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Lung volume reduction surgery (LVRS) offers improvement in lung function, quality of life and even survival in well selected patients with severe emphysema. Patients with all types of emphysema morphology can profit from LVRS when certain selection criteria are present. Hyperinflation plays a key role in qualifying for the procedure. Candidate selection should be performed at high volume centers with a multidisciplinary emphysema board. Qualified thoracic surgeons together with pulmonologists and radiologists identify the suitable patient considering emphysema morphology with its target areas for resection, lung function parameters and cardiac comorbidities. This review outlines candidate selection, technique and results of LVRS to inform referring physicians how to screen und inform their patients., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Alpha1-antitrypsin deficiency is a rare hereditary disorder. Deficient patients are at a higher risk to develop lung emphysema at an early age. The alpha1-antitrypsin registry was founded on 1996 to get new insights into the pathogenesis of the disease and to develop new therapeutic strategies. In this study the epidemiological and clinical findings of the Austrian alpha1-antitrypsin deficient patients are presented., Material and Methods: A total of 139 patients with severe alpha1-antitrypsin deficiency, identified by phenol- and genotyping, were evaluated retrospectively by their physicians with the help of a questionnaire., Results: Most patients were smokers or ex-smokers (71.9%) who developed symptoms in their fourth decade. The mean duration between the onset of symptoms and the final diagnosis was 6.5 years. About 25% of the evaluated patients were unable to practice their profession because of their illness., Conclusion: Alpha1-antitrypsin deficiency is a rare condition with delayed diagnosis. Because of the benefit of an early diagnosis further effort should be put towards early detection.

COPD is a frequent disease, affecting approximately one in four smokers. In older patients > 70 years of age, the proportion of individuals who never have smoked increases up to one in three individuals. Severe disease is present in 10%, and the limitation of performance is usually caused by airway obstruction, in a smaller portion of patients by the loss of alveolar surface (emphysema). After medical treatment with antiobstructive and anti-inflammatory drugs, oxygen remains a major therapy option. With it, hypercapnic patients benefit most from long-term therapy. Patients with predominant emphysema benefit most from high-flow (6-8 l/min) oxygen therapy during exercise. Permanent yellow or greenish sputum decoloration is suggestive of chronic bacterial colonization. This group of patients may benefit from a permanent inhalative therapy with antibiotics (mainly aminoglycosides). There is growing evidence from current literature to support this concept. If dyspnea is severe, especially during mild exercise, a subset of patients might benefit from the use of long-acting morphium. Goal of this therapy is to downregulate breathing control. Predominantly "pink puffers" seem to respond. A dose of 10-20 mg will usually be sufficient. Life-threatening hypercapnia is usually not observed with this form of therapy. Noninvasive ventilation is an option for patients with severe hypercapnia. Thereby, ventilatory pressure or inspiratory volume should be selected to effectively unload the respiratory muscles. This will increase quality of life. Life span is likely to be prolonged, however, comparative data where patients were effectively ventilated (as seen on the reduction of hypercapnia) are missing. A multicenter trial addressing this topic is currently being conducted in Germany. Independent of the severity of COPD, patients in general benefit from physical training with alternation of endurance and interval training being most effective. This will decrease the number of hospital admissions and probably mortality as well. Lung volume reduction surgery virtually treats lung hyperinflation. Bullectomy is still considered effective for isolated bullous emphysema as well as lobectomy, if this portion of the lung is without function. Shaving procedures are still associated with high rates of complications and should only be performed in selected cases. Effectiveness of endoscopic lung volume reduction surgery by implantation of plugs or valves cannot be assessed yet. First data are rather disappointing. Ultimate alternative remains lung transplantation with life expectancy ranging between 5-6 years independent of age. Indeed, consequent application of previously described measures might preserve a stable state over many years.

Emphysema is defined as a condition of the lung characterized by abnormal, permanent enlargement of airspaces distal to the terminal bronchiole accompanied by destruction of the alveolar walls and without obvious fibrosis. It is a very common disease with high morbidity and mortality. Histopathologically, there are two types of emphysema: panlobular emphysema, typically occurring in alpha1-antitrypsin deficiency, and centrilobular emphysema, which is strongly associated with cigarette smoking. Computed tomography (CT) allows detection of emphysema with higher sensitivity than conventional chest radiography and pulmonary function tests. CT also allows quantification of emphysema and depicts associated changes and complications. The differential diagnosis of emphysema, which is characterized by the absence of clearly definable walls on CT, includes cystic lung disease, bullae, lung laceration, Langerhans cell histiocytosis, and lymphangioleiomyomatosis -which are all characterized by visible walls on CT.

