[How to become a Respiratory Therapist in Germany - Status quo and Development Prospects]. / Der Weg zum Atmungstherapeuten in Deutschland ­ Status quo und Entwicklungsperspektiven.

The profession respiratory therapist is well established in Germany 10 years after the introduction. 600 participants have successfully graduated from the training facilities.Our goals are high quality interprofessional teamwork and medical assistance inclusive delegation of formerly physician activities. The duties are comparable to the work pattern of Technical Assistants in surgery. For this profession different ways of qualification are possible: primary training, advanced training and academic studies Physician Assistance. The Geman Medical Association worked up standards for a delegation model to physician assistants and relief and assictance for physicians. These standards were finalised in 2017 during the 120th german physician convention. After this decision we can estimate that the number of physician assistants will be growing up. The german respiratory society can imagine physician assistants with special knowledge in respiratory care. But we are not sure wether our previous educational courses will be completely substituted by academic studies. Temporary there will coexist different educational concepts on different levels. In one german country it is also possible for nurses to pass federal certified advanced training in respiratory care. This is why it will be hard to make a choice on this matter in the future.

[Further training for medical specialists in respiratory medicine: how can we improve it?]. / Facharztweiterbildung Pneumologie: Wie können wir sie verbessern?

Young physicians in Germany often criticize the advanced training programme, especially the lack of structure and the insufficient rotations. The Medical Association in each Bundesland/federal state require to include a proposal for advanced training and rotation in a trainer's aplication for an educational license. However, there is no systematic scrutiny of these concepts and therefore the criteria stated outcomes are often only incompletely met. Trainers engage too little in training methods and medical didactics. They rarely evaluate learning outcomes, and structured assessments based on workplace are exceptions. The reasons are deeply rooted in Germany's education system: Resources for specialist training are not provided, and there is no funding for a commitment in continued medical education. In addition, teaching is not assigned a quantifiable value. However, during the last decade awareness has arisen that good training programmes are an important part of quality assurance and the validation of a hospital. Better planning, structuring and evaluation of training programmes is necessary. New learning methods should be incorporated in training programmes. The German Respiratory Society (DGP) wishes to contribute to the improvement of advanced training: for example with "train the trainer" seminars for teachers, with a structured educational course programme for the trainees, with assessments such as the HERMES (Harmonized Education in Respiratory Medicine for European Specialists) exam and with support for the accreditation as a Respiratory Training Centre of the ERS (European Respiratory Society) and EBAP (European Board for Accreditation in Pneumology).

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.

[Noninvasive Mechanical Ventilation in Acute Respiratory Failure]. / Nicht-invasive Beatmung als Therapie der akuten respiratorischen Insuffizienz.

The non-invasive ventilation (NIV) is widespread in the clinical medicine and has attained meanwhile a high value in the clinical daily routine. The application of NIV reduces the length of ICU stay and hospitalization as well as mortality of patients with hypercapnic acute respiratory failure. Patients with acute respiratory failure in context of a cardiopulmonary edema should be treated in addition to necessary cardiological interventions with continuous positive airway pressure (CPAP) or NIV. In case of other forms of acute hypoxaemic respiratory failure it is recommended the application of NIV to be limited to mild forms of ARDS as the application of NIV in severe forms of ARDS is associated with higher rates of treatment failure and mortality. In weaning process from invasive ventilation the NIV reduces the risk of reintubation essentially in hypercapnic patients. A delayed intubation of patients with NIV failure leads to an increase of mortality and should therefore be avoided. With appropriate monitoring in intensive care NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency. Furthermore NIV can be useful within palliative care for reduction of dyspnea and improving quality of life. The aim of the guideline update is, taking into account the growing scientific evidence, to outline the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.

[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.

[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.

[Management of secretion in patients with neuromuscular diseases]. / Sekretmanagement bei neuromuskulären Erkrankungen.

