Diagnosis and management of chronic obstructive pulmonary disease: the Swiss guidelines. Official guidelines of the Swiss Respiratory Society.

The new Swiss Chronic Obstructive Pulmonary Disease (COPD) Guidelines are based on a previous version, which was published 10 years ago. The Swiss Respiratory Society felt the need to update the previous document due to new knowledge and novel therapeutic developments about this prevalent and important disease. The recommendations and statements are based on the available literature, on other national guidelines and, in particular, on the GOLD (Global Initiative for Chronic Obstructive Lung Disease) report. Our aim is to advise pulmonary physicians, general practitioners and other health care workers on the early detection and diagnosis, prevention, best symptomatic control, and avoidance of COPD as well as its complications and deterioration.

Successful closure of chronic BPF by thoracoscopy after failure of endoscopic fibrin glue application and thoracoplasty.

We report a case of chronic debilitating BPF following right upper lobe resection. Despite several endobronchial applications of fibrin glue, we could not close it. Since the patient was extremely debilitated by symptoms due to the BPF, a thoracoplasty was attempted but was not successful. Finally, the BPF was definitely closed by instillation of talc into the pleura through thoracoscopy. To our knowledge, this is the first reported case of chemical closure of a recalcitrant BPF by the route of thoracoscopy. It also shows the failure of endoscopic fibrin glue application in such a condition.

Occupational exposure to inhalative irritants and methacholine responsiveness.

OBJECTIVES: Occupational exposures to inhalative irritants have been associated with an increased reporting of respiratory symptoms in previous studies. Methacholine responsiveness represents a continuous measure of airway responsiveness. As such, it may be less subject to recall bias and more sensitive to detecting effects of occupational exposure on airways. Such effects may be stronger among atopic persons. The objective of the study was to examine the relationship between self-reports of occupational exposure to dusts, gases, vapors, aerosols, and fumes and methacholine responsiveness. METHODS: A sample was studied of never smokers (N=3044) chosen randomly from 8 areas in Switzerland. Atopy was defined as any positive skin test to 8 inhalative allergens. Nonspecific bronchial reactivity was tested using methacholine chloride and quantified by calculating the slope of the dose-response. RESULTS: The methacholine slopes were 19% [95% confidence interval (95% CI) 6-32] higher for never smokers with exposure to dusts, fumes, vapors, gases, or aerosols than for the unexposed group. When only atopic never smokers were examined. the increase was larger (37%, 95% CI 7-75), and for persons with >2 positive skin prick tests the effect was still higher (42%, 95% CI -1.5-104). Exposure to vapors and aerosols was strongly associated with increased methacholine slopes among the atopic subjects. CONCLUSIONS: Occupational exposure, particularly to dusts and fumes, was associated with increased bronchial reactivity in never smokers in this study. The magnitude of the effect was larger among atopic subjects.

SAPALDIA: methods and participation in the cross-sectional part of the Swiss Study on Air Pollution and Lung Diseases in Adults.

SAPALDIA--the Swiss Study on Air Pollution and Lung Diseases in Adults--focuses on the long term health effects of low to moderate levels of air pollutants as typically seen in different parts of Switzerland. The aim of the SAPALDIA cross-sectional study carried out in 1991 was to determine the prevalence of bronchial asthma, chronic bronchitis and allergic conditions in the adult population of Switzerland and to identify and to determine the respective importance of potentially influencing factors. These could be both personal (smoking habits, allergy status, family history, occupation) and environmental (outdoor and indoor pollution, aeroallergens, climate). A further aim of the cross-sectional study consisted in the identification of individuals susceptible to present symptoms during a two year observation period and to be included in the SAPALDIA follow-up study. This technical report represents the methodological documentation for the cross-sectional study of SAPALDIA. The instruments and the methods of standardisation are presented and discussed. The medical examination consisted of a computerised interview using a standardised questionnaire, the taking of a blood sample for serological tests, allergy skin testing, the measurement of end expiratory CO and body height, and pulmonary function testing followed by methacholine challenge testing or bronchodilatation testing. The pattern of participation and the 9651 participants of the study, representing 59.3% of the sample, are described. Based on information on non-participants gained by telephone interviews and mailed short questionnaires, possible selection biases are quantified and discussed.

[Nocturnal oxygen therapy in chronic obstructive bronchitis?]. / Nächtliche Sauerstofftherapie bei chronischer obstruktiver Bronchitis?

