ABSTRACT
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
Subject(s)
Communicable Diseases , Emergency Medicine , Pneumonia , Pulmonary Medicine , Adult , Aged , Austria , Critical Care , Germany , Humans , Physicians, FamilyABSTRACT
Die vorliegende Leitlinie umfasst ein aktualisiertes Konzept der Behandlung und Prävention von erwachsenen Patienten mit ambulant erworbener Pneumonie und löst die bisherige Leitlinie aus dem Jahre 2016 ab. Sie wurde entsprechend den Maßgaben zur Methodologie einer S3-Leitlinie erarbeitet und verabschiedet. Hierzu gehören eine systematische Literaturrecherche und -bewertung, die strukturierte Diskussion der aus der Literatur begründbaren Empfehlungen sowie eine Offenlegung und Bewertung möglicher Interessenskonflikte. Die Leitlinie zeichnet sich aus durch eine Zentrierung auf definierte klinische Situationen, eine aktualisierte Maßgabe der Schweregradbestimmung sowie Empfehlungen zu einer individualisierten Auswahl der initialen antimikrobiellen Therapie. Die Empfehlungen zielen gleichzeitig auf eine strukturierte Risikoevaluation als auch auf eine frühzeitige Bestimmung des Therapieziels, um einerseits bei kurativem Therapieziel die Letalität der Erkrankung zu reduzieren, andererseits bei palliativem Therapieziel eine palliative Therapie zu eröffnen.
The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.
Subject(s)
Humans , Pneumonia/drug therapy , Pneumonia/diagnosis , Anti-Infective Agents/therapeutic useABSTRACT
BACKGROUND: Rheumatic diseases frequently present with pulmonary involvement. All anatomic structures of the lungs can be affected. Interstitial lung diseases are characterized by a system of patterns evident in high-resolution computed tomography (HR-CT) scanning of the lungs. The HR-CT pattern can differ between rheumatic diseases. OBJECTIVE: Systematic description of all variants and patterns of pulmonary involvement in rheumatic diseases. MATERIAL AND METHODS: Narrative review based on the current literature on the topic from the perspective of rheumatology, pulmonary diseases and radiology. RESULTS: Pulmonary involvement is frequent and prognostically relevant. The summary of pulmonary involvement reveals a high variability of affected anatomical structures as well as patterns of interstitial diseases for inflammatory rheumatic diseases. A synopsis of the main diagnostic findings is provided. CONCLUSION: Every rheumatic disease presented here can be associated with pulmonary involvement. Therefore, a systematic diagnostic evaluation is mandatory at the first diagnosis as well as during follow-up. Apart from clinical findings and lung function HR-CT of the lungs is decisive for the diagnostics.
Subject(s)
Collagen Diseases , Lung Diseases, Interstitial , Rheumatic Diseases , Humans , Lung/diagnostic imaging , Lung Diseases, Interstitial/diagnostic imaging , Lung Diseases, Interstitial/etiology , Rheumatic Diseases/complications , Rheumatic Diseases/diagnostic imagingABSTRACT
The present guideline aims to improve the evidence-based management of children and adolescents with pediatric community-acquired pneumonia (pCAP). Despite a prevalence of approx. 300 cases per 100â000 children per year in Central Europe, mortality is very low. Prevention includes infection control measures and comprehensive immunization. The diagnosis can and should be established clinically by history, physical examination and pulse oximetry, with fever and tachypnea as cardinal features. Additional signs or symptoms such as severely compromised general condition, poor feeding, dehydration, altered consciousness or seizures discriminate subjects with severe pCAP from those with non-severe pCAP. Within an age-dependent spectrum of infectious agents, bacterial etiology cannot be reliably differentiated from viral or mixed infections by currently available biomarkers. Most children and adolescents with non-severe pCAP and oxygen saturation >â92â% can be managed as outpatients without laboratory/microbiology workup or imaging. Anti-infective agents are not generally indicated and can be safely withheld especially in children of young age, with wheeze or other indices suggesting a viral origin. For calculated antibiotic therapy, aminopenicillins are the preferred drug class with comparable efficacy of oral (amoxicillin) and intravenous administration (ampicillin). Follow-up evaluation after 48â-â72 hours is mandatory for the assessment of clinical course, treatment success and potential complications such as parapneumonic pleural effusion or empyema, which may necessitate alternative or add-on therapy.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Community-Acquired Infections/drug therapy , Pneumonia/drug therapy , Practice Guidelines as Topic , Pulmonary Medicine/standards , Adolescent , Anti-Bacterial Agents/administration & dosage , Child , Community-Acquired Infections/diagnosis , Community-Acquired Infections/virology , Europe , Germany , Humans , Infant , Pneumonia/diagnosis , Pneumonia/virology , Societies, MedicalSubject(s)