BACKGROUND: Many patients with neuromuscular diseases suffer from a weak cough. Due to infection or aspiration a life-threatening situation may occur. There are different options for the therapists to improve secretion clearance from the airways in the patient with a weak cough. Furthermore, there are indications that consequent practice of techniques to ameliorate bronchial clearance may also improve the prognosis of patients with neuromuscular diseases. MANAGEMENT: The management of secretions in neuromuscular disorders does not consist of single actions but is rather a complex programme. Diagnostics and several therapeutic measures have to be performed intensely and regularly. The diagnosis of a weak cough flow is based on anamnestic data, e. g., increase in secretions or dysphagia, physical examination, e. g., paradoxical breathing, and easily measured lung function parameters like vital capacity and peak cough flow (PCF). The diagnosis of an accumulation of secretions in the airways can be made easily by means of a pulse oximetry: while breathing room air the oxygen saturation in the case of a healthy lung and clean airways will be better than 95 %. A decline can, among others, be induced by amounts of secretions in the airways. The consequence should be measures to improve secretion expectoration (so-called oximetry-feedback protocol). To assist in secretion elimination from the airways several means are available like air stacking, manually assisted cough and mechanical assisted coughing--e. g., mechanical insufflator-exsufflator. Which of these techniques should be used depends on the extent of the disease: with preserved facial and bulbar muscles, air stacking alone or in combination with manually assisted coughing may be adequate and effective in the home care of the patient. In case of failure of these means, e. g., in bulbar paralysis, there is the possibility to apply mechanically assisted coughing by means of the mechanical insufflator-exsufflator. In case of tracheostomy, air stacking or mechanical assisted coughing has to be combined with tracheal suctioning. Acute infections of the lower airways are a special challenge: personnel intensive application of a combination of different secretion eliminating techniques, e. g., bronchoscopy in the hospital, manually assisted coughing and mechanically assisted coughing have to be performed in high intensity to avoid intubation. CONCLUSION: The early diagnosis of a weak cough in NMD patients is important for the timely start of existing and effective measures for improving the capacity of elimination of secretions--air stacking, manually assisted cough and mechanically assisted cough. Although there is no high degree of evidence, we believe that morbidity and possibly mortality can be affected in a positive manner.

[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.

[Care of patients under mechanical ventilation at home and in nursing home conditions. Position paper of the German Medical Associations of Pneumology and Ventilatory Support ("Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V." and "Arbeitsgemeinschaft für Heimbeatmung und Respiratorentwöhnung e. V.")]. / Betreuung von Patienten mit maschineller Beatmung unter häuslichen und heimpflegerischen Bedingungen. Stellungnahme der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP) und der Arbeitsgemeinschaft für Heimbeatmung und Respiratorentwöhnung e. V.

The advances in intensive and critical care medicine have not only improved the prognosis of patients with acute respiratory failure but have also increased the number of ventilator-dependent patients. The continuously increasing number of patients, the differentiation of care-giving institutions and the technical progress make it necessary to re-evaluate the quality of health care in weaning centres and outpatient care of patients on long-term ventilation. Therefore, the German medical associations of pneumology and ventilatory support, "Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V." and the "Arbeitsgemeinschaft für Heimbeatmung und Respiratorentwöhnung e. V.", wish to present this actual position paper. However, scientific guidelines are in preparation.

[Mechanical ventilation in acute ventilatory insufficiency]. / Beatmung bei akuter ventilatorischer Insuffizienz.

Acute ventilatory insufficiency is characterized by hypercapnia, respiratory acidosis and secondary hypoxemia. The primary target of mechanical ventilation is improvement of alveolar ventilation, that means compensation of the ventilatory insufficiency. Noninvasive ventilation started as ventilatory support during the big polio epidemic, at that time in form of negative pressure ventilation. In the last two decades NIV is in form of positive pressure ventilation important for long-term ventilation at home, but there is also growing importance of NIV in the treatment of acute respiratory insufficiency in the intensive care unit. Main indication is the hypercapnic ventilatory failure in acute exacerbation of COPD. This paper will discuss ventilator therapy in general but also the data regarding the role of NIV in the treatment of hypercapnic failure. Specific points like interfaces, indications and contraindications of NIV are addressed.

Immunocytological detection of bone marrow micrometastasis in operable non-small cell lung cancer.

Present diagnostic techniques do not allow the detection of early metastatic spread of tumor cells, although this spread largely determines the clinical course of patients with small primary cancers. By use of monoclonal antibody CK2 to the epithelial cytokeratin component number 18 (CK18), individual disseminated carcinoma cells present in bone marrow of cancer patients can now be identified (G. Schlimok, I. Funke, B. Holzmann, G. Göttlinger, G. Schmidt, H. Häuser, S. Swierkot, H. H. Warnecke, B. Schneider, H. Koprowski, and G. Riethmüller, Proc. Natl. Acad. Sci. USA, 84: 8672-8676, 1987; F. Lindemann, G. Schlimok, P. Dirschedl, J. Witte, and G. Riethmüller, Lancet, 340: 685-689, 1992). In the present study, we applied this approach to patients with operable non-small cell lung cancer. CK18 was expressed on 84 of 88 (95.5%) primary adenocarcinomas and squamous cell carcinomas. Irrespective of primary tumor histology, single aspirates of iliac bone marrow from 18 of 82 (21.9%) lung cancer patients exhibited between 1 and 531 CK18+ cells/4 x 10(5) nucleated marrow cells. The specificity of our assay is underlined by the small rate of "false-positive" cells being observed in only 2 of 117 (1.7%) marrow samples from control patients with no evidence for an epithelial malignancy at the time of aspiration. Comparison with established risk factors demonstrated positive correlations (P < 0.05) between the size and histological grade of the primary carcinoma and cytokeratin positivity in iliac bone marrow. In contrast, the association with the metastatic involvement of regional lymph nodes was only weak (P = 0.09). Following a median observation period of 13 months, patients who displayed cytokeratin-positive cells in iliac bone marrow at the time of primary surgery relapsed more frequently as compared to patients with a negative marrow finding (66.7 versus 36.6%; P < 0.05). This difference was even more pronounced by comparing the rates of manifest skeleton metastasis observed in both groups (26.7 versus 2.4%; P < 0.005). Finally, colabeling of CK18+ cells in marrow with monoclonal antibodies to proliferation-associated markers, such as the nucleolar antigen p120 or the tyrosine kinase receptor erbB2, exemplified the oncogenic capacity of CK18+ micrometastatic cells. In conclusion, CK18+ cells present in the bone marrow of patients with apparently operable non-small cell lung cancer exhibit the potential to form solid metastases. Therefore, the approach presented here may be used to determine the risk of early relapse in operable non-small cell lung cancer with potential consequences for adjuvant therapy.

Expression of major histocompatibility class I and class II antigens and intercellular adhesion molecule-1 on operable non-small cell lung carcinomas: frequency and prognostic significance.

Major histocompatibility complex (MHC) antigens and adhesion molecules, such as the intercellular adhesion molecule-1 (ICAM-1), appear to play an important role in the immunological recognition and destruction of tumour cells. We, therefore, examined the expression patterns of these proteins on primary tumours of 91 patients with operable non-small cell lung cancer (NSCLC). Applying immunohistochemistry with monoclonal antibody (MAb) W6/32 against a common framework determinant of HLA class I antigens revealed a deficient expression in 33.0% of the cases analysed, while neo-expression of either HLA class II antigens (MAb TAL.1B5) or ICAM-1 (MAb PA3.58-14) was observed in 26.4 or 29.7% of tumours, respectively. Analysis of consecutive tumour specimens indicated that HLA antigens and ICAM-1 were frequently coexpressed. With regard to clinicopathological risk factors, we could demonstrate a preferential expression of those markers in patients with locally restricted and well-differentiated tumours or no lymph node metastases, which was more pronounced in adenocarcinomas than in squamous cell carcinomas. In contrast, the presence versus the absence of HLA antigens and ICAM-1 was not correlated with the rate of tumour recurrence or overall survival in patients with NSCLC. In conclusion, the co-ordinated expression of immunologically relevant cell surface molecules on primary NSCLC is a frequent event that correlates with distinct parameters of favourable prognosis. However, we have no evidence that the immune response facilitated by these molecules can effectively influence the clinical course of the disease.

Risk analysis and long-term survival in patients undergoing extended resection of locally advanced lung cancer.

Although locally advanced lung cancer frequently necessitates extended resections to preserve a chance for cure, a higher morbidity is associated with extended resections. It is not known whether the increased morbidity is of relevance for the long-term outcome. It also remains unclear whether exclusion of certain patients according to their risk factors can diminish mortality in these patients. This study therefore investigated whether certain risk factors predispose patients undergoing extended pulmonary resections to increased morbidity or mortality. It also assessed the long-term survival. The cases of 126 consecutive patients with locally advanced lung cancer (stage T3 or T4) were prospectively documented. Seventy-five percent of the patients required an extended resection and 25% a nonextended resection. Extended resections were associated with a significantly increased overall morbidity (p < 0.002). However, mortality, severe complications, or multiple complications were not significantly increased after extended resections. No risk factor predisposed to an increased mortality. Risk factors that were associated with particular postoperative complications were pathologic ergonometry (p < 0.002), a positive cardiac score (p < 0.003), coronary artery disease (p = 0.021), and an increased pulmonary risk score (p < 0.05). Overall 3-year survival was 31%. Patients undergoing extended resections for stage T3 or T4 tumors with no residual tumor (70% of the patients) showed a 3-year survival of 33%. We conclude that postoperative mortality cannot be reduced by excluding patients on the basis of particular risk factors from operations that require extended resections. If a patient is considered to be eligible to undergo pulmonary resection, he or she can be considered to be eligible to undergo extended pulmonary resection. Because prognosis is dismal in nonresected locally advanced lung cancer, we recommend an aggressive surgical approach.

Accuracy of computed tomographic scan and surgical assessment for staging of bronchial carcinoma. A prospective study.

There is an increasing demand for accurate preoperative and intraoperative staging of bronchial carcinoma with respect to neoadjuvant therapy protocols and parenchyma-sparing operations. This study prospectively evaluated accuracy of computed tomographic scan and surgical assessment for staging of bronchial carcinoma in 108 consecutive patients. The stage of the primary tumor (T stage) was correctly determined in 85% of the patients, and surgical evaluation correctly determined the T stage in 92%. Invasion of major mediastinal structures posed a major problem for computed tomographic scan. On a node-by-node basis, computed tomographic scan predicted involvement of lymph nodes in 81% (sensitivity 29%, specificity 93%, positive predictive value 49%, negative predictive value 85%). The surgeon correctly determined the lymph node status in 69% of lymph nodes (sensitivity 90%, specificity 63%, positive predictive value 39%, negative predictive value 96%). On a patient-by-patient basis, computed tomographic scan correctly predicted the nodal status in 58% of patients. Accuracy of computed tomographic scan and surgical assessment in determination of the lymph node status strongly depended on tumor type and lymph node region (hilar or mediastinal region) studied. This was partly due to the fact that adenocarcinomas exhibited a high proportion of tumor-positive normal-sized lymph nodes, whereas squamous cell carcinomas showed a high proportion of enlarged tumor-free lymph nodes. In conclusion, computed tomographic scan and surgical assessment are sufficiently accurate for determination of the tumor stage but are insufficient in determining the nodal status.

Impact of radical systematic mediastinal lymphadenectomy on tumor staging in lung cancer.

The extent of lymphadenectomy in the treatment of non-small cell lung cancer is still a matter of controversy. While some centers perform mediastinal lymph node sampling with resection of only suspicious lymph nodes, others recommend a radical, systematic mediastinal lymphadenectomy (LA) to improve survival and achieve a better staging. Herein we report on the impact of LA on tumor staging in a controlled, prospective, randomized clinical trial comparing lymph node sampling and LA in a total of 182 patients with operable non-small cell lung cancer. Regardless of the type of lymphadenectomy performed, the percentage of patients with pathologic N1 or N2 (sampling: n = 23, 23.0%; LA: n = 22, 26.8%) disease was very similar in both groups, indicating that systematic radical lymphadenectomy is not an essential prerequisite to determine the N stage of a patient. In contrast, the number of patients detected to have lymph node involvement at multiple levels was significantly increased by LA. In the lymph node sampling group only 4 of 23 patients (17.4%) with N2 disease were found to have more than one lymph node level involved, whereas LA results in the detection of excessive N2 disease in 12 of 21 patients (57.2%; p = 0.007), which was associated with a shorter distant metastases-free (p = 0.021) and overall survival. In conclusion, LA is not essential to determine the N stage of a patient, but results in a more detailed staging of the N2 region, which is of prognostic significance. Therefore, it might be useful to identify patients with a higher risk for tumor relapse.

Native pulmonary muscular proliferation.

Four cases with native pulmonary muscular proliferation (NPMP) are reported. The etiology of this rare condition is unknown. A hamartomatous process is discussed. In spite of its rarity the correct diagnosis of this condition is important. Both clinically and histologically in transbronchial biopsies, NPMP may be mistaken for pulmonary lymphangioleiomyomatosis (PLAM). Distinction of these 2 conditions is adamant, as PLAM has a poor prognosis, and, moreover may be associated with general disease, as with tuberous sclerosis. Whereas the typical distribution of more mature desmin positive muscle cells in a dense center core and more immature desmin negative radiating peripheral muscle cell proliferation with fascicular pattern in NPMP may be recognized in open lung biopsy, these differences may not become evident in small transbronchial biopsies. Immunohistochemical methods play an important role in the differential diagnosis--as with PLAM estrogen and progesterone receptors may be expressed and, most importantly, the reaction of the HMB45-antibody appears consistently positive in muscle cells of PLAM, while negative with NPMP. Thus, recognition of this clinically innocent disease is also possible in small tissue particles.