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Background Unilateral diaphragmatic paralysis or paresis (UDP) in adults is an often overlooked disease which relevantly impairs the patient's lung function and quality of life. Particularly in idiopathic UDP, there is no evidence for conservative therapy and only little evidence for surgical therapy. Methods The method involves retrospective single-center analysis of patients with UDP persistent for at least 1 year who were operated by diaphragmatic resection, plication, and augmentation with a polypropylene mesh. The patients were tested for lung and diaphragmatic function, six-minute walk test (6MWT), and blood gas analysis before, 3 and 12 months after surgery. Results In total, 85 patients received surgery for UDP. The most frequent reasons for UDP were idiopathic (67%), iatrogenic (mainly cardiac and cervical spine surgery; 24%), and trauma (9%). The mean operation time was 84 ± 24 minutes, the length of hospital stay 8.4 ± 3.9 days, chest tubes were removed after 11.7 ± 4.1 days. Overall morbidity was 42%, mortality 0%. Forced expiratory volume in one second (FEV1) in supine position improved by 12.4% absolute, vital capacity by 11.8% absolute, and sniff nasal inspiratory pressure by 1.4 kPa 12 months after surgery (p <0.001 each). Total lung capacity increased by 6.8% absolute at 12 months (p = 0.001) The 6MWT distance improved by 45.9 m at 3 months and 50.9 m at 12 months (p = 0.001, each). Conclusion Surgical therapy for UDP is highly effective in the long term. The superiority over conservative treatments needs to be evaluated prospectively with standardized physiotherapeutic protocols. FEV1 in supine position and 6MWT are easy to perform tests and represent statistically and patient-relevant outcomes. [ABSTRACT FROM AUTHOR]

Background: Non-invasive ventilation (NIV) has been shown to be the most appropriate therapy for COPD patients with chronic respiratory failure. While physiological parameters and long-term outcome frequently serve as primary outcomes, very few studies have primarily addressed the impact of NIV initiation on sleep quality in COPD. Methods: This single-center prospective cohort study comprised NIV-naïve patients with COPD. All patients underwent polysomnographic evaluation both at baseline and at 3 months follow-up, accompanied by the assessment of health-related quality of life (HRQL) using the Severe Respiratory Insufficiency Questionnaire (SRI) and the Epworth Sleepiness Scale (ESS). A subgroup evaluation was performed to address the impact of comorbid obstructive sleep apnea syndrome (OSAS). Results: Forty-six patients were enrolled and twenty-five patients completed the follow-up period (66.7 ± 7.4 years). NIV resulted in an increase in slow-wave sleep (+2% (−3.5/7.5), p = 0.465) and rapid eye movement sleep (+2.2% (−1.0/5.4), p = 0.174), although no statistical significance could be detected. ESS (−1.7(−3.6/0.1), p = 0.066) also showed a positive trend. Significant improvements in the Respiratory Disturbance Index (RDI) (−12.6(−23.7/−1.5), p = 0.027), lung function parameters, transcutaneous PCO2 and the SRI summary scale (4.5(0.9/8), p = 0.016) were observed. Conclusion: NIV therapy does not decrease sleep quality and is even capable of improving HRQL, transcutaneous PaCO2, daytime sleepiness and RDI, and the latter especially holds true for patients with comorbid OSAS. [ABSTRACT FROM AUTHOR]

Advanced chronic obstructive pulmonary disease (COPD) might result in chronic hypercapnic ventilatory failure. Similar to neuromuscular and restrictive chest wall diseases, long-term non-invasive positive pressure ventilation (NPPV) is increasingly used in chronic hypercapnic COPD. This review describes the methods, patient selection, ventilatory strategies, and therapeutic effects of long-term Home-NPPV based on randomized controlled clinical trials published since 1985 in English language retrieved from the databases PubMed and Scopus. Long-term NPPV is feasible and effective in stable, non-exacerbated COPD patients with daytime hypercapnia with arterial pressure of carbon dioxide (PaCO2) levels ≥50 mm Hg (6.6 kPa), if the applied ventilatory pressures and application times improve baseline hypercapnia by at least 20%. Patients who survived an acute hypercapnic exacerbation might benefit from long-term NPPV if hypercapnia persists 2–4 weeks after resolution of the exacerbation. Pressure-controlled ventilation or pressure-support ventilation with adequate minimum backup breathing frequencies, in combination with nasal masks or oronasal masks have been successfully used in all larger clinical trials. Ventilatory strategies with mean inspiratory pressures of up to 28 cm H2O are well-tolerated by patients, but limitations exist in patients with impaired cardiac performance. Home-NPPV with a PaCO2-reductive approach might be considered as an additional treatment option in patients with stable chronic hypercapnic COPD. [ABSTRACT FROM AUTHOR]

