Long-Term Mechanical Ventilation: Recommendations of the Swiss Society of Pulmonology.

Long-term mechanical ventilation is a well-established treatment for chronic hypercapnic respiratory failure (CHRF). It is aimed at improving CHRF-related symptoms, health-related quality of life, survival, and decreasing hospital admissions. In Switzerland, long-term mechanical ventilation has been increasingly used since the 1980s in hospital and home care settings. Over the years, its application has considerably expanded with accumulating evidence of beneficial effects in a broad range of conditions associated with CHRF. Most frequent indications for long-term mechanical ventilation are chronic obstructive pulmonary disease, obesity hypoventilation syndrome, neuromuscular and chest wall diseases. In the current consensus document, the Special Interest Group of the Swiss Society of Pulmonology reviews the most recent scientific literature on long-term mechanical ventilation and provides recommendations adapted to the particular setting of the Swiss healthcare system with a focus on the practice of non-invasive and invasive home ventilation in adults.

Patients' views on their decision making during inpatient rehabilitation after newly acquired spinal cord injury-A qualitative interview-based study.

INTRODUCTION: Involving patients in decision making is a legal requirement in many countries, associated with better rehabilitation outcomes, but not easily accomplished during initial inpatient rehabilitation after severe trauma. Providing medical treatment according to the principles of shared decision making is challenging as a point in case for persons with spinal cord injury (SCI). OBJECTIVES: The aim of this study was to retrospectively explore the patients' views on their participation in decision making during their first inpatient rehabilitation after onset of SCI, in order to optimize treatment concepts. METHODS: A total of 22 participants with SCI were interviewed in-depth using a semi-structured interview scheme between 6 months and 35 years post-onset. Interviews were transcribed verbatim and analysed with the Mayring method for qualitative content analysis. RESULTS: Participants experienced a substantially reduced ability to participate in decision making during the early phase after SCI. They perceived physical, psychological and environmental factors to have impacted upon this ability. Patients mentioned regaining their ability to make decisions was an important goal during their first rehabilitation. Receiving adequate information in an understandable and personalized way was a prerequisite to achieve this goal. Other important factors included medical and psychological condition, personal engagement, time and dialogue with peers. CONCLUSION: During the initial rehabilitation of patients with SCI, professionals need to deal with the discrepancy between the obligation to respect a patient's autonomy and their diminished ability for decision making.

Maximum Inspiratory Pressure is a Discriminator of Pneumonia in Individuals With Spinal-Cord Injury.

BACKGROUND: Respiratory complications remain a major cause of mortality among individuals with spinal-cord injury (SCI). The present study investigated whether respiratory function is a discriminator of pneumonia in individuals with SCI and is aimed to determine the best predictive parameter. METHODS: This was a retrospective cohort study. Individuals with traumatic SCI, level C3 to T12, complete and incomplete lesions, were included. Data on respiratory function were extracted from medical records. The receiver operating characteristic curve was calculated for each parameter (forced vital capacity, FEV1, peak expiratory flow, and maximum inspiratory and expiratory pressure [PImax and PEmax]) to determine the discriminator with the largest area under the curve between individuals with and without pneumonia. RESULTS: Data of 307 subjects were analyzed. PImax was identified as the best discriminator between individuals with and without pneumonia, both in motor complete (area under the curve 0.86, 95% CI 0.78-0.93, P < .001) and incomplete individuals (area under the curve 1.0, 95% CI 1.00-1.00, P < .001). In individuals with motor complete lesions, the threshold value for PImax was 115% of the lesion-specific reference value (sensitivity 74.4%, specificity 83.4%). In motor incomplete individuals, the PImax threshold value was 93.5 cm H2O (sensitivity 100%, specificity 100%). CONCLUSIONS: PImax is the best discriminator between spinal cord-injured individuals with versus those without pneumonia. Individuals with a PImax below threshold values are at risk of pneumonia.

Topical tacrolimus treatment of atopic eyelid disease.

PURPOSE: To describe the effects of topical tacrolimus treatment of severe atopic eyelid disease. DESIGN: Interventional consecutive case series. METHODS: A description of clinical findings and therapeutic response for five consecutive adult patients (mean age, 56.2 years; range 44-62) treated with topical tacrolimus for severe atopic eyelid disease at one institution. RESULTS: Five patients with bilateral atopic eyelid disease that was refractory to treatment with topical corticosteroids were treated with tacrolimus 0.03% ointment, applied to the affected eyelid skin of both eyes twice daily. Eyelid induration, erythema, and eczematous changes were substantially improved within 1 to 3 weeks after initiation of topical tacrolimus treatment in all patients. There was an associated decrease in ocular surface irritation and inflammatory signs in each of four patients who also had atopic keratoconjunctivitis. No adverse effect associated with tacrolimus treatment was noted during continued treatment for 5 to 14 months. All patients were able to discontinue longstanding use of topical corticosteroid drugs. CONCLUSIONS: Application of topical tacrolimus on eyelid skin may be effective for treatment of severe atopic dermatitis of the eyelids, and may have secondary benefits for atopic keratoconjunctivitis. Topical tacrolimus may be used for at least 1 year without apparent adverse reaction in some patients, although the rate of adverse reaction cannot be determined from this small series.