Anti-Inflammatory Agents/therapeutic use , Coronavirus Infections/drug therapy , Coronavirus/isolation & purification , Dexamethasone/therapeutic use , Pandemics , Pneumonia, Viral/drug therapy , Practice Guidelines as Topic , Betacoronavirus , COVID-19 , Coronavirus Infections/diagnosis , Germany , Humans , Pneumonia, Viral/diagnosis , SARS-CoV-2 , Societies, Medical , Treatment Outcome , COVID-19 Drug TreatmentABSTRACT
We present the case of a 48-year old man, a triathlet, with severe COVID-19 and extensive bilateral pneumonia. On day 7 since onset of symptoms, the patient had fever, cough, rheumatic pain, dyspnea as well as severe hypoxemic respiratory failure (PaO2 49,9âmmHg, PaCO2 35,7âmmHg, Horovitz-Index 130). CT of the lung showed extensive bilateral ground glass opacities.The patient was treated according to a predefined standard, including oxygen supplementation and, after intermittent worsening, with CPAP-ventilation. The patient improved and could be discharged with normal blood gases at ambient air after 12 days of hospitalization. Six weeks after discharge the patient was fully recovered and lung function as well as CT of the lungs were normal.Our case demonstrates that invasive ventilation can successfully be avoided in patients with severe hypoxemia caused by COVID-19 with bilateral pneumonia.
Subject(s)
Betacoronavirus , Continuous Positive Airway Pressure/methods , Coronavirus Infections , Oxygen/therapeutic use , Pandemics , Pneumonia, Viral/complications , Pneumonia/complications , Respiratory Insufficiency/therapy , COVID-19 , Humans , Intubation, Intratracheal , Male , Masks , Middle Aged , Oxygen/blood , Respiratory Insufficiency/etiology , SARS-CoV-2 , Treatment OutcomeABSTRACT
We report the case of a 60-year old female patient with advanced severe lung injury as a consequence of COVID-19-pneumonia. The patient was initially treated with highflow oxygen via nasal cannula (HFNC) and CPAP for two days but had to be intubated and mechanically ventilated. After failure of mechanical ventilation because of persistant severe hypoxemia treatment was switched to ECMO which was applicated for 24 days. Prognostic parameters indicated a favourable trend after day 14. After discontinuation of ECMO and 11 days of intermittent assisted ventilation via tracheostoma and low dose oxygen (1âl/min), the patient could be transferred to rehabilitation. The last chest radiograph prior to transferral revealed a nearly complete resolution of bilateral pulmonary infiltrates. Our case demonstrates that severe COVID-19-associated lung injury can be reversible even after prolonged ECMO.
Subject(s)
Coronavirus Infections/complications , Coronavirus , Extracorporeal Membrane Oxygenation/methods , Pneumonia, Viral/complications , Respiratory Distress Syndrome/therapy , Respiratory Insufficiency/therapy , Betacoronavirus , COVID-19 , Coronavirus Infections/virology , Female , Humans , Lung/physiopathology , Middle Aged , Pandemics , Pneumonia, Viral/virology , Respiratory Distress Syndrome/etiology , SARS-CoV-2 , Treatment OutcomeABSTRACT
Surgical resection continues to be a mainstay of curative treatment of patients with non-small cell lung cancers stages Iâ-âIII and some small cell lung cancers. Reported rates of complications and mortality vary considerably. Therefore, a thorough and comprehensive preoperative evaluation of lung cancer patients is crucial in order to select appropriate surgical candidates and to determine their individual risk, including the extent of resection possible. Following available data and guidelines, such evaluation should include: ECOG-scoring, cardiac risk assessment, cerebrovascular assessment, pulmonary risk assessment, including split function analysis, and additional initiation or adjustment of treatment where appropriate; in patients aged ≥ 70 years: functional scoring (IADL). Risk stratification results in three groups: patients at low risk for complications and mortality, patients at increased risk, and patients who usually are not candidates for surgical resection. Finally, in order to support autonomous decisions of patients on optimal treatment based on defined risks, physicians must be familiar with values and preferences of patients as well as their familial and social situation.
Subject(s)
Carcinoma, Non-Small-Cell Lung , Lung Neoplasms , Aged , Carcinoma, Non-Small-Cell Lung/surgery , Humans , Lung Neoplasms/surgery , Pneumonectomy , Postoperative Complications , Preoperative Care , Risk AssessmentABSTRACT
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.
Subject(s)
Continuous Positive Airway Pressure , Noninvasive Ventilation/methods , Positive-Pressure Respiration , Practice Guidelines as Topic , Pulmonary Edema/therapy , Respiratory Distress Syndrome/therapy , Respiratory Insufficiency/therapy , Berlin , Betacoronavirus , COVID-19 , Continuous Positive Airway Pressure/standards , Coronavirus Infections/complications , Coronavirus Infections/epidemiology , Humans , Intubation, Intratracheal , Lung/physiopathology , Lung/virology , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/epidemiology , Pulmonary Edema/etiology , Respiratory Distress Syndrome/etiology , Respiratory Insufficiency/prevention & control , SARS-CoV-2 , Societies, MedicalSubject(s)
Air Pollution , Lung Injury , Lung/physiopathology , Pulmonary Emphysema , Pulmonary Medicine , Child , Humans , Nitrogen OxidesABSTRACT
Surgical resection continues to be a mainstay of curative treatment of patients with non-small cell lung cancers stages Iâ-âIII and some small cell lung cancers. Reported rates of complications and mortality vary considerably. Therefore, a thorough and comprehensive preoperative evaluation of lung cancer patients is crucial in order to select appropriate surgical candidates and to determine their individual risk, including the extent of resection possible. Following available data and guidelines, such evaluation should include: ECOG-scoring, cardiac risk assessment, cerebrovascular assessment, pulmonary risk assessment, including split function analysis, and additional initiation or adjustment of treatment where appropriate; in patients aged ≥â70 years: functional scoring (IADL).Risk stratification results in three groups: patients at low risk for complications and mortality, patients at increased risk, and patients who usually are not candidates for surgical resection.Finally, in order to support autonomous decisions of patients on optimal treatment based on defined risks, physicians must be familiar with values and preferences of patients as well as their familial and social situation.
Subject(s)
Carcinoma, Non-Small-Cell Lung , Lung Neoplasms , Preoperative Care/methods , Adult , Age Factors , Aged , Carcinoma, Non-Small-Cell Lung/pathology , Carcinoma, Non-Small-Cell Lung/surgery , Female , Humans , Lung Neoplasms/pathology , Lung Neoplasms/surgery , Male , Middle Aged , Pneumonectomy , Risk AssessmentSubject(s)
Anniversaries and Special Events , Government , Physicians , Constitution and Bylaws , Germany , Germany, West , History, 20th Century , HumansABSTRACT
BACKGROUND: There is an ongoing controversy on the role of the healthcare-associated pneumonia (HCAP) label in the treatment of patients with pneumonia. OBJECTIVE: To provide an update of the literature on patients meeting criteria for HCAP between 2014 and 2018. SOURCES: The review is based on a systematic literature search using PubMed-Central full-text archive of biomedical and life sciences literature at the U.S. National Institutes of Health's National Library of Medicine (NIH/NLM). CONTENT: Studies compared clinical characteristics of patients with HCAP and community-acquired pneumonia (CAP). HCAP patients were older and had a higher comorbidity. Mortality rates in HCAP varied from 5% to 33%, but seemed lower than those cited in the initial reports. Criteria behind the HCAP classification differed considerably within populations. Microbial patterns differed in that there was a higher incidence of methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, and, to a lesser extent, enterobacteriaceae. Definitions and rates of multidrug-resistant (MDR) pneumonia also varied considerably. Broad-spectrum guideline-concordant treatment did not reduce mortality in four observational studies. The HCAP criteria performed poorly as a predictive tool to identify MDR pneumonia or pathogens not covered by treatment for CAP. A new score (Drug Resistance in Pneumonia, DRIP) outperformed HCAP in the prediction of MDR pathogens. Comorbidity and functional status, but not different microbial patterns, seem to account for increased mortality. IMPLICATIONS: HCAP should no longer be used to identify patients at risk of MDR pathogens. The use of validated predictive scores along with implementation of de-escalation strategies and careful individual assessment of comorbidity and functional status seem superior strategies for clinical management.