Background/Objective: To assess whether and how the use of scientifically established Web-based training videos for teaching correct inhalation technique in patients with chronic airway diseases has become accepted among the wider population. Methods: The viewing trends of 141 freely available YouTube videos (full playing time, 01:31–04:37 min:s) provided by the German Respiratory League, covering a broad range of internationally prescribed devices, were analyzed over a 10-year period. Specific emphasis was placed both on German and international videos. Results: The total number of views was 3,350,678. Non-German videos (English, Russian, Turkish, Greek, Arabic, Farsi, and Slovakian) accounted for 23.2% of the views. The number of views steadily increased between 2011 and 2020 with a mean annual increase of 54.0% (range 24.5/119.9%) compared to the respective previous year. By 2020, the incidence of views per 100,000 German inhabitants was 725 for German videos only and 1,030 for all videos. In terms of the annual trend, there were two peak viewing periods, namely in spring and late fall, while the lowest amount of views occurred in summer. Conclusion: This study highlights the rising impact of Web-based training videos used for teaching the correct use of inhalation devices, with a steady increase in the number of annual views and a clear seasonal peaking of views in spring and late fall. [ABSTRACT FROM AUTHOR]

Background: The Severe Respiratory Insufficiency Questionnaire (SRI) is a multidimensional instrument for health-related quality of life (HRQL) assessment in patients with chronic respiratory failure (CRF). The SRI has originally been developed in German in 2003, but 15 translated versions have been created during the last 18 years with the exclusion of the Italian translation. Aims of the Study: The present project was aimed at creating an Italian version of the SRI. Methods: Professional forward-translation and back-translation procedures have been provided based on the original German version by independent translators, and this was followed by final reconciliation. Results: The Italian SRI contains 49 items covering 7 different subscales which can summarize to one Summary Score. Conclusions: The Italian SRI is a multidimensional instrument, which can be used for HRQL assessment in Italian-speaking patients with CRF. Validation of the Italian version of the questionnaire is formally required in the future. [ABSTRACT FROM AUTHOR]

Background: Electronic auscultation technology has advanced dramatically in the last few years. Therefore, long-term pulmonary auscultation could provide additional information about respiratory system by monitoring acute chronic obstructive pulmonary disease (AECOPD) exacerbations or by identifying wheezing phenotypes amongst stable COPD patients. Objectives: Comparison of respiratory sounds in stable versus AECOPD patients recorded with a portable respiratory sound monitor over a period of 24 h. Methods: This prospective trial evaluated cough and wheezing events using an auscultation monitor specially developed for this purpose with 4 integrated highly sensitive microphones, in stable and severely AECOPD patients for a period of 24 h in an inpatient setting. Results: Twenty stable COPD patients (12 male, 60%) and 20 severely exacerbated COPD patients (14 male, 70%) were analyzed. In AECOPD patients, long-term auscultation revealed a significantly higher number of wheezing epochs than stable COPD patients (591 [IQR: 145–1,645] vs. 152 [IQR: 90–400]; p = 0.021). Conversely, cough epochs did not differ between AECOPD and stable COPD patients (213 [IQR: 140–327] vs. 162 [IQR: 123–243]; p = 0.256). The Borg-dyspnea scale, CAT score, and total CCQ score each showed no correlation with wheezing frequency, while CAT and CCQ scores did correlate with coughing frequency. Conclusion: Wheezing, but not coughing, occurs more frequently in AECOPD patients than in stable COPD patients, indicating that severe wheezing is an important clinical sign of exacerbation, while coughing is not. Therefore, the patterns of wheezing and coughing, as assessed by long-term auscultation, differ in stable versus exacerbated COPD patients. [ABSTRACT FROM AUTHOR]

