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Asthma is not a homogenous disease but a bundle of different phenotypes producing common symptoms due to swelling of bronchial mucosa and constriction of the airway smooth muscle. Beyond the treatment with a combination of topical steroids and long-acting beta agonists, new therapeutic options arise with the knowledge of different phenotypes. One option, specifically in allergic asthma, is the long known allergen immunotherapy. To identify the individual phenotype a diagnostic work up is warranted when asthma is diagnosed and whenever asthma control cannot be maintained. [ABSTRACT FROM AUTHOR]

According to the international guidelines of COPD (GOLD) and asthma (GINA) diagnosis and treatment of both diseases necessitate spirometry in the private practice as well as in hospital setting. However today, spirometry is not sufficiently used in Switzerland. This paper intends to give an easy overview how spirometry is performed and spirometric values can be interpreted. [ABSTRACT FROM AUTHOR]

In clinical practice, differentiation of COPD and asthma is difficult. A case report of an asthma patient with a drifter type of asthma imitating COPD is presented. In this context differences and similarities of both diseases are highlighted. The definitions of asthma and COPD in international guidelines leave some space to misdiagnosing. [ABSTRACT FROM AUTHOR]

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Introduction: For 7 years we gained experience of how asthma and chronic rhinosinusitis with nasal polyposis respond to biologics. In contrast, it is much less known, how ASA/NSAID intolerance (Widal's disease) behaves under biologicals. We therefore describe the case of a patient with both clinical conditions who reacted with a severe intolerance reaction under perioperative metamizole administration., Competing Interests: Es bestehen keine Interessenkonflikte, (© 2024 Aerzteverlag medinfo AG.)

COPD - An Underestimated Disease Abstract: Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition with a complex clinical picture. The diagnosis is not easy to make because COPD can develop insidiously and remain unnoticed for a long time. Therefore, general practitioners play a central role in the early detection of the disease. Suspected COPD can be confirmed by special examinations in collaboration with pulmonologists. The new GOLD guideline defines three COPD risk groups (A-B-E) which should guide the personalized treatment concept. A short- or long-acting bronchodilator (SAMA/SABA or LAMA/LABA) is recommended for group A, and a dual long-acting bronchodilator therapy (LABA+LAMA) is recommended for group B and E. In case of blood eosinophilia (≥300 cells/µl) and/or recent hospitalization for COPD exacerbation, triple therapy (LABA+LAMA+ICS) is recommended. General practitioners are important in implementing non-pharmacological measures (smoking cessation, regular exercise, vaccinations, patient selfmanagement education). However, this also underlines the high demands of the implementation of the GOLD guideline in daily practice.

Spirometry in the Medical Practice - Part 2: Interpretation Abstract. The way in which spirometry should be assessed correctly was defined internationally in 2005. Compared to before, it was newly defined that the FEV1/VC ratio is used as a parameter to detect an obstruction. An obstruction is of significance if this measured value is below the 5 % percentile, which is usually indicated as a Z-Score of minus 1,645 in the automatically generated protocol. To generate this value, the software must contain the modern GLI standard values and the patient data (gender, age, height). A proven obstruction shows significant reversibility if bronchospasmolysis improves FEV1 by at least 12 % and 200 ml absolute. The determination of the severity of obstruction is based on the extent of the reduction in FEV1 relative to the individual norm. Even after reading both parts of this publication, ambiguities will still arise in individual cases when performing spirometry in clinical practice. In such cases, it is worthwhile to present these findings to the local pulmonologist for co-assessment. This results in a learning effect that will consolidate expertise.

Spirometry in the Medical Practice - Part 1: Measuring Abstract. Today, every practitioner, as well as every hospital emergency, should be able to perform spirometry. However, the measurement requires solid basic knowledge as well as a certain amount of experience so that consistent and reproducible measurements are possible. Since the measurement depends heavily on the cooperation of the patient, typical errors must be recognised and corrected immediately. A rounded forced expiratory flow volume curve, or a sudden drop of the curve towards zero at the end of exhalation as well as clearly deviating curves or values in the minimum required three measurement manoeuvres are clear hints for an insufficiently forced expiration or an expiration that was stopped too early. Pulmonary function assistants need instructions as to when application of a rapid acting beta agonist with repeated spirometry to detect possible reversibility is necessary. This includes knowing how long therapeutic bronchodilators must be stopped prior to the test.

