[Home mechancial ventilation: quality of life and the final stage of life]. / Außerklinische Beatmung: Lebensqualität und Lebensende.

The evaluation of health-related quality of life (HRQL) has gained importance in recent years. Disease-specific questionnaires are available for respiratory insufficiency, which enable the assessment of HRQL. The Severe Respiratory Insufficiency (SRI) questionnaire, which was specially developed for patients with respiratory insufficiency, is ideal for quantifying the quality of life in patients receiving home mechanical ventilation (HMV). Studies using the SRI questionnaire demonstrated that the physical functioning of patients with chronic lung diseases of various etiologies is significantly impaired, but frequently without significant impairment of psychological well-being. Therefore, severity of the disease and HRQL do not necessarily correlate with each other.Both invasive and non-invasive mechanical ventilation can improve quality of life. Co-morbidity, and above all advanced age, have the highest negative predictive value with regard to in-hospital mortality and weaning failure. The number of patients older than 80 years who remain dependent on invasive HMV after prolonged weaning in Germany is increasing significantly. High dependence on invasive HMV is often associated with a loss of quality of life and autonomy. Thus, ethical issues of the continued treatment of ventilated patients at the end of life are discussed increasingly.After weaning failure, the indication for invasive HMV should be critically examined and should focus on potentially severely reduced quality of life and poor prognosis, as well as the patient's wishes. If previously agreed treatment goals can no longer be achieved during the course of invasive HMV, changing the therapy goals should be discussed within the clinical team, with the patient, their relatives and, if necessary, with legal representatives.In order to avoid overtreatment and unnecessary patient suffering during invasive HMV, advanced care planning should be started as early as possible and if necessary accompanied by palliative medical measures.

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. / S2k-Leitlinie Nichtinvasive Beatmung als Therapie der akuten respiratorischen Insuffizienz.

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

[Transition of long-term ventilated children to adult medical care]. / Transition von langzeitbeatmeten Kindern in die Erwachsenenmedizin.

Through advances in long-term ventilation, the number of children with chronic respiratory insufficiency reaching adult age has increased tremendously. Therefore, transition of children from pediatric to adult care has become inevitable. Transition is necessary for medicolegal reasons, to increase autonomy of the young patients and because of change in the disease as a result of increasing age. Transition bears the risks of uncertainty of patients and parents, loss of the medical home or even loss of complete medical care. Good structural conditions, professional preparation of patient and parents, a comprehensive formalized transfer and patient coaching are prerequisites for a successful professional transition. This article discusses issues of transition with focus on long-term ventilated children.

[Lung contusion after jumping from a 10 meter tower in a swimming pool]. / Lungenkontusion nach Sprung ins Wasser.

BACKGROUND: Lung contusions often occur in the context of polytrauma, but much less frequently in sports injuries. CASE DESCRIPTION: We report on a 22-year-old patient who presented to our emergency room. On the same day he jumped from a 10 meter tower in a swimming pool and hit the surface of the water with his thorax and abdomen. He complained of pain in the right chest and hemoptysis immediately after the jump.The examination findings remained without further abnormalities.In the chest x-ray no abnormalities were found.The CT thorax with contrast medium revealed homogeneous ground-glass opacities in the middle lobe and less in the ventrobasal upper lobe on the right, consistent with the pulmonary contusion with parenchymal bleeding. In addition, there was a minimal pneumothorax border on the paracardial right side.Bronchoscopy performed on the same day showed evidence of blood in the middle lobe bronchus.The hemoptysis stopped spontaneously. On the 3rd day of the hospital stay, the patient was discharged with stable vital parameters and asymptomatic. CONCLUSION: Hemoptysis immediately after a sports chest injury may occur as a result of pulmonary contusion. In contrast to conventional chest x-rays, computed tomography is of great importance in the diagnosis of pulmonary contusion.

[Endobronchial Foreign Bodies Telling Readable Stories]. / Endobronchiale Fremdkörper, die lesbare Geschichten erzählen.

