[Implementation of the German Guideline for the Prevention, Diagnosis, Treatment, and Follow-up of Lung Cancer in the Federal State of Berlin]. / Umsetzung der S3-Leitlinie zur Prävention, Diagnostik, Therapie und Nachsorge des Lungenkarzinoms im Land Berlin.

BACKGROUND: In February 2010, the German guideline for the Prevention, Diagnosis and Treatment of Lung Cancer has been published. For the first time in Germany, the implementation of relevant guideline recommendations has been assessed in the federal state of Berlin. METHODS: Based on the quality indicators of the guideline, a questionnaire was designed which aimed at the application of selected diagnostic and therapeutic concepts. This questionnaire was sent out to all outpatient and inpatient units in the federal state of Berlin being presumably involved in lung cancer care. RESULTS: Overall response rate was good (39.8 %), especially from the addressed inpatient units. Inpatient pneumology units showed the highest application rates of guideline recommendations, followed by oncology units. CONCLUSIONS: Taking the methodologically reduced significance of a survey design into account, this study determined a negative trend of decreasing guideline implementation in units with a lesser grade of specialisation in terms of lung cancer care.

[Lung cancer - historical development, current status, future prospects]. / Lungenkrebs - Geschichtliche Entwicklung, derzeitiger Stand und Ausblick.

One hundred years ago lung cancer was a rare disease. In the meantime, as a result of the sharp increase of tobacco smoking, in Germany and worldwide it is the most common cause of cancer death. Since lung cancer is largely asymptomatic in its early stages, the diagnosis is usually first made in the advanced stages IIIB or IV. The development of diagnostic imaging and minimally invasive procedures as well as the refinement of the staging classification allow a better allocation to the tumor stages. The surgical mortality has declined significantly since the 1950s, yet the 5-year survival rates are low. For locally advanced, unresectable non-small cell lung carcinoma a moderate improvement of the prognosis could be achieved by newer methods of radiotherapy and the combination of radiotherapy with chemotherapy. As a result of chemotherapy in patients with non-small cell lung cancer a moderate life extension has been reached, while the new agents are better tolerated and allow for an improved quality of life. The survival of small cell lung cancer has been significantly prolonged by chemotherapy since the 1970s, however, little progress was made in the last 15 - 20 years. The most important and effective preventive measure against lung cancer is to avoid tobacco smoke. Screening tests using annual chest X-ray images and sputum cytology have shown no improvement in overall mortality compared with the control groups in extensive studies. Whether or not an improvement of prognosis is possible by a screening using low-dose CT is being tested by the ongoing studies. For patients with lung cancer more effective agents and therapies are still needed.

Problems of continuous Pa, O2 monitoring by means of indwelling intra-arterial electrodes.

Continuous monitoring of intra-arterial PO2 has many advantages in intensive care. However, there are some problems which have prevented the routine use of this method until now. A commercially available polarographic oxygen electrode was tested in vitro. Continuous PO2 monitoring was performed in vivo in 63 adult patients. The electrode is suitable for intensive care with regard to handling, dimensions, biocompatibility, mechanical stability, electrical safety, sensitivity, flow dependency, response time and costs. It should be improved with regard to the instability of the measuring properties and its non-linearity in hyperoxia. Serious complications of continuous PO2 monitoring were not observed. In view of the specific properties of the polarographic electrode and the contraindications of arterial cannulation, the continuous intra-arterial PO2 measurement has proved to be a valuable, safe and simple technique of monitoring, especially for short-term changes of arterial PO2.

Cellular autofluorescent pigment and interstitial fibrosis in smoker's lung.

The mechanisms by which cigarette smoking lead to bronchopulmonary diseases are incompletely understood. The most characteristic lesion is a chronic macrophage-alveolitis accompanied by slight fibrosis and emphysema. The macrophages contain a ceroid-like granular autofluorescent pigment in their lysosomes. Using immunohistochemical methods, open lung-, transbronchial biopsies and cells obtained by broncho-alveolar lavage from cigarette smokers were studied: anti-human macrophage serum and anti-human elastase, immune sera against type I, type III collagens and fibronectin were used in the demonstration of the cellular components of alveolitis and the connective tissue constituents of fibrosis. The characteristic red-brown autofluorescent pigment of the macrophages was also found in an extra-alveolar location mainly in peribronchial, septal and pleural scars. Similar emission colour occurred focally in the elastic laminae of fibrotic alveoli and sclerotic arteries. Granular fluorescent pigment was found in many bronchial epithelial cells. The epithelial pigmentation was associated with increased transcription of nucleic acid proteins, revealed by colloid silver (AgNOR) reaction. The results suggest that the autofluorescent pigment substances in macrophages may indicate or also play a role in the development of pathological connective tissue and epithelial changes of smoker's lung, in addition to the known mediators and enzymes.

[Evolutionary quality assurance. A new concept for improving process and outcome quality]. / Evolutionäre Qualitätssicherung. Ein neues Konzept zur Verbesserung der Prozess-und Ergebnisqualität.

BACKGROUND: The concept evolutionary quality assurance is a new, non-mandatory, open peer review process for in-patients settings. METHOD: Ten medical charts (with radiographs) from participating hospitals were randomly chosen and assessed using a prespecified questionnaire (total 134). Individual inadequacies had to be justified on a case by case level. Reviewer and reviewee are known by names, allowing subsequent discussions on content between reviewer and reviewee prior to a final judgement. The final analysis was performed anonymously and communicated to the participants after completion of the process. Patients had to give their consent to the review process. The report, however, is not part of the medical patient file, so that access is not warranted. For the first cycle, all lung clinics and departments throughout Germany were asked to participate. 35 chest hospital (approximately 50%) agreed to participate. RESULTS: Data analysis revealed that almost all detected inadequacies were apparent, i.e. discussions on the discordant interpretation of diagnostic and therapeutic strategies rarely occurred (0.25%). Final analysis of the evaluation performance of reviewers judged less than 5% and 14% judged more than 30% of all quality inadequacies. CONCLUSIONS: The quality assurance process is comparably cheap and can be implemented without delay, because standards for reference values are not required. The structure allows adaptation in all areas of clinical medicine.

Continuous measurement of arterial PO2. Significance and indications in intensive care.

The use of continuous arterial PO2 monitoring with the aid of intra-arterial electrodes is discussed with reference to 50 patients in an intensive care unit specializing in internal medicine. Monitoring time ranged from 2 h to 15 days. There were no serious complications which could, with certainty, be attributed to the intravascular measurement of PO2. The advantages of this method lie particularly in the early detection of hypoxemias, in the uninterrupted monitoring of artificial respiration and in the immediate indication of favorable and unfavorable response to therapy. Finally, a list is given of possible indications in which this method can be used in intensive medicine.

[Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD)]. / Respiratorische Bronchiolitis mit interstitieller Lungenerkrankung (RB-ILD).

Respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) designates interstitial lung changes in smokers, characterized histologically by bronchiolocentric accumulation of pigmented alveolar macrophages and fibrotic or cellular inflammatory changes of pulmonary interstitium. The definition is nearly identical to that of condensate pneumopathy, smoker's pneumopathy or smoker's lung, defined by accumulation of pigmented alveolar macrophages with bland alveoloseptal or peribronchial fibrosis and cellular inflammation of the bronchial wall. In addition to respiratory bronchiolitis, which is found in nearly all smokers, RB-ILD comprises a broad spectrum of varying degrees of the interstitial reaction to the exogenous injury of inhalation smoking with gradual transition to desquamative interstitial pneumonia (DIP). In most cases RB-ILD manifestations are subclinical and detected coincidentally. Radiographic features are reticulonodular and ground glass opacities of the lung. The high resolution computed tomography reveals centrilobular nodules, ground glass opacities, thickening of bronchial walls, and in some cases a reticular pattern. Mild emphysema is frequent. Lung function analysis reveals only minor restrictive or obstructive defects in most cases, often combined with hyperinflation. CO diffusing capacity is slightly to moderately impaired. Pronounced interstitial lung diseases with serious restrictive defects and arterial hypoxemia have been reported infrequently. In differential diagnosis smoking related interstitial lung diseases (DIP, Langerhans cell histiocytosis, idiopathic pulmonary fibrosis) and other interstitial lung diseases have to be excluded. In most cases diagnosis can be achieved by bronchoalveolar lavage and transbronchial lung biopsy. In cases of pronounced interstitial lung disease or assumption of an additional interstitial lung disease besides RB-ILD a thoracoscopic or open lung biopsy can be necessary. RB-ILD has a favourable prognosis. After smoking cessation lung changes are reversible. Corticosteroid therapy is not necessary. A fatal outcome of RB-ILD has not been reported. Follow-up examinations are advisable in order to preclude other interstitial lung diseases. RB-ILD seems to be more frequent than it is assumed at present. The clinical picture is masked in most cases by the concomitant smoking induced chronic bronchitis. Thus only pronounced cases with structural changes and resulting differential diagnostic problems are diagnosed.

[A simple method for pleural drainage (author's transl)]. / Ein einfaches Verfahren zur Pleuradrainage.

21 patients had pleural drainage with a rubber valve (Heimlich) on account of pneumothorax (15) and massive pleural effusion (6). The method succeeded in every case. It has the advantage that it dispenses with suction and bottles, that it needs no turning-off when the patient gets up, but maintains its draining action, and that in cases of persisting broncho-pleural fistula there is no additional suction. The technique represents a simplified alternative to the customy methods of pleural drainage.

[Evaluation of lung function tests by means of a programmed minicomputer (author's transl)]. / Auswertung von Lungenfunktionsuntersuchungen mit Hilfe eines programmierbaren Taschenrechners.

A computer programme for a small programmable electronic calculator is introduced which considerably facilitates the offline evaluation of tests of the ventilatory lung function and mechanics of breathing, including the establishment of individuel ideal values. This favourably priced computer reduces the time required for calculation by about one-third compared with the conventional method. The process of assessment is rendered strikingly simple and hence safer by this highly versatile computer.

Relation of transcutaneous to arterial pO2 in hypoxaemia, normoxaemia and hyperoxaemia. Investigations in adults with normal circulation and in patients with circulatory insufficiency.

The transcutaneous oxygen tension was monitored continuously by a heated cutaneous polarographic electrode in 7 adult intensive care patients, 12 patients without circulatory insufficiency, and 5 healthy volunteers, Arterial pO2 values were varied from hypoxaemia to normoxaemia and hyperoxaemia by variations of the inspired oxygen concentration. In normal volunteers and in patients without circulatory failure, transcutaneous pO2 indicated on an average about 81-92% of the arterial pO2 in normoxaemia and hyperoxaemia with a correlation coefficient of 0.97. In hypoxaemia there was an over-proportional decrease of the transcutaneous pO2 to a mean value of 44% fo the arterial pO2. In one case the transcutaneous pO2 reproducibly dropped to zero at paO2 values of 41 respectively 38 mm Hg (5.5 respectively 5.1 kPa). In intensive care patients the transcutaneous pO2 values were considerably lower than the paO2 values. There was no constant transcutaneous to arterial pO2 ration in most of the intensive care patients at different pO2 levels. In adults without disturbance of peripheral perfusion paO2 can be predicted with satisfactory accuracy from transcutaneous pO2 values in normoxaemia and in hyperoxaemia. In hypoxaemia and in circulatory insufficiency, the transcutaneous pO2 is only an indicator of the trend of the arterial pO2. Under these conditions it does not allow a quantitative estimate of paO2 changes.

[Scanning electron microscopic examination of intra-arterial PO2 electrodes (author's transl)]. / Rasterelektronenmikroskopische Untersuchungen intraarterieller PO2-Elektroden.

Continuous blood gas measurement by means of indwelling intraarterial electrodes facilitates and contributes to considerably improve the monitoring of pulmonary gas exchange in intensive care and anaesthesiology. Knowledge of the behaviour of the electrode surface in the blood stream is necessary to assess the characteristics of the measuring and the possible risks or complications. Scanning electron microscopic examinations were performed in a commercial-type polarographic PO2 electrode after in vitro and in vivo application. 14 electrodes were examined after continuous intra-arterial measurements in patients with chronic obstructive pulmonary disease and in intensive care patients. Duration of intra-arterial measurements was 2-109 h. Already after a measuring period of 2 h in nearly all cases a protein film was discovered on the electrode surface. Microthrombotic deposits were seen in 2 cases, in one of these despite of treatment with heparin. The electrode membrane showed a network ofmicro-cracks, small bubbles and dents. The membrane changes were probably the result of the drying process during the electron microscopic preparation, because the membrane material (Hydron) is hydrophil and swells during the measurement. Yet it cannot be excluded that these changes occur, in part, during the measurements. From these and other studies we conclude that the intra-arterial application of this electrode has a low risk of thromboembolic complications. The deposits on the electrode surface and the membrane changes may probably affect the response time and possibly also the stability of the electrode.

The monitoring of adult intensive care patients by transcutaneous PO2 measurements.

In intensive care medicine the tcPO2 measurement can be used efficiently if the problems discussed are taken into consideration. The advantages of the method follow. 1) The trend of the arterial PO2 can be monitored continuously. 2) A large fall in tcPO2 can be a sign of arterial PO2 decrease or of circulatory insufficiency.

Use of the continuous transcutaneous PO2 measurement in lung function tests.

Continuous measurements of transcutaneous PO2 are of interest in pulmonary function tests by which dynamic processes of pulmonary gas exchange are examined. The aim of the present study is to clarify the question of whether the transition function of transcutaneous PO2 after a step change of inspiratory oxygen concentration could give information about pulmonary gas exchange. In 8 healthy volunteers and 31 patients with chronic obstructive pulmonary disease of various degrees the half-value mixing times of transcutaneous PO2 were correlated with parameters of respiratory mechanics and pulmonary gas exchange. In spite of a damping of rapid changes of arterial PO2 by the transcutaneous measurement, there were significant correlations of the mixing times with physiologic right-to-left shunt; with physiologic dead space, alveolar ventilation, and blood gases; and with the parameters of lung overinflation and airway obstruction. There was a significant correlation with the age of the subjects, too. This had to be attributed mainly to an increase in severity of lung function disturbances with advancing age. Aging of the skin seemed to have a minor influence. According to these results, the transition function of transcutaneous PO2 after a step change of inspiratory oxygen concentration is determined mainly by the alveolar ventilation and the ventilation-perfusion inhomogeneity. This paper describes a short test that only takes some minutes of oxygen breathing and that has nearly the same diagnostic value as the measurement of the half-value mixing time.

[Continuous monitoring of pO2 by means of intravascular indwelling oxygen electrodes (author's transl)]. / Kontinuierliche pO2-Uberwachung mittels intravasaler Sauerstoffelektroden

Two intravascular oxygen electrodes (of the International Biophysics Corporation and Roche) were tested in vitro and in long-term monitoring of arterial oxygen partial pressure in 19 patients. There were no complications. Both electrodes proved suitable for use for monitoring in an intensive-care situation. But both could still be improved by having greater stability and a shorter response time. Some of the indications for continuous monitoring of pO2 are mentioned: incipient respiratory failure, shock-lung, pulmonary oedema, and artificial ventilation. Haemorrhagic diatheses and arterial occlusive disease are contra-indications to its use.

[Lymphography with oily contrast media. Complications and contra-indications (author's transl)]. / Lymphographie mit öligen Kontrastmitteln--Komplikationen und Kontraindikationen

Following lymphography pulmonary fat microembolization is regularly found. It is accompanied by hemodynamic pulmonary changes as well as by impairment of respiratory lung function and respiratory metabolism. The risks of complications and several contra-indications are described. To avoid complications explicit precautions are recommended.

[Pulmonary oedema as a complication of tocolytic therapy (author's transl)]. / Lungenödem als Tokolyse-Komplikation.

Tocolytic treatment with fenoterol and additional administration of betamethasone and acetyl salicylic acid to a 19-year-old girl caused irreversible and finally fatal pulmonary changes. The clinical course in this and that of other published cases indicates a causal relationship between the tocolytic treatment and the onset of pulmonary oedema. The pulmonary arterial pressures in this patient, the poor therapeutic response and the shock-lung picture without corresponding myocardial changes suggest a non-cardiogenic cause of pulmonary oedema. Any of the three drugs administered could have been responsible.

[Effects of long-term ventilation on the bronchial system. Bronchoscopic, cytologic and microbiological findings]. / Auswirkungen der Langzeitbeatmung auf das Bronchialsystem. Bronchoskopische, zytologische und mikrobiologische verlaufsuntersuchungen.

UNLABELLED: The effects of longterm ventilation were evaluated in 50 patients from a medical intensive care unit. The bronchial tract was investigated using repeated bronchoscopy and assessed by semiquantitative scoring. Prior to each endoscopy tracheal secretions were obtained for microbiological and cytological evaluation, in 20 patients histological analysis of the bronchial mucosa was done in addition. RESULTS: 1. Within 24-48 hours after initiation of respirator ventilation alterations of the bronchial mucosa occur. The extent progresses rapidly, however no further increase of progression is to be observed after ventilation of approximately 150-200 hours. 2. Endoscopic assessment of the severity of mucosal changes correlates well with cytological and histologic results. 3. In 34 patients microbial agents could be demonstrated. In 8 of them mucosal changes preceded demonstration of microbial organisms. The extent of mucosal changes is independent of category or count of pathogen. Endoscopic follow-up investigations of the bronchial tract affected by long-term ventilation serve both direct bronchial clearing and control of position of the intubation tube as well as assessment of mucosal alterations and control of treatment of bronchial infection.