Patients with chronic obstructive pulmonary disease suffer often from sleeping disorders. A cause for these complaints is the disturbed respiration during sleep. By such ventilatory alterations arterial oxygenation is decreased and periodic severe desaturation may occur. For investigation of oxygenation during the night, pulse oximetry is suited best. For difficult problems polysomnography may be used. Treatment is based primarily on optimal anti-obstructive therapy with bronchodilators and antiinflammatory agents and an adapted physical therapy. In selected patients administration of oxygen by a nasal tube is advantageous. Patients with severe desaturation and with an overlap syndrome profit most from additional oxygen treatment. Survival can thus be prolonged and the quality of life is improved.

[Tuberculosis--recurrence: incidence, causes, treatment]. / Tuberkulose--Rezidive. Häufigkeit, Ursachen, Behandlung.

By reducing the anti-tuberculous therapy to six to nine months and the fact that tuberculosis occurs in immunocompromised patients raises the question of relapse after treatment. In order to avoid such relapses the drug therapy has to be optimized regarding duration (minimum six months) as well as combination (bactericidal antituberculous drugs) and the patients' compliance has to be monitored carefully. Special monitoring is necessary with immunocompromised patients. The problem of resistance against antituberculous drugs (especially Isoniazid) has to be taken into consideration. The most relapses occur during the first year after termination of therapy.

[Tuberculosis--prevention. Diagnostic and therapeutic measures]. / Tuberkulose--Prävention. Diagnostische und therapeutische Massnahmen.

The most effective prevention of an infectious disease is the correct treatment of patients already affected. While dealing with infected tuberculosis patients one has to take hygienic measures in order to protect doctors and nursing staff as well as relatives. However, very often neither the source of infection nor other affected persons are known. Through careful examination of the environment such patients have to be defined and treated accordingly. Other possibilities of reducing the danger of infection are BCG-vaccination and serial examination of high risk groups (especially tuberculin skin test). For newly infected patients or patients with extended residues on x-ray, chemoprophylaxis is used.

[Pillars of therapy of chronic obstructive bronchitis]. / Grundpfeiler der Therapie der chronischen obstruktiven Bronchitis.

While bronchial asthma is defined on the basis of pulmonary function, emphysema has a patho-anatomic substrate. Chronic bronchitis on the other hand is defined clinically: productive cough of three months duration per year occurring in two successive years. Complete abstinence of smoking is a prerequisite for a meaningful anti-obstructive therapy. Beta-2-adrenergic stimulation and corticosteroids represent the treatment of choice. Beta-2-agonists are effectively complemented by anticholinergic drugs. Oral or parenteral corticosteroids should be used liberally for exacerbations. For prolonged treatment topical steroids are prescribed exclusively in order to prevent systemic side effects. The type of inhalation therapy (electric nebulizer, aerosol spray, insufflator) has to be adapted to the individual patient. Correct application of inhalation-technique is important. Topical steroids should be administered by means of a spacer chamber. Physical therapy is the most important adjuvant treatment. Selective respiration-training, a correction of breath-technique and autogenic bronchial drainage manoeuvres have to be learned in the setting of a rehabilitation program and are controlled frequently by the treating physician. The integration of all these measures into a treatment and rehabilitation plan is facilitated in a specialized clinic.

[Pickwick syndrome. A case example of an obesity-hypoventilation syndrome, combined with obstructive sleep apnea]. / Das Pickwick-Syndrom. Fallbeispiel eines Adipositas-Hypoventilationssyndroms, kombiniert mit einer obstruktiven Schlafapnoe.

Nocturnal intrinsic disorders of sleep are much more common than hitherto assumed. In middle-aged men, a prevalence of 0.3 to 3% of severe obstructive sleep apnea syndromes necessitating treatment is expected. The international classification of sleep disorders (ICSD 1990) contains the definitions and descriptions of the different entities. A patient with combined obstructive sleep apnea and a hypoventilation syndrome due to obesity serves to illustrate problems with diagnosis and particularly treatment of this respiratory disorder during sleep. The most frequent sleep disorders are briefly presented and placed in the context of other concomitant somatic diseases. Because of the possible serious course of nocturnal hypoxemias, the conclusion is justified that a timely and accurate diagnosis is essential for the patient. Transcutaneous oximetry during the night is sufficient as screening procedure. It can be applied to outpatients. In depth, evaluation should be carried out at a specialized center with polysomnography.