Novelties in the Treatment of Asthma Abstract. For general practitioners there have been important novelties in the treatment of asthma due to recent modifications of the international guidelines from Global Initiative for Asthma (GINA). Step 1 no longer recommends the use of short-acting β2-agonists (SABA) without concomitant inhaled corticosteroids (ICS) as a controller because of the lack of efficacy and for safety reasons. Instead, low dose ICS-formoterol as needed is recommended. GINA step 5 recommends targeted biologic therapies like interleukin antibodies in patients with severe uncontrolled asthma. Asthma patients presenting simultaneously with symptoms of chronic obstructive pulmonary disease (COPD) should receive treatment containing ICS. Independent of the current corona pandemic, GINA recommendations stay in place. Recent data on prescriptions of SABA and oral corticosteroids (OCS) in Switzerland indicate that they still play an important role in asthma management and that GINA recommendations have not yet been sufficiently implemented into practice.

Type-2 Asthma: Leaving Behind the Perspective of the Seventies Abstract. The diagnosis 'bronchial asthma' spans different phenotypes of this disease like an umbrella. The differentiation of these phenotypes and their overlaps is becoming increasingly important, as the phenotype-specific treatment approaches of today are not effective with every form of asthma. These approaches include the strategy of allergen avoidance, allergen immunotherapy and, most importantly, the newly available biologics for asthma. Treatable disease patterns, so-called 'treatable traits', require targeted diagnostics. The knowledge necessary to identify these traits still needs to be established in practice.

Physical and Clinical Aspects of Inhalation Therapy for Asthma and COPD Abstract. Inhalations form the basis of the medicinal treatment of respiratory diseases. In recent years, therapy has become more complex for patients, but also for medical professionals, as new systems have come onto the market. The knowledge required for this shall be conveyed in this article.

The data situation for the use of ICS in asthma is clear. In the case of COPD, on the other hand, where in recent years the pendulum has moved away from ICS towards a dual therapy based on LABA / LAMA, the discussion is open again thanks to new work. However, it would certainly be wrong to recommend ICS as a meaningful therapy for all COPD patients at this point in time, since therapy with ICS is associated with side effects, in particular an increase in the risk of developing pneumonia or osteoporosis. However, there is no doubt that patients with asthma COPD overlap require ICS therapy.

Benralizumab: Targeting the IL-5 Receptor in Severe Eosinophilic Asthma Abstract. For patients with difficult-to-control, severe bronchial asthma, highly effective, targeted treatment options are available in addition to inhaled medication. In the presence of eosinophilia, inhibition of the interleukin-5 (IL‑5) axis with specific monoclonal antibodies promises to be an effective alternative to continuous systemic steroid therapy with few side effects. This review summarizes the data on benralizumab, a specific antibody against the IL-5 receptor alpha preventing receptor stimulation by IL-5 and activating a NK-cell mediated cytotoxic reaction with apoptosis of eosinophils. The s.c.-application of benralizumab leads within days to a virtually complete depletion of blood eosinophils with consecutive improvement in lung function and stabilization of asthma. For selected severe asthmatics, this is a promising therapy option.

COPD is not a homogenous disease but consists of at least four different phenotypes: Emphysema, COPD with chronic bronchitis, asthma-COPD overlap syndrome (ACOS), and COPD with recurrent exacerbations. With differentiation, treatment can be designed phenotype-specific. Some modern drugs are not indicated in all phenotypes.

4 clinical phenotypes can be differentiated in asthma and COPD. Apart from routine treatment strategies, phenotyp-specific options in treatment are important to optimise therapy in these patients. Identification of phenotypes and re-evaluation of patients not responding to treatment in the practitioners practise belong in the hand of the pneumologist as well as treatment of severe asthma. Acute severe asthma attacks have become rare in Swiss hospitals. Despite this progress, asthma control in our patients can still be improved. In COPD, any effort of primary respectively secondary smoking prevention is important.

Upper and lower airways have to be looked at as a functional unit, as well as in allergic and intrinsic asthma. Intrinsic asthma is characterized by chronic eosinophilic inflammation of the bronchial mucosa of unknown origin. Often it is associated with non allergic rhinitis with eosinophilia syndrome (NARES), nasal polyposis and intolerance to Aspirin and NSAID's. NARE-syndrome may precede asthmatic symptoms for years. Treatment with nasal steroids and Aspirin desensitisation improve nasal and sinus symptoms and may have a positive effect on the underlying asthma.

The concept of the minimal clinically important difference (MCID) is intended to provide a measure of relevance for a statistically applied in patients with COPD. Clinically important differences are those differences relevant to the individual patient and important to the patient's life. However, people's difference in a diagnostic parameter perception of what is important vary. Furthermore, physicians may rate the significance of a particular marker and its difference which can be achieved by a pharmacological intervention differently from the patient. Thus, the major problem with defining an MCID for any measure is that the most important differences, which require the most subtle measures for an individual patient, are likely to have the least general application. Conversely, measures that can be generalised are unlikely to have much individual importance and will be very crude tools for an individual assessment. In medical trials both, statistical rigor and clinical relevance are generally required, and MCID is without doubt a key application tool defining treatment success or treatment failure. This paper gives an update on the concept of a minimal important difference of most relevant parameters in COPD treatment.

Any anti-asthmatic therapy aims to control the disease activity. The amount of medication necessary to maintain asthma control over a longer period may vary. In the course of a long-term treatment, achievement of asthma control has regularly to be assessed. This case reports of a patient suffering from steroid dependent intrinsic asthma illustrates the different parameters being used to evaluate asthma control.

In clinical practice, gastrooesophageal reflux (GER) and bronchial asthma often coincide. In the case of sufficient asthma control, the asthma does not need to be taken into account when treatment of GER is being evaluated. In patients with symptomatic asthma despite adequate antiasthmatic treatment, a possible causal relationship between GER and the poor responsiveness to asthma therapy has to be considered. An algorithm to guide the diagnostic and therapeutic steps in such cases is presented.

We aimed in 186 patients with obstructive sleep apnoea, consecutively treated with nasal CPAP between January 1990 and December 1997, to evaluate compliance with nCPAP therapy and to explore factors influencing compliance. At 3 to 6 months (K1), 1 to 2 years (K2) and more than 3 years (K3) patients were reexamined regarding clinical conditions, the mean time of nCPAP usage per night, nCPAP pressure, and body mass index (BMI). The regularly conducted controls consisted of checking mask fitting, polygraphy with automatic pressure titration and once, mostly at K1, polysomnography. Compliance with nCPAP was considered to be sufficient more than 4 hours of usage per night. At K1, 9 patients had stopped therapy, 5 had moved away, 6 had changed therapy, 6 had died, and 41 had not been treated long enough to have a follow-up at K1. Thus we were able to reexamine 119 patients with ongoing nCPAP therapy. We found no correlation between indices of severeness of sleep apnoea (apnoea/hypopnea index, mean low of night time oxygen saturation, nCPAP pressure, and BMI) and compliance. At K1 87 patients (73%) had sufficient nCPAP compliance. All of them showed sufficient compliance at K2 and K3 too. We conclude that a sufficient compliance at an initial control implies sufficient compliance later on. 32 patients (27%) showed insufficient compliance at K1. Of this group 41% (13 patients) improved compliance at K2. This result underlines the value of a second instruction in nCPAP therapy when patient compliance was lacking initially.

By the example of 2 adult patients with cystic fibrosis (CF) problems of pulmonary manifestation of CF and its complications are discussed. In both patients disease manifested late. Life expectancy of CF-patients has markedly increased over the last decades. In the adult distinct complications appear more often such as exacerbation of bronchitis due to pseudomonas aeruginosa, colonisation of air ways by Burkholderia cepacia or by atypical mycobacteria, development of allergic bronchopulmonary aspergillosis, bronchiectases and spontaneous pneumothorax. Today, even in adults with chronic bronchitis of unknown origin the possibility of CF has to be considered. Optimized treatment under clinical conditions, in combination with a physical training program and a diet rich in calories will ameliorate subjective physical performance as well as objective pulmonary function and work capacity. Regular rehabilitation programs contribute to better compliance. In patients with CF direct transition from pediatric to pneumologic/internistic treatment for adults is mandatory in order to optimize expectancy and quality of life.

Peak flow meters do not allow to perform lung function analysis in the private practice. However, they can be used for the diagnosis of reversible airway obstruction, to search for exacerbation factors in asthma, and to monitor drug therapy in chronic asthma. Peak flow measurements provide the means for self-assessment and self-management of asthma by the patients themselves allowing treatment to be optimized and guaranteeing a better quality of life. The plotting of daily pre- and post-bronchodilator peak flow values enables the patient to understand the pathophysiologic changes in his respiratory tract. Therapeutic implications are easily recognized and can be performed without delay by the patient himself on the basis of the so-called "traffic light system".

A portable oxygen system in combination with transtracheal O2 delivery (SCOOP(R)) permits patients with respiratory failure optimal mobility and facilitates longterm oxygen therapy. This report describes a 70 year old female with COPD that developed acute respiratory distress 18 days after inserting PRESCOOP(R) and 11 days after changing to SCOOP 1 catheter. Catheter stripping had not revealed any pathology. Flexible bronchoscopy showed a mucus ball at the catheter tip leading to a 80% stenosis of the trachea. Trials to remove the ball with forceps and a loop were not successful until a rigid bronchoscop was inserted. Up to 10% of patients develop mucus ball formation with SCOOP 1 catheter which remains in situ for 6 weeks. In patients with high risk of mucus formation (high O2 flow, viscous mucus, low FEV1) the manufacturers of SCOOP recommend catheter stripping. We consider a control bronchoscopy being safer 1 week after changing from PRESCOOP to SCOOP because one patient has been reported to have died of this complication and our patient has developed a near fatal situation.

Despite the introduction of new and potent antiasthmatic drugs, a minority of asthma patients, remains without response to therapy. Some of the patients with asthma refractory to therapy actually do not have asthma at all, but suffer from another syndrome mimicking asthma. Asthma may also exist in combination with a syndrome mimicking asthma (e.g. vocal cord dysfunction). Patients may then get treated with high doses of corticosteroids unnecessarily, because the symptoms due to vocal cord dysfunction are misinterpreted as being asthmatic. Sometimes asthma is complicated by an independent factor (e.g. gastroesophageal reflux), which does not respond to antiasthmatic drugs. In all cases of asthma being unresponsive to therapy, the diagnosis of asthma must be questioned, and other complicating factors need to be excluded. The patient's compliance should be encouraged, and correct handling of modern inhalation devices has to be monitored. Patients with refractory asthma should also undergo flexible bronchoscopy to exclude morphologic changes of the bronchial system and to obtain mucosal biopsies.

This case report illustrates the spontaneous course of allergic bronchopulmonary aspergillosis (ABPA). The x-ray images cover a time-frame of nearly 20 years. All of the main criteria of ABPA are fulfilled. Despite intermittent oral corticosteroid treatment, recurrent eosinophilic infiltrates of the lungs occurred. New strategies in diagnosis and treatment of ABPA are discussed.

Up to 10% of all asthmatics are intolerant to aspirin reacting with bronchospasm after intake of this drug. The triad aspirin-intolerance, glucocorticoid-dependent intrinsic asthma and nasal polyps is common in these patients. The reaction to aspirin is not mediated by IgE. Cross-intolerance is observed with all non-steroidal antiinflammatory drugs inhibiting the enzyme cyclooxygenase. If intolerance to aspirin is suspected such drugs have to be strictly avoided. Paracetamol is the alternative in most instances. Only rarely an adaptive desensitization with acetylsalicylic acid is indicated. This method may help to overcome the intolerance. Non-acetylated salicylates occurring also in some foods, preservatives, and food dyes must not generally be avoided in aspirin-induced asthma.