[Long-term follow-up in patients with spinal cord injury - prevention and comprehensive care]. / Langzeitbetreuung von Menschen mit Querschnittslähmung - Vorsorge und Nachsorge.

Patients with spinal cord injuries suffer not only from sensory and motor deficits, but from failure of the autonomic nerve system which in consequence involves many organs and metabolic pathways. These deficits lead to a different approach to these patients and their medical, psychological and social problems. Three examples will illustrate the different approaches to typical medical problems of these patients. Regularly ambulatory long term follow up visits in specialized centres in close collaboration with general practitioners help to diminish complications and rehospitalisations. Facing the now ageing population with a spinal cord injury we need evidence based guidelines in follow up and preventive strategies for these patients. We updated these recommendations recently. The brochure is available on the webside oft he swiss society of paraplegia www.ssop.ch.

Une lésion de la moelle épinière n'est pas seulement associée à des troubles sensibles et moteurs, mais aussi à des troubles du système nerveux autonome, ce qui en conséquence influence tous les organes et le métabolisme. Au moyen de trois exemples nous illustrons les differents approches de diagnostic et de traitement chez les paraplégiques. A l'aide de contrôles annuels spécifiques et en collaboration étroite avec les médécins de famille nous suivons les patients durant toute la vie avec comme but de minimaliser les complications typiques comme par exemple les risques cardiovasculaires, pulmonaires, intestinaux et les troubles du métabolisme du glucose et des lipides. L'éffet de l'âge avancé est aussi à considérer de plus en plus, car nos patients survivent beaucoup plus long temps à cause des progrès medicaux et sociaux et du soutien des patients. Nous avons developpé des directives basées sur la littérature existante des soins spécifiques et des mesures préventives chez les paraplégiques (accessible sur le site de la société suisse de paraplégie: www.ssop.ch).

Laboratory evaluation of four different devices for secretion mobilization: Acapella choice, green and blue versus water bottle.

BACKGROUND: Secretion removal is a key issue in patients with respiratory diseases, and is known to be most effective at vibration frequencies of ∼ 13 Hz and with the greatest amplitudes possible. The Acapella devices and the water bottle are used for secretion removal in daily clinical practice but without detailed knowledge on optimal settings. The aim of this study was to evaluate the 3 different Acapella devices and the water bottle at various settings and flows to determine the optimal devices and settings for effective secretion removal. METHODS: Three different Acapella devices were tested at flows of 6, 12, 20, 30, 40, and 50 L/min, and at all 5 settings. The water bottle was filled with 5, 10, or 15 cm of water, and tested at flows of 3, 6, 10, 12, and 20 L/min. For all devices and combinations of settings, we measured the frequency and amplitude of the vibrations, as well as the required pressure to generate vibrations. RESULTS: Setting 4 was the best for all 3 Acapella devices, and the filling height of the water bottle should be 5 cm. At these settings, all devices elicited vibration frequencies between 12 and 15 Hz, which is theoretically optimal for secretion mobilization. The resistance pressures of the devices to elicit these vibrations were between 5 and 11 cm H2O. However, the Acapella devices elicit higher vibration amplitudes (5-8 cm H2O) than the water bottle (1.8 cm H2O) CONCLUSIONS:: Setting 4 was optimal for all 3 Acapella devices. The Acapella devices may be more efficient for secretion mobilization than the water bottle, because they elicit greater amplitude of vibrations.

Bronchial hyperresponsiveness testing in athletes of the Swiss Paralympic team.

BACKGROUND: The aim of this study was to assess airway hyperresponsiveness to eucapnic voluntary hyperventilation and dry powder mannitol challenge in athletes aiming to participate at the Paralympic Games 2008 in Beijing, especially in athletes with spinal cord injury. METHODS: Forty-four athletes with a disability (27 with paraplegia (group 1), 3 with tetraplegia (group 2) and 14 with other disabilities such as blindness or single limb amputations (group 3) performed spirometry, skin prick testing, measurement of exhaled nitric oxide, eucapnic voluntary hyperventilation challenge test (EVH) and mannitol challenge test (MCT). A fall in FEV1 of ≥10% in either challenge test was deemed positive for exercise-induced bronchoconstriction. RESULTS: Fourteen (32%) athletes were atopic and 7 (16%) had a history of physician-diagnosed asthma. Absolute lung function values were significantly lower in patients of group 1 and 2 compared to group 3. Nine (20%) athletes were positive to EVH (8 paraplegics, 1 tetraplegic), and 8 (18%) athletes were positive to MCT (7 paraplegics, 1 tetraplegic). Fourteen (22.7%) subjects were positive to at least one challenge; only three athletes were positive to both tests. None of the athletes in group 3 had a positive test. Both challenge tests showed a significant association with physician-diagnosed asthma status (p = 0.0001). The positive and negative predictive value to diagnose physician-diagnosed asthma was 89% and 91% for EHV, and 75% and 86% for MCT, respectively. CONCLUSION: EVH and MCT can be used to identify, but especially exclude asthma in Paralympic athletes.

Reproducibility of assessing rib cage mobility from computed tomography images.

BACKGROUND: Rib cage mobility decreases in various health conditions, for example neuromuscular diseases. A decrease in rib cage mobility reduces respiratory function and therefore increases the risk of respiratory complications. To evaluate the effects of interventions aiming at increasing rib cage mobility, changes should be calculated from measurements before and after such interventions. Therefore, an accurate and easy to perform method is needed. OBJECTIVE: To assess rib cage mobility using computed tomography (CT). METHODS: We analysed single-image CT scans of the chest to assess its reproducibility at maximal inspiration and expiration in ten able-bodied individuals and ten subjects with tetraplegia. CT scans were taken twice in the supine position, with a repositioning of subjects in-between. At maximal inspiration and expiration, two images at the fourth and ninth vertebral body were recorded. Intra-costal areas, anterior-posterior distances from the sternum to the vertebral body as well as transversal distances of the chest were measured manually by three independent testers, each of them analysing all data twice. Intra-class correlation coefficients (ICCs) and Bland and Altman plots were calculated for intra-subject reproducibility at maximal inspiration and expiration as well as for intra- and inter-tester reproducibility. RESULTS: Mean differences between the two intra-subject measurements expressed as percentage of their mean were 2.3 ± 1.3% in able-bodied individuals and 2.1 ± 1.3% in subjects with tetraplegia. All ICCs were above 0.95 and thus showed very high reproducibility. CONCLUSION: Assessing rib cage mobility by analysing CT scans of the chest is a simple and highly reproducible method.

Prediction models and development of an easy to use open-access tool for measuring lung function of individuals with motor complete spinal cord injury.

OBJECTIVE: To develop statistical models to predict lung function and respiratory muscle strength from personal and lesion characteristics of individuals with motor complete spinal cord injury. DESIGN: Cross-sectional, multi-centre cohort study. SUBJECTS: A total of 440 individuals with traumatic, motor complete spinal cord injury, time post-injury ≥ 6 months, lesion level C4-T12, underwent measurements of lung function and respiratory muscle strength. METHODS: Prediction models for lung volumes and peak inspiratory and expiratory muscle strength were calculated. Using multi-level regression models, the effects of personal characteristics (gender, age, height, body mass) and lesion characteristics (time post-injury and lesion level) were determined. RESULTS: Positive predictors of lung function parameters were: male gender, younger age, greater height, greater body mass and lower lesion level. For maximal inspiratory muscle strength, male gender, younger age, greater body mass and lower lesion level were significant positive predictors, whereas for maximal expiratory muscle strength, male gender, younger age, longer time post-injury and lower lesion level were positive influencing parameters. CONCLUSION: In contrast to predictive models for able-bodied individuals, lung function parameters of persons with spinal cord injury are influenced by body mass and lesion level. Maximal expiratory muscle strength improves with longer time post-injury.

Part 1. International Classification of Functioning, Disability and Health (ICF) Core Sets for persons with sleep disorders: results of the consensus process integrating evidence from preparatory studies.

BACKGROUND/OBJECTIVES: The International Classification of Functioning, Disability and Health (ICF) provides a comprehensive and universally accepted framework to classify changes in functioning related to health conditions. Comprehensive and Brief Core Sets have been defined for various disorders but not for sleep disorders. Such a Core Set would greatly enhance the techniques available to describe the impact of sleep disorders on patients. The overarching purpose of this paper is to report on phase 1 of the international and World Health Organization (WHO) endorsed consensus process in identifying ICF Core Sets for sleep disorders. METHODS: A formal decision-making and consensus process which integrated evidence gathered from preparatory studies was carried out. Relevant ICF categories were selected by a sample of international experts from different backgrounds using the nominal group technique. RESULTS: Twenty-six experts from 22 countries and different professional backgrounds attended the consensus conference. Altogether 120 second- or third-level ICF categories were included in the Comprehensive ICF Core Set with the following ICF component split: 49 categories from body functions, 8 from body structures, 31 from activities and participation and 32 from environmental factors. The Brief ICF Core Set included a total of 15 second-level categories: 5 body functions (sleep, energy and drive, attention, consciousness, respiration functions); 3 body structures (brain, respiratory system, pharynx); 4 activities and participation (focusing attention, driving, handling stress and other psychological demands, carrying out daily routine); and 3 environmental factors (immediate family; health services, systems, and policies; and health professionals). CONCLUSION: A formal consensus process integrating evidence and expert opinion led to the first version of the ICF Core Sets for persons with sleep disorders. Further validation of the Core Set is needed.