≤ 45% in combination with AHI 15/h, central apnoea-hyponoea index [CAHI/AHI] 50% and central apnoea index [CAI] 10/h were subsequently listed as contraindications for ASV. The intention of our study was to analyse the clinical relevance of this limitation.Data were analysed retrospectively for patients treated with ASV who received follow-up echocardiography to identify contraindications for ASV.Echocardiography was conducted in 23 patients. The echocardiogram was normal in 10 cases, a left ventricular hypertrophy with normal EF was found in 8 patients, there was an EF 45-50% in 2 cases and a valvular aortic stenosis (grade II) with normal EF was found in 1 case. EF45% was present in just 2 cases, and only 1 of these patients also had more than 50% central events in the diagnostic night.The population typically treated with ASV is entirely different from the study population in SERVE-HF, as nearly half of the patients treated with ASV showed a normal echocardiogram. Thus, the modified indication for ASV has little impact on the majority of treated patients. The current pathomechanistic hypothesis of central apnoea must be reviewed.Die SERVE-HF-Studie ergab keinen Vorteil der adaptiven Servoventilation (ASV) gegenüber der leitlinienbasierten medizinischen Therapie von Patienten mit symptomatischer Herzinsuffizienz, einer Ejektionsfraktion (EF) ≤45% und überwiegend zentralen Ereignissen (Apnoe-Hypopnoe-Index [AHI]15/h). Weil die Gesamt- und die kardiovaskulär bedingte Mortalität in der ASV-Gruppe höher waren, wurden eine EF ≤45% in Kombination mit einem AHI 15/h, einem zentralen Apnoe-Hypopnoe-Index (CAHI)/AHI50% und einem zentralen Apnoe-Index (CAI)10/h als Kontraindikationen für die ASV aufgeführt. Ziel der vorliegenden Studie war es, die klinische Relevanz dieser Einschränkungen zu untersuchen.Retrospektiv wurden die Daten von mit ASV behandelten Patienten ausgewertet, bei denen in der Nachsorge eine Echokardiographie zur Feststellung von Kontraindikationen für eine ASV erfolgt war.Bei 23 Patienten wurde eine Echokardiographie durchgeführt. In 10 Fällen war der Befund der Echokardiographie normal, eine linksventrikuläre Hypertrophie mit normaler EF wurde bei 8 Patienten festgestellt, eine EF von 45–50% bestand in 2 Fällen und eine valvuläre Aortenstenose (Grad II) mit normaler EF in einem Fall. Eine EF45% bestand in nur 2 Fällen, und lediglich einer dieser Patienten wies mehr als 50% zentrale Ereignisse in der diagnostisch ausgewerteten Nacht auf.Die gewöhnlich mit ASV behandelte Population stellt sich völlig anders dar als die Studienpopulation in der SERVE-HF-Studie, da fast die Hälfte der Patienten mit ASV-Therapie einen normalen Echokardiographiebefund aufwies. Daher hat die modifizierte Indikation für eine ASV nur geringen Einfluss auf die Mehrzahl der behandelten Patienten. Die aktuelle Hypothese zu den Pathomechanismen der zentralen Apnoe muss überprüft werden.

Advanced age is not an obstacle to carring out a lung function test. In most cases a lung function test is necessary due to the fact that about 20% of older persons are affected by an obstructive respiratory disorder. Standard values for the lung function test are available up to advanced ages. The experience of the examiner and a calm environment for the lung function test have an impact on the quality of the measurement results. Severe cognitive impairments and severe immobility make the performance of a lung function test impossible. Simple geriatric assessments can help to reliably identify these patients. Alternative lung function test procedures have to be validated in order to adequately diagnose this vulnerable subgroup of patients at risk.Höheres Lebensalter ist kein Argument gegen die Durchführung einer Lungenfunktionsprüfung. Die Notwendigkeit einer Lungenfunktionsprüfung ergibt sich allein aufgrund der mit über 20 % hohen Prävalenz einer obstruktiven Ventilationsstörung bei älteren Menschen. Normwerte für die Lungenfunktionsprüfung sind bis ins hohe Lebensalter verfügbar. Erfahrung des Untersuchers und eine ruhige Umgebung beeinflussen das Messergebnis. Ausgeprägte Hirnleistungsstörungen und schwere Immobilität machen eine Lungenfunktionsprüfung unmöglich. Einfache Assessments helfen, diese Patienten verlässlich zu identifizieren. Um diese gefährdete und vulnerable Subgruppe adäquat behandeln zu können, müssen alternative Untersuchungsverfahren entwickelt und validiert werden.