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic diseases worldwide, and its morbidity and mortality are still increasing. Thus, it is expected that, globally, COPD will be the third most common cause of death by 2020. Moreover, COPD leads to enormous health-economic costs (i. e., outpatient and inpatient treatment, inability to work). Nevertheless, the prevalence of COPD is underestimated also in Germany. This is partly because often, the disease is symptomatic only in its advanced stages and as a result it is not diagnosed until late. In addition, the therapeutic effects on the long-term course and the progression of the disease are limited. Therefore, a much deeper understanding of the manifold and complex pathomechanisms of this pathomorphologically varied disease is needed before new therapeutic strategies can be developed. The aim of this review is to discuss current concepts of the pathophysiology of COPD and their scientific bases. The authors will concentrate mainly on a differentiated description of the pathomechanisms which cause chronic obstructive bronchiolitis and obstructive pulmonary emphysema.

Unlabelled: PURPOSE of this study was to determine the prevalence of bronchiectasis in patients suffering from alpha-1-antitrypsin deficiency and to compare its extent with the frequency of infections., Material and Methods: High-resolution CT examinations (HRCT) of 23 patients with alpha-1-antitrypsin deficiency were retrospectively assessed for extent, severity and localisation of bronchiectasis, bronchial wall thickening and extent of emphysema. Chest radiographs and clinical records were available for correlation., Results: HRCT scans showed bronchiectasis in 14 of 23 patients, bronchial wall thickening in 3/14, and panlobular emphysema in 23/23. Chest radiographs showed bronchiectasis in 4/23 patients. Only two of 9 patients without bronchiectasis had a history of infections; all 8 patients with multiple bronchiectasis had a history of recurrent infections., Conclusion: Bronchiectasis is a common finding in alpha-1-antitrypsin deficiency, and is associated with recurrent infections. HRCT is superior to chest radiography as an indicator for the risk of infection in these patients.

The macroscopic findings of 2385 autopsy protocolls of 70-102 year-old males and females were analysed for frequency and functional significance of diseases. 1. Severe coronary arteriosclerosis was found up to 60% of the cases, with increasing frequency in higher age groups. However decrease of acute myocardial necrosis was stated including the highest age group. 2. The mean values of heart weights decrease in the highest age groups. 3. While the frequency of arteriosclerosis in the cerebral arteries increases the frequency of ischemic lesions of the brain decreases. 4. Benign hyperplasia of the prostate is found in 85% of the cases. 5. 80% of the patients had severe substantial chronic pulmonary emphysema and acute tracheobronchitis. These pulmonary lesions are supposed to be the functionally most important disease in patients of old age.

Report on chronic nonspecific lung diseases (CNLD) in the Estonian SSR basing on the data of the ministry of health. The statistical incidence of chronic nonspecific lung diseases has increased from 59.7 new cases per 10 000 inhabitants (1967) to 93.7 in 1974 (100.2 in males and 88.1 in females). This increase is resulting from a real increase of new cases but also from the improvement of diagnostics and better coverage in the degree as tuberculosis has diminished. Cases of tuberculosis among adults decreased to 1/8 and among children to 1/100 of that 20 years ago. Among CNLD the portion of chronic bronchitis amounted to 48%, of chronic bronchitis to 35.9% and bronchial asthma to 16.1%. CNLD is rather frequent among children. In persons older than 40 years CNLD becomes more common, more in males than in females. Not all persons notified with the diagnosis chronic lung disease need treatment. In epidemiological surveys 5.5 to 9.3% of the population corresponded to the definition of chronic airway disease. A systematic dispensary care of CNLD is going to be organised since 1969. It is the task of all therapeutists in the medical districts. More and more the tuberculosis clinics are integrated into this system.

In Yugoslavia the diseases of the respiratory system (without tuberculosis) ranges with 23% in front of all other organ-localised diseases. 53--95% of all chronic non-specific lung diseases are registrated in the chest clinics of the different republics. 67% of all lung diseases registrated belong to the obstructive syndrom, 6% are bronchial carcinomas and 27% represent the group of other chronic pulmonary diseases. 31,5% of all patients with chronic obstructive bronchitis are younger than 50 years old, 34,7% are in the age-group between 50-65 years. Assuming the best registered incidence and prevalence rates of bronchial carcinoma, chronic bronchitis, asthma and emphysema in Slowenia as a basis, the expected morbidity of these diseases in each autonomic republic are compared.

Analysis of 1385 autopsies of 80-102 year-old patients was performed to investigate the frequency of simultaneous occurence of the following functionally pertinent diseases in one organism (polypathia): Severe aortic, coronary and cerebral arteriosclerosis, chronic pulmonary emphysema, contracted kidneys, fractures of the femur and malignant tumors. 80% of all patients of both sexes suffered from 2-4 of the above diseases. Even in the highest age group, however, 5 and more of the above diseases were very rarely developed. Patients with none of the above diagnoses were almost never encountered. The "polypathia" was stated also in patients who died by suicide or accident.