[Guidelines for Non-Invasive and Invasive Home Mechanical Ventilation for Treatment of Chronic Respiratory Failure - Update 2017]. / S2k-Leitlinie: Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz ­ Revision 2017.

Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010 the German Society of Pneumology and Mechanical Ventilation (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure". However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines.For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning.In the current guidelines different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.The currently updated guidelines are valid for the next three years, following their first online publication on the home page of the Association of the Scientific Medical Societies in German (AWMF) in the beginning of July 2017. A subsequent revision of the guidelines remains the aim for the future.

Respiratory Muscle Assessment in Acute Guillain-Barré Syndrome.

PURPOSE: Guillain-Barré Syndrome (GBS) is a life-threatening disease due to respiratory muscle involvement. This study aimed at objectively assessing the course of respiratory muscle function in GBS subjects within the first week of admission to an intensive care unit. METHODS: Medical Research Council Sum Score (MRC-SS), vigorimetry, spirometry, and respiratory muscle function tests (inspiratory/expiratory muscle strength: PImax/PEmax, sniff nasal pressure: SnPna) were assessed twice daily. GBS Disability Score (GBS-DS) was assessed once daily. On days one (d1) and seven (d7), blood gases and twitch mouth pressure during magnetic phrenic nerve stimulation (Pmo,tw) were additionally evaluated. RESULTS: Nine subjects were included. MRC-SS, vigorimetry, PImax, and SnPna increased between d1 and d7. GBS-DS, spirometry and Pmo,tw remained unaltered. Only SnPna correlated closely with the MRC-SS on both d1 (r = 0.77, p = 0.02) and d7 (r = 0.74, p = 0.02). CONCLUSION: SnPna was the only parameter that correlated with MRC-SS, while the current gold standard of spirometry measurement did not.

[Respiratory Muscle Training: State of the Art]. / Atemmuskeltraining: State-of-the-Art.

Specific respiratory muscle training (IMT) improves the function of the inspiratory muscles. According to literature and clinical experience, there are 3 established methods: 1.) resistive load 2.) threshold load and 3.) normocapnic hyperpnea. Each training method and the associated devices have specific characteristics. Setting up an IMT should start with specific diagnostics of respiratory muscle function and be followed by detailed individual introduction to training. The aim of this review is to take a closer look at the different training methods for the most relevant indications and to discuss these results in the context of current literature. The group of neuromuscular diseases includes muscular dystrophy, spinal muscular atrophy, amyotrophic lateral sclerosis, paralysis of the phrenic nerve, and injuries to the spinal cord. Furthermore, interstitial lung diseases, sarcoidosis, left ventricular heart failure, pulmonary arterial hypertension (PAH), kyphoscoliosis and obesity are also discussed in this context. COPD, asthma, cystic fibrosis (CF) and non-CF-bronchiectasis are among the group of obstructive lung diseases. Last but not least, we summarize current knowledge on weaning from respirator in the context of physical activity.

Non-invasive ventilation in the treatment of sleep-related breathing disorders: A review and update.

Non-invasive mechanical ventilation (NIV) was originally used in patients with acute respiratory compromises or exacerbations of chronic respiratory diseases as an alternative to intubation. Over the last thirty years NIV has been used during the night in patients with stable chronic lung diseases such as obstructive sleep apnea, the overlap syndrome (COPD and obstructive sleep apnea), neuromuscular disorders, obesity-hypoventilation syndrome and in other conditions such as sleep disorders associated with congestive heart failure. In this review we discuss the different types of NIV, the specific conditions in which they can be used as well as the indications, recommendations, and evidence supporting the efficacy of NIV.

[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.

[Cardiac effects of noninvasive ventilation]. / Kardiale Wirkungen der nicht-invasiven Beatmung.

Noninvasive ventilation is becoming increasingly important in the treatment of acute and chronic respiratory failure. However, noninvasive ventilation not only influences respiratory failure but also cardiac (dys-)function. Furthermore, cardiac comorbidities are often present in systemic diseases with respiratory failure such as COPD or obesity hypoventilation syndrome. This review covers the (patho-)physiological causes of hypoxic and hypercapnic respiratory insufficiency and its treatment with noninvasive ventilation. A special focus on acute and chronic effects on cardiac function will be addressed.

[Non-invasive and invasive mechanical ventilation for treatment of chronic respiratory failure. S2-Guidelines published by the German Medical Association of Pneumology and Ventilatory Support]. / Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz. S2-Leitlinie herausgegeben von der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e. V.

