[Guideline for the Diagnosis and Treatment of Asthma - Addendum 2020 - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]. / S2k-Leitlinie zur Diagnostik und Therapie von Patienten mit Asthma ­ Addendum 2020.

The present addendum of the guideline for the diagnosis and treatment of asthma (2017) complements new insights into the diagnosis and management of asthma as well as for the newly approved drugs for the treatment of asthma. Current, evidence-based recommendations on diagnostic and therapeutic approaches are presented for children and adolescents as well as for adults with asthma.

[Pathophysiology, diagnostics and treatment of the respiratory pump]. / Pathophysiologie, Diagnostik und Therapie der Atempumpe.

Diseases of the lung result in oxygen deficiency, hypoxemia, with the indications for oxygen supplementation, whereas hypercapnia and dyspnea are consequences of disorders and failure of the ventilatory pump, which need to be treated by mechanical ventilation. Early diagnostics enable a timely noninvasive ventilation treatment and can prevent overt ventilatory failure and avoid acute invasive ventilation. Diagnostic measures are available, so that the risk of developing overt respiratory failure can be ascertained in time. Treatment of respiratory pump insufficiency, i.e. ventilatory insufficiency, is also established. Many patients with ventilatory insufficiency use intermittent or continuous ventilation every day in order to relieve the respiratory musculature. Many studies have confirmed an extension of life expectancy and a better quality of life, when this relief together with a lowering of the pCO2 is achieved under ventilation and more importantly while breathing spontaneously. If the target of lowering the pCO2 is not achieved, an effect of intermittent ventilation cannot be detected. The more severe the disease, the more difficult it is to achieve relief, because the substantial effort needed for breathing by the patient can hardly be relieved by assisted ventilation alone. The relief is always guaranteed by a total passive mechanical ventilation below the apnea threshold so that the patient does not need to independently breathe. A high tidal volume, an adequately high respiratory rate and a prolonged inspiration time are necessary in order to reduce the pCO2 to below the normal range and to induce passive ventilation. No lung damage has been observed with this treatment strategy in a large number of patients.

[Guideline for the Diagnosis and Treatment of COPD Patients - Issued by the German Respiratory Society and the German Atemwegsliga in Cooperation with the Austrian Society of Pneumology]. / Leitlinie zur Diagnostik und Therapie von Patienten mit chronisch obstruktiver Bronchitis und Lungenemphysem (COPD).

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.

[Guideline for the Diagnosis and Treatment of Asthma - Guideline of the German Respiratory Society and the German Atemwegsliga in Cooperation with the Paediatric Respiratory Society and the Austrian Society of Pneumology]. / S2k-Leitlinie zur Diagnostik und Therapie von Patienten mit Asthma.

The present guideline is a new version and an update of the guideline for the diagnosis and treatment of asthma, which replaces the previous version for german speaking countries from the year 2006. The wealth of new data on the pathophysiology and the phenotypes of asthma, and the expanded spectrum of diagnostic and therapeutic options necessitated a new version and an update. This guideline presents the current, evidence-based recommendations for the diagnosis and treatment of asthma, for children and adolescents as well as for adults with asthma.

Checklists for the Assessment of Correct Inhalation Therapy.

Introduction For the long-term treatment of obstructive lung diseases inhalation therapy with drugs being delivered directly to the lungs as an aerosol has become the method of choice. However, patient-related mistakes in inhalation techniques are frequent and recognized to be associated with reduced disease control. Since the assessment of patient-mistakes in inhalation has yet not been standardized, the present study was aimed at developing checklists for the assessment of correct inhalation. Methods Checklists were developed in German by an expert panel of pneumologists and professionally translated into English following back-translation procedures. The checklists comparably assessed three major steps of inhalation: 1) inhalation preparation, 2) inhalation routine, and 3) closure of inhalation. Results Checklists for eight frequently used inhalers were developed: Aerolizer, Breezhaler, Diskus (Accuhaler), metered-dose inhaler, Handihaler, Novolizer, Respimat, Turbohaler. Each checklist consists of ten items: three for inhalation preparation, six for inhalation routine, and one for closure of inhalation. Discussion Standardized checklists for frequently used inhalers are available in German and English. These checklists can be used for clinical routines or for clinical trials. All checklists can be downloaded free of charge for non-profit application from the homepage of the German Airway League (Deutsche Atemwegsliga e. V.): www.atemwegsliga.de.

What patients really think about asthma guidelines: barriers to guideline implementation from the patients' perspective.

