[Early Pulmonary Rehabilitation after Long Term Mechanical Ventilation]. / Pneumologische Frührehabilitation nach Langzeitbeatmung.

BACKGROUND: The term early rehabilitation is defined as a rehabilitation that begins in the early phase after acute illness and is statutory positioned in §â€Š39SGB V. Aim of this investigation is to describe the quality of outcome of pulmonary early rehabilitation. METHOD: Prospective census of functional parameters, status of ventilation and discharge-disposition in a specialized unit for early pulmonary rehabilitation over a period of one year. RESULTS: Out of 190 patients 179 (94.2 %) were previously invasively ventilated. During the treatment period of 39 ±â€Š17 days, FAM-Index increased from 84.4 ±â€Š19.8 to 118.5 ±â€Š23.3 (Ci 30.9 - 37.3, Cohen'd 1.58; p < 0.001), Barthel-Index from 30.5 ±â€Š13.8 to 58.3 ±â€Š16.2 (Ci 25.4 - 33.8, Cohen's d 1.4; p < 0.001) six minute walking distance from 12.9 ±â€Š40.1 m to 131.4 ±â€Š85.2 m (Ci 105.6 - 131.4 m, Cohn's d 1.78; p < 0.001). Patients were less likely to be receive further post-discharge rehabilitation if they were ventilated. CONCLUSION: Patients admitted to the early pulmonary rehabilitation unit were severely compromised, however quality of outcome was favourable and independent of the breathing status (spontaneously breathing vs. non-invasive ventilation or invasive ventilation). Finding discharge dispositions appeared to be more difficult if patients were ventilated.

[The Overrated Impact of Inhaled Substances (LABA, LAMA, ICS) on Exacerbation Rates in COPD]. / Die überschätzte Beeinflussung der Exazerbationsrate bei COPD durch Inhalativa (LABA, LAMA, ICS).

Numerous studies have shown that exacerbation rates in COPD can be significantly reduced by long acting beta-2-agonists (LABA), long acting anticholinergic agents (LAMA) and inhaled steroids (ICS). Elaborate and extensive investigations however failed to prove that the reduction in exacerbation rates leads to life prolongation. As opposed to this, numerous studies have shown a reduction in life expectancy with increasing number and severity of exacerbations.This review aimed at comparing these studies and to elaborate the relevance and reduction of exacerbations rates by LABA, LAMA and ICS application through effect size calculation by means of Cohens' d. These studies display a common pattern. The reduction of exacerbation rates is only being achieved for less severe exacerbations (Cohens' d max. 0.21). For more severe exacerbations and for the comparison of different substances Cohens' d remains below 0.1, indicating that the effect of the medications is practically irrelevant. The impact of LABA's, LAMA's and ICS on exacerbation rates in COPD patients is obviously overrated.

[Standardization of spirometry: 2015 update. Published by German Atemwegsliga, German Respiratory Society and German Society of Occupational and Environmental Medicine]. / Leitlinie zur Spirometrie. Leitlinie der Deutschen Atemwegsliga, der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin und der Deutschen Gesellschaft für Arbeitsmedizin und Umweltmedizin zur Spirometrie.

Spirometry is a simple test and considered the gold standard in lung function. An obstructive ventilatory defect is a disproportionate reduction of maximal airflow from the lung in relation to the maximal volume that can be displaced from the lung. It implies airway narrowing and is defined by a reduced FEV1/FVC ratio below the 5th percentile of the predicted value (lower limit of normal, LLN). A restrictive disorder may be suspected when vital capacity (FVC) is reduced and FEV1/FVC is normal. It is definitely proven, however, only by a decrease in TLC below the 5th percentile of predicted value (LLN). The measurement of TLC by body plethysmography is necessary to confirm or exclude a restrictive defect or hyperinflation of the lung when FVC is below the LLN. 2012 a task force of the ERS published new reference values based on 74,187 records from healthy non-smoking males and females from 26 countries. The new reference equations for the 3-95 age range are now available that include appropriate age-dependent mean values and lower limits of normal (LLN). This presentation aims at providing the reader with recommendations dealing with standardization and interpretation of spirometry.

