[Day/Night Variability of Coughing Events in Interstitial Lung Disease]. / Tag-/Nachtvariabilität von Hustenereignissen bei interstitiellen Lungenerkrankungen.

INTRODUCTION: Besides dyspnea a dry cough is one of the main symptoms in patients with pulmonary fibrosis. Little is known about the 24-hour-variability of this symptom. Moreover, it is unclear if other auscultation phenomena occur. METHODS: A long-term auscultation for 24-hours was performed in patients with fibrotic lung diseases (LEOSound, Löwenstein Medical GmbH & Co. KG, Medical-Electronics, Bad Ems, Germany). Coughing and wheezing sounds were recorded. For the following analysis the 24-hour period was divided into two intervals of 12 hours each (daytime and nighttime). Events were registered in epochs (at least one event in 30 seconds). RESULTS: 20 patients were included (6 with nonspecific interstitial pneumonia and 14 with idiopathic pulmonary fibrosis). On average 166 coughing epochs were recorded in a 24-hour-period (day/night 116/50; P < 0.001). Moreover, 203 wheezing epochs were registered (day/night 84/119; P = 0.273). Auscultation phenomena did not correlate with spirometric and bodyplethymographic data, nor with data of diffusion capacity. DISCUSSION: The study is showing the clinical potential of long-term auscultation in patients with fibrotic lung diseases. Especially the findings concerning the coughing symptoms were remarkable. It could be shown that there was a decrease of coughing during nighttime in comparison to daytime. In contrast to this, wheezing sounds were increasing at nighttime. The clinical relevance of this finding is yet to be assessed. Finally, there was no correlation between the severity of the disease measured by functional diagnostics and the amount of coughing.

[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]. / Leitlinie zur Langzeit-Sauerstofftherapie.

Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.

The spontaneous breathing trial is of low predictive value regarding spontaneous breathing ability in subjects with prolonged, unsuccessful weaning.

BACKGROUND: The spontaneous breathing trial (SBT) is a well-established diagnostic test for predicting extubation failure in intubated intensive care unit (ICU) patients. However, the SBT has not been evaluated in a specific cohort of tracheostomized patients in whom weaning is prolonged and ultimately unsuccessful. OBJECTIVE: The aim of the trial was to investigate the relevance of SBT failure criteria in chronic respiratory failure subjects undergoing long-term invasive home mechanical ventilation following tracheostomy and weaning failure. METHODS: Measurement of all established failure criteria including pneumotachygraphical assessment of the rapid shallow breathing index (RSBI) took place during an SBT. The decision to continue spontaneous breathing was based on failure criteria as well as the subjective willingness of the patient. RESULTS: Fifteen subjects with a median age of 58 years (interquartile range [IQR] 44-74) were studied; 10 with COPD, 4 with neuromuscular diseases and 1 with both. Twelve subjects met the SBT failure criteria within 30 min, but one third of these subjects were still able to continue with spontaneous breathing. In contrast, 3 subjects could not be weaned despite the SBT being successful. An increased RSBI was the most frequently observed SBT failure criterion (57% of all SBT). However, the SBT varied substantially in individual subjects who were able to sustain spontaneous breathing, despite having reached the cut-off for SBT failure. CONCLUSION: The SBT was of low predictive value regarding spontaneous breathing ability in chronic respiratory failure subjects with prolonged, unsuccessful weaning.

Why High-Intensity NPPV is Favourable to Low-Intensity NPPV: Clinical and Physiological Reasons.

High-intensity non-invasive positive pressure ventilation (NPPV) was originally described for chronic hypercapnic chronic obstructive pulmonary disease (COPD) patients in 2009, and refers to a specific ventilatory approach whereby NPPV settings are aimed at achieving the lowest arterial partial pressure of carbon dioxide (PaCO2) values possible. Thus, high-intensity NPPV requires ventilator settings to be increased in a stepwise approach to either an individually tolerated maximum, or to the levels necessary to achieve normocapnia. This differs from the classic approach to low-intensity NPPV, which comprises considerably lower ventilator settings and typically fails to lower elevated PaCO2 values. The ongoing discussion about whether or not long-term NPPV should be used in chronic hypercapnic COPD patients is based on the observation that many studies in the last two decades have failed to provide evidence for this particular patient cohort. In addition, these trials preferably used low-intensity NPPV. There is now, however, increasing evidence to suggest that high-intensity NPPV is capable of improving important physiological parameters such as blood gases and lung function, as well as health-related quality of life. Moreover, this approach also produced positive outcomes following two recent randomized controlled trials, e.g., improved survival rates in stable COPD patients, and admission-free survival in patients with persisting hypercapnia following acute in-hospital NPPV to treat acute acidotic respiratory failure. As a consequence, the time has now come to evaluate the impact of long-term NPPV on both the physiological and clinical outcomes, with emphasis on the different approaches to NPPV. Therefore, the aim of the current review article is to elaborate on the clinical and physiological reasons for why high-intensity NPPV is favourable to low-intensity NPPV.

Home oxygen therapy: evidence versus reality.

INTRODUCTION: LTOT is a well-established treatment option for hypoxemic patients. Scientific evidence for its benefits of LTOT dates back to the 1980s, when two randomized controlled trials showed prolonged survival in COPD-patients undergoing LTOT for at least 15 hours/day. In contrast, the potential benefits of LTOT in non-COPD-patients has not been well researched and the recommendations for its application are primarily extrapolated from trials on COPD-patients. Recently, a large trial confirmed that COPD-patients who don't meet classic indication criteria, and have moderate desaturation at rest or during exercise, do not benefit from oxygen therapy. Also the significant technical evolution of LTOT devices has improved its application. Areas covered: A literature research was performed in pubmed regarding home oxygen therapy (terms: LTOT, ambulatory oxygen therapy, short burst oxygen therapy, nocturnal oxygen therapy). Expert commentary: LTOT proved a survival benefit for COPD patients about 30 years ago. Whether the results of these trials are still valid for patients under modern treatment guidelines remains unknown. Nevertheless, the classic indication criteria for LTOT still persist in guidelines, since there is a lack of updated evidence for the effects of LTOT in more severe hypoxemic patients.

[A Young Asylum Seeker with Hemoptysis and Positive Tuberculosis Screening: Not Always Tuberculosis!] / Hämoptysen bei einem jungen Asylbewerber mit positivem Tuberkulose-Screening: Nicht immer Tuberkulose!

This paper reports on the case of a 19 year old asylum seeker from Eritrea who presented with hemoptysis, a positive tuberculosis screening (Enzyme Linked Immuno Spot Assay - EliSpot) and mushy faeces submitted with a suspected diagnosis of tuberculosis. Laboratory testing revealed thrombopenia, leukopenia and eosinophilia, while the chest X-ray was inconspicuous. Acid-proof rod bacteria were neither evident in bronchoscopy samples nor in expectorated sputum samples. However, sonographic findings showed a profound splenomegaly, and laboratory testing revealed a Schistosoma mansoni infection. This case demonstrates that in asylum seekers with suspected tuberculosis endemic diseases of the home country need to be considered as alternative diagnoses.

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.

[Impact of a Senso-Motoric Intervention in COPD-Patients Participating in an Outpatient Pulmonary Rehabilitation Program: A Randomized Controlled Trial]. / Effektivität eines sensomotorischen Krafttrainings im Rahmen einer ambulanten pneumologischen Rehabilitation bei COPD-Patienten: eine randomisierte kontrollierte Studie.

Objective Exercise training provides a cornerstone of pulmonary rehabilitation (PR) in COPD-patients. However, the components of the training are not yet fully investigated. We conducted a randomized controlled trial to investigate the effectiveness of a sensory-motoric training (SMT) in comparison to a conventional strength training (KT) according to the physical performance. Patients and Methods: 43 COPD patients were randomized and participated either in the intervention group (SMT = 30 minutes SMT per day) or in the control group (KT = 30 minutes KT per day). The SMT was performed as circuit training with five stations. The primary endpoint was the difference between T1 (start of the PR) and T2 (end of the PR) in 5-Times Sit-to-stand test (5-STST) in the intergroup comparison. Secondary endpoints were the intra- and intergroup comparisons of T1 and T2 in the 6-Minute Walk Test (6-MWT), COPD Assessment Test (CAT), St. George Respiratory Questionnaire (SGRQ), Hospital Anxiety- and Depression Scale (HADS) and in lung function. Results No significant differences were seen in the results of the 5-STST between the groups. Likewise, in the 6-MWT, SGRQ, CAT, HADS and lung function. The intragroup comparison between T1 and T2 showed significant differences in 5-STST, 6-MWT, SGRQ, CAT and HADS in both groups. The differences in lung function were not significantly, neither in the inter- nor in the intragroup comparison. Conclusion Similarly to a conventional strength training improvements in exercise capacity could be achieved with a SMT during PR in COPD patients. Further studies are necessary to define the role of the SMT in regards to postural control.

[Outcome predictors for COPD patients hospitalized for acute exacerbation]. / Outcomeprädiktoren für hospitalisierte COPD-Patienten bei akuter Exazerbation.

BACKGROUND: Prognostic factors for clinical failure of acute exacerbation in patients with COPD (AECOPD) are of special importance in order to choose an adequate therapy and resources during inpatient treatment. Our database was analyzed to identify predictors for a negative outcome. MATERIALS AND METHODS: In a retrospective analysis medical records of 616 patients (299 women; 317 men) hospitalized for AECOPD between January 2011 and January 2016 were analyzed in order to evaluate demographic and clinical parameters leading to adverse events. Only the first admission was considered. Logistic regression analysis was performed to determine the relative risk (odds ratio (OR) leading to severe adverse events such as intensive care unit (ICU) admission, mechanical ventilation (invasive or noninvasive), early readmission to ICU and hospital and death). RESULTS: An increased risk of an ICU admission was found for patients with a coronary heart disease (OR = 5.734; p = 0.009) and for patients requiring an antibiotic therapy (OR = 11.721; p = 0.003). An increased risk for rehospitalisation and mortality was found for age (OR = 1.034; p = 0.028) and a longer duration of the hospital stay (OR = 1.063; p = 0.042). A lower C­reactive protein (CRP) level was associated with a lower risk of readmission to the hospital (OR = 0.991; p = 0.03). An increased risk of ventilator therapy was found for patients with chronic heart failure (OR = 6.166; p = 0.02) and sleep apnea syndrome (OR = 6.698; p = 0.003), diabetes (OR = 3.754; p = 0.041) and a long stay in the ICU (OR = 2.018; p = 0.000). CONCLUSIONS: Comorbidities in patients with AECOPD were found to be a major risk factor for ICU admission and mechanical ventilation. Elderly patients and patients with prolonged hospital stay showed a higher risk for readmission and mortality. Patients with a low CRP blood level seemed to have a lower risk for rehospitalisation.

[Diagnosis and Treatment of Diaphragmatic Dysfunction]. / Diagnostik und Therapie der gestörten Zwerchfellfunktion.

There are many reasons for an impairment of the diaphragmatic function potentially affecting all components of the respiratory pump. Particularly, diagnosis and treatment of unilateral and bilateral phrenic nerve paralysis are challenging. Neuromuscular disorders, trauma, iatrogenic conditions, tumor compression, but also infectious and inflammatory conditions in addition to neuralgic amyotrophy and idiopathic phrenic nerve paralysis are reasons for phrenic nerve paralysis. Primarily, diagnostic procedures include the anamnesis, physical examination, blood gas analysis, lung function testing and the diagnosis of the underlying disease. In addition, specific respiratory muscle testing and respiratory imaging are available today. Current established treatment options include respiratory muscle training, long-term non-invasive ventilation and surgical diaphragm plication in selected patients.

[Monitoring of pCO2 during ventilation]. / Monitoring des pCO2 unter Beatmung.

Respiratory insufficiency type 2 (ventilatory failure) is characterized by hypercapnia due to alveolar hypoventilation. Therefore, the monitoring of pCO2 is essential for diagnostic and surveillance purposes. Various techniques which differ in the way of measurement (e.g., invasive/noninvasive, continuous/noncontinuous) and their indication are available. Arterial blood gas analysis (ABG) as an invasive procedure is the gold standard procedure and is mostly used in emergency medicine or intensive care units (ICUs). Another method to evaluate pCO2 is capillary blood gas analysis (CBG). Furthermore, endtidal pCO2-(PetCO2) and transcutaneous CO2-measurement (PtcCO2) are able to continuously and noninvasively monitor pCO2. PetCO2 is mostly used in the field of anesthesiology during general anesthesia and is integrated in many ventilators, also in ICUs. However, PetCO2 is limited in monitoring pCO2 in patients with lung disease and it is only reasonably usable in invasively ventilated patients. Transcutaneous pCO2 (PtcCO2) is available as an alternative, especially in chronic respiratory failure and to diagnose hypoventilation in sleep-related breathing disorders, and it has substantial advantages in these indications compared to discontinuous measurements, e.g., blood gas analysis. The various methods to monitor pCO2 are generally used synergistically in clinical practice.

[Unilateral agenesis of pulmonal artery in adults: a rare disease frequently undiagnosed]. / Unilaterale Agenesie der Pulmonalarterie bei Erwachsenen. Eine häufig nicht diagnostizierte seltene Erkrankung.

INTRODUCTION: Unilateral absence of a pulmonary artery (UAPA) in adults without any other cardiovascular anomalies is a very rare clinical entity. Usually UAPA in adults remains undetected because of the symptom-free clinical course. The most common symptoms are hemoptysis and recurrent pulmonary infections. PATIENTS AND THERAPY: During 2006 - 2014 four adult patients with UAPA were diagnosed and treated in our institution. Recurrent pulmonary infections in combination with existing bronchiectasis and hemoptysis led to hospital treatment for three of the patients. In two cases, because of persevering hemoptysis and pathologically enlarged systemic arteries (intercostal, bronchial, diaphragm), pneumonectomy was indicated. Preoperative embolization of the enlarged arteries reduced the systemic arterial perfusion of the lung and led to minimal intraoperative blood loss. DISCUSSION: UAPA in the adulthood can frequently lead to hypertrophic systemic arterial perfusion of the lung. This abnormal systemic perfusion in combination with the co-existing bronchiectasis and persevering hemoptysis can cause a life-threatening clinical scenario. A combined interdisciplinary treatment through pneumology, thoracic surgery and radiology is therefore indicated.

Una experiencia comunitaria de estimulación temprana: el programa de SERCO en Maipú / A communitary experience in early stimulation: the SERCO programme in Maipú

En 1979 un grupo de profesionales comenzó a implementar en la Comuna de Maipú un Programa de Estimulación Temprana con participación de la comunidad. Este Programa nació como una adaptación del Programa de Estimulación Temprana que formaba parte del Programa del Control del Niño Sano del Ministerio de Salud, y que en esta comuna fue aplicado sólo durante un breve periodo. En 1979, dicho programa fue recogido para ser aplicado en la zona de la Vicaría Oeste con el auspicio del Comité Poblacional del Centro Ecuménico de Maipú. Inicialmente, el proyecto contaba con un psicólogo, una asistente social y un médico que estuvieron vinculados al Servicio de Salud Metropolitana de esa área, y su objetivo era preparar a las madres de la comunidad para trabajar en estimulación del desarrollo psicomotor de los niños. Más tarde, se incorporó al equipo un grupo de madres de la propia comunidad como monitoras. Desde entonces, el Servicio de Recursos Comunitarios (SERCO), la institución patrocinante, ha seguido trabajando hasta la actualidad con el Programa gracias a distintas fuentes de financiamiento. El objetivo de este relato es trazar el desarrollo de este esfuerzo comunitario desde sus inicios hasta el presente, poniendo de relieve sus planteamientos y logros a través de las vivencias de sus diversos actores