Sufficient and refreshing sleep is important for good health, physical and cognitive functioning as well as quality of life. An assessment of sleep quality and sleep disorders is therefore mandatory in geriatric patients. Despite a variety of clinical assessment tools for screening and diagnosing sleep disorders, only some of them have been validated in older subjects and nearly none in geriatric patients or in individuals with dementia. Therefore, the aim of this review is to present a concise overview of assessment tools for sleep disorders that are widely used in sleep medicine and to briefly discuss the suitability and limitations in geriatric patients and subjects with dementia.Ausreichender und erholsamer Schlaf ist wichtig für Gesundheit, körperliche und kognitive Funktionalität und Lebensqualität. Eine Einschätzung der Schlafqualität und von gestörtem Schlaf ist daher bei geriatrischen Patienten obligatorisch. Trotz einer Vielzahl von klinischen Bewertungsinstrumenten für das Screening und die Diagnostik von Schlafstörungen wurden nur wenige dieser Instrumente bei älteren Probanden und fast keine bei geriatrischen Patienten oder Personen mit Demenz validiert. Ziel dieser Arbeit ist es daher, einen prägnanten Überblick über die in der Schlafmedizin weit verbreiteten Bewertungsinstrumente für Schlafstörungen zu geben und deren Eignung bzw. Grenzen bei geriatrischen Patienten und Demenzpatienten kurz zu diskutieren.

Background Recently, taurolidine has been intensively studied on a variety of in-vitro cancer cell-lines and first data exhibit encouraging antitumoral effects. While the clinical use of taurolidine is considered, some studies with in-vivo experiments contradict this beneficial effect and even indicate advanced cancer growth. The aim of this study is to further investigate this paradox in-vivo effect by taurolidine and closely analyze the interaction of cancer cells with the surrounding environment following taurolidine exposure. Methods HT-29 (ATCC® HTB-38™) cells were treated with taurolidine at different concentrations and oxaliplatin using an in-vitro model. Morphological changes with respect to increasing taurolidine dosage were visualized and monitored using electron microscopy. Cytotoxicity of the agents as well as extent of cellular detachment by mechanical stress was measured for each substance using a colorimetric MTS assay. Results Both taurolidine and oxaliplatin exhibit cell toxicity on colon cancer cells. Taurolidine reshapes colon cancer cells from round into spheric cells and further induces cluster formation. When exposed to mechanical stress, taurolidine significantly enhances detachment of adherent colon carcinoma cells compared to the control (p 0.05) and the oxaliplatin group (p 0.05). This effect is dose dependent. Conclusions Beside its cytotoxic effects, taurolidine could also change mechanical interactions of cancer cells with their environment. Local cancer cell conglomerates could be mechanically mobilized and may cause metastatic growth further downstream. The significance of changes in cellular morphology caused by taurolidine as well as its interaction with the microenvironment must be further addressed in clinical cancer therapies. Further clinical studies are needed to evaluate both the safety and efficacy of taurolidine for the treatment of peritoneal surface malignancies.

Wir werden immer alter. Und das Alter wirkt sich auf die Lunge aus. Die zugrundeliegenden Mechanismen sollten wir kennen, um der Entstehung von Erkrankungen wie der idiopathischen Lungenfibrose, aber auch von Asthma bronchiale entgegenwirken zu konnen. Was ist noch physiologisch und wann wird es pathologisch?

Intra-hospital transport is often needed for diagnostic and therapeutic procedures that cannot be performed at the bedside. However, moving patients from the safe environment of an Intensive Care Unit (ICU) can lead to a variety of complications and adverse events, the risk is even higher in ventilated patients. This review is intended as a guide on how to prevent and avoid these adverse events during intra-hospital transport of patients on non-invasive ventilation (NIV). Greater attention should be paid to NIV indications and the selection of the patients to be transported. Detailed planning, preparation, and communication between the ward of origin and destination site, appropriate equipment, skilled staff, and continuous monitoring are the key major determinants of success in transporting critically ill patients on NIV. These points are discussed and analyzed in detail.

Objectives The number of ventilated patients is further increasing which leads to an increasing number of patients with weaning failure. In Germany, the treatment of patients with invasive out-of-hospital becomes more and more common. The aim of the study was to observe the outcome, the frequency and character of emergencies of patients with invasive out-of-hospital ventilation. Methods We conducted a prospective study over 1 year. Fifty-nine invasively ventilated patients living either at home or at nursing homes specialized in ventilator medicine were included. Results Forty-one (71%) of the patients were living in a nursing home. Chronic obstructive pulmonary disease (COPD) was the most common underlying disease (52.5%). Duration of daily ventilation did not change over the 1-year period. 52.8% of the months went without a documented emergency. The most common emergencies were oxygen desaturation (29.6%), increase of secretion (12.2%) and dyspnea (8.7%). We found no difference in the frequency of emergencies between patients cared for in their own home compared with residential care. Ten patients died during the observation period. Fewer emergencies (P = .02, CI 0.03-0.85) was the only parameter associated with a reduced mortality. Frequency of emergencies as well as survival showed no difference regarding the way patients were cared for. Conclusions In patients with invasive home mechanical ventilation survival for more than 1 year seems to be common. Only the rate of emergencies affected survival.

Hospital discharge of elder patients with multi-morbidity and poly-pharmacy is challenging and requires standard procedures to ensure the transfer from hospital to ambulant nursing care properly. The situation is even more challenging when patients are discharged with oxygen and/or NIV becomes. There are tremendous organizational requirements to ensure that the patient is supplied with oxygen at home at the time of hospital discharge and to guarantee that a NIV newly implemented at hospital is connected correctly by the patient. Since this may not be managed by the discharging doctor at the hospital, a discharge coordinator is necessary who integrates the patient, his family, the doctor, caregivers, technical health care providers, and the family doctor. A checklist is helpful to ensure that all the necessary information regarding therapy (medication, oxygen flow rate, NIV parameter settings) and clinical condition (mobilization, feeding, do-not-resuscitate/best measure only/no-readmission order, palliative therapy) is given by the discharge letter which has to be delivered promptly. By this, the transfer of complex patients may be enhanced and hospital readmission rate and emergency department visits may be reduced.

The first patients on home mechanical ventilation were treated already about 80 years ago. The technical development of compact, easy to use and less expensive ventilators contributes to a still increasing number of patients with home mechanical ventilation.

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries. info:eu-repo/semantics/publishedVersion

BACKGROUND: Measurement of P CO2 is vital in determining effective alveolar ventilation. However, obtaining capillary P CO2 by a skin prick of the earlobe is painful, and nocturnal measurements disturb sleep. End-expiratory measurement of P CO2 is also well established, but there is a low precision in predicting arterial or capillary CO2. The purpose of the study was to evaluate nocturnal measurement of noninvasive, transcutaneous P CO2 ( P tcCO2) measurement in hypercapnic subjects. METHODS: In this prospective study, 31 subjects with chronic hypercapnic failure—in a stable phase of the underlying disease—and a control group of 12 healthy volunteers were included. Transcutaneous measurements were taken by the Tosca sensor (Radiometer, Copenhagen, Denmark) over a period of at least 6 h during the night. A capillary blood gas was measured at midnight and 4:00 am. RESULTS: The mean nocturnal capillary P CO2 ( P capCO2) of subjects was 50.6 ± 10.2 mm Hg. In the 31 subjects with known hypercapnic respiratory failure, the correlation between P tcCO2 and P capCO2 at midnight was 0.86 and at 4:00 am r = 0.80. The bias of the hypercapnic subjects was d = + 4.5 with a limit(s) of agreement of 2SD = 13.0. The process of blood sampling caused no significant change in P tcCO2. CONCLUSIONS: Our study evaluated transcutaneous capnography as a continuous nocturnal measurement in hypercapnic subjects. We found a good agreement between the methods. Because CO2 is not constant in patients with respiratory failure, but instead fluctuates, we would recommend the continuous transcutaneous measurement of P CO2 as our method of choice in the diagnosis of nocturnal hypercapnia.

The study from Dreyfuss in 1985 demonstrated impressively that ventilation alone may harm and destroy even healthy lungs [1]. The reason is that ventilation itself may damage the lung by developing a ventilator-induced lung injury (VILI).

The growing interest in the quality of patient care at the levels of the health care managers, insurance companies, and health professionals is evident. Further, the growing population requires good quality health services. In this review, we analyzed the cost-effectiveness of noninvasive ventilation (NIV) in an acute setting for the treatment of respiratory failure. The strength of this review is that it identified and summarized the most relevant studies regarding various aspects of the cost-utility of NIV in an acute setting. This is the first review that focuses on the importance of the skills and training of the team in the reduction of costs associated with NIV. However, the small number of studies, heterogeneity of quality, and different outcomes of the different studies are the greatest limitations of this review. In conclusion, although there is great variation in the data drawn from the literature, NIV seems to be a cost-effective tool, especially in specific patients (those with chronic obstructive pulmonary disease) for whom the addition of NIV improves outcomes and has a positive impact on this expenditure.

Background and Aims Conventional and electromagnetic navigation bronchoscopy (ENB) is generally used as a diagnostic tool in suspicious pulmonary nodules. The use of this technique for the placement of fiducial markers in patients with inoperable but early-stage lung cancer could present an innovative approach enabling risk-reduced therapy. Methods We present seven clinical cases where conventional bronchoscopy and ENB were used as part of an experimental interdisciplinary approach to clinical management and therapy planning. In each case, we analyzed the clinical indication, endoscopic procedures and post-interventional outcome. Results In six patients (three females, three males) with peripheral non-small cell lung cancer (NSCLC), stage cT1cN0cM0, surgery and conventional stereotactic radiation therapy was not possible because of end-stage chronic obstructive pulmonary disease. ENB was used for fiducial marker placement prior to cyberknife radiotherapy. No procedure-related complications were observed. Complete remission could be achieved in four cases, partial remission in two cases and no relevant complications induced by radiotherapy were observed. In one male patient, an endoluminal relapse in the right lower lobe was diagnosed following a right upper lobe resection for a NSCLC. The tumor could not be clearly identified by computerized tomography, so that the bronchoscopic placement of a fiducial marker in the tumor was performed in order to allow stereotactic radiochemotherapy, by which complete remission could be achieved. Conclusion Fiducial marker placement may be an interesting bronchoscopic technique in the interdisciplinary therapeutic approach to inoperable early-stage lung cancer. In the described cases, therapy planning was successful and no procedure-related complications were observed.

Background Hypercapnic respiratory failure in patients with COPD frequently requires mechanical ventilatory support. Extracorporeal CO 2 removal (ECCO 2 R) techniques have not been systematically evaluated in these patients. Methods This is a pilot study of a novel ECCO 2 R device that utilizes a single venous catheter with high CO 2 removal rates at low blood flows. Twenty hypercapnic patients with COPD received ECCO 2 R. Group 1 (n = 7) consisted of patients receiving noninvasive ventilation with a high likelihood of requiring invasive ventilation, group 2 (n = 2) consisted of patients who could not be weaned from noninvasive ventilation, and group 3 (n = 11) consisted of patients on invasive ventilation who had failed attempts to wean. Results The device was well tolerated, with complications and rates similar to those seen with central venous catheterization. Blood flow through the system was 430.5 ± 73.7 mL/min, and ECCO 2 R was 82.5 ± 15.6 mL/min and did not change significantly with time. Invasive ventilation was avoided in all patients in group 1 and both patients in group 2 were weaned; PaCO 2 decreased significantly ( P Conclusions This single-catheter, low-flow ECCO 2 R system provided clinically useful levels of CO 2 removal in these patients with COPD. The system appears to be a potentially valuable additional modality for the treatment of hypercapnic respiratory failure. Trial registry ClinicalTrials.gov; No.: NCT00987740 and 01021605; URL: www.clinicaltrials.gov

Im pneumologischen Fachgebiet ist die Amyloidose eine seltene Krankheitsentitat. Wahrscheinlich gibt es jedoch eine relevante Dunkelziffer an nicht diagnostizierten Fallen. Nach wie vor wird diese Erkrankung kaum ins differenzialdiagnostische Kalkul bei der Abklarung unklarer respiratorischer Beschwerden und bildmorphologischer Befunde mit einbezogen. Vielmehr handelt es sich bei den meisten Fallen um Zufallsdiagnosen, in der Regel erfolgt die Diagnosestellung erst durch den Pathologen anhand einer Gewebeprobe. Nur wenn die mannigfaltigen Manifestationsformen dem Kliniker bekannt sind, wird die Amyloidose im Einzelfall in der Differenzialdiagnose Berucksichtigung finden. Bei Verdacht auf das Vorliegen einer Amyloidose ist der zielfuhrende diagnostische Schritt die Durchfuhrung einer Gewebebiopsie. Wird die Diagnose in der Kongorotfarbung bestatigt, ist eine Subtypisierung des Amyloidproteins erforderlich, um nach moglichen behandelbaren Grunderkrankungen suchen zu konnen und die Therapie zu planen. Die Klassifikation der Amyloidosen erfolgt anhand des detektierten Amyloidproteins, klinisch werden hereditare von erworbenen und lokale von generalisierten Formen abgegrenzt. Neben der Behandlung einer eventuell vorliegenden Grunderkrankung stehen fur die generalisierten Amyloidosen systemische Therapien zur Verfugung. Lokale Amyloidosemanifestationen konnen oft gut mit spezifischen Lokalmasnahmen behandelt werden. In dieser Ubersichtsarbeit soll ein Uberblick uber die Pathophysiologie, die Klassifikation der Amyloidose-Unterformen, sowie deren Diagnostik und Therapie ermoglicht werden. Ein spezielles Augenmerk soll dabei auf die besonderen Manifestationen aus dem pneumologischen Fachgebiet und deren spezifische Therapiemoglichkeiten gelenkt werden.

Continuous positive airway pressure (CPAP) treatment in obstructive sleep apnea syndrome (OSAS) requires pressure titration usually performed during attended in-hospital polysomnography. This manual titration procedure is not well standardized. The aim of the study was to ascertain whether a new automatic titration device is as effective as standard manual titration in determining constant CPAP pressure.We included 38 patients with a newly diagnosed OSAS. Participants were randomly assigned to attended in-laboratory manual titration and automatic titration in two consecutive nights. Fixed CPAP pressure was set at the optimal pressure determined during the second night. The follow-up period was 6 weeks. Main outcomes were apnea/hypopnea index (AHI) and Epworth sleepiness scale (ESS).AHI (manual: baseline 40.5+/-21.5/h vs. treatment 6.4+/-3.3/h (p0.001); automatic: 53.3+/-28.1/h vs. 7.8+/-3.3/h (p0.001)) and ESS (manual: 11.3+/-4.7 vs. 8.8+/-5.1 (ns); automatic: 11.5+/-5.6 vs. 7.0+/-3.8 (p0.05)) showed a similar improvement in both groups. Pressure recommendation by the device and the technician, although not statistically different (8.7+/-2.9 vs. 9.0+/-3.3 mbar), corresponded only in 50% of the patients.Automatic titration effectively predicts constant CPAP pressure for long-term treatment when performed during an attended polysomnography. Careful evaluation of raw data and polysomnography recording is mandatory before choosing a fixed CPAP pressure after automatic titration.

The clinical symptoms of spinal cord paralysis depend on the level of injury. The respiratory failure is often transient if the trauma is below C4. Nevertheless, injuries above C3 lead to nearly complete respiratory muscle paralysis. The consequence is chronic respiratory failure. Furthermore, severe consequences of upper spinal cord paralysis are impaired cough and hypophonia. Noninvasive ventilation (NIV) is well established in spinal cord injury, although intubation is often required in the acute phase of the disease. Typically, patients with spinal paralysis are ventilated for long periods (even more than 20 h per day) but with low pressure. Intensive monitoring of the ventilation and the patient is needed because of the paralysis of the limbs and the tendency to hyperventilate these patients. Taking all this together, NIV is the preferred approach for ventilation in spinal cord injury, but establishing NIV in these patients requires special attention and individual solutions.

When ventilating patients noninvasively, it is important to employ ventilators that generate high flow rates. The flow is necessary to compensate for the leakage due to the mask, to avoid CO2-rebreathing, and to handle the high flow that may be generated by spontaneously breathing patients, especially in case of acute respiratory failure. Turbine-driven ventilators are optimized to meet these criteria. Two different noninvasive ventilation (NIV) systems are available: one uses a breathing circuit with an integrated expiratory valve (active or passive), which requires a non-vented mask, and the other uses a breathing circuit without an expiratory valve, which requires a vented mask. A specialized “NIV team” is recommended to avoid misconnections. A higher oxygen delivery is necessary when patients are ventilated with NIV compared with spontaneous breathing. When the flow of the spontaneous breathing is lower than the flow generated by NIV, oxygen is diluted by the ambient air, which reduces the hemoglobin oxygen saturation. Therefore, an increase of the oxygen flow during NIV is often necessary. In conclusion, patients with severe hypoxemia who are ventilated with NIV require an optimal medical surveillance.

Background: Long-term compliance is suboptimal in the treatment of the obstructive sleep apnea syndrome (OSAS). Objectives: We compared the efficacy of and the adherence to automatic continuous positive airway pressure (APAP) and constant continuous positive airway pressure (CPAP) based on a night-by-night analysis. Methods: We performed a randomized, single-blind crossover study in 20 patients with moderate-to-severe OSAS. After diagnostic polysomnography and manual titration, patients were treated for 8 weeks with both constant CPAP and APAP in random order. Compliance and leakage were analyzed night by night using the software LOGSoft® of the Magellan® iPAP device. Results: The reduction in the apnea/hypopnea index (baseline 32.9 ± 19.1/h, CPAP 4.6 ± 2.9/h, APAP 5.6 ± 3.6/h; p < 0.001 compared to baseline) and the Epworth Sleepiness Scale (baseline 10.3 ± 5.7, CPAP 6.6 ± 4.8, APAP 4.9 ± 4.6; p < 0.001 compared to baseline) did not significantly differ between the treatment modes. Leakage time and compliance per night were not statistically different (leakage CPAP 31 ± 57 min, APAP 25 ± 49 min; compliance CPAP 383 ± 116 min, APAP 382 ± 107 min). There was no correlation between leakage and compliance. Thirteen patients (65%) preferred APAP at the end of the study. Conclusions: Treatment efficacy and adherence are similar with CPAP and APAP. There is a trend towards lower leakage with APAP therapy. Patients prefer the automatic mode to fixed pressure.

Conventional and electromagnetic navigation bronchoscopy (ENB) is generally used as a diagnostic tool in suspicious pulmonary nodules. The use of this technique for the placement of fiducial markers in patients with inoperable but early-stage lung cancer could present an innovative approach enabling risk-reduced therapy.We present seven clinical cases where conventional bronchoscopy and ENB were used as part of an experimental interdisciplinary approach to clinical management and therapy planning. In each case, we analyzed the clinical indication, endoscopic procedures and post-interventional outcome.In six patients (three females, three males) with peripheral non-small cell lung cancer (NSCLC), stage cT1cN0cM0, surgery and conventional stereotactic radiation therapy was not possible because of end-stage chronic obstructive pulmonary disease. ENB was used for fiducial marker placement prior to cyberknife radiotherapy. No procedure-related complications were observed. Complete remission could be achieved in four cases, partial remission in two cases and no relevant complications induced by radiotherapy were observed. In one male patient, an endoluminal relapse in the right lower lobe was diagnosed following a right upper lobe resection for a NSCLC. The tumor could not be clearly identified by computerized tomography, so that the bronchoscopic placement of a fiducial marker in the tumor was performed in order to allow stereotactic radiochemotherapy, by which complete remission could be achieved.Fiducial marker placement may be an interesting bronchoscopic technique in the interdisciplinary therapeutic approach to inoperable early-stage lung cancer. In the described cases, therapy planning was successful and no procedure-related complications were observed.

Although coexisting obstructive sleep apnea (OSA) and Cheyne-Stokes respiration (CSR) occur frequently in patients with heart diseases, optimal treatment remains unclear. Positive airway pressure (PAP) effectively treats OSA and adaptive servo-ventilation (ASV) has been shown to improve CSR. We compared a new treatment algorithm combining automatic continuous positive airway pressure (APAP) and ASV (anticyclic modulated ventilation, ACMV) versus continuous positive airway pressure (CPAP).Thirty-nine patients (35 male, four female; aged 65.5±9.7 years; body mass index, 31.0±5.9 kg/m2) with underlying heart disease and coexisting OSA and CSR were enrolled. After diagnostic polysomnography (PSG) and CPAP titration, patients were randomized either to CPAP or to ACMV for four weeks of treatment in a crossover design.Total apnea-hypopnea index (AHI) was 49.0±18.8/h at baseline, 12.3±14.6/h with CPAP (P0.001 vs baseline), and 3.7±5.6/h with ACMV (P0.001 vs. baseline and vs. CPAP). Obstructive AHI was 20.7±14.4/h at baseline, 5.1±9.3/h with CPAP (P0.001 vs. baseline), and 0.4±0.4/h with ACMV (P0.001 vs. baseline and vs. CPAP). Central AHI was 28.3±13.4/h at baseline, 7.2±9.7/h with CPAP (P0.001 vs baseline) and 3.3±5.4/h with ACMV (P0.001 vs. baseline and vs. CPAP). Ejection fraction was increased significantly (from 38.6±15.6 to 44.4±12.2%) only with ACMV. Subjective sleepiness significantly improved only with CPAP whereas objective sleep quality and treatment adherence were not different between both treatment modalities.ACMV is an effective treatment option in patients with coexisting OSA and CSR. It is superior to CPAP in reducing total AHI as well as obstructive and central AHI.

Purpose Early posttracheostomy tracheal stenosis (PTTS) may cause weaning and decannulation failure. Although bronchoscopic recanalization offers an effective treatment, it is not known how successfully patients can be weaned and decannulated after recanalization. The aims of this study were to determine the incidence of PTTS in a modern weaning center and to elucidate the benefit of interventional recanalization in terms of weaning and decannulation success. Materials and methods A total of 722 patients admitted within a 24-month period were examined. Patients' baseline characteristics, incidence of weaning and decannulation failure, incidence of PTTS, and rate of postinterventional weaning and decannulation success were determined. Results Of 722 patients, 450 were deemed suitable for weaning from invasive ventilation. Two hundred eighty-eight patients showed initial weaning and decannulation failure, and 14 of these 288 patients (4.9%) were found to have a PTTS. Recanalization was performed in all cases without procedure-associated complications. Ten (71%) of 14 patients could be successfully weaned and decannulated. Seven of these 10 patients were discharged, 3 patients died during the hospital stay, and 4 (29%) of 14 patients could not be weaned. Conclusions Posttracheostomy tracheal stenosis remains a relevant cause of weaning and decannulation failure. Bronchoscopic recanalization is safe and facilitates weaning and successful decannulation in about half of the cases.

There has been a rise in the number of patients requiring long-term ventilation, both in the in-hospital and the out-of-hospital setting. Despite this, little is known about the subsequent clinical course of these patients following hospital discharge. The purpose of this study was to determine the frequency and management of respiratory incidents in patients with invasive out-of-hospital ventilation living in a nursing home allied to a weaning centre. We evaluated retrospectively the protocols that are used to monitor the patients over a period of 2 months. The average time from hospital discharge was 386 ± 330 days. Of the total 17 patients, 9 (53%) patients remained free from any respiratory incidents, while the remaining 8 (47%) patients were responsible for a total of 95 respiratory incidents. Patients that suffered respiratory incidents had been ventilated at home for an average of 194 days, while the others were receiving out-of-hospital ventilation for an average of 557 days. Desaturation (17), dyspnoea (17) and reduced general condition (10) were the most common respiratory incidents. Also, the use of an Ambu bag (bag valve mask; 17), request for a pneumologist review (12) and replacement of the tracheal cannula (7) were the most common interventions. Respiratory incidents are common in invasive home mechanical ventilation, and so home mechanical ventilation needed to be organized safely. Being allied to a weaning centre helps to organize invasive home mechanical ventilation in a safe manner over the long-term ventilation.

Purpose: Both the parallel use of intensive care unit (ICU)-ventilators and ventilators dedicated to non-invasive ventilation (NIV), as well as the construction of some expiratory valves in single circuit breathing tubes may lead to misconnections which are potentially fatal for the patient. Methods: We demonstrate first a case of a misconnected expiratory valve in a patient with invasive home ventilation. In a second case, the mistaken connection of a non-invasive ventilator to an endotracheal tube leading to carbon dioxide (CO2)-rebreathing is demonstrated. A third case describes a patient with home non-invasive ventilation who had been delivered a non-vented mask out-of-hospital, likewise leading to CO2-rebreathing. Conclusion: Human error is the main reason for critical incidents in medicine and the most serious unintended events often involve mechanical ventilation. A regular instruction of medical staff and patients is necessary. The demonstrated misconnections are examples of latent errors “waiting to happen”. To prevent these errors from being made in the future, technological solutions similar to the aviation effort to improve safety are needed.

Hypercapnic respiratory failure in patients with COPD frequently requires mechanical ventilatory support. Extracorporeal CO2 removal (ECCO2R) techniques have not been systematically evaluated in these patients.This is a pilot study of a novel ECCO2R device that utilizes a single venous catheter with high CO2 removal rates at low blood flows. Twenty hypercapnic patients with COPD received ECCO2R. Group 1 (n = 7) consisted of patients receiving noninvasive ventilation with a high likelihood of requiring invasive ventilation, group 2 (n = 2) consisted of patients who could not be weaned from noninvasive ventilation, and group 3 (n = 11) consisted of patients on invasive ventilation who had failed attempts to wean.The device was well tolerated, with complications and rates similar to those seen with central venous catheterization. Blood flow through the system was 430.5 ± 73.7 mL/min, and ECCO2R was 82.5 ± 15.6 mL/min and did not change significantly with time. Invasive ventilation was avoided in all patients in group 1 and both patients in group 2 were weaned; PaCO2 decreased significantly (P.003) with application of the device from 78.9 ± 16.8 mm Hg to 65.9 ± 11.5 mm Hg. In group 3, three patients were weaned, while the level of invasive ventilatory support was reduced in three patients. One patient in group 3 died due to a retroperitoneal bleed following catheterization.This single-catheter, low-flow ECCO2R system provided clinically useful levels of CO2 removal in these patients with COPD. The system appears to be a potentially valuable additional modality for the treatment of hypercapnic respiratory failure.

Study Objectives: The clear discrimination of central and obstructive hypopneas is highly relevant to avoid misinterpretation and inappropriate treatment of complicated breathing patterns. Esophageal manometry is the accepted standard for the differentiation of the phenotypes of sleep apnea. However, it is limited in its use due to poor acceptance by patients and therefore rarely performed in routine clinical practice. Flattening of the inspiratory airflow curve, paradoxical breathing, arousal position, sleep stages, and breathing pattern at the end of the hypopnea can each give hints for the classification of hypopnea. The aim of this study was to evaluate a standardized algorithm combining these polysomnographic parameters for the discrimination of hypopneas in everyday practice. Methods: Polysomnography (PSG) and esophageal manometry were performed in 41 patients suspected of having sleep apnea (33 male, 52.3 ± 15.9 yr, body mass index 28.6 ± 4.5 kg/m2). Hypopneas were independently discriminated by blinded investigators based on esophageal pressure and the PSG-based algorithm. Only those hypopneas that could be differentiated with both methods were evaluated. Results: There were 1,175 of 1,837 hypopneas (64%) that could be defined by esophageal pressure, 1,812 (98.6%) by the PSG-based algorithm. Using esophageal pressure as a reference, the new algorithm correctly defined 76.9% of central and 60.5% of obstructive hypopneas. The overall accuracy was 68%. The isolated analysis of single PSG parameters revealed a lower accuracy compared with the combined algorithm. Conclusions: The PSG-based algorithm allows for discrimination of most hypopneas. It is advantageous in comparison with esophageal pressure because it is noninvasive and less impaired by artefacts. Therefore, it is a potentially helpful tool for sleep specialists.

The coexistence of obstructive (OSAS) and central sleep apnoea (CSA) and Cheyne-Stokes respiration (CSR) is common in patients with and without underlying heart diseases. CPAP has been shown to improve CSA/CSR by about 50%, but recent data suggest maximal suppression of CSA is important in improving clinical outcomes in heart failure patients. Adaptive servo-ventilation (ASV) effectively suppresses CSA/CSR in heart failure, but only few trials have considered patients with coexisting OSAS and CSA/CSR.Prospective, observational pilot study to evaluate the efficacy of a new ASV device, the BiPAP AutoSV, in 10 male consecutive patients with coexisting OSAS and CSA/CSR with and without heart failure over eight weeks. Six had stable heart failure.The total AHI improved from 48.9+/-20.6/h to 8.7+/-7.4, the obstructive AHI from 15.8+/-16.2/h to 2.6+/-2.5/h and the central AHI from 33.1+/-10.8/h to 6.1+/-5.9/h (all p0.01). Furthermore, there was a significant improvement in sleep profile and respiratory related arousals. The six patients with cardiovascular disease, including three with congestive heart failure, showed similar improvements in all parameters.BiPAP AutoSV was effective in reducing all types of respiratory disturbances in coexisting OSAS and CSA/CSR with and without heart failure. Further studies comparing the long-term clinical efficacy of this device against CPAP are warranted.

Background Awake tracheal intubation may evoke reflex bronchoconstriction in asthmatics. Whether this effect is altered by the choice of the local anesthetic used or by pretreatment with a beta2-adrenoceptor agonist is unknown. Therefore, we assessed the effect of awake fiberoptic intubation after lidocaine or dyclonine inhalation with or without pretreatment with salbutamol on lung function in asthmatic volunteers. Methods Bronchial hyperreactivity was verified by an inhalational histamine challenge. On four different days in a randomized, double blind fashion the volunteers (n = 10) inhaled either dyclonine or lidocaine with or without salbutamol pretreatment. FEV1 was measured at baseline, following salbutamol or saline inhalation, after lidocaine or dyclonine inhalation, while intubated, and after extubation. Lidocaine and dyclonine plasma concentrations were also measured. Statistics Two-way ANOVA, post hoc tests with Bonferroni correction, results are presented as mean +/- SD. Results Neither lidocaine nor dyclonine inhalation changed FEV1 significantly from baseline compared with placebo inhalation (4.43 +/- 0.67 l vs. 4.29 +/- 0.72 l, and 4.53 +/- 0.63 l vs. 4.24 +/- 0.80 l, respectively). Salbutamol slightly but significantly increased FEV1 (4.45 +/- 0.76 l vs. 4.71 +/- 0.61 l, P = 0.0034, and 4.48 +/- 0.62 l vs. 4.71 +/- 0.61 l, P = 0.0121, respectively). Following awake intubation FEV1 significantly decreased under lidocaine topical anesthesia (4.29 +/- 0.72 l to 2.86 +/- 0.87 l) but decreased even more under dyclonine anesthesia (4.24 +/- 0.80 l to 2.20 +/- 0.67 l; P < 0.0001). While salbutamol pretreatment significantly attenuated the response to intubation, it did not eliminate the difference between the effects of lidocaine and dyclonine. Only minutes after extubation FEV1 was similar compared with baseline. Conclusion In asthmatics, awake fiberoptic intubation evokes a more than 50% decrease in FEV1 following dyclonine inhalation. Using lidocaine for topical anesthesia the decrease in FEV1 is significantly mitigated (35%) and can be even further attenuated by salbutamol pretreatment. Therefore, combined treatment with lidocaine and salbutamol can be recommended for awake intubation while the use of dyclonine, despite its excellent and longer lasting topical anesthesia, may be contraindicated in patients with bronchial hyperreactivity.

Background In standard textbooks, intravenous lidocaine is recommended for intubation of patients with bronchial hyperreactivity. However, whether and to what extent intravenous local anesthetics attenuate bronchial hyperreactivity in humans is unknown. Accordingly, nine awake volunteers with known bronchial hyperreactivity were subjected to an inhalational challenge with acetylcholine before and during intravenous infusion of lidocaine, bupivacaine, or placebo in a randomized, double-blinded fashion. Methods Baseline acetylcholine threshold concentrations were determined 3-5 days before initiation of the investigation. The response to the acetylcholine challenge was defined as hyperreactive, if forced expiratory volume in 1 s decreased by at least 20%. In addition, the acetylcholine threshold for a 100% increase in airway resistance was obtained by body plethysmography. On seven different days, the acetylcholine challenge was repeated at the end of a 30-min intravenous infusion period of three doses of lidocaine (1, 3, and 6 mg.min(-1)) or bupivacaine (0.25, 0.75, and 1.5 mg.min(-1)), during saline placebo infusion, respectively. Acetylcholine-threshold concentrations were presented with the respective plasma concentrations of the local anesthetic. Results The infusion of lidocaine and bupivacaine resulted in plasma concentrations (means +/- SD) of 0.29 +/- 0.11, 1.14 +/- 0.39, and 2.02 +/- 0.5 microg.ml(-1) for lidocaine and 0.11 +/- 0.04, 0.31 +/- 0.09, and 0.80 +/- 0.18 microg.ml(-1) for bupivacaine, respectively. Compared to baseline, the acetylcholine threshold for a 20% decrease of forced expiratory volume in 1 s as well as the threshold for a 100% increase in total airway resistance increased significantly with increasing plasma concentrations of both local anesthetics. Compared to placebo, acetylcholine threshold was almost quadrupled for lidocaine and tripled for bupivacaine with the highest plasma concentration of each local anesthetic. Conclusions In awake humans, intravenous lidocaine and bupivacaine both dose-dependently attenuated the hyperreactive response to a nonspecific inhalational challenge with acetylcholine.