Prediction of abdominal CT body composition parameters by thoracic measurements as a new approach to detect sarcopenia in a COVID-19 cohort.

As most COVID-19 patients only receive thoracic CT scans, but body composition, which is relevant to detect sarcopenia, is determined in abdominal scans, this study aimed to investigate the relationship between thoracic and abdominal CT body composition parameters in a cohort of COVID-19 patients. This retrospective study included n = 46 SARS-CoV-2-positive patients who received CT scans of the thorax and abdomen due to severe disease progression. The subcutaneous fat area (SF), the skeletal muscle area (SMA), and the muscle radiodensity attenuation (MRA) were measured at the level of the twelfth thoracic (T12) and the third lumbar (L3) vertebra. Necessity of invasive mechanical ventilation (IMV), length of stay, or time to death (TTD) were noted. For statistics correlation, multivariable linear, logistic, and Cox regression analyses were employed. Correlation was excellent for the SF (r = 0.96) between T12 and L3, and good for the respective SMA (r = 0.80) and MRA (r = 0.82) values. With adjustment (adj.) for sex, age, and body-mass-index the variability of SF (adj. r2 = 0.93; adj. mean difference = 1.24 [95% confidence interval (95% CI) 1.02-1.45]), of the SMA (adj. r2 = 0.76; 2.59 [95% CI 1.92-3.26]), and of the MRA (adj. r2 = 0.67; 0.67 [95% CI 0.45-0.88]) at L3 was well explained by the respective values at T12. There was no relevant influence of the SF, MRA, or SMA on the clinical outcome. If only thoracic CT scans are available, CT body composition values at T12 can be used to predict abdominal fat and muscle parameters, by which sarcopenia and obesity can be assessed.

Quality indicators for the prevention of type 2 diabetes in Europe--IMAGE.

BACKGROUND: The marked increase of type 2 diabetes necessitates active development and implementation of efficient prevention programs. A European level action has been taken by launching the IMAGE project to unify and improve the various prevention management concepts, which currently exist within the EU. This report describes the background and the methods used in the development of the IMAGE project quality indicators for diabetes primary prevention programs. It is targeted to the persons responsible for diabetes prevention at different levels of the health care systems. METHODS: Development of the quality indicators was conducted by a group of specialists representing different professional groups from several European countries. Indicators and measurement recommendations were produced by the expert group in consensus meetings and further developed by combining evidence and expert opinion. RESULTS: The quality indicators were developed for different prevention strategies: population level prevention strategy, screening for high risk, and high risk prevention strategy. Totally, 22 quality indicators were generated. They constitute the minimum level of quality assurance recommended for diabetes prevention programs. In addition, 20 scientific evaluation indicators with measurement standards were produced. These micro level indicators describe measurements, which should be used if evaluation, reporting, and scientific analysis are planned. CONCLUSIONS: We hope that these quality tools together with the IMAGE guidelines will provide a useful tool for improving the quality of diabetes prevention in Europe and make different prevention approaches comparable.

[Protracted respiratory insufficiency - epidemiology and network on respiratory weaning after prolonged ventilation]. / Protrahierte respiratorische Insuffizienz - Epidemiologie und Netzwerk zur Respiratorentwöhnung (Weaning) nach prolongierter Beatmung.