The influence of physical training on the cardiopulmonary system and on lung function of asthmatic children was determined in a controlled study. The children were all indoor patients of the Hochgebirgsklinik Davos, Switzerland. 36 children at the age of 10 to 16 years entered the study. They were placed into either a "free running group", a "swimming group" or a "control group." The children of the training groups underwent a training of at least 10 units of 30 minutes each in 3 weeks. The control group did not participate in any regular physical training. Heart rate was measured before and after a bicycle ergometer exercise of 5 minutes at 2.5 watts/kg body weight. This was repeated at the end of the study. In the "free running group" a significant decrease of the heart rate at rest (p less than 0.05) and at the end of bicycle ergometer exercise (p less than 0.01) could be seen. In the "swimming group" the decrease of the latter was significant (p less than 0.05). In both groups an increase in work tolerance could be demonstrated, but not in the "control group." In all three groups an improvement of lung function (IVC, FEV1) was found, but it was not significant in any of the groups. The small improvement might be due to a reduction in allergen exposure and better medical treatment. The study confirms the possibility of physical training of children with asthma even if exercise-induced asthmatic signs and symptoms are present.

In conditions associated with stimulation of cellular immunity and enhanced macrophage activity, for example, in viral infections, neopterin is elevated. Acute exacerbations of bronchial asthma--in particular in the case of intrinsic asthma--are frequently precipitated by viral infections of the upper airways. In both extrinsic and intrinsic asthma, neopterin is normal in the stable phases. In the exacerbation phase with signs of infection of the upper airways, however, neopterin in significantly elevated both in the serum and in the urine. In contrast, during and following positive inhalative provocation testing with histamine, allergens and aspirin, no increase in neopterin is to be observed.

Although treatment comprising a combination of methylprednisolone (MP) and troleandomycin (TAO) has been employed to treat cases of severe bronchial asthma requiring high doses of corticosteroids, for about 20 years, now, it has always been associated with major adverse reactions (1). A new protocol avoids these adverse effects by a rapid reduction in the dose of MP to alternating administrations and low TAO dosage (250 mg). Nineteen patients were treated using this protocol, 16 of whom for more than two months (maximum 21, minimum 4 months). Three patients were taken out of the study as early non-responders in the initial phase. Five patients must be considered to be late non-responders, or were discharged from the study on account of pathological liver parameters. In 8 patients who showed good tolerance, an appreciable reduction in the dose of steroids, with stabilisation of the asthma, was observed.

The efficiency of separation of the radioligand receptor complex from the unbound ligand by both rapid filtration and centrifugation is compared for two standard receptor assays in the rat brain: the beta-adrenergic receptor using 3H-dihydroalprenolol and the benzodiazepine receptor using 3H-flunitrazepam. Whereas in beta-adrenergic binding studies both separation procedures yield similar binding data, the apparent binding in the benzodiazepine receptor assay is lower in the filtration experiments as compared to the data obtained by centrifugation, indicating an incomplete retention of the ligand receptor complex by filter. However, in both assays the results of the binding studies are highly dependent on the type of filters used. The following filters were compared: glass fibre filters GE/B and GF/C (Whatman Ltd., Kent, England), membrane filter HAWP (pore size 0.45 micrometer, Millipore Corporation, Bedford, U.S.A.) and glass fibre filters NK I, NK VIII, NK-15-90, NK 13-90, NK 14-120 (all produced by VEB Feinpapierfabrik Neu-Kaliss, G.D.R.). Although a somewhat higher specific binding can be obtained by the membrane filter and several types of the NK filters as compared to the most widely used Whatman GF/C the manifold higher unspecific binding of the radioligand by these filters does not favour their use in ligand assays. Retention as well as unspecific binding of the filter NK VIII is very similar to the Whatman GF/C filter. This new filter seems, therefore, well suited for radioligand studies.