The field of mechanical ventilation is highly important in pulmonary medicine. The German Medical Association of Pneumology and Ventilatory Support ["Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP)"] therefore has formulated these guidelines for home mechanical non-invasive and invasive ventilation. Non-invasive home mechanical ventilation can be administered using various facial masks; invasive home mechanical ventilation is performed via a tracheostomy. Home mechanical ventilation is widely and increasingly accepted as a treatment option for chronic ventilatory failure which most often occurs in COPD, restrictive lung diseases, obesity-hypoventilation syndrome and neuromuscular disorders. Essential for the initiation of home mechanical ventilation are the presence of symptoms of ventilatory failure and the detection of hypoventilation, most importantly hypercapnia. These guidelines comprise general indication criteria along with disease-specific criteria summarised by treatment algorithms. In addition, the management of bronchial secretions and care of paediatric patients are addressed. Home mechanical ventilation must be organised around a specialised respiratory care centre with expertise in patient selection, the initiation and the control of home mechanical ventilation. In this regard, the guidelines provide detailed information about technical requirements (equipment), control and settings of mechanical ventilation as well as organisation of patient care. A key requirement for home mechanical ventilation is the qualification of specialised home-care services, which is addressed in detail. Independent living and the quality of respiratory care are of highest priority in patients receiving home mechanical ventilation, since home mechanical ventilation can interfere with the integrity of a patient and often marks a life-sustaining therapy. Home mechanical ventilation has been shown to improve health-related quality of life of patients with chronic ventilatory failure. Long-term survival is improved in most patient groups, even though the long-term prognosis is often severely limited. For this reason, ethical issues regarding patient education, communication with ventilated patients at the end of life, living will, testament and medical care during the dying process are discussed.

Preserving oxygenation during walking in severe chronic obstructive pulmonary disease: noninvasive ventilation versus oxygen therapy.

BACKGROUND: Physical activity is known to cause significant deoxygenation in patients with severe chronic obstructive pulmonary disease (COPD). Although noninvasive positive pressure ventilation (NPPV) has been shown to improve oxygenation and physical activity in these patients, no practical approach for the application of NPPV during walking has yet been established. OBJECTIVE: To elucidate the most effective approach to preserving oxygenation during walking in patients with severe COPD receiving long-term NPPV. METHODS: Three 12-min walking tests were performed in a randomized cross-over design on 3 consecutive days, comparing the usual and double dosages of oxygen versus NPPV plus the usual dosage of oxygen. The ventilator and oxygen tank were placed in a backpack. RESULTS: Eleven patients (FEV(1) 26 +/- 9% predicted) completed the study, while 8 patients refused to walk with NPPV, due to the weight of the ventilatory device (7.3 kg with NPPV vs. 3.1 kg without). PaO(2) changes during walking differed [p = 0.01, repeated-measures (RM)-ANOVA], whereas dyspnea was unchanged. The difference in PaO(2) change was 14.0 +/- 16.6 mm Hg (unadjusted p = 0.0036, critical level = 0.017, RM-ANOVA) in favor of NPPV compared to the usual dosage of oxygen. Changes in FEV(1), tidal volume and inspiratory impedance were in favor of NPPV-aided exercise (all p < 0.05, RM-ANOVA). Walking distance was reduced under NPPV (555 +/- 227 m) compared to the usual (619 +/- 210 m) and double (622 +/- 215 m) dosages of oxygen (p = 0.024, RM-ANOVA). CONCLUSIONS: NPPV plus supplemental oxygen, but not oxygen alone, preserves oxygenation during walking in patients with severe COPD. However, dyspnea and walking distance were not improved due to the burden of carrying the heavy ventilatory equipment in a backpack.

Lung hyperinflation: foe or friend?

Breath-hold divers employ glossopharyngeal insufflation (GI) in order to prevent the lungs from compressing at great depth and to increase intrapulmonary oxygen stores, thus increasing breath-hold time. The presented case study shows the physiological data and dynamic magnetic resonance imaging (dMRI) findings of acute hyperinflation, deliberately induced by GI, in a breath-hold diver and discusses the current state of knowledge regarding the associated hazards of this unique competitive sport. Static and dynamic lung volumes and expiratory flows were within the normal range, with vital capacity and peak expiratory flow being higher than the predicted values. Airway resistance and diffusing capacity of the lung for carbon monoxide were normal. Static compliance was normal and increased five-fold with hyperinflation. dMRI revealed a preserved shape of the thorax and diaphragm with hyperinflation. A herniation of the lung beneath the sternum and enlargement of the costodiaphragmatic angle were additional findings during the GI manoeuvre. After expiration, complete resolution to baseline was demonstrated. Hyperinflation can be physiological and even protective under abnormal physical conditions in the sense of acute adaptation to deep breath-hold diving. Dynamic magnetic resonance imaging is adequate for visualisation of the sequence of the glossopharyngeal insufflation manoeuvre and the complete reversibility of deliberate hyperinflation.

Exercise in severe COPD: is walking different from stair-climbing?

BACKGROUND: It remains unclear whether the 6-min walking test can predict performance during stair-climbing in severe COPD patients. The present study aimed to assess different pathophysiological changes between walking and stair-climbing in these patients. METHODS: Sixteen COPD patients (mean FEV1 33+/-13% predicted) underwent a 6-min walking test and performed stair-climbing (44 steps) in a randomized, cross-over design. Blood gases, blood lactate, lung function parameters, maximal inspiratory mouth, sniff nasal and twitch mouth pressures, blood pressure, heart rate, and Borg Dyspnea Scale (BDS) were measured before and after exercise. RESULTS: The median drop of PaO2 during walking (2.6 mmHg) and stair-climbing (2.4 mmHg) was comparable (p=0.93). However, stair-climbing caused more dyspnea (median BDS 6.5 vs. 5.5, p=0.01), a higher median blood lactate (1.1 vs. 0.3 mmol/l p<0.001), a more pronounced drop in mean pH (-0.05+/-0.02 vs. -0.03+/-0.03, p=0.02) and a higher increase in mean systolic blood pressure (27+/-11 vs. 13+/-16 mmHg; p=0.009). Stair-climbing, but not walking, caused prolonged lung hyperinflation (mean TLC difference 4.4+/-4.7% predicted, p=0.003). There was no relationship between the 6-min walking distance (314+/-104 m) and the time needed for stair-climbing (55+/-33 s), nor were there any differences in inspiratory muscle strength and heart rate. CONCLUSION: Although the drop of PaO2 was comparable, stair-climbing resulted in more prolonged hyperinflation of the lungs, higher blood lactate production and more dyspnea than walking. The walking distance was not related to the time needed to manage stair-climbing. Therefore, pathophysiological changes during the 6-min walking test do not anticipate those during stair-climbing in patients with severe COPD.

Diabetic polyneuropathy is associated with respiratory muscle impairment in type 2 diabetes.

AIMS/HYPOTHESIS: Diabetes has a major negative effect on intensive care unit outcome. This has been partly attributed to impaired respiratory neuromuscular function. However, data on respiratory neuromuscular involvement in diabetes are lacking. This study therefore aimed to assess respiratory neuromuscular function related to diabetic polyneuropathy in patients with type 2 diabetes. METHODS: Respiratory neuromuscular function was assessed by the use of volitional tests and twitch mouth (TwPmo) and twitch transdiaphragmatic (TwPdi) pressures during non-volitional bilateral anterior magnetic phrenic nerve stimulation in 21 male type 2 diabetic patients without pulmonary disease and in 23 healthy, well-matched controls (forced expiratory volume in 1 s 103 +/- 11 vs 103 +/- 12% predicted; p = 0.9). RESULTS: Both volitionally assessed maximal inspiratory and expiratory mouth pressures, and sniff nasal and transdiaphragmatic pressures were comparable between diabetic patients and controls (p > 0.1 for all). TwPmo was reduced in diabetic patients compared with controls (1.3 +/- 0.5 vs 1.0 +/- 0.4 kPa; p = 0.04), while TwPdi was comparable (1.7 +/- 0.5 vs 1.6 +/- 0.7 kPa; p = 0.6). Following subgroup analysis, patients with no or mild polyneuropathy (n = 10) as assessed by neurological disability scoring had normal respiratory neuromuscular function, whereas patients with moderate or severe polyneuropathy (n = 11) presented with markedly impaired respiratory neuromuscular function as indicated by TwPmo (1.3 +/- 0.4 vs 0.8 +/- 0.3 kPa; p = 0.01) and TwPdi (1.9 +/- 0.6 vs 1.1 +/- 0.4 kPa; p < 0.01). CONCLUSIONS/INTERPRETATION: With regard to volitional tests, diabetes does not affect respiratory neuromuscular function. In contrast, the application of non-volitional phrenic nerve stimulation provides strong evidence that diabetic polyneuropathy, as simply assessed by neurological disability scoring, is associated with substantially impaired respiratory neuromuscular function in type 2 diabetic patients.