The prevalence of difficult or prolonged weaning from the ventilator is increasing due to a growing number of multi-morbid, elderly and pulmonary deficient patients being mechanically ventilated. Intensive care units (ICU) tend to refer difficult to wean patients to specialised weaning facilities. A survey of 38 centres - performed in 2006 - included a total number of 2718 patients with difficult or prolonged weaning. Almost three quarters of the patients were transferred to a weaning centre from an external ICU. The weaning success rate was 66.3 %. After weaning in 31.9 % of the patients, home mechanical ventilation was started. The overall hospital mortality rate was 20.8 %. Recently the task force "WeanNet" - a network of weaning units - was founded under the auspices of the German Thoracic Society. The main aim of WeanNet is to improve cooperation among the weaning centres and the quality of patient management. Important tools of WeanNet are (i) the register of weaning patients and (ii) accreditation of the weaning centres. To develop the register an intensive cooperation between the task force and the Institute for Lung Research (ILF) was necessary. The finished register is now logistically run by ILF. In less than 1 year after the official start, already 70 weaning units with ca. 3000 patients are registered. In future "WeanNet", in particular in terms of the register and the accreditation, will stand for the quality of weaning centres in Germany.

[Management of a new influenza A/H1N1 virus pandemic within the hospital. Statement of the German Society of Pneumology]. / Management der Influenza A/H1N1 - Pandemie im Krankenhaus: Update Januar 2010. Eine Stellungnahme der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin.

This update summarized the hospital experience from the first wave of the new influenza A/H1/N1 pandemic.

[Health effects of particulate matter exposure: current scientific knowledge]. / Gesundheitliche Effekte der Feinstaubbelastung - aktueller wissenschaftlicher Kenntnisstand.

INTRODUCTION: Air quality is not only important for respiratory health but it also influences the homeostasis of the whole human organism. In the past years numerous violations of European Union particulate matter thresholds have been recorded. METHODS: The present study is a selective literature analysis encompassing the epidemiology and pathophysiological effects of particulate matter. RESULTS: Epidemiological studies point to an association between chronic particulate matter exposure and mortality. The most prominent effects on the human body are present in subjects with cardiovascular or respiratory conditions. However, the effects of air pollutants need to be examined critically and the plausibility of thresholds should be evaluated in detail. DISCUSSION: The negative influences of chronic particulate matter exposure have been proven by a multitude of epidemiological and experimental studies. From the viewpoint of primary prevention, air quality plays a crucial role. This encompasses both the outdoor compartment with particulate matter and other pollutants and the indoor compartment with tobacco smoke.

Nonrigid registration of 3-d multichannel microscopy images of cell nuclei.

We present an intensity-based nonrigid registration approach for the normalization of 3-D multichannel microscopy images of cell nuclei. A main problem with cell nuclei images is that the intensity structure of different nuclei differs very much; thus, an intensity-based registration scheme cannot be used directly. Instead, we first perform a segmentation of the images from the cell nucleus channel, smooth the resulting images by a Gaussian filter, and then apply an intensity-based registration algorithm. The obtained transformation is applied to the images from the nucleus channel as well as to the images from the other channels. To improve the convergence rate of the algorithm, we propose an adaptive step length optimization scheme and also employ a multiresolution scheme. Our approach has been successfully applied using 2-D cell-like synthetic images, 3-D phantom images as well as 3-D multichannel microscopy images representing different chromosome territories and gene regions. We also describe an extension of our approach, which is applied for the registration of 3D + t (4-D) image series of moving cell nuclei.

[Physiology and physiopathology of cough]. / Physiologie und Pathophysiologie des Hustens.

Cough clears off foreign bodies from the airways and maintains bronchial clearance when mucociliary transport is defective. Cough requires intact inspiratory muscles to inflate the lung up to 80 % of vital capacity and sound expiratory muscles to generate pressure against a closed glottis. Two mechanisms are required to facilitate proximal mucus transport: 1. Constriction of the cartilage containing airways caused by anterior bulging of the pars membranacea due to high air-flow velocity. 2. Thixotropia of the sputum. This feature changes mechanical properties in a way that sputum viscosity decreases with motion. Thixotropia is caused by the complex mucin-structure of the mucus.

[Cardiopulmonary exercise testing before and after blood donation]. / Spiroergometrische Leistungsdiagnostik vor und nach Blutspende.