An application (app) for the Severe Respiratory Insufficiency Questionnaire (SRI) has been designed and developed for mobile devices. In a randomised controlled trial comprising 60 patients with chronic respiratory failure, the app was compared with the classic paper SRI. Thereby, it was shown that the SRI app is a practical tool that is well accepted. Missing values can be completely avoided by using the SRI app. Finally, reliability, convergent and discriminant validities were established. Accordingly, for the individual SRI subscales, Cronbach's alpha ranged between 0.56 and 0.81 (app) and between 0.54 and 0.83 (paper), respectively. The multilingual SRI app is accessible free of charge for non-profit research purposes. [ABSTRACT FROM AUTHOR]

Background: Inhalation errors frequently occur in patients receiving inhalation treatment, which can significantly impair treatment success. While this underscores the importance of inhalation training, the role of modern web-based instructional videos has not yet been investigated. Methods: A randomized controlled trial using standardized checklists (10 items: preparation, N = 3, inhalation routine, N = 6, and closure of inhalation, N = 1) was carried out to determine the relative effects of web-based, device-specific videos versus standard personal instruction on reducing multiple (≥2) inhalation errors in severe COPD patients requiring hospitalisation. Investigators assessing inhalation errors were blinded to the intervention. Results: Multiple handling errors were recorded at baseline in 152 out of 159 patients (95.6%). Each teaching method led to a similar reduction in errors (videos: from 4.2±1.6 to 1.5±1.5 errors; personal instruction: from 3.8±1.5 to 1.3±1.6; p<0.0001), although non-inferiority of web-based video teaching could not be confirmed statistically due to an unpredictably high number of patients in both groups still making multiple handling errors (44.0% versus 40.3%, mean difference 3.7%; 95%CI [-12.0–19.4%]). Conclusion: Multiple inhalation errors regularly occur in severe COPD patients requiring hospitalisation. Web-based video teaching is capable of reducing inhalation errors. However, compared to personal instruction non-inferiority could not be established. This was due to an unexpectedly high number of patients with persisting inhalation errors despite training. Trial registration: Clinical trial Registration: German Clinical Trial Register, . [ABSTRACT FROM AUTHOR]

Background: Long-term non-invasive ventilation (NIV) is an established and increasingly used treatment option for patients with chronic hypercapnic chronic obstructive pulmonary disease (COPD). Following inpatient NIV establishment, inpatient control visits regularly occur thereafter. However, it remains unclear whether such control visits can also be performed in an outpatient setting, which, in turn, would reduce costs, patient burden and the complications related to hospitalization. Objectives: To investigate an outpatient setting with predefined criteria for hospitalization for patients with chronic hypercapnic COPD. Methods: An outpatient clinic located within the hospital in the vicinity of the respiratory care unit provided predefined criteria for hospitalization of COPD patients receiving long-term NIV therapy. The results of this setting were retrospectively analysed. Results: A total of 130 outpatient visits (80 patients) were analysed. In 93 cases (71.5%), hospital admission was not necessary, while hospitalization was performed in 37 cases (28.5%). Out of these, 7 cases with acute conditions required prompt hospitalization. Patients without hospitalization had better PaCO2 values (45.40 ± 5.27 vs. 50.05 ± 8.04, p = 0.002) and Severe Respiratory Insufficiency Questionnaire Summary scores (55.54 ± 19.74 vs. 41.82 ± 19.59, p = 0.012). Conclusion: Outpatient control of long-term NIV in a hospital setting is feasible and has the capacity to identify stable COPD patients in whom NIV therapy is sufficient according to predefined criteria. These patients may not require hospitalization and may account for more than two thirds of cases. [ABSTRACT FROM AUTHOR]

Background: The German guideline on long-term oxygen therapy (LTOT) was published in 2008 by the German Respiratory Society (DGP), while the British Thoracic Society (BTS) published their most recent guideline in 2015. Objectives: The aim of the present article was to highlight the major areas of consensus and disagreement in the recently published BTS and DGP guidelines on LTOT. Methods: The BTS and DGP guidelines were directly compared in terms of congruencies and differences. A critical appraisal was then performed and authors' suggestions were provided. Results: The 2 guidelines are almost congruent in 2 major areas, namely, (1) the indication criteria for LTOT in chronic obstructive pulmonary disease (COPD) patients at rest and (2) the recommended duration of LTOT over a 24-h period. However, 8 major areas in which the guidelines differ considerably were identified: (1) techniques for blood gas analysis; (2) timing of LTOT in stable patients; (3) LTOT in postexacerbation COPD patients; (4) ambulatory oxygen therapy; (5) nocturnal oxygen therapy; (6) titration of oxygen flow rates; (7) follow-up visits; and (8) LTOT for patients who still smoke. Furthermore, the BTS guideline is much more detailed, includes more references (161 vs. 71) and is more up to date than the DGP guideline. Conclusion: There are major differences between the 2 guidelines. Many of the aspects raised by the BTS guideline appear to be reasonable with regard to the current literature, clinical experience and prescription practices. However, an international consensus on LTOT is lacking. [ABSTRACT FROM AUTHOR]

There are several causes for unilateral or bilateral diaphragmatic paresis. The most common cause is an (intraoperative) injury to the phrenic nerve.However, in up to 20% of cases, no explanation can be found despite extensive workup. Neuralgic amyotrophy (NA, also known as Parsonage-Turner syndrome) is a common underdiagnosed multifocal autoimmune-inflammatory disease that predominantly affects proximal nerve segments of the upper extremities. Classic symptoms include acute onset of severe pain in the shoulder girdle with delayed onset of paresis of the shoulder and arm muscles. In at least 7% of cases, the phrenic nerve is also affected. Based on the annual incidence of NA of 1:1000, the entity as a cause of diaphragmatic dysfunction is probably not as uncommon as previously thought. However, clinical experience shows that this diagnosis is often not considered, and diaphragmatic paresis gets wrongly classified as idiopathic.This is particularly disastrous because in the early stage of NA, medical therapy with corticosteroids is mostly not considered and the possibility that surgical repair of the diaphragm may be performed prematurely, given that the condition may resolve spontaneously many months after symptom onset.The aim of the present article is to raise awareness of the entity of NA as a cause of diaphragmatic paresis and to establish a standardized approach to diagnosis and treatment., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Scientifically validated web-based training videos for proper inhalation technique were increasingly used by an international audience during the pandemic. Translations into additional languages would support a larger patient population. https://bit.ly/3lYQwsD., Competing Interests: Conflict of interest: None declared., (Copyright ©The authors 2023.)

Background: Medicine is becoming increasingly digitalized. Digital applications are finding their way into health care. The aim of the study was to record the attitudes of members of the German Respiratory Society (DGP) towards digitalization., Methods: The study was conducted in cooperation with the DGP, the German Respiratory League and the Health Innovation Hub (HIH) of the German Federal Ministry of Health. Data were gathered with the help of an online questionnaire (July/August 2021), analyzed descriptively and supplemented with a subgroup comparison regarding proactivity of the members., Results: 284 questionnaires were complete and included in the analysis (31% female); 76.4% believed that digitalization would change their daily professional life within five years. 47.2% had prescribed or planned to prescribe Digital Health Applications (DiGA). Lack of technology skills of patients and the time required for health professionals were seen as critical (49.3 and 47.5%). Regarding DiGA, scientific proof of efficacy (48.9%) and ease of use for patients (47.9%) were rated as most important. The subgroup comparison showed that 42.7% actively informed themselves about digital medicine and that this group saw more opportunities for meaningful use of DiGA., Conclusion: The members of the DGP have mostly a positive view about the profound changes expected from digital medicine. The more active the role of DGP members and other professional societies, the more digital elements can add value to practice., Competing Interests: Die Autor:innen sind Mitglieder verschiedener Fachgesellschaften, wie oben angegeben, und bekleiden unterschiedliche ehrenamtliche Ämter innerhalb der Fachgesellschaften. Dr. Majorski erhielt zweckgebundene Forschungsförderungen der Deutschen Atemwegsliga e.V. zur Entwicklung der SRI-App. Prof. Mathes erhielt Honorare der Deutschen Atemwegsliga e.V. für die methodische Betreuung. Weitere Interessenkonflikte bestehen nicht., (Thieme. All rights reserved.)

Background:  The number of patients using home mechanical ventilation (HMV) is steadily increasing in Germany. Detailed data on inpatient initiation and control of HMV are not available. This, however, is absolutely necessary in order to optimize the medical care structures in Germany. Regional diversities must be taken into consideration in order to provide care structures that reflect the local needs., Method:  The data sets of the German Federal Statistical Office on the OPS (Operation and Procedure Classification System) for HMV from 2008 to 2019 were analysed (N = 572,494)., Results:  Between 2008 and 2019 there was a doubling of the number of HMV initiations and controls. The number of initiations (N = 17,958) and controls (N = 49,140) was highest in 2019. Furthermore, at the state level, the development of HMV is very heterogeneous. Finally, the increases were particularly due to an increase in non-invasively ventilated patients., Conclusion:  The rapid increase in HMV is reaching capacity limits of the existing healthcare structure. New healthcare structures should provide an integrated approach between outpatient and inpatient care in order to ensure a high quality of care for patients receiving HMV without compromising the human and economic resources of the system., Competing Interests: Die Autorinnen/Autoren geben an, Fördermittel über den Innovationsfonds des gemeinsamen Bundesausschusses (G-BA) erhalten zu haben. Das Förder kennzeichen lautet: 01VSF19051. Die Forschergruppe (D. S. Majorski, F. S. Magnet, W. Windisch, S. B. Schwarz) erhielt Forschungsförderungen von Philips Respironics, Löwenstein Medical, Weinmann und Vivisol.S. B. Schwarz erhielt Reisekostenunterstützung von Löwenstein Medical und Philips Respironics sowie Honorare durch Beratertätigkeiten von Philips Respironics.F. S. Magnet erhielt Honorare durch Beratertätigkeiten oder Vorträge von Philips Respironics, GHD und Smith Medical. Sie erhielt Reisekostenunterstützung von Vivisol, Löwenstein Medical und Philips Respironics.D. S. Majorski erhielt Reisekostenunterstützung von ResMed.W. Windisch erhielt Honorare für die Konzeption wissenschaftlicher Tagungen sowie Vorträge von Löwenstein Medical, ResMed und Philips Respironics. Weder bei der Konzeption noch bei der Ausarbeitung der Studie wurde Einfluss von Dritten genommen., (Thieme. All rights reserved.)

Non-invasive strategies such as HFOT (high-flow oxygen therapy), CPAP (continuous positive airway pressure) and NIV (non-invasive ventilation) are increasingly being used during the COVID-19 pandemics in order to treat acute hypoxemic respiratory failure related to COVID-19, and this is aimed at avoiding intubation. This review article summarizes the current evidence by also emphasizing its heterogeneity. Importantly, current evidence suggests that these non-invasive strategies can be successfully used even in case of severe respiratory failure and are, thus, indeed capable of avoiding intubation, and consequently, tube-related complications. In contrast, it also remains to be emphasized that prolonged spontaneous breathing supported by non-invasive treatment strategies is also prone to complications. In particular, late NIV failure is associated with substantially deteriorated outcome, which is suggested to be meaningful in view of NIV failure rates still being high in Germany. Finally, the current article also refers to a parallel article that addresses the discussion being held in the public media in Germany concerning this topic. Here, its textual questionability, but also its negative consequences for both the research community and the general society are elaborated. In this context, the importance of national and regularly updated guidelines is emphasized., Competing Interests: W. Windisch hat Vortragshonorare erhalten von Firmen der Beatmungsindustrie. Zudem sind Forschungsaktivitäten in der Klinik von W. Windisch, S. B. Schwarz, D. S. Majorski und M. Wollsching-Strobel durch Firmen der Beatmungsindustrie unterstützt worden. S. B. Schwarz hat Reisekostenunterstützungen durch Firmen der Beatmungsindustrie erhalten. B. Schönhofer und C.-P. Criée geben an, dass kein Interessenkonflikt besteht. M. Westhoff hat Vortragshonorare sowie Beraterhonorare erhalten von Firmen der Beatmungsindustrie. Weiterhin wurden Forschungsaktivitäten in der Klinik von M. Westhoff durch Firmen der Beatmungsindustrie unterstützt., (Thieme. All rights reserved.)

Competing Interests: W. Windisch hat Vortragshonorare erhalten von Firmen der Beatmungsindustrie. Zudem sind Forschungsaktivitäten in der Klinik von W. Windisch, S. B. Schwarz, D. S. Majorski und M. Wollsching-Strobel durch Firmen der Beatmungsindustrie unterstützt worden. S. B. Schwarz hat Reisekostenunterstützungen durch Firmen der Beatmungsindustrie erhalten.M. Westhoff hat Vortragshonorare sowie Beraterhonorare erhalten von Firmen der Beatmungsindustrie. Weiterhin wurden Forschungsaktivitäten in der Klinik von M. Westhoff durch Firmen der Beatmungsindustrie unterstützt.B. Schönhofer und C.-P. Criée geben an, dass kein Interessenkonflikt besteht.

Purpose: To compare arterial (P a O 2 ) with capillary (P c O 2 ) partial pressure of oxygen in hypoxemic COPD patients because capillary blood gas analysis (CBG) is increasingly being used as an alternative to arterial blood gas analysis (ABG) in a non-intensive care unit setting, although the agreement between P c O 2 and P a O 2 has not been evaluated in hypoxemic COPD patients., Patients and Methods: Bland-Altman comparison of P a O 2 and P c O 2 served as the primary outcome parameter if P c O 2 values were ≤60 mmHg and the secondary outcome parameter if P c O 2 values were ≤55 mmHg. Pain associated with the measurements was assessed using a 100-mm visual analog scale., Results: One hundred and two P a O 2 /P c O 2 measurement pairs were obtained. For P c O 2 values ≤60 mmHg, the mean difference between P a O 2 and P c O 2 was 5.99±6.05 mmHg (limits of agreement: -5.88 to 17.85 mmHg). For P c O 2 values ≤55 mmHg (n=73), the mean difference was 5.33±5.52 mmHg (limits of agreement: -5.48 to 16.15 mmHg). If P a O 2 ≤55 (≤60) mmHg was set as the cut-off value, in 20.6% (30.4%) of all patients, long-term oxygen therapy have been unnecessarily prescribed if only P c O 2 would have been assessed. ABG was rated as more painful compared with CBG., Conclusions: P c O 2 does not adequately reflect P a O 2 in hypoxemic COPD patients, which can lead to a relevant number of unnecessary long-term oxygen therapy prescriptions., Competing Interests: Disclosure FSM, JC, JHS, and SBS received personal travel grants from companies dealing with LTOT. WW and JHS received speaking fees from companies dealing with LTOT. The authors report no other conflicts of interest in this work.

The prognosis of patients receiving home mechanical ventilation is very heterogeneous and depends on the underlying disease, the degree of respiratory dependency and the comorbidities. Due to the severe chronic diseases, the initiation of a long-term NIV must be done during an inpatient treatment. Two recently published randomized controlled trials using more aggressive forms of NPPV targeted at normalizing hypercapnic PaCO 2 values, showed improved long term survival also in patients with an underlying diagnosis of COPD. Consequently, the number of patients receiving home mechanical ventilation has dramatically increased in recent years and more and more outpatient settings has been established without scientific evidence. Nevertheless, beside reliable care structures, ethical aspects and health related quality of life are of great importance in the context of home mechanical ventilation., Competing Interests: Interessenkonflikte: Sarah Bettina Schwarz gibt an, Reisekostenunterstützng und Vortragshonorare von Heinen und Löwenstein, SenTec und Philips Respironics erhalten zu haben. Friederike Sophie Magnet gibt an, Reisekostenunterstützung und Vortragshonorare von Heinen und Löwenstein, SenTec und Philips Respironics erhalten zu haben. Bernd Schönhofer gibt an, Vortragshonorare von Resmed & