[Early Pulmonary Rehabilitation after Long Term Mechanical Ventilation]. / Pneumologische Frührehabilitation nach Langzeitbeatmung.

BACKGROUND: The term early rehabilitation is defined as a rehabilitation that begins in the early phase after acute illness and is statutory positioned in §â€Š39SGB V. Aim of this investigation is to describe the quality of outcome of pulmonary early rehabilitation. METHOD: Prospective census of functional parameters, status of ventilation and discharge-disposition in a specialized unit for early pulmonary rehabilitation over a period of one year. RESULTS: Out of 190 patients 179 (94.2 %) were previously invasively ventilated. During the treatment period of 39 ±â€Š17 days, FAM-Index increased from 84.4 ±â€Š19.8 to 118.5 ±â€Š23.3 (Ci 30.9 - 37.3, Cohen'd 1.58; p < 0.001), Barthel-Index from 30.5 ±â€Š13.8 to 58.3 ±â€Š16.2 (Ci 25.4 - 33.8, Cohen's d 1.4; p < 0.001) six minute walking distance from 12.9 ±â€Š40.1 m to 131.4 ±â€Š85.2 m (Ci 105.6 - 131.4 m, Cohn's d 1.78; p < 0.001). Patients were less likely to be receive further post-discharge rehabilitation if they were ventilated. CONCLUSION: Patients admitted to the early pulmonary rehabilitation unit were severely compromised, however quality of outcome was favourable and independent of the breathing status (spontaneously breathing vs. non-invasive ventilation or invasive ventilation). Finding discharge dispositions appeared to be more difficult if patients were ventilated.

[Limits and Ethics of Mechanical Ventilation and Intensive Care Medicine in Old Age]. / Grenzen und Ethik der Beatmung und Intensivmedizin im Alter.

Changing demography with more older people and more patients with chronic diseases as well as the progress of medicine leads to more geriatric patients treated in intensive care and requiring mechanical ventilation due to severe respiratory insufficiency.Frailty is associated with a more complicated intensive care stay, more difficult convalescence and with a higher mortality.In principle, geriatric expertise should be brought in as early as possible in the course of intensive care treatment for older patients in order to carry out adequate risk stratification and, depending on the extent of the impairment, to plan discharge or early rehabilitation.In older and frail patients preexisting chronic ventilatory insufficiency often leads to prolonged weaning. Patients with weaning failure should be referred to a specialized weaning center. Part of the assessment will be whether out-of-hospital invasive or non invasive ventilation is indicated and the wish of the patient.In intensive care the likelihood of a successful outcome and the patient's wishes must constantly be re-evaluated. This is particularly true in older patients. In addition it should be clarified with the patients and relatives what constitutes "success"; for example a patient may consider intensive care "worth it" if the ultimate goal is discharge to their own home but not if nursing home care and tracheostomy ventilation is the best that can be achieved. It may become apparent that a successful outcome is unlikely and then withdrawal of invasive ventilation is appropriate.

[Noninvasive Mechanical Ventilation in Acute Respiratory Failure]. / Nicht-invasive Beatmung als Therapie der akuten respiratorischen Insuffizienz.

The non-invasive ventilation (NIV) is widespread in the clinical medicine and has attained meanwhile a high value in the clinical daily routine. The application of NIV reduces the length of ICU stay and hospitalization as well as mortality of patients with hypercapnic acute respiratory failure. Patients with acute respiratory failure in context of a cardiopulmonary edema should be treated in addition to necessary cardiological interventions with continuous positive airway pressure (CPAP) or NIV. In case of other forms of acute hypoxaemic respiratory failure it is recommended the application of NIV to be limited to mild forms of ARDS as the application of NIV in severe forms of ARDS is associated with higher rates of treatment failure and mortality. In weaning process from invasive ventilation the NIV reduces the risk of reintubation essentially in hypercapnic patients. A delayed intubation of patients with NIV failure leads to an increase of mortality and should therefore be avoided. With appropriate monitoring in intensive care NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency. Furthermore NIV can be useful within palliative care for reduction of dyspnea and improving quality of life. The aim of the guideline update is, taking into account the growing scientific evidence, to outline the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.

S2k-Guideline "Prolonged Weaning".

All mechanically ventilated patients must be weaned from the ventilator at some stage. According to an International Consensus Conference the criteria for "prolonged weaning" are fulfilled if patients fail at least 3 weaning attempts (i. e. spontaneous breathing trial, SBT) or require more than 7 days of weaning after the first SBT. This occurs in about 15 - 20 % of patients.Because of the growing number of patients requiring prolonged weaning a German guideline on prolonged weaning has been developed. It is an initiative of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP) in cooperation with other societies (see acknowledgement) engaged in the field chaired by the Association of Scientific and Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF).This guideline deals with the definition, epidemiology, weaning categories, underlying pathophysiology, therapeutic strategies, the weaning unit, transition to out-of-hospital ventilation and therapeutic recommendations for end of life care. This short version summarises recommendations on prolonged weaning from the German guideline.

[Prolonged weaning: S2k-guideline published by the German Respiratory Society]. / Prolongiertes Weaning: S2k-Leitlinie herausgegeben von der Deutschen Gesellschaftfür Pneumologie und Beatmungsmedizin e.V.

Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by insufficiency of the respiratory muscles and/or lung parenchymal disease when/after other treatments, i. e. oxygen, body position, secretion management, medication or non invasive ventilation have failed.In the majority of ICU patients weaning is routine and does not present any problems. Nevertheless 40-50 % of the time during mechanical ventilation is spent on weaning. About 20 % of patients need continued MV despite resolution of the conditions which originally precipitated the need for MV.There maybe a combination of reasons; chronic lung disease, comorbidities, age and conditions acquired in ICU (critical care neuromyopathy, psychological problems). According to an International Consensus Conference the criteria for "prolonged weaning" are fulfilled if patients fail at least three weaning attempts or require more than 7 days of weaning after the first spontaneous breathing trial. Prolonged weaning is a challenge. An inter- and multi-disciplinary approach is essential for weaning success. Complex, difficult to wean patients who fulfill the criteria for "prolonged weaning" can still be successfully weaned in specialised weaning units in about 50% of cases.In patients with unsuccessful weaning, invasive mechanical ventilation has to be arranged either at home or in a long term care facility.This S2-guideline was developed because of the growing number of patients requiring prolonged weaning. It is an initiative of the German Respiratory Society (Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V., DGP) in cooperation with other societies engaged in the field.The guideline is based on a systematic literature review of other guidelines, the Cochrane Library and PubMed.The consensus project was chaired by the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften, AWMF) based on a formal interdisciplinary process applying the Delphi-concept. The guideline covers the following topics: Definitions, epidemiology, weaning categories, pathophysiology, the spectrum of treatment strategies, the weaning unit, discharge from hospital on MV and recommendations for end of life decisions. Special issues relating to paediatric patients were considered at the end of each chapter.The target audience for this guideline are intensivists, pneumologists, anesthesiologists, internists, cardiologists, surgeons, neurologists, pediatricians, geriatricians, palliative care clinicians, nurses, physiotherapists, respiratory therapists, ventilator manufacturers.The aim of the guideline is to disseminate current knowledge about prolonged weaning to all interested parties. Because there is a lack of clinical research data in this field the guideline is mainly based on expert opinion.

[Weaning from long-term mechanical ventilation: data of a single weaning center from 2007 to 2011]. / Entwöhnung von der Langzeitbeatmung: Daten eines Weaningzentrums von 2007 bis 2011.

INTRODUCTION: Regional weaning centers play a more and more important role in the weaning process of long-term ventilated patients. The medical center Kloster Grafschaft is one of the oldest and largest centers in Germany. There is very little published data from larger weaning centers in Europe. METHODS: From 2007 to 2011 all weaning patients were registered in a database. Additional information of the transferring hospitals was inquired. Prolonged weaning was defined by a period of at least 7 days of mechanical ventilation as well as three unsuccessful weaning trials. RESULTS: Data from 867 of 916 registered patients could be analyzed. 71.1% could be successfully weaned from mechanical ventilation. All patients were suffering from a hypercapnic insufficiency as well as a variety of secondary diagnoses, on average 15.1 per patient. The median of age was 70 years, 62 % were male. Prior to hospital transfer patients had been ventilated for a median of 41 days. Time to successful removal of the artificial airway was 8 days according to the DRG code directive and 13.4 days when non-invasive ventilation (NIV) time was included. Of the 616 patients who could be successfully weaned, 42 % were discharged on NIV. Out of the 251 patients who could not be weaned, 107 were discharged. The remaining 144 (16.7 %) patients died, 33 % due to the primary underlying disease or a complication. 66 % of the deceased patients received palliative care. Patients with successful and unsuccessful weaning did not differ by age, by duration of mechanical ventilation or time until tracheostomy. Postoperative patients could be weaned more often than medical patients (p < 0.05). Discrimination between patients with successful and unsuccessful weaning was not possible by the point in time of the first spontaneous breathing trial in regard to the duration of ventilation but only by the duration of this trial after transfer to our unit (150 vs. 60 min; p < 10-6). The TISS-28 and the SAPS-II-Score did not differ between the two groups. Patients with successful weaning had less agitation according to the RASS-Score (0.47 vs. 0.15; p < 0.005). CONCLUSION: It becomes apparent that in a specialized weaning center the majority of difficult to wean patients can be liberated in short time from mechanical ventilation.

[Cerebral arterial gas embolism as complication during the therapeutic endobronchial use of argon plasma coagulation]. / Zerebrale arterielle Gasembolie als Komplikation während einer therapeutischen endobronchialen Anwendung der Argon-Plasma-Koagulation.

In this case report, argon plasma coagulation (APC) was applied in a male individual to treat an occluding tumour of the right middle lobe bronchus with a post-stenotic atelectasis. During attempted recanalisation, the patient suffered a cerebral gas embolism as seen on CT scan, resulting in a distinct neurological deficit. We discuss the available data about cerebral gas embolism as a complication of APC and possibilities to avoid such complications.

[Frequency and influence of nosocomial pathogens on weaning outcome and in-hospital mortality in mechanically ventilated patients in a regional weaning centre in comparison of the years 2002 and 2006]. / Häufigkeit und Bedeutung von Bakterienisolaten bei langzeitbeatmeten Patienten und deren Einfluss auf das Weaning-Outcome und die Hospital-Letalität in einem überregionalen Weaningzentrum im Verlauf.

BACKGROUND: Patients with nosocomial infections in the intensive care unit (ICU) seem to have a poor prognosis. In this retrospective cohort study we investigated the relationship between weaning outcome, in-hospital mortality and the microbiological proof of nosocomial pathogens from secretions in mechanically ventilated patients in the years 2002 and 2006. PATIENTS AND METHODS: 311 patients with long term (> 14 days) invasive (tube or tracheostomy) mechanical ventilation (MV) were enrolled in to the study when they had failed at least two weaning attempts prior to transfer. Microbiological proof of nosocomial pathogens from secretions sampled by the bronchoscope and an X-ray of the chest on admission day (in the transferring ICU and in our ICU) was collected from all patients. RESULTS: There was a significant decline of the weaning success rate between 2002 and 2006 (p = 0.001). The In-hospital mortality was higher in 2006 (p = 0.03). The microbiological proof of nosocomial pathogens had no influence on the weanability (exception: MRSA patients in 2002). In both years, patients with infiltrates on X-ray of the chest showed no increased mortality. But in 2006 it took longer to liberate these patients from invasive MV. In 2002 microbiological proof of pathogens was related to higher in-hospital mortality. In 2006, there was no difference concerning mortality in both groups. CONCLUSIONS: Proof of nosocomial pathogens and infiltrates had no influence on the weanability of long-term mechanically ventilated patients. For in-hospital mortality, the results are contradictory.

[Time-adaptive mode, a new ventilation form for the treatment of respiratory insufficiency--a self-learning system]. / Time-adaptiver Modus, eine neue Beatmungsform zur Behandlung der ventilatorischen Insuffizienz--ein selbstlernendes System.

Hypercapnic respiratory failure is usually caused by an overload of the respiratory muscles (respiratory pump). After treatment of the underlying disease, mechanical ventilation will achieve optimal treatment success and higher degrees of respiratory muscle unloading will improve the outcome in terms of lower PaCO (2) levels and improved exercise performance. Routinely assisted modes are being used for ventilation, where the patient has to trigger the ventilator with his effort. Controlled ventilation is usually applied in sedated patients lacking spontaneous breathing efforts that are necessary to trigger the ventilator. Controlled ventilation, however, is feasible in awake patients but requires operator expertise. In this process, the respiratory pattern of the ventilator has to be adapted to the patient's own respiratory pattern. Changing conditions require a re-adaptation of parameters. In order to automatise this complex and time-consuming operation, a time-adaptive mode (TA-mode) has been developed. This programmed mode incorporates a self-learning algorithm, primarily detecting the patient's respiratory pattern. The software then calculates a matching flow profile using a motion equation that gives consideration to resistance and compliance. The operator has to pre-select allowed ranges of parameters (especially in- and expiratory pressures, IPAP and EPAP). After detection of a stable respiratory pattern (usually after 10 - 20 breaths), the ventilator will slowly increase the calculated flow profile and achieve controlled ventilation without irritating respiratory centres of the brain. Respiratory drive will cease usually within three to five minutes. Restart of the respiratory drive, for example, after coughing or during REM sleep with an altered respiratory pattern will be detected as ventilator fighting and the programme will return to the analysis algorithm again. After the respiratory pattern has become stable, the ventilator will take over ventilation again. The new mode has been validated in an accreditation study. For this purpose we selected 21 patients with stable hypercapnic respiratory failure, most of whom (20) had previously been ventilated with a controlled T-mode and only one patient had previously been ventilated with an assisted mode and adapted them to the new ventilator under polygraphic surveillance. Each time seven patients were adapted to a T-, ST- and TA-mode, respectively. Two patients, however, could not be adapted to ST-mode ventilation and were switched to TA-mode. PCO (2) values before and after ventilation were not significantly different between modes. Patient satisfaction was rated very good in 34 %, good in 45 % and non-gratifying in 21 % of cases ventilated with TA-mode. Consideration has to be given to the fact that patients previously had been receiving optimal ventilator treatment. The TA-mode is a self-learning system, capable of copying the patients own breathing pattern while awake, in order to achieve complete unloading of the respiratory muscles through controlled ventilation during a circumscribed period.

[Weaning from mechanical ventilation. A survey of the situation in pneumologic respiratory facilities in Germany]. / Entwöhnung von der Beatmungstherapie. Eine Erhebung zur Situation pneumologischer Beatmungszentren in Deutschland.

BACKGROUND AND OBJECTIVE: The prevalence of difficult or prolonged weaning from mechanical ventilation is increasing because of a growing number of elderly patients with multiple diseases and pulmonary problems requiring mechanical ventilation. Intensive care units (ICU) are inclined to refer to specialized unit those patients who are difficult to wean. A nationwide survey of German facilities was conducted and this article reports the current state of weaning centers staffed by chest physicians. PATIENTS AND METHODS: 38 centers participated in the survey, which was divided into 10 items, covering characteristics of the hospital, weaning strategies, patients and outcomes during 2006. The survey included 2718 patients in whom weaning was difficult or prolonged. Almost three quarters of patients were transferred to one of the weaning centers from the ICU of another hospital. RESULTS: The weaning success rate was 66.4%. In 31,9 % of patients home mechanical ventilation was started after they had been weaned. The overall hospital mortality rate was 20.8%. There were major differences between individual centres concerning the number of patients, organization of the weaning unit and weaning strategies. CONCLUSIONS: Weaning was successful in two thirds of patients who had been on prolonged mechanical ventilation and had then been transferred to weaning facilities staffed by chest physicians. These centres effectively improved the quality of care of patients on prolonged mechanical ventilation by avoiding long-term invasive ventilation and sparing cost-intensive ICU resources. The problems that still exist may be overcome by a network of weaning facilities.

[Expiratory pressure reduction (C-Flex Method) versus fix CPAP in the therapy for obstructive sleep apnoea]. / Exspiratorische Druckabsenkung (C-Flex) versus konstantem CPAP in der Therapie schlafbezogener obstruktiver Atemstörungen.

INTRODUCTION: The REM star C-Flex (Fa. Respironics) was introduced in 2003. In contrast to the conventionel fix CPAP mode, the C-Flex mode is characterised by a pressure reduction at the beginning of expiration. In a randomised cross-over design, we investigated if this C-Flex-mode has advantages compared to the fix CPAP mode in terms of treatment quality and patient satisfaction. METHODS: In this prospective randomised single-blinded cross-over study we investigated 20 patients with obstructive sleep apnoea treated with fix CPAP versus treatment with the C-Flex mode (level 2) for 6 weeks, respectively. We compared the polysomnographically measured quality of treatment and the subjective satisfaction of either form of therapy. Additionally, we measured long-term compliance of the C-Flex therapy in a 3-year follow-up with the integrated counter of the C-Flex devices. RESULTS: The mean levels of pressure of the fix CPAP and the C-Flex therapies were 8.4 +/- 2.9 mbar in both groups. There was an identical quality of treatment in terms of respiratory events, arousal index, slow wave sleep and Epworth sleepiness scale. The compliance of nocturnal use of the C-Flex and the fix CPAP was identical (6.0 +/- 0.67 C-Flex use vs. 5.8 +/- 0.98 CPAP use [h/night]). The subjective satisfaction was higher in the C-Flex mode at the end of the study since 18 of 20 patients (90%) subjectively prefered the C-Flex mode because of the easier expiration. 19 patients received a C-Flex device for long-term therapy. The 3-year-follow-up showed a regular utilisation of the C-Flex by 16 of 19 (84.2%) of these patients (mean nocturnal use 6.0 +/- 0.9 h/night). 3 of the 19 patients (15.8%) did not use their C-Flex regulary. None of the patients has terminated therapy completely. CONCLUSION: C-Flex mode and the conventional fix CPAP therapies show an equivalent treatment quality according to polysomnographic data. The expiratory pressure reduction compared to conventional CPAP was felt to be more comfortable by 90% of patients. The long-term-compliance as measured by regular use of the C-Flex device was 84.2% (16 out of 19 patients) after 3 years, these numbers are higher than published data on compliance with conventional CPAP therapy.

[Difficult weaning]. / Schwierige Entwöhnung vom Respirator: Beatmung und weitere Strategien.

Respiratory failure as a result of overload and/or reduced capacity of the respiratory muscles is the most common cause of unsuccessful weaning and the need for long term mechanical ventilation. Chronic obstructive pulmonary disease (COPD) is the most common underlying cause leading into long term mechanical ventilation. The most important clinical parameter for fatigue of the respiratory muscles is the rapid shallow breathing index. Other essential factors which impact weaning failure, are the underlying diseases (e. g. neuromuscular disease or heart failure), micro- and macro aspiration, malnutrition, anemia and obesity. A protocol based strategy to discontinue mechanical ventilation and the use of weaning predictors are helpful. Nonetheless the experienced physician is irreplacable in the weaning process. Reconditioning of the respiratory muscles is the main focus during weaning after long term mechanical ventilation and all therapeutic measures should be targeted to unload the fatiguing respiratory muscles. With the widely used assisted ventilation modes, the inspiratory work of breathing is still significantly increased. Only controlled mechanical ventilation (pressure- or volume controlled), which may also be applied to unsedated patients when individually adapted, offers the best possible relief and recovery of the respiratory muscles. Additional strategies, such as the balancing of anemia, reduction of the respiratory drive with i. e. morphine derivates, oxygen therapy during spontaneous-breathing trials and supine position for patients with obesity contribute to the recovery. Particularly patients with chronic lung diseases with hypercapnia benefit from the use of non invasive ventilation (NIV) after extubation to prevent postextubation failure and even after tracheostomy. However, NIV should only be applied under close monitoring and in cooperative patients, always considering the limits of the method. Dying under mechanical ventilation in the end stage illness is still a challenge for all involved persons. In the end stage of their disease for some patients it is possible to discontinue mechanical ventilation so they can spend the last period of their lives on a normal ward or even at home.

[Positive pressure ventilation in Cheyne-Stokes respiration]. / Positivdruckverfahren bei Cheyne-Stokes-Atmung infolge chronischer Herzerkrankung.

Cheyne-Stokes respiration (CSR) is found in patients with chronic left ventricular failure and associated with a reduced prognosis. Continuous positive airway pressure (CPAP) improves the survival rate. In this retrospective study we report on the effect of different positive pressure ventilation modes in CSR. The observation period lasted from 1995 - 1999. Inclusion criteria was CSR with a respiratory disturbance index > 10/h whereas > 50 % of the events had to be central and/or mixed. In each patient a 4 week lasting intervention with each of CPAP, Bilevel CPAP in spontan mode (i.e. BiPAP S or BiPAP ST) and BiPAP in controlled mode (i.e. BiPAP T) was performed. Responder were defined by subjective and objective criteria. In total 41 males were included. Responder were distributed as follows: CPAP: n = 13 patients (31.7 %), BiPAP S/ST: n = 9 patients (22.0 %) and BiPAP T: n = 12 patients (29.3 %). In total 7 from 41 patients (17.1 %) rejected a long-term treatment with positive pressure ventilation. The majority of patients with CSR responded to CPAP and BiPAP S/ST mode. Compared to the other responder groups the best quality was reached with BiPAP T. However the latter was performed only by 29 % of the population.

Long term effects of non-invasive mechanical ventilation on pulmonary haemodynamics in patients with chronic respiratory failure.

BACKGROUND: It is not known whether long term nocturnal mechanical ventilation (NMV) reduces pulmonary hypertension in patients with chronic respiratory failure (CRF). METHODS: Pulmonary haemodynamics, spirometric values, and gas exchange were studied in 33 patients requiring NMV due to CRF (20 with thoracic restriction, 13 with chronic obstructive pulmonary disease (COPD)) at baseline and after 1 year of NMV given in the volume cycled mode. Patients with COPD also received supplemental oxygen. RESULTS: Long term NMV improved gas exchange while lung function remained unchanged. Mean pulmonary artery pressure at rest before NMV was higher in patients with thoracic restriction than in those with COPD (33 (10) mm Hg v 25 (6) mm Hg). After 1 year of NMV mean pulmonary artery pressure decreased in patients with thoracic restriction to 25 (6) mm Hg (mean change -8.5 mm Hg (95% CI -12.6 to -4.3), p<0.01) but did not change significantly in patients with COPD (mean change 2.2 mm Hg (95% CI -0.3 to 4.8)). CONCLUSIONS: Long term NMV in CRF improves pulmonary haemodynamics in patients with thoracic restriction but not in patients with COPD.

[Effect of intermittent ventilation on pulmonary hypertension in chronic respiratory failure]. / Auswirkungen der intermittierenden Selbstbeatmung auf die pulmonale Hypertonie bei chronisch ventilatorischer Insuffizienz.

Intermittent non-invasive (or nocturnal mechanical ventilation) eliminates symptoms of hypoventilation and improves gas exchange in patients with chronic respiratory failure. Performing right heart catheterisation we studied the influence of nocturnal mechanical ventilation on pulmonary hemodynamics. We investigated 20 patients with restrictive thoracic diseases (Post-TBC: n = 9, scoliosis: n = 11, PaCO2: 59.8 +/- 7.6 mmHg) and 13 patients with COPD (n = 13, PaCO2: 58.5 +/- 7.8 mmHg). All patients were mechanically ventilated in controlled mode. During the study the medication was not changed; COPD patients with long-term oxygen maintained this therapy. Right-heart catheterisation was performed immediately before and after 1 year nocturnal mechanical ventilation. In patients with thoracic restriction NMV induced a marked reduction of pulmonary artery pressure (PAP) from 33.2 +/- 10.0 mmHg before to 24.8 +/- 6.2 mmHg after 1 year nocturnal mechanical ventilation. In the COPD group PAP increased from 25.3 +/- 6.0 mmHg before to 27.5 +/- 6.0 mmHg after 1 year nocturnal mechanical ventilation. In contrast to the COPD group in patients with chronic respiratory failure due to thoracic restriction nocturnal mechanical ventilation causes substantial reduction in pulmonary artery pressure after a one year application.

[Evaluation of daily activity in patients with COPD]. / Reproduzierbarkeit der Messung der körperlichen Aktivität bei Patienten mit COPD.

BACKGROUND: Recently we could show that the daily activity in patients with hypercapnic respiratory failure as judged by the total amount of movements per day increased by 120% after 3 months of non-invasive mechanical ventilation. This study was designed to evaluate the reproducibility of the result of a movement detector in measuring daily activity of patients with COPD. PATIENTS AND METHODS: 25 outpatients (11 females, 56 +/- 12 years old) with stable non-hypercapnic COPD (FEV1 = 47 +/- 9% predicted) were examined twice during a 7 days lasting interval, one month apart using a pedometer. RESULTS AND CONCLUSIONS: The repeatability of the activity counts in the non-hypercapnic COPD patients was high (1st study period: 3,781 +/- 2,320 movements/d, 2nd study period: 3,626 +/- 2,149 movements/d) and in these patients activity correlated significantly with FEV1 (r = 0.54, p = 0.006).

Scintigraphy for evaluating early aspiration after oral feeding in patients receiving prolonged ventilation via tracheostomy.

OBJECTIVE: In tracheotomised patients the incidence of aspiration is difficult to determine because investigators often apply different criteria. In this study a scintigraphic method was used to visualise feeding aspiration directly and the results were compared with clinical evidence of aspiration. DESIGN: Prospective study in difficult-to-wean patients with tracheostomy. SETTING: Respiratory ICU. PATIENTS AND METHODS: The study population consisted of 62 consecutive patients (16 females, age: 64.1+/-11.1 years). All patients were tracheotomised and had previously been long-term ventilated in other ICUs due to weaning failure. The scintigraphic test was performed during spontaneous breathing. The standard nutrition consisted of a liquid, semi-liquid and solid meal which was labelled with 100 MBq 99mTc-human serum albumin. MEASUREMENTS AND RESULTS: Scintigraphic aspiration (SA) was defined as positive if radioactivity was detected in the bronchial system using a scintillation camera. Furthermore, aspiration was proven clinically (CA). CA and SA yielded identical results in 54 of the 62 patients [10 positive (16%) and in 44 negative (71%)]. CA, but not SA, was seen in 4/62 (6.5%) and SA, but not CA, was found in 4/62 (6.5%) patients. CONCLUSIONS: Our data re-emphasise that aspiration in tracheotomised patients is common (in our study approximately 30%). The scintigraphic method failed to identify all tracheotomised patients with clinically significant aspiration; however, it did suggest that some patients had subclinical aspiration.

[Work of breathing in differentiation of various forms of sleep-related breathing disorders]. / Atemarbeit zur Differenzierung verschiedener Formen der schlafbezogenen Atmungsstörung.

BACKGROUND: In contrast to the obstructive sleep apnoea syndrome (OSA) the obesity-hypoventilation syndrome (OHS) is characterised by persistent hypercapnia during the day and predominant hypoventilation during sleep. In this study we wanted to know whether work of breathing (WOB) in a sitting and supine position separates both groups. PATIENTS AND METHODS: OSA population: 20 men, 50.5 +/- 9.2 years, Body Mass Index (BMI: 54.1 +/- 6.9 kg/m2, pO2: 65.6 +/- 6.6 mmHg, pCO2: 40.6 +/- 3.1 mmHg, OHS-group: 14 patients, 13 men age: 53.1 +/- 9.3 years, BMI: 53.1 +/- 9.3 kg/m2, pO2: 51.8 +/- 10.5 mmHg, pCO2: 53.8 +/- 9.2 mmHg. The control group consisted of 10 normal weighted subjects. The intrathoracic pressures were assessed by an oesophageal catheter; at the same time, the minute ventilation (VE) and the breathing frequency (fb) were measured via a pneumotachygraph. The area under the pressure-volume loop was correlated to WOB. After reaching steady state VE, fb, and WOB were determined in sitting and supine position. RESULTS: In the OSA-group the apnoea index (AI) was 48.6 +/- 17.7/h and the respiratory disturbance index (RDI) was 66.3 +/- 19.4/h. The forced expiratory volume (FEV1) was 77.3 +/- 23% pred. and the vital capacity (VC) was 76.3 +/- 18.6% pred.; 7 out of 20 patients suffered from chronic bronchitis. In the OHS-group the AI was 21.5 +/- 19/h and the RDI 44.3 +/- 28.2/h. The majority of OHS patients had an airway obstruction (FEV1: 55.8 +/- 17.5% pred., VC: 58.8 +/- 12.8% pred.); 12 out of 14 patients suffered from chronic bronchitis. Compared to the OSA population WOB in the OHS group was significantly higher both in the sitting (0.67 +/- 0.28 J/I versus 1.04 +/- 0.32 J/I, p < 0.001) and supine positions (1.23 +/- 0.25 J/I versus 1.91 +/- 0.43 J/I, p < 0.001). Compared to the sitting position VE and fb did not change significantly in both groups lying supine. CONCLUSIONS: Compared to the OSA group at the same BMI the WOB of the OHS population was significantly increased in the sitting and supine position. The main reason for these findings may be the increased airway obstruction due to chronic bronchitis. Both populations did not change the breathing patterns during the different positions.

[Value of various intra- and extraoral therapeutic procedures for treatment of obstructive sleep apnea and snoring]. / Wertigkeit verschiedener intra- und extraoraler Therapieverfahren für die Behandlung der obstruktiven Schlafapnoe und des Schnarchens.

BACKGROUND: Recently intra- and extraoral devices are increasingly used in order to treat obstructive sleep apnea (OSA) and snoring. We examined the value of some devices according to the literature and our own results. PATIENTS AND METHODS: The mandibular advancing devices aim at increasing upper airway diameter. The active part of the tongue extending device (SnorEx) is a stamp connected to a piston which exerts pressure at the base of the tongue causing its forward displacement; we studied 23 patients. The principle of an optically stimulating system ("eye-cover", Snore-Stop) consists of a microphone and light diods which are integrated in the eye-cover. After detecting acoustic signals (for example snoring) optical stimuli are generated in front of the eyes, which are thought to induce arousals causing a change of body position and the reduction of the snoring and apneas; we measured 24 patients. The principle of the tongue-retainer (Snore-Master) is the fixation of the tongue in a ventral position, which is thought to enlarge the mesopharyngeal area; we studied 14 patients. The nose plaster (Breathe-Right) contains an elastic spine that pulls the alae nasi cranial. This manipulation is thought to increase the diameter of the nostril and reduce the airway resistance. We measured 30 patients with obstructive sleep apnea and 20 snoring subjects without obstructive sleep apnea. RESULTS: Regarding the mandibular advancing due to different appliance designs and study protocols variable success rates have been documented. In patients with mild to moderate obstructive sleep apnea a reduction of the sleep related breathing disorder could be shown. Non compliance (NC) to the tongue extending device was 75% (17/23). Non-compliance-patients were characterized by unacceptable local-side-effects of the prosthesis, lacking improvement of symptoms and of the respiratory disturbance index. Both tongue-retainer and -extensor are characterized by a high incidence of local side effects. Neither the eye-cover nor the nose plaster could improve the severity of obstructive sleep apnoe or snoring. In contrast to another study we could not show a significant effect of the tongue-retainer. CONCLUSIONS: Neither the nose plaster nor the optical stimulating device influenced the degree of obstructive sleep apnea and snoring. There are conflicting data regarding the tongue retainer. The high rate of non-compliant subjects and the low efficacy of the tongue extending prosthesis precludes large-scale use of this treatment modality in patients with obstructive sleep apnoe and snoring. In selected individuals suffering from a mild to moderate degree of obstructive sleep apnea with CPAP-inefficiency and -incompliance the mandibular advancing principle may be an therapeutic alternative to CPAP.

[Optical stimulation method (Snore-Stop) and tongue retainer (Snore-Master) without relevance in therapy of obstructive sleep apnea and snoring]. / Optisches Stimulationsverfahren (Snore-stop) und Zungenretainer (Snore-master) ohne Relevanz in der Therapie der obstruktiven Schlafapnoe und des Schnarchens.

Recently intra- und extraoral devices are increasingly used in order to treat obstructive sleep apnea and snoring. We examined the value of an optically stimulating system ("eye-cover", Snore-Stop) and a tongue-retainer (Snore-Master) as treatment of the obstructive sleep apnoe or snoring. In case of the eye-cover is a microphone integrated, which detects acoustic signals (e.g. snoring). After detection of snoring optical stimuli are generated in front of the eyes. This is intended to induce an arousal of the patient, without awaking him, causing a change of body position and this reduces the snoring or apneas. For the examination of the eye-cover in 26 patients (23 men, 55.6 +/- 10.3 years) polygraphic studies were performed while sleeping one night with the eye-cover and one night without, respectively. Visual analogue scales (VAS) were used in order to measure quality of life and sleep and the adverse effects of the device. To examine the tongue-retainer 14 patients (13 men, aged 52.9 +/- 11.8 years) were measured polygraphically. Again the subjective scores were assessed using the VAS. The principle of the tongue-retainer is to create a hollow space in front of the teeth, in which the tongue is positioned. Fixation of the tongue in this ventral position is thought to enlarge the mesopharyngeal area in order to reduce the upper airway obstruction. For both devices the index of snoring, the apnea-hypopnea-index, the index of desaturation, the mean and minimal SaO2 and SaO2 < 90 % in % of the night did not change significantly. Furthermore the subjective perception of the patients concerning their quality of sleep and life did not change. Moreover, despite of an adequate adaptation-period the use of the tongue-retainer was associated with considerable adverse effects. Neither the eye-cover nor the tongue-retainer could improve the severity of obstructive sleep apnoe or snoring.