[Weaning from mechanical ventilation. Weaning categories and weaning concepts]. / Entwöhnung von der mechanischen Beatmung. Weaningkategorien und Weaningkonzepte.

The international classification of three weaning categories (simple weaning, difficult weaning, prolonged weaning) has been modified in the German weaning guidelines: the group of prolonged weaning has been subclassified into weaning without noninvasive ventilation (NIV), weaning with NIV, if necessary with continuing NIV in the form of home mechanical ventilation, and weaning failure.Strategies to prevent prolonged weaning comprise daily interruption of sedation, daily screening of capability of spontaneous breathing by a spontaneous breathing trial (SBT) and early implementation of NIV instead of continuing invasive mechanical ventilation especially in hypercapnic patients. The comorbidity left heart failure plays a major role in weaning failure and need for re-intubation-in this case early diagnosis and if necessary modification of heart therapy are important.Specialised weaning-centres offer the option for successful weaning for about 50-60 % of patients declared as unweanable by usual intensive care units. A multimodal therapy concept with respiratory therapists, physiotherapists and speech therapy is necessary to reach this goal. In case of weaning failure a professional discharge management to invasive home mechanical ventilation is important. Competent care by physicians in the out-of-hospital area is restricted by the sectoral division of responsibility by the German health care system. Improvement in this area is urgently needed.

[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.

[Ventilation and analgo-sedation]. / Beatmung und Analgosedierung.

Every patient receiving invasive mechanical ventilation needs an adequate analgesia and sedation. Based on validated scores, the individual titration of sedation and analgesia aims to maximise patient comfort and optimise patient-ventilator synchrony. By regular re-evaluation (e. g., three times a day) of the drug doses a day-night-time rhythm, with a deeper sedation during the night, can be achieved. It is important to know that the recommendations concerning the drug doses are often based on a single application, which does not reflect the real elimination kinetics of a continuous drug delivery. This may significantly change in critically ill patients. Using a modern concept of analgo-sedation, it is often possible to establish spontaneous breathing during mechanical ventilation and to promote successful early weaning of the patient.

[Principles and function of mechanical ventilation: classification and modes of ventilators]. / Grundprinzipien und Arbeitsweise von Beatmungsmaschinen: Klassifikation und Modi.

A spectrum of diseases is associated with the necessity for partial or total support of pulmonary ventilation. The insight into the function of ventilators and their modes reduces the spectrum of ventilatory support to a few basic principles. The knowledge enables the pulmonary intensivist to adapt mechanical ventilation to the individual patient's needs. This overview describes the technical aspects of mechanical ventilation and summarizes the variety of specific modes implied.

[Role of serum adenosine deaminase as an immune parameter of tuberculosis]. / Die Rolle der Serum-Adenosindeaminase als Immunparameter der Tuberkulose.

We measured serum levels of adenosine-deaminase (ADA) in 44 tuberculosis patients, 70 patients with lung cancer pre treatment, and 130 normal blood donors. Increased ADA levels were found in 64.4% of the tuberculosis patients, in 95.2% in the case of bacillary tuberculosis, but only in 2.8% in the tumor patients. ADA serum levels were statistically significantly increased in tuberculosis patients when compared to lung cancer patients and controls and did not differ between controls and the tumor group. We conclude that serum ADA is a selective marker of immune stimulation in tuberculosis but not in lung cancer. Serum levels positively correlated to the disease extent in tuberculosis of immunocompetent patients. This marker deserves further investigation with respect to its clinical significance.

[Chronic pulmonary berylliosis: imaging with high-resolution computerized tomography]. / Chronische pulmonale Berylliose: Darstellung mit der hochauflösenden Computertomographie.

Chronic pulmonary berylliosis presents both in computed tomography, including high resolution techniques, and in plain radiographs of the chest with unspecific results: subpleural micronodular changes, thickening of interlobular septa, occurrence of intralobular septa, traction bronchiectasis, and honeycombing. Conspicuous in high resolution expiratory scans are density inhomogeneities which are interpreted as expiratory obstructions in small airways with ventilation-perfusion mismatches that accompany respiratory partial insufficiency. A differentiation from other pneumoconioses or other interstitial pulmonary diseases is not possible. The significance of CT lies in the exact documentation of the localization and extent of the lesions and in evaluation.

[Detection of a bronchopleural fistula with spiral CT and 3D reconstruction]. / Nachweis einer bronchopleuralen Fistel mit der Spiral-CT und 3D-Rekonstruktion.

A patient with a carcinoma of the oral cavity, pleural empyema, persisting seropneumothorax, and suspected bronchopleural fistula underwent computed tomography for further evaluation. Volume acquisition using the spiral technique was the prerequisite for three-dimensional reconstruction, which was done by minimum intensity-projection and seed-based "volume of interest" segmentation. The diagnosis "bronchopleural fistula", which was displayed in its entire course, was confirmed.

[Solitary epithelioid hemangioendothelioma, a rare vascular tumor of the lung]. / Solitäres epitheloides Hämangioendotheliom (Epitheloid haemangioendothelioma), ein seltener vaskulärer Tumor der Lunge.

The following case report describes a solitary epithelioid haemangioendothelioma of the lung as an uncommon radiomorphologic differential diagnosis of an aspergilloma. Epithelioid haemangioendotheliomas are rare low-grade malignant mesenchymal tumours that typically appear multifocally in the body.