BACKGROUND: The link between haemoglobin and physical performance was established a long time ago and is the underlying principle of blood doping. Blood loss on the other hand decreases physical capacity. The aim of this study is to evaluate physical performance loss and underlying mechanisms following voluntary blood donation. METHOD AND PATIENTS: Eleven voluntary subjects (four female) completed a symptom-limiting cardio-pulmonary exercise test before and after blood donation (500 mL blood). RESULTS: The haemoglobin value decreased by 1.2 mg/dL (9%, p < 0.001), maximal oxygen uptake by 9% (p = 0.006), maximal work rate by 13% (p = 0.001) and duration of exercise fell from 663 down to 607 seconds (p = 0.005). Anaerobic transition occurred at 81.2% and 71.5% of maximal oxygen uptake before and after blood donation, respectively (p = 0.001). Subjects who practise recreational endurance sports appear to be more effected by endurance loss. The haemoglobin value was the only significant predictor of maximal oxygen uptake in regression analysis (p < 0.001). CONCLUSION: Maximal physical performance is impaired after blood donation. Haemoglobin decline accounts for the decreased oxygen uptake. As a consequence thereof the anaerobic transition occurs earlier. Subjects not engaged in regular sports activity did not experience a decline in their capacity. Inclusion of the haemoglobin value into equations predicting maximal oxygen uptake could improve prediction precision.

[Time-adaptive mode, a new ventilation form for the treatment of respiratory insufficiency--a self-learning system]. / Time-adaptiver Modus, eine neue Beatmungsform zur Behandlung der ventilatorischen Insuffizienz--ein selbstlernendes System.

Hypercapnic respiratory failure is usually caused by an overload of the respiratory muscles (respiratory pump). After treatment of the underlying disease, mechanical ventilation will achieve optimal treatment success and higher degrees of respiratory muscle unloading will improve the outcome in terms of lower PaCO (2) levels and improved exercise performance. Routinely assisted modes are being used for ventilation, where the patient has to trigger the ventilator with his effort. Controlled ventilation is usually applied in sedated patients lacking spontaneous breathing efforts that are necessary to trigger the ventilator. Controlled ventilation, however, is feasible in awake patients but requires operator expertise. In this process, the respiratory pattern of the ventilator has to be adapted to the patient's own respiratory pattern. Changing conditions require a re-adaptation of parameters. In order to automatise this complex and time-consuming operation, a time-adaptive mode (TA-mode) has been developed. This programmed mode incorporates a self-learning algorithm, primarily detecting the patient's respiratory pattern. The software then calculates a matching flow profile using a motion equation that gives consideration to resistance and compliance. The operator has to pre-select allowed ranges of parameters (especially in- and expiratory pressures, IPAP and EPAP). After detection of a stable respiratory pattern (usually after 10 - 20 breaths), the ventilator will slowly increase the calculated flow profile and achieve controlled ventilation without irritating respiratory centres of the brain. Respiratory drive will cease usually within three to five minutes. Restart of the respiratory drive, for example, after coughing or during REM sleep with an altered respiratory pattern will be detected as ventilator fighting and the programme will return to the analysis algorithm again. After the respiratory pattern has become stable, the ventilator will take over ventilation again. The new mode has been validated in an accreditation study. For this purpose we selected 21 patients with stable hypercapnic respiratory failure, most of whom (20) had previously been ventilated with a controlled T-mode and only one patient had previously been ventilated with an assisted mode and adapted them to the new ventilator under polygraphic surveillance. Each time seven patients were adapted to a T-, ST- and TA-mode, respectively. Two patients, however, could not be adapted to ST-mode ventilation and were switched to TA-mode. PCO (2) values before and after ventilation were not significantly different between modes. Patient satisfaction was rated very good in 34 %, good in 45 % and non-gratifying in 21 % of cases ventilated with TA-mode. Consideration has to be given to the fact that patients previously had been receiving optimal ventilator treatment. The TA-mode is a self-learning system, capable of copying the patients own breathing pattern while awake, in order to achieve complete unloading of the respiratory muscles through controlled ventilation during a circumscribed period.