Subject(s)
Bacterial Infections/epidemiology , Bacterial Infections/pathology , Enterobacteriaceae/isolation & purification , Healthcare-Associated Pneumonia/diagnosis , Healthcare-Associated Pneumonia/pathology , Pseudomonas aeruginosa/isolation & purification , Staphylococcus aureus/isolation & purification , Aged , Aged, 80 and over , Bacterial Infections/microbiology , Clinical Decision Rules , Disease Management , Drug Resistance, Multiple, Bacterial , Enterobacteriaceae/classification , Enterobacteriaceae/drug effects , Female , Healthcare-Associated Pneumonia/microbiology , Healthcare-Associated Pneumonia/mortality , Humans , Incidence , Male , Pseudomonas aeruginosa/drug effects , Staphylococcus aureus/drug effects , United StatesABSTRACT
A young man presented with haemoptysis, eight years after foreign body aspiration. The initial evaluation took place in the emergency department of a general hospital. However, neither chest x-ray nor bronchoscopy were performed. Bronchoscopy performed in our hospital revealed a foreign body in right lower lobe bronchus. Extraction failed because it was embedded in granulation tissue. The chronic atelectasis of right lower lobe and recurrent bronchopulmonary infections during the last years were the indication for lobectomy.
Subject(s)
Bronchi/diagnostic imaging , Bronchoscopy/methods , Foreign Bodies/diagnostic imaging , Hemoptysis/etiology , Pneumonectomy , Pulmonary Atelectasis/diagnostic imaging , Pulmonary Atelectasis/surgery , Humans , Male , Pulmonary Atelectasis/etiology , Trachea , Treatment OutcomeABSTRACT
OBJECTIVES: Evaluation of a standardised management for the treatment of patients with parapneumonic empyema. METHODS: A retrospective 10-year single-centre analysis of all patients with parapneumonic empyema undergoing a standardised thoracoscopic treatment approach. We describe referral and age patterns, microbiological results, overall and stage-dependent success rates, conversion rates, 30-day and in-hospital mortality. RESULTS: From May 2003 to April 2013, 248 patients with parapneumonic empyemas were treated in our centre. Most patients were referred at weekends, and younger patients had advanced stages. The cure rate in stage I was 97.6â% and reached 80.3â% in stage II and 63.1â% in stage III. 6 patients (2.4â%) (all stage III) needed conversion to an open procedure. A revision was required in 19.7â% of cases in stage II and 27.7â% in stage III. 30-day mortality was 4.8â%, in-hospital mortality was 8.1â%. CONCLUSION: A standardised approach, including VATS, is associated with a high cure, low revision and moderate conversion rates. In view of a still considerable mortality, a higher index of suspicion and detection of advanced stages, especially in younger patients, is required to improve outcomes.
Subject(s)
Empyema/surgery , Thoracic Surgery, Video-Assisted , Thoracostomy , Empyema/mortality , Germany/epidemiology , Hospital Mortality , Humans , Length of Stay , Male , Pleural Effusion/surgery , Retrospective Studies , Treatment OutcomeABSTRACT
This document is a revision of the guideline for diagnosis and treatment of COPD that replaces the version from 2007. A multitude of recent reports regarding risk factors, diagnosis, assessment, prevention and pharmacological as well as non-pharmacological treatment options made a major revision mandatory. The new guideline is based on the GOLD document taking into account specifics in Germany and Austria.
Subject(s)
Pulmonary Disease, Chronic Obstructive/diagnosis , Pulmonary Disease, Chronic Obstructive/therapy , Pulmonary Medicine/standards , Societies, Medical , Austria , Evidence-Based Medicine , Germany , HumansABSTRACT
Nosocomial pneumonia (HAP) is a frequent complication of hospital care. Most data are available on ventilator-associated pneumonia. However, infections on general wards are increasing. A central issue are infections with multidrug resistant (MDR) pathogens which are difficult to treat in the empirical setting potentially leading to inappropriate use of antimicrobial therapy.This guideline update was compiled by an interdisciplinary group on the basis of a systematic literature review. Recommendations are made according to GRADE giving guidance for the diagnosis and treatment of HAP on the basis of quality of evidence and benefit/risk ratio.This guideline has two parts. First an update on epidemiology, spectrum of pathogens and antimicrobials is provided. In the second part recommendations for the management of diagnosis and treatment are given. New recommendations with respect to imaging, diagnosis of nosocomial viral pneumonia and prolonged infusion of antibacterial drugs have been added. The statements to risk factors for infections with MDR pathogens and recommendations for monotherapy vs combination therapy have been actualised. The importance of structured deescalation concepts and limitation of treatment duration is emphasized.