We present two case reports in which, in a surprising way, readable writing or numbers on the aspirated material provided useful information about the more detailed circumstances of the aspiration.In the first case, the patient complained of foreign body sensation after using a metered dose inhaler. A few hours later, the initially unknown aspirated material was recovered by flexible bronchoscopy. With the help of the text fragment on the material, it could be concluded that it was the packaging foil of a candy, which had entered the mouthpiece of the metered dose inhaler while stored in the patient's jacket pocket.In the second case, the patient experienced recurrent pneumonia over a period of years. With the help of the serial number on the bronchoscopically recovered plastic material, the exact time and place of aspiration could be determined. The patient had aspirated the plastic label of a spare part during his occupational activity in a car repair shop.

[Pneumology in the Model Degree Program of the Medical Faculty Ostwestfalen Lippe, Germany]. / Das Fach Pneumologie im Modellstudiengang der Medizinischen Fakultät Ostwestfalen-Lippe (OWL).

The specialist field of "pneumology" is still underrepresented in university clinics in Germany, but this is not the case at the newly founded medical faculty Ostwestfalen-Lippe (OWL) in Bielefeld. This is linked to representing pneumology and internal intensive care medicine in patient care, teaching and research across the board and the opportunity to actively help shape the development of the human medicine faculty in an exciting environment.The early anchoring of the subject "Pneumology" in the model degree program of medical school in OWL (begin winter semester 2021/22) contributes to further visibility and a university medical orientation. In this overview various issues of Pneumology in the Model Degree Program are explored by basic scientists, clinical teachers, members of the medical faculty and a student.In today's Evangelisches Klinikum Bethel (EvKB), pulmonary medicine has a long tradition. The hospital's first lung and infection center was opened in 1927. The EvKB's department for internal medicine, pneumology and intensive care medicine, which has been independent since 2009, is becoming a university clinic for pneumology within the medical faculty OWL. Relevant translational and interdisciplinary research can be intensified.There are 30 "Pneumology" teaching units in the model degree program, which are divided into two study sections using different formats, such as lectures, seminars, hands on courses and skills lab. It is represented in particular in the module complex "Circulation and Respiration". The content of the first phase of teaching was carried out by a module commission, with members representing the subjects involved in the module.Knowledge of the basics from, for example, physiology, pathophysiology, anatomy and pathology are taught to the students in the run-up to the pneumology course. Using the example of physiology, the presentation of the learning content of a basic subject is elaborated in this article.Half of all teaching units on pneumology of the entire course took place in the 2nd semester (in March and April 2022), so that students experienced the clinical relevance of the content at an early stage. There was a particular focus on obstructive airway and restrictive lung diseases. After imparting the basic knowledge of the physical examination of the lungs in the Skills Lab, the most important pathological findings in the above-mentioned diseases on inspection, palpation, auscultation and percussion are demonstrated and practised in patients as part of bedside teaching under supervision.Communication training is also longitudinally integrated into the modular teaching, with a total of more than 200 teaching hours and is performed interdisciplinary. In the "Circulation and Breathing" module eight hours are devoted to this with simulated patients, the anamnesis and therapy advice on classic cardiopulmonary diseases. For the students, integrating the teaching of basic theory and its clinical application for each organ systems represents a challenge in the model degree program, the advantages outweigh from today's perspective.

[Physicians with cancer: when doctors get a life-changing diagnosis]. / Diagnose Krebs: Wenn Ärzte schwer erkranken.

We doctors often have a detached approach to our relationship to patients: we see ourselves as healthy helpers of the sick, needy patients. But some of us are, or have been, patients, and many of us have treated colleagues who were ill. What happens when a doctor becomes seriously ill? In this paper, we describe the change of perspective that resulted from our experience with cancer, and how it has shaped our attitude toward modern medicine.

[Physicians with cancer: when doctors get a life-changing diagnosis]. / Diagnose Krebs: Wenn Ärzte schwer erkranken.

We doctors often have a detached approach to our relationship to patients: we see ourselves as healthy helpers of the sick, needy patients. But some of us are, or have been, patients, and many of us have treated colleagues who were ill. What happens when a doctor becomes seriously ill? In this paper, we describe the change of perspective that resulted from our experience with cancer, and how it has shaped our attitude toward modern medicine.

[Outcome in Prolonged Weaning - Results of a Regional Weaning Center]. / Outcome beim prolongierten Weaning.

BACKGROUND: The number of patients with prolonged mechanical ventilation is increasing. Weaning units (WU) in the German network "WeanNet" are specialized in the treatment of patients needing prolonged weaning. In this study we present outcome data on the patients in our WU from 2011 to 2015. METHODS: A distinction is made between the 4 outcome groups: 1. Successful weaning without mechanical ventilation, 2. Successful weaning with non-invasive mechanical ventilation (NIV), 3. Weaning failure with subsequent invasive ventilation and 4. Death in the WU. RESULTS: In 272 patients, the following distribution within the 4 outcome groups was found: Group 1: 116 patients (42.6 %), Group 2: 52 patients (19.1 %), Group 3: 45 patients (16.5 %) and Group 4: 59 patients (21.7 %).The duration of treatment in the WU depended primarily on co-morbidities and the hemoglobin level.Despite successful weaning, the tracheostoma was completely closed in only 60.3 % of patients with continuous spontaneous breathing and 67.3 % of patients with NIV at the time of discharge from the clinic.After discharge from the WU, patients with weaning failure and subsequent invasive long-term ventilation, in contrast to patients with successful weaning, were rarely transferred to rehabilitation, but re-admitted more frequently to the clinic as emergency cases (29 %).The 1-year survival rate was 59 %. Half of the patients died in less than 2 years. CONCLUSION: The majority of patients with prolonged mechanical ventilation are successfully weaned from the respirator in the WU. Nevertheless, the proportion of patients with weaning failure and subsequent invasive long-term out-of-hospital ventilation as well as the mortality rate in the WU and after discharge were high. The ethical implications of these observations are discussed in the paper.

[Development and progress in mechanical ventilation]. / Entwicklung und Fortschritt in der Beatmungsmedizin.

Mechanical ventilation comprises two important sectors: 1) the acute application in intensive care medicine and 2) long-term mechanical ventilation, i.e. home mechanical ventilation. Today, based on increasing scientific evidence the approach to mechanical ventilation is highly sophisticated and this is true for both sectors. For this reason, several guidelines have been established in Germany with specific emphasis on mechanical ventilation. In addition, the current development of mechanical ventilation in Germany is influenced by the corona pandemic and also by the economization of the healthcare system. Notably, home mechanical ventilation is steadily increasing, while intensive care unit (ICU) capacities are currently decreasing. The current article focuses on these developments.

Outcomes after Prolonged Weaning in Chronic Obstructive Pulmonary Disease Patients: Data from the German WeanNet Initiative.

BACKGROUND: The outcome of prolonged weaning in COPD patients is still unclear. METHODS: A subgroup analysis of 2,937 COPD patients (median: age 69 years, 5 comorbidities, 43% female) from the entire WeanNet cohort of specialized German weaning centers previously published (N = 11,424) was performed. RESULTS: Weaning outcomes were as follows: successful weaning without subsequent long-term noninvasive ventilation (NIV): N = 900; 30.6%; successful weaning with subsequent long-term NIV: N = 900; 30.6%; weaning failure with subsequent long-term invasive ventilation: N = 780; 26.6%; and death: N = 357; 12.2%. Most important predictors of mortality and weaning failure were advanced age and duration of mechanical ventilation in the transferring ICU, respectively. On discharge, the tracheostoma was closed in only 53% and 59% of patients with successful weaning not receiving and receiving long-term NIV, respectively. Unsuccessfully weaned patients were predominantly discharged home (20.5%) or to long-term care facilities (57.2%). Successfully weaned patients were predominantly discharged home (22.4%/35.9%: without/with NIV) and to rehabilitation (41.0%/43.1%: without/with NIV), respectively. CONCLUSION: COPD forms an important subgroup of prolonged weaning patients. Following transfer from the ICU to a specialized weaning center, weaning is successful more than 60%. Importantly, both tracheostomy status and initial destination following discharge are highly dependent on the weaning outcome.

[Role of Non-Invasive Strategies in the Treatment of Acute Hypoxemic Respiratory Failure Related to COVID-19]. / Bedeutung nicht-invasiver Verfahren in der Therapie des akuten hypoxämischen Versagens bei COVID-19.

Non-invasive strategies such as HFOT (high-flow oxygen therapy), CPAP (continuous positive airway pressure) and NIV (non-invasive ventilation) are increasingly being used during the COVID-19 pandemics in order to treat acute hypoxemic respiratory failure related to COVID-19, and this is aimed at avoiding intubation. This review article summarizes the current evidence by also emphasizing its heterogeneity. Importantly, current evidence suggests that these non-invasive strategies can be successfully used even in case of severe respiratory failure and are, thus, indeed capable of avoiding intubation, and consequently, tube-related complications. In contrast, it also remains to be emphasized that prolonged spontaneous breathing supported by non-invasive treatment strategies is also prone to complications. In particular, late NIV failure is associated with substantially deteriorated outcome, which is suggested to be meaningful in view of NIV failure rates still being high in Germany. Finally, the current article also refers to a parallel article that addresses the discussion being held in the public media in Germany concerning this topic. Here, its textual questionability, but also its negative consequences for both the research community and the general society are elaborated. In this context, the importance of national and regularly updated guidelines is emphasized.

Prolonged Weaning: S2k Guideline Published by the German Respiratory Society.

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.

Recurrent Life-threatening Pneumonitis in a 37-Year-Old Woman.

CASE PRESENTATION: A 37-year-old previously healthy and athletic woman presented to the ED in October 2018 with acute-onset high fever, dyspnea, and productive cough. Chest radiograph showed bilateral infiltrates that correlated with multifocal ground glass opacities in a thoracic CT scan (Fig 1). The patient was severely hypoxemic and required intensive care and oxygen administration via a high-flow nasal cannula. On admission, leucocyte counts were 23.3 k/µL; platelet counts were 518 k/µL; hemoglobin level was 12 g/dL; C-reactive protein was 83 mg/L, and procalcitonin was 0.7 µg/L. An auto-antibody panel that included antinuclear antibodies, extractable nuclear antigen (including anti-centromere-antibodies), antineutrophil cytoplasmic antibodies, and myositis- and granulocyte macrophage colony-stimulating factor-antibodies was negative, as was the rheumatoid factor. Immunoglobulins that included IgG1-4 and IgA and renal function were normal. Sicca symptoms like xerophthalmia and xerostomia were negated. The patient fully recovered after empiric administration of antibiotics and glucocorticoids (initially 500 mg methylprednisolone daily over 3 days with consecutive tapering).

Position Paper for the State-of-the-Art Application of Respiratory Support in Patients with COVID-19.

Against the background of the pandemic caused by infection with the SARS-CoV-2 virus, the German Respiratory Society has appointed experts to develop therapy strategies for COVID-19 patients with acute respiratory failure (ARF). Here we present key position statements including observations about the pathophysiology of (ARF). In terms of the pathophysiology of pulmonary infection with SARS-CoV-2, COVID-19 can be divided into 3 phases. Pulmonary damage in advanced COVID-19 often differs from the known changes in acute respiratory distress syndrome (ARDS). Two types (type L and type H) are differentiated, corresponding to early- and late-stage lung damage. This differentiation should be taken into consideration in the respiratory support of ARF. The assessment of the extent of ARF should be based on arterial or capillary blood gas analysis under room air conditions, and it needs to include the calculation of oxygen supply (measured from the variables of oxygen saturation, hemoglobin level, the corrected values of Hüfner's factor, and cardiac output). Aerosols can cause transmission of infectious, virus-laden particles. Open systems or vented systems can increase the release of respirable particles. Procedures in which the invasive ventilation system must be opened and endotracheal intubation carried out are associated with an increased risk of infection. Personal protective equipment (PPE) should have top priority because fear of contagion should not be a primary reason for intubation. Based on the current knowledge, inhalation therapy, nasal high-flow therapy (NHF), continuous positive airway pressure (CPAP), or noninvasive ventilation (NIV) can be performed without an increased risk of infection to staff if PPE is provided. A significant proportion of patients with ARF present with relevant hypoxemia, which often cannot be fully corrected, even with a high inspired oxygen fraction (FiO2) under NHF. In this situation, the oxygen therapy can be escalated to CPAP or NIV when the criteria for endotracheal intubation are not met. In ARF, NIV should be carried out in an intensive care unit or a comparable setting by experienced staff. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring and readiness for intubation are to be ensured at all times. If the ARF progresses under CPAP/NIV, intubation should be implemented without delay in patients who do not have a "do not intubate" order.