[Long-term trans-tracheal oxygen therapy. Simple management for the patient--improved compliance]. / Die transtracheale Sauerstoff-Langzeittherapie. Einfache Handhabung für den Patienten--verbesserte Compliance.

Long-term oxygen therapy is an established treatment of severe hypoxemia in patients with chronic obstructive or other pulmonary diseases. Quality of life and survival time can be improved significantly. Objective patient evaluation and compliance are most important. The transtracheal oxygen therapy is an alternative method to nasal cannulas for oxygen supply. Cosmetic problems and nasal discomfort are avoided. The oxygen flow-rate can be reduced by up to 50%. If an on demand-system is used, the oxygen flow-rate can be adapted to exercise. The change and cleaning of the catheter is easy and is performed twice daily by the patient himself.

Acute respiratory health effects of urban air pollutants in adults with different patterns of underlying respiratory disease.

OBJECTIVE: Whether underlying chronic respiratory diseases are susceptible factors for symptomatic episodes, which lead to primary-level care, in association with air pollutant exposures is unknown. We evaluated and compared association lag structures between daily ambient levels of nitrogen dioxide (NO(2)) and total suspended particulates (TSP) and respiratory symptom-related doctor visits in adults with different patterns of underlying chronic respiratory disease. METHODS: In a time-stratified case-crossover analysis nested within a diary panel study, 459 Swiss adult participants with asthma, chronic bronchitis, chronic obstructive pulmonary disease (COPD) and healthy participants recorded occurrence of respiratory-symptom related doctor visits (n = 1,048) in one to six four-week intervals over two years. For each disease subgroup, odds ratios (ORs) for doctor visit were estimated as a function of NO(2) or TSP concentrations (per 10 micrograms per cubic meter [µg/m(3)]) lagged between 0-13 days in a polynomial distributed lag model. RESULTS: Higher ORs for NO(2) in participants with COPD (OR: 1.17, 95%CI: 1.02-1.35) and asthma (OR: 1.15, 95%CI: 1.02-1.30) occurred at exposure lags of two and five days, respectively. Doctor visits increased by 9.1% (95%CI: 3.2-15.4%) and 4.2% (95%CI: 1.2-7.2%) over the first week following a 10 µg/m(3) increase in NO(2) concentration in the COPD and chronic bronchitis subgroups, respectively. The percent increase in the COPD subgroup was significantly greater (p <0.05) when compared with the healthy subgroup. Observed findings were similar for TSP. CONCLUSIONS: Respiratory problems leading to a doctor visit, associated with an increase in exposure to NO(2) and TSP, may have a faster dynamic in individuals with COPD.

[How is your asthma today?--A case report considering different parameters of asthma control]. / Wie geht es denn heute mit dem Asthma? Eine Fallstudie unter Berücksichtigung verschiedener Parameter der Asthma-kontrolle.

Any anti-asthmatic therapy aims to control the disease activity. The amount of medication necessary to maintain asthma control over a longer period may vary. In the course of a long-term treatment, achievement of asthma control has regularly to be assessed. This case reports of a patient suffering from steroid dependent intrinsic asthma illustrates the different parameters being used to evaluate asthma control.

[Tuberculosis in Switzerland--a millenium problem?]. / Tuberkulose in der Schweiz--ein Millenniumproblem?

In Switzerland a family physician sees a case of tuberculosis only every 4-6 years. While tuberculosis does not seem to be a major medical challenge in western countries, it is a real problem in the developing world. Nevertheless, special situations do arise in the western hemisphere where the standard therapy needs to be changed. HIV-positive patients are at greater risk of contracting tuberculosis after exposure, and therapy must be adjusted to the patient's immunological status. Multidrug-resistant tuberculosis is a major challenge to the attending physician, and takes us back to the time before antitubercular drugs existed. Standard medication is ineffective and we have to fall back on alternative drugs. Compliance of patient and physician are crucial for effective treatment, as in the case of all long-term therapy. Medical staff, and especially hospital personnel in emergency and tuberculosis departments, are at high risk of infection. Younger staff are no longer immunised by vaccination or earlier infection as they were a few decades ago. Multidrug-resistant bacteria pose a real threat for these groups and effective protection against transmission is important. Discovering a new vaccine which provides adequate immunisation is the only way to tackle the problem of tuberculosis worldwide. New drugs must also be developed to treat those already suffering from the disease.

[The treatment of obstructive sleep apnea]. / Die Behandlung des obstruktiven Schlafapnoesyndroms.

Diagnosis of obstructive sleep apnea syndrome may be suspected clinically, screened for by oximetry and proven by polysomnography. A sufficient number of centers performing polysomnography and providing appropriate treatment is available today in Switzerland. The patient does not need to be admitted to a university center since nearly all high altitude clinics with pneumonologic orientation are equipped to diagnose and treat patients with obstructive sleep apnea syndrome. The treatment of choice is nocturnal CPAP-therapy which is simple, poor in complications and well tolerated. Regular follow-up by cantonal leagues for pulmonary diseases, practising pneumologists and pneumonologic centers are, however, necessary.

[Mechanical home ventilation: indications for and application of nocturnal ventilation using nasal masks in chronic hypoventilation]. / Mechanische Heimventilation: Indikationsstellung und Durchführung einer nächtlichen Beatmung mit Nasenmaske bei chronischer Hypoventilation.

Mechanical ventilation at home has formerly been used mainly to treat respiratory failure after poliomyelitis. Nowadays this method has been refined such that insufflation is no longer necessary through a tracheostoma but via either a specially molded or a customized nose-mask. Ventilation occurs mainly at night for periodic relief of the respiratory musculature. Indications are restrictive ventilatory deficits such as kyphoscoliosis or the postthoracoplasty syndrome, slowly progressing neuromuscular diseases and sometimes traumatic tetraparesis. Evaluation and instruction of the patient take place in a pneumologic center in close cooperation with the cantonal leagues for pulmonary diseases and the family physician. Accordingly a collaboration of all social and medical institutions as well as the participation of close relatives are a prerequisite for a successful mechanical ventilation at home.

[Sleep and respiration]. / Schlaf und Atmung.

Nocturnal sleep-associated breathing disorders have only been investigated thoroughly since about 15 years. From these studies it became clear that many respiratory disorders, in particular chronic obstructive ones, may severely impair nocturnal breathing and thus oxygen supply. by physiologically reduced ventilation at night, particularly in patients with already reduced pulmonary function, oxygen supply may become insufficient. In order to prevent late sequelae, early invalidity or precocious death, a comprehensive diagnostic approach is mandatory. Therapy consists of thorough anti-obstructive and anti-inflammatory inhalations, aided by additional oxygen supply during the night sleep in selected cases. Sleep-apnea syndrome is a frequent disease. About 3%, of males between 25 and 75 and at least 1% of females particularly after menopause, are affected. In most cases diagnosis can be suspected by clinical symptoms and nocturnal pulse oximetry. Sensitivity of pulse oximetry, however, is insufficient, thus polysomnography is necessary to establish the diagnosis and to control therapy. The most important therapeutic measure is to establish a nocturnal nasal continuous positive airway pressure (nCPAP) that may lead to immediate amelioration of symptoms and may normalize survival of patients. In particular, patients with obstructive sleep apnea should not drive motorized vehicles because of their excessive daytime sleepiness until a therapeutic success is evident. In this paper chronic obstructive pulmonary diseases, the central and the obstructive sleep-apnea syndrome are covered in particular.

[Inhalation therapy--advantages and difficulties]. / Die Inhalationstherapie--Vorteile und Schwierigkeiten.

Asthma bronchiale is a very common disease in our western countries. According to the SAPALDIA study (Swiss study on air pollution and lung diseases in adults) 7% of the Swiss population suffer from bronchial asthma or have complained once or several times about asthmatic symptoms. Roughly 3% of the Swiss suffer from chronic obstructive pulmonary disease. The standard treatment for both these conditions of bronchi and bronchioles is inhalation therapy. The enormous advantages of inhalation therapy, i.e. direct action of the drugs at the site of disease and the good acceptance by patients are opposed by the difficulties for correct inhalation. All devices, pressure nebulizers, powder delivery systems or aerosol dispensers have to be explained in depth to patients to achieve optimal results. Teaching of inhalation technique is the mission of the physician, in hospitals also of physiotherapists and nursing staff. Patients with chronic pulmonary diseases are cared for by the lung leagues whose collaborators are carefully trained for treating, instructing and surveilling patients.