BACKGROUND: Treatment of asthma does not always comply with asthma guidelines (AG). This may be rooted in direct or indirect resistance on the doctors' and/or patients' side or be caused by the healthcare system. To assess whether patients' concepts and attitudes are really an implementation barrier for AG, we analysed the patients' perspective of a "good asthma therapy" and contrasted their wishes with current recommendations. METHODS: Using a qualitative exploratory design, topic centred focus group (FG) discussions were performed until theoretical saturation was reached. Inclusion criteria were an asthma diagnosis and age above 18. FG sessions were recorded audio-visually and analysed via a mapping technique and content analysis performed according to Mayring (supported by MAXQDA®). Participants' speech times and the proportion of time devoted to different themes were calculated using the Videograph System® and related to the content analysis. RESULTS: Thirteen men and 24 women aged between 20 and 77 from rural and urban areas attended five FG. Some patients had been recently diagnosed with asthma, others years previously or in childhood. The following topics were addressed: (a) concern about or rejection of therapy components, particularly corticosteroids, which sometimes resulted in autonomous uncommunicated medication changes, (b) lack of time or money for optimal treatment, (c) insufficient involvement in therapy choices and (d) a desire for greater empowerment, (e) suboptimal communication between healthcare professionals and (f) difficulties with recommendations conflicting with daily life. Primarily, (g) participants wanted more time with doctors to discuss difficulties and (h) all aspects of living with an impairing condition. CONCLUSIONS: We identified some important patient driven barriers to implementing AG recommendations. In order to advance AG implementation and improve asthma treatment, the patients' perspective needs to be considered before drafting new versions of AG. These issues should be addressed at the planning stage. TRIAL REGISTRATION: DRKS00000562 (German Clinical Trials Registry).

[Correct Inhalation Therapy for Patients with Cystic Fibrosis Provided by Internet-based Video Clips of the German Airway League]. / Richtig inhalieren bei Mukoviszidose: Internet-verfügbare Videoclips der Deutschen Atemwegsliga e.V.

Adolescents and young adults with cystic fibrosis (CF) are increasingly having difficulties to take over the complete responsibility for their daily treatment. Particularly inhalative therapy poses special problems. In order to overcome this unsatisfactory situation typically occurring during this vulnerable period, the German Airway League has now created a poster "Correct Inhalation Therapy For Patients With Cystic Fibrosis", according to the model presented by this League already in 2013 for correct inhalation under certain disease conditions. This give an opportunity to adolescents and young adults with CF to obtain anonymously, independently of time and location, autonomously and in a time-saving manner information on correct inhalative treatment. Adolescents and young adults with CF can thus be actively supported on their way to independence. Furthermore, the video clips and the poster offer support physicians, nurses and physiotherapists and can be employed in training of all involved persons in inhalation techniques.

[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.

[Recommendations for respiratory muscle testing]. / Empfehlungen der Deutschen Atemwegsliga zur Messung der Atemmuskelfunktion.

Based on the tremendous impact of impaired respiratory muscle function, tests on their function play a significant role in respiratory and intensive care medicine. Besides differential diagnosing e.g. during prolonged weaning and quantification of impaired respiratory muscle function, e.g. in COPD, neuro-muscular diseases or ventilator-induced diaphragmatic dysfunction, those tests qualify for follow-up assessment, e.g. phrenic nerve lesions or specific respiratory muscle training. In general, (simple) volitional and (complex) non-volitional tests are available. Volitional tests aim at screening for potential respiratory muscle impairment, while non-volitional tests - including ultrasound application - are used to further specify low values assessed by volitional tests and to assess complex clinical conditions (e.g. intubated, sedated patients). Several tests are complementary or additive to each other. Complete assessment for respiratory muscle function, therefore, frequently requires the combination of different test regimes. The current recommendations include in-depth description and practical guidelines for the different tests and approaches to assess respiratory muscle function.

[Asthma guidelines: knowledge of family doctors and trainees in Germany]. / Wissen von Hausärzten und Ärzten in Weiterbildung über nationale Asthmaleitlinien.

In Germany as well as internationally, evidence-based asthma guidelines were developed as a decision aid for diagnosis and therapy. However, adherence to recommendations is usually less than optimal. The authors explore potential implementation barriers: knowledge gaps, practical presentation of guidelines, and attitudes of doctors and patients. In this paper, we compare results of our knowledge survey of family doctors and trainees with results of similar national and international studies. In all studies, all surveyed groups of physicians revealed considerable knowledge gaps. Many physicians in our own study erroneously preferred mucolytics and antibiotics to treat acute or subacute asthma symptoms though these drugs are not or only exceptionally indicated. The inflammatory character of asthma often goes unrecognized, as well as the importance of inhaled (and systemic) corticosteroids in long term treatment (or treatment of exacerbations).