[Follow-up examination and probatory CPAP therapy of obstructive sleep apnoea increase the long-term compliance]. / Poststationäre Nachsorge und probatorische CPAP-Therapie schlafbezogener obstruktiver Atemstörungen steigern die Langzeitcompliance.

INTRODUCTION: Since the implementation of CPAP therapy in the treatment of obstructive sleep apnoea in the 1980 s researchers have been looking for predictors and possibilities to improve long-term compliance. In a prospective randomised trial we examined the influence of a follow-up examination two weeks after the start of probatory CPAP therapy compared to immediate prescription of the CPAP device. METHODS: 249 new patients with a newly diagnosed obstructive sleep apnoea (OSA) started with a CPAP therapy. These patients were prospectively randomised depending on the dates of admission (even/uneven). The CPAP device for the first group was immediately prescribed. Patients of the second group were seen in our sleep laboratory ambulance after a probatory usage of the CPAP therapy over a period of fourteen days. After 433 +/- 138 days we measured the compliance by reading off the operating hours counter. In order to collect these data all patients received written simple instructions how to read off the operating hours counter. They sent back the results via a prepaid return envelope. In addition, we obtained the information as to whether a hot water bath humidifier was used. RESULTS: 171 of the initially 249 patients sent back the evaluation form. The randomisation of the groups was successful concerning: age, sex as well as the apnoea-hypopnoea index before and under CPAP therapy. 226 patients were treated with the fix-CPAP mode (mean pressure 8.1 +/- 1.8 cm H(2)O), 23 patients received auto CPAP therapy. The patients with a probatory CPAP therapy and follow-up examination showed a significantly (p = 0.01) better compliance of nocturnal CPAP use with 4.5 +/- 1.8 h/night versus those who had their CPAP device immediately prescribed with a use of 3.8 +/- 2.1 h/night. The percentage of patients with a use of CPAP more than 4 h/night was significantly higher in the group with probatory therapy (66.3 % vs. 45.6 %; p = 0.008). Patients with probatory CPAP therapy made more use of humidifiers than the immediate prescription group; however, the use of a humidifier did not have any significant influence on the long-term compliance (p = 0.58). CONCLUSION: The combination of probatory CPAP therapy and follow-up examination increases the long-term compliance significantly in the treatment of obstructive sleep apnoea.

[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.

Clinical outcome and costs of nosocomial and community-acquired Staphylococcus aureus bloodstream infection in haemodialysis patients.

The main aim of this study was to evaluate the clinical outcome and costs of nosocomial and community-acquired methicillin-susceptible Staphylococcus aureus (MSSA) or methicillin-resistant S. aureus (MRSA) bloodstream infection (BSI) in patients undergoing haemodialysis. A multicentre retrospective study was conducted that included 109 patients with end-stage renal disease and S. aureus BSI who were hospitalised in three German centres between 1999 and 2005. Nosocomial and community-acquired infections were analysed separately with regard to costs and outcome. Forty-nine (45%) patients had nosocomial infection. Compared to patients with community-acquired infection, these patients were more likely to have had BSI caused by MRSA (40.8% vs. 13.3%, p <0.05). BSI was the initial reason for admission for 33 (55%) patients who had community-acquired infection. The mean length of hospitalisation was 24 days for patients with community-acquired infection and 51 days for patients with nosocomial infection (p <0.05). Costs per treatment episode were 20,024 Euros for nosocomial infection vs. 9554 Euros for community-acquired infection (p <0.05). The average treatment costs for patients with MSSA BSI were <50% of those for patients with MRSA BSI (10,573 vs. 24,931 Euros, p <0.05). S. aureus BSI is an underlying cause of substantial health risk and high morbidity among the haemodialysis-dependent population, who are already at high-risk for other reasons. This study also highlighted differences according to the source of BSI, including costs arising from hospitalisation and treatment.