[The use of low-molecular heparin for anticoagulation in pregnancy]. / Einsatz von niedermolekularem Heparin zur Antikoagulation in der Schwangerschaft.

A 26-year-old woman, on bedrest since the 6th week of pregnancy because of threatened abortion, developed thrombosis in the left iliac, superficial femoral and common femoral veins with small pulmonary emboli in the 11th week. Inhibitor deficiency was excluded. The thrombosis was only partially recanalized by unfractionated heparin at therapeutic dosage (38,400 IU per 24 h). As thrombolysis treatment and oral anticoagulation were contraindicated because of the threatened abortion, coagulation with low molecular weight heparin (LMWH) was started in the 18th week (5000 anti-Xa units daily subcutaneously). Maximal anti-Xa activity in plasma never exceeded 0.3 U/ml and there were no complications. The patient was delivered of a healthy girl (2,660 g, 48 cm) by caesarean section in the 37th week. Immediately post-partum LMWH was demonstrated with an anti-Xa activity of 0.3 U/ml in maternal blood, but none in simultaneously obtained cord venous blood. This case suggests that treatment of phlebothrombosis with LMWH is a reasonable measure even during pregnancy.

[Prognostic factors of small-cell bronchial carcinoma]. / Prognosefaktoren des kleinzelligen Bronchialkarzinoms.

137 patients with small cell lung cancer (SCLC) were retrospectively analysed. The median survival for all patients were 284 days, for limited disease patients 399 days, and for extensive disease patients 252 days. Univariate statistical analysis based on Kaplan-Meier-estimates and Log-Rank-Test showed the following prognostically beneficial factors: Limited disease stage (p = 0.009), NSE serum level less than 25 micrograms/l (p = 0.016), serum alkaline phosphatase less than 200 U/l (p = 0.035), normal serum albumin (p = 0.003) and activity index of minimum of 70 (p < 0.001). The patient age and sex did not image as relevant prognostical factors.

[Diagnosis of pleural effusions and atelectases: sonography and radiology compared]. / Diagnostik von Pleuraergüssen und Atelektasen: Sonographie und Radiologie im Vergleich.

In a prospective study it was shown that chest ultrasonography is superior to conventional x-ray diagnosis of recumbent patients in diagnosing pleural effusion and lung atelectasis. In 110 supine radiographs we found a sensitivity of 47% and a specificity of 71% for right pleural effusions and a sensitivity of 55% and a specificity of 93% for left pleural effusions in comparison to 110 sonographic examinations. The results of supine radiographs in detection of atelectasis were less efficient: sensitivity for the right side: 7%; sensitivity for the left side: 13.5%. Hence, the knowledge of chest ultrasonographic diagnosis can improve the interpretation of supine radiographs.

[Ultrasound scanning of thickening of the gallbladder wall and its diagnostic significance in critical care patients]. / Die sonographische Gallenblasenwandverdickung und ihre diagnostische Bedeutung bei intensivpflichtigen Patienten.

In a prospective study including 398 intensive-care patients, we analysed the ultrasonographic relevance of a gallbladder wall thickening. In 24 of 398 (6%) cases a wall thickening was found that could be differentiated into two types of walls. In 20.8% (5/24) the gallbladder wall thickening was an expression of an acute cholecystitis. In further differential diagnosis of a gallbladder wall thickening pathological states with hypoalbuminaemia occupy the prime position. The pathological mechanism has not yet been completely clarified. Hypoalbuminaemia without inflammatory alterations of the organ was found in 37.5% of the cases with gallbladder wall thickening. In 41.6% of the patients the wall thickening had to be taken as a non-specific ultrasonographic sign. On the whole, therefore, gallbladder wall thickening has thus to be valued primarily as non-specific sign. In a few cases only, it implies an autonomous affection of the gallbladder.

[Technic of real-time ultrasonic examination of the adrenal glands and adrenal gland tumors]. / Technik der real-time-Ultraschalluntersuchung von Nebenniere und Nebennierentumoren.

A prospective examination was carried out to determine the optimum technique for demonstrating the adrenal glands; there were 60 normal persons, 16 with small adrenal tumours (average size 13 mm.) and 10 with large adrenal tumours (average size 38 mm.). A normal adrenal gland was identified only once amongst the 60 patients as a hypoechoic structure. Fifteen of the 16 small, and eight of nine large tumours could be demonstrated sonographically. An intercostal approach was particularly suitable for showing the suprarenal region and for small tumours. Large tumours could be shown by a ventral, lateral or dorsal approach.

Real-time ultrasound of normal adrenal glands and small tumors.

The adrenals were studied prospectively with real-time ultrasound in a series of 60 healthy individuals and 13 patients with small adrenal masses sized 8-20 mm in diameter. In only one of the 60 healthy subjects was a normal adrenal gland delineated as a distinct hypoechoic structure. In all other instances only the highly echogenic suprarenal fat could be displayed. Visualization of small tumors was successful in 12 of 13 patients. The suprarenal area and small lesions were best demonstrated by a lateral intercostal approach using longitudinal and transverse scanning planes. The best access was through the 9th/10th intercostal space at the junction with the anterior and middle axillary lines on the right and the posterior axillary line on the left.