[Correct inhalation therapy: instructions provided by Internet-based video screens. An initiative of the German Airway League]. / Korrekte Inhalationstherapie: Einweisung mittels Internet-verfügbarer Filmsequenzen. Eine Initiative der Deutschen Atemwegsliga e.V.

BACKGROUND: Inhalation therapy is well recognized as a cornerstone treatment of airway diseases. In daily practice, however, high failure rates of inhalation technique are evident, which substantially attenuates the treatment success. METHODS: In 2011 the German Airway League has initiated the production of video screens for correct inhalation aimed at providing an efficient and globally available platform for information. All devices regularly used have been filmed and published via internet and DVD; thereby, video screens, spoken text passages, and visual insertion of information have been combined. Here, all important steps of inhalation therapy like preparation, performance, and termination have been covered. RESULTS: Video screens of 20 different devices lasting between 1:42 and 3:11 min:sec have been produced between July 2011 and January 2013 and published on the YouTube channel of the German Airway League with more than 70.000 clicks so far (27. February 2013). CONCLUSIONS: Pragmatic, internet-based video screens on the correct inhalation therapy are available and are cost-free. Further studies aimed at evaluating the benefits of these screens are necessary.

[Abdominal free air without signs of perforated abdominal viscus during non-invasive ventilation]. / Freie abdominelle Luft ohne Hinweis auf eine Hohlorganperforation unter nichtinvasiver Beatmung.

HISTORY: A 19-year-old patient suffering from Duchenne muscular dystrophy was admitted to our hospital with an acute bronchopulmonary infection. Four months ago noninvasive ventilation was started because of hypercapnic respiratory failure. Mechanical ventilation had been used so far only at night. At the time of admission spontaneous breathing was not possible due to exhaustion of the respiratory muscles. The patient suffered from fever, limited cough strength and dyspnoea at rest. The abdomen was distended because of intestinal gas without clinical signs of acute abdomen. INVESTIGATIONS: Blood gas analysis showed respiratory acidosis even under mechanical ventilation. Laboratory tests showed an elevation of the inflammation indicating parameters. X-rays of the chest showed elevated diaphragms. Within the next days pneumonia could be seen in the left lower lobe. The patient had to be under mechanical ventilation almost 24 hours per day. Hypercapnia and respiratory acidosis normalized and the patient was able to breathe spontaneously for longer periods. The following days cutaneous emphysema developed and X-rays revealed free abdominal air on day 9 of the hospital stay. DIAGNOSIS, TREATMENT AND COURSE: The radiological findings have been confirmed during follow up X-rays without any clinical correlate. Inflammatory markers were decreasing. After the pneumonia had healed almost completely, the times on mechanical ventilation could be reduced. Subphrenic air resolved completely without any intervention. CONCLUSION: Free subphrenic air without any clinical signs of acute abdomen does not necessarily force a surgical exploration. Under frequent follow up investigations a wait-and-see strategy could be justified. An explanation for the subphrenic air could be an interstitial emphysema due to increased intrathoracic pressure caused by the prolonged noninvasive ventilation, releasing the air through the diaphragmatic gaps into the abdomen.

Body plethysmography--its principles and clinical use.

Body plethysmography allows to assess functional residual capacity (FRC(pleth)) and specific airway resistance (sRaw) as primary measures. In combination with deep expirations and inspirations, total lung capacity (TLC) and residual volume (RV) can be determined. Airway resistance (Raw) is calculated as the ratio of sRaw to FRC(pleth). Raw is a measure of airway obstruction and indicates the alveolar pressure needed to establish a flow rate of 1 L s(-1). In contrast, sRaw can be interpreted as the work to be performed by volume displacement to establish this flow rate. These measures represent different functional aspects and should both be considered. The measurement relies on the fact that generation of airflow needs generation of pressure. Pressure generation means that a mass of air is compressed or decompressed relative to its equilibrium volume. This difference is called "shift volume". As the body box is sealed and has rigid walls, its free volume experiences the same, mirror image-like shift volume as the lung. This shift volume can be measured via the variation of box pressure. The relationship between shift volume and alveolar pressure is assessed in a shutter maneuver, by identifying mouth and alveolar pressure under zero-flow conditions. These variables are combined to obtain FRC(pleth), sRaw and Raw. This presentation aims at providing the reader with a thorough and precise but non-technical understanding of the working principle of body plethysmography. It also aims at showing that this method yields significant additional information compared to spirometry and even bears a potential for further development.