Prolonged Weaning from Mechanical Ventilation.

BACKGROUND: To accommodate the increasing number of patients requiring prolonged weaning from mechanical ventilation, specialized weaning centers have been established for patients in whom weaning on the intensive care unit (ICU) was unsuccessful. METHODS: This study aimed to determine both the outcome of treatment and the factors associated with prolonged weaning in patients who were transferred from the ICU to specialized weaning centers in Germany during the period 2011 to 2015, based on a nationwide registry covering all specialized weaning centers currently going through the process of accreditation by the German Respiratory Society. RESULTS: Of 11 424 patients, 7346 (64.3%) were successfully weaned, of whom 2236 were switched to long-term non-invasive ventilation; 1658 (14.5%) died in the weaning unit; and 2420 (21.2%) could not be weaned. The duration of weaning decreased significantly from 22 to 18 days between 2011 and 2015 (p <0.0001). Multivariate analysis revealed that the factor most strongly associated with in-hospital mortality was advanced age (odds ratio [OR] 11.07, 95% confidence interval [6.51; 18.82], p <0.0001). The need to continue with invasive ventilation was most strongly associated with the duration mechanical ventilation prior to transfer from the ICU (OR 4.73 [3.25; 6.89]), followed by a low body mass index (OR 0.38 [0.26; 0.58]), pre-existing neuromuscular disorders (OR 2.98 [1.88; 4.73]), and advanced age (OR 2.96 [1.87; 4.69]) (each p <0.0001). CONCLUSION: Weaning duration has decreased over time, but prolonged weaning is still unsuccessful in one third of patients.Overall, the results warrant the establishment of specialized weaning centers. Variables associated with death and weaningfailure can be integrated into ICU decision-making processes.

[Experience of disease, relationship and sexuality in patients with COPD]. / Krankheitserleben, Partnerschaft und Sexualität bei Patienten mit COPD.

Experience of disease, relationship and sexuality in patients with COPD Objectives: We aimed to determine the impacts of chronic obstructive pulmonary disease (COPD) on the patient's relationship and sexuality. Methods: In a multicentric study 105, 52 of them female, non-selected COPD patients who were married or in a partnership were interviewed about their partnership and sexuality. Results: Average age was 64.1 ± 9.2 years. Patients with a more severe COPD had a lower Self-Illness-Separation (SIS), i. e. they reveal significantly higher burden of suffering. Life satisfaction and satisfaction with partnership, sexuality and sexual intercourse has decreased significantly since the diagnosis (p < 0.05). Desire and frequency to be sexually active have also decreased (p < 0.001). 61 % of the respondents felt increasingly dependent from their partner. Conclusion: The results underline that patients have a stage-dependent emotional distance to their illness, the partnership develops in direction of dependency, and sexuality deteriorates with increasing severity of the COPD. The PRISM test proved to be a great way to illustrate this development and to start a conversation with the patients about it. COPD patients and their partners should be referred to the potential impact of the disease on their partnership and sexuality and should be supported in their potential solutions considering gender-specific aspects.