[Limits and Ethics of Mechanical Ventilation and Intensive Care Medicine in Old Age]. / Grenzen und Ethik der Beatmung und Intensivmedizin im Alter.

Changing demography with more older people and more patients with chronic diseases as well as the progress of medicine leads to more geriatric patients treated in intensive care and requiring mechanical ventilation due to severe respiratory insufficiency.Frailty is associated with a more complicated intensive care stay, more difficult convalescence and with a higher mortality.In principle, geriatric expertise should be brought in as early as possible in the course of intensive care treatment for older patients in order to carry out adequate risk stratification and, depending on the extent of the impairment, to plan discharge or early rehabilitation.In older and frail patients preexisting chronic ventilatory insufficiency often leads to prolonged weaning. Patients with weaning failure should be referred to a specialized weaning center. Part of the assessment will be whether out-of-hospital invasive or non invasive ventilation is indicated and the wish of the patient.In intensive care the likelihood of a successful outcome and the patient's wishes must constantly be re-evaluated. This is particularly true in older patients. In addition it should be clarified with the patients and relatives what constitutes "success"; for example a patient may consider intensive care "worth it" if the ultimate goal is discharge to their own home but not if nursing home care and tracheostomy ventilation is the best that can be achieved. It may become apparent that a successful outcome is unlikely and then withdrawal of invasive ventilation is appropriate.

[Weaning in a Pandemic Situation - A Position Paper]. / Weaning in der Situation einer Pandemie ­ Ein Positionspapier.

The logistical and infectious peculiarities and requirements challenge the intensive care treatment teams aiming at a successful liberation of patients from long-term mechanical ventilation. Especially in the pandemic, it is therefore important to use all potentials for weaning and decannulation, respectively, in patients with prolonged weaning.Weaning centers represent units of intensive medical care with a particular specialization in prolonged weaning. They are an integral part of a continuous care concept for these patients. A systematic weaning concept in the pandemic includes structural, personnel, equipment, infectiological and hygienic issues. In addition to the S2k guideline "Prolonged weaning" this position paper hightlights a new classification in prolonged weaning and organizational structures required in the future for the challenging pandemic situation. Category A patients with high weaning potential require a structured respiratory weaning in specialized weaning units, so as to get the greatest possible chance to realize successful weaning. Patients in category B with low or currently nonexistent weaning potential should receive a weaning attempt after an intermediate phase of further stabilization in an out-of-hospital ventilator unit. Category C patients with no weaning potential require a permanent out-of-hospital care, alternatively finishing mechanical ventilation with palliative support.Finally, under perspective in the position paper the following conceivable networks and registers in the future are presented: 1. locally organized regional networks of certified weaning centers, 2. a central, nationwide register of weaning capacities accordingly the already existing DIVI register and 3. registration of patients in difficult or prolonged weaning.

[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]. / Leitlinie zur Langzeit-Sauerstofftherapie.

Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.

[Position Paper for the State of the Art Application of Respiratory Support in Patients with COVID-19 - German Respiratory Society]. / Positionspapier zur praktischen Umsetzung der apparativen Differenzialtherapie der akuten respiratorischen Insuffizienz bei COVID-19.

Against the background of the pandemic caused by infection with the SARS-CoV-2, the German Society for Pneumology and Respiratory Medicine (DGP e.V.), in cooperation with other associations, has designated a team of experts in order to answer the currently pressing questions about therapy strategies in dealing with COVID-19 patients suffering from acute respiratory insufficiency (ARI).The position paper is based on the current knowledge that is evolving daily. Many of the published and cited studies require further review, also because many of them did not undergo standard review processes.Therefore, this position paper is also subject to a continuous review process and will be further developed in cooperation with the other professional societies.This position paper is structured into the following five topics:1. Pathophysiology of acute respiratory insufficiency in patients without immunity infected with SARS-CoV-22. Temporal course and prognosis of acute respiratory insufficiency during the course of the disease3. Oxygen insufflation, high-flow oxygen, non-invasive ventilation and invasive ventilation with special consideration of infectious aerosol formation4. Non-invasive ventilation in ARI5. Supply continuum for the treatment of ARIKey points have been highlighted as core statements and significant observations. Regarding the pathophysiological aspects of acute respiratory insufficiency (ARI), the pulmonary infection with SARS-CoV-2 COVID-19 runs through three phases: early infection, pulmonary manifestation and severe hyperinflammatory phase.There are differences between advanced COVID-19-induced lung damage and those changes seen in Acute Respiratory Distress Syndromes (ARDS) as defined by the Berlin criteria. In a pathophysiologically plausible - but currently not yet histopathologically substantiated - model, two types (L-type and H-type) are distinguished, which correspond to an early and late phase. This distinction can be taken into consideration in the differential instrumentation in the therapy of ARI.The assessment of the extent of ARI should be carried out by an arterial or capillary blood gas analysis under room air conditions and must include the calculation of the oxygen supply (measured from the variables of oxygen saturation, the Hb value, the corrected values of the Hüfner number and the cardiac output). In principle, aerosols can cause transmission of infectious viral particles. Open systems or leakage systems (so-called vented masks) can prevent the release of respirable particles. Procedures in which the invasive ventilation system must be opened, and endotracheal intubation must be carried out are associated with an increased risk of infection.The protection of personnel with personal protective equipment should have very high priority because fear of contagion must not be a primary reason for intubation. If the specifications for protective equipment (eye protection, FFP2 or FFP-3 mask, gown) are adhered to, inhalation therapy, nasal high-flow (NHF) therapy, CPAP therapy or NIV can be carried out according to the current state of knowledge without increased risk of infection to the staff. A significant proportion of patients with respiratory failure presents with relevant hypoxemia, often also caused by a high inspiratory oxygen fraction (FiO2) including NHF, and this hypoxemia cannot be not completely corrected. In this situation, CPAP/NIV therapy can be administered under use of a mouth and nose mask or a respiratory helmet as therapy escalation, as long as the criteria for endotracheal intubation are not fulfilled.In acute hypoxemic respiratory insufficiency, NIV should be performed in an intensive care unit or in a comparable unit by personnel with appropriate expertise. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring with readiness to carry out intubation must be ensured at all times. If CPAP/NIV leads to further progression of ARI, intubation and subsequent invasive ventilation should be carried out without delay if no DNI order is in place.In the case of patients in whom invasive ventilation, after exhausting all guideline-based measures, is not sufficient, extracorporeal membrane oxygenation procedure (ECMO) should be considered to ensure sufficient oxygen supply and to remove CO2.

[Responsibilities of Weaning Centers during the COVID-19 Pandemic Outbreak - Recommendations for the Assignment of ICU Capacities in COVID-19 Patients as shown by the Berlin-Brandenburg POST-SAVE-Model]. / Aufgaben der Weaning-Zentren im Pandemiefall COVID-19.

The enormous increase in patients with severe respiratory distress due to the COVID-19 pandemic outbreak requires a systematic approach to optimize ventilated patient at risk flow. A standardised algorithm called "SAVE" was developed to distribute patients with COVID-19 respiratory distress syndrome requiring invasive ventilation. This program is established by now in Berlin. An instrumental bottleneck of this approach is the vacant slot assignment in the intensive care unit to guarantee constant patient flow. The transfer of the patients after acute care treatment is needed urgently to facilitate the weaning process. In a next step we developed a triage algorithm to identify patients at SAVE intensive care units with potential to wean and transfer to weaning institutions - we called POST SAVE. This manuscript highlights the algorithms including the use of a standardised digital evaluation tool, the use of trained navigators to facilitate the communication between SAVE intensive care units and weaning institutions and the establishment of a prospective data registry for patient assignment and reevaluation of the weaning potential in the future.

[Prolonged Weaning - S2k-Guideline Published by the German Respiratory Society]. / Prolongiertes Weaning.

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by insufficiency of respiratory muscles and/or lung parenchymal disease when/after other treatments, (i. e. medication, oxygen, secretion management, continuous positive airway pressure or nasal highflow) have failed.MV is required to maintain gas exchange and to buy time for curative therapy of the underlying cause of respiratory failure. In the majority of patients weaning from MV is routine and causes no special problems. However, about 20 % of patients need ongoing MV despite resolution of the conditions which precipitated the need for MV. Approximately 40 - 50 % of time spent on MV is required to liberate the patient from the ventilator, a process called "weaning."There are numberous factors besides the acute respiratory failure that have an impact on duration and success rate of the weaning process such as age, comorbidities and conditions and complications acquired in the ICU. According to an international consensus conference "prolonged weaning" is defined as weaning process of patients who have failed at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Prolonged weaning is a challenge, therefore, an inter- and multi-disciplinary approach is essential for a weaning success.In specialised weaning centers about 50 % of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, heterogeneity of patients with prolonged weaning precludes direct comparisons of individual centers. Patients with persistant weaning failure either die during the weaning process or are discharged home or to a long term care facility with ongoing MV.Urged by the growing importance of prolonged weaning, this Sk2-guideline was first published in 2014 on the initiative of the German Respiratory Society (DGP) together with other scientific societies involved in prolonged weaning. Current research and study results, registry data and experience in daily practice made the revision of this guideline necessary.The following topics are dealt with in the guideline: Definitions, epidemiology, weaning categories, the underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV and recommendations for end of life decisions.Special emphasis in the revision of the guideline was laid on the following topics:- A new classification of subgroups of patients in prolonged weaning- Important aspects of pneumological rehabilitation and neurorehabilitation in prolonged weaning- Infrastructure and process organization in the care of patients in prolonged weaning in the sense of a continuous treatment concept- Therapeutic goal change and communication with relativesAspects of pediatric weaning are given separately within the individual chapters.The main aim of the revised guideline is to summarize current evidence and also expert based- knowledge on the topic of "prolonged weaning" and, based on the evidence and the experience of experts, make recommendations with regard to "prolonged weaning" not only in the field of acute medicine but also for chronic critical care.Important addressees of this guideline are Intensivists, Pneumologists, Anesthesiologists, Internists, Cardiologists, Surgeons, Neurologists, Pediatricians, Geriatricians, Palliative care clinicians, Rehabilitation physicians, Nurses in intensive and chronic care, Physiotherapists, Respiratory therapists, Speech therapists, Medical service of health insurance and associated ventilator manufacturers.

[Guidelines for Non-Invasive and Invasive Home Mechanical Ventilation for Treatment of Chronic Respiratory Failure - Update 2017]. / S2k-Leitlinie: Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz ­ Revision 2017.

Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010 the German Society of Pneumology and Mechanical Ventilation (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure". However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines.For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning.In the current guidelines different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.The currently updated guidelines are valid for the next three years, following their first online publication on the home page of the Association of the Scientific Medical Societies in German (AWMF) in the beginning of July 2017. A subsequent revision of the guidelines remains the aim for the future.

[Weaning from mechanical ventilation. Weaning categories and weaning concepts]. / Entwöhnung von der mechanischen Beatmung. Weaningkategorien und Weaningkonzepte.

The international classification of three weaning categories (simple weaning, difficult weaning, prolonged weaning) has been modified in the German weaning guidelines: the group of prolonged weaning has been subclassified into weaning without noninvasive ventilation (NIV), weaning with NIV, if necessary with continuing NIV in the form of home mechanical ventilation, and weaning failure.Strategies to prevent prolonged weaning comprise daily interruption of sedation, daily screening of capability of spontaneous breathing by a spontaneous breathing trial (SBT) and early implementation of NIV instead of continuing invasive mechanical ventilation especially in hypercapnic patients. The comorbidity left heart failure plays a major role in weaning failure and need for re-intubation-in this case early diagnosis and if necessary modification of heart therapy are important.Specialised weaning-centres offer the option for successful weaning for about 50-60 % of patients declared as unweanable by usual intensive care units. A multimodal therapy concept with respiratory therapists, physiotherapists and speech therapy is necessary to reach this goal. In case of weaning failure a professional discharge management to invasive home mechanical ventilation is important. Competent care by physicians in the out-of-hospital area is restricted by the sectoral division of responsibility by the German health care system. Improvement in this area is urgently needed.

S2k-Guideline "Prolonged Weaning".

All mechanically ventilated patients must be weaned from the ventilator at some stage. According to an International Consensus Conference the criteria for "prolonged weaning" are fulfilled if patients fail at least 3 weaning attempts (i. e. spontaneous breathing trial, SBT) or require more than 7 days of weaning after the first SBT. This occurs in about 15 - 20 % of patients.Because of the growing number of patients requiring prolonged weaning a German guideline on prolonged weaning has been developed. It is an initiative of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP) in cooperation with other societies (see acknowledgement) engaged in the field chaired by the Association of Scientific and Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF).This guideline deals with the definition, epidemiology, weaning categories, underlying pathophysiology, therapeutic strategies, the weaning unit, transition to out-of-hospital ventilation and therapeutic recommendations for end of life care. This short version summarises recommendations on prolonged weaning from the German guideline.

[WeanNet: a network of weaning units headed by pneumologists]. / WeanNet: Das Netzwerk pneumologischer Weaningzentren.

There is an increase of both prolonged mechanical ventilation (MV) and prolonged weaning from the respirator in the last decade in Germany. Prolonged MV is associated with an increase of morbidity, mortality and costs.The network "WeanNet", which has been founded by the "Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP, German Respiratory Society) connects weaning units headed by pneumologists with special experience in intensive care medicine.The certification of a weaning unit within WeanNet aims at the improvement of treatment quality, outcome and reduction of costs by well defined structures and processes.Based on growing experience the criteria and procedures of the certification process were adjusted in the last years, leading to a higher transparency and acceleration of the process. On this background WeanNet is necessary to improve the communication about prolonged weaning in public health, with insurance companies and associated scientific societies.

[Prolonged weaning: S2k-guideline published by the German Respiratory Society]. / Prolongiertes Weaning: S2k-Leitlinie herausgegeben von der Deutschen Gesellschaftfür Pneumologie und Beatmungsmedizin e.V.

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by insufficiency of the respiratory muscles and/or lung parenchymal disease when/after other treatments, i. e. oxygen, body position, secretion management, medication or non invasive ventilation have failed.In the majority of ICU patients weaning is routine and does not present any problems. Nevertheless 40-50 % of the time during mechanical ventilation is spent on weaning. About 20 % of patients need continued MV despite resolution of the conditions which originally precipitated the need for MV.There maybe a combination of reasons; chronic lung disease, comorbidities, age and conditions acquired in ICU (critical care neuromyopathy, psychological problems). According to an International Consensus Conference the criteria for "prolonged weaning" are fulfilled if patients fail at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial. Prolonged weaning is a challenge. An inter- and multi-disciplinary approach is essential for weaning success. Complex, difficult to wean patients who fulfill the criteria for "prolonged weaning" can still be successfully weaned in specialised weaning units in about 50% of cases.In patients with unsuccessful weaning, invasive mechanical ventilation has to be arranged either at home or in a long term care facility.This S2-guideline was developed because of the growing number of patients requiring prolonged weaning. It is an initiative of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP) in cooperation with other societies engaged in the field.The guideline is based on a systematic literature review of other guidelines, the Cochrane Library and PubMed.The consensus project was chaired by the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) based on a formal interdisciplinary process applying the Delphi-concept. The guideline covers the following topics: Definitions, epidemiology, weaning categories, pathophysiology, the spectrum of treatment strategies, the weaning unit, discharge from hospital on MV and recommendations for end of life decisions. Special issues relating to paediatric patients were considered at the end of each chapter.The target audience for this guideline are intensivists, pneumologists, anesthesiologists, internists, cardiologists, surgeons, neurologists, pediatricians, geriatricians, palliative care clinicians, nurses, physiotherapists, respiratory therapists, ventilator manufacturers.The aim of the guideline is to disseminate current knowledge about prolonged weaning to all interested parties. Because there is a lack of clinical research data in this field the guideline is mainly based on expert opinion.

[Acceptance of a telemonitoring device in patients with chronic obstructive pulmonary disease]. / Akzeptanz einer telemedizinischen Intervention bei Patienten mit chronisch-obstruktiver Lungenerkrankung.

OBJECTIVE: The aim of this trial was to assess the acceptance of a telemonitoring device (Health Buddy®) by patients with chronic obstructive pulmonary disease (COPD). The device makes it possible to monitor vital parameters and to ask questions about symptoms, behavior and disease-specific knowledge. METHOD: A single-arm non-randomized clinical study was performed for three months in 43 patients with severe/very severe COPD. The primary intent was to determine the patients' compliance with the device. In addition the patients were questioned about their general acceptance of the telemonitoring intervention, their quality of life and the overall use of resources. RESULTS: 36 patients (25 men, 11 women, mean age 67,9 ± 6,9; range 54 - 81 years) completed the protocol. All 43 patients were using the device (Health Buddy®) on two thirds of all possible working days (this had been predefined as full compliance). Especially the questions on technical functioning of the device, trust in the technique and data security, as well as the confidentiality of communication with the physician via telemedicine were very positively answered. Health-related quality of life did not change and no rise of autonomy was noted. However, the objective of early detecting of acute exacerbations by daily measurements of vital parameters and assessment of symptoms was difficult to achieve because of inadequate definition of the parameters. CONCLUSION: This cohort of patients with advanced COPD was highly compliant in the use of the telemonitoring device. But clinical efficacy and economic effectiveness remain to be investigated.

[Non-invasive and invasive mechanical ventilation for treatment of chronic respiratory failure. S2-Guidelines published by the German Medical Association of Pneumology and Ventilatory Support]. / Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz. S2-Leitlinie herausgegeben von der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e. V.

The field of mechanical ventilation is highly important in pulmonary medicine. The German Medical Association of Pneumology and Ventilatory Support ["Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP)"] therefore has formulated these guidelines for home mechanical non-invasive and invasive ventilation. Non-invasive home mechanical ventilation can be administered using various facial masks; invasive home mechanical ventilation is performed via a tracheostomy. Home mechanical ventilation is widely and increasingly accepted as a treatment option for chronic ventilatory failure which most often occurs in COPD, restrictive lung diseases, obesity-hypoventilation syndrome and neuromuscular disorders. Essential for the initiation of home mechanical ventilation are the presence of symptoms of ventilatory failure and the detection of hypoventilation, most importantly hypercapnia. These guidelines comprise general indication criteria along with disease-specific criteria summarised by treatment algorithms. In addition, the management of bronchial secretions and care of paediatric patients are addressed. Home mechanical ventilation must be organised around a specialised respiratory care centre with expertise in patient selection, the initiation and the control of home mechanical ventilation. In this regard, the guidelines provide detailed information about technical requirements (equipment), control and settings of mechanical ventilation as well as organisation of patient care. A key requirement for home mechanical ventilation is the qualification of specialised home-care services, which is addressed in detail. Independent living and the quality of respiratory care are of highest priority in patients receiving home mechanical ventilation, since home mechanical ventilation can interfere with the integrity of a patient and often marks a life-sustaining therapy. Home mechanical ventilation has been shown to improve health-related quality of life of patients with chronic ventilatory failure. Long-term survival is improved in most patient groups, even though the long-term prognosis is often severely limited. For this reason, ethical issues regarding patient education, communication with ventilated patients at the end of life, living will, testament and medical care during the dying process are discussed.

[Palliative care in respiratory medicine]. / Palliativmedizin in der Pneumologie.

Palliative care should be part of respiratory medicine for two reasons: first, many respiratory diseases--besides thoracic tumours--need palliative care in the late stages of the disease. Second, dyspnoea is a common symptom in advanced, primary extrapulmonary diseases and the knowledge of respiratory specialists can be beneficial in the treatment of this symptom. In this paper we describe frequent symptoms of advanced pulmonary diseases and their treatment. Moreover, we focus on the structure of palliative care in Germany.

[The respiratory therapist]. / Der Atmungstherapeut.

Because of the expected significant growth in the elderly population and respiratory diseases, the topic of "delegation of physician's duties" is of increasing importance to the German health-care system. In 2004 the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP)) established the new profession: respiratory therapist. A curriculum was defined which offers training for certified nurses and physiotherapists. Respiratory therapists evaluate, treat, document and care for patients with pulmonary disorders. Under appropriate supervision a licensed respiratory therapist performs some of the work previously done by physicians at the same quality of care. The first respiratory therapists have finished their professional training in Germany. Most of these respiratory therapists are now employed in hospital-based positions requiring their specific skills. Generally, the increased medical responsibility and the increased degree of decision-making possibilities associated with the new profession contribute to a better job satisfaction. However, this is not yet true for all the newly employed respiratory therapists. Only few of the new graduate respiratory therapists were awarded higher salaries. It is a strongly recommendation to the heads of medical departments and the human resources managers of hospitals that they should recognise the increased qualifications of nurses and physiotherapists who become respiratory therapists by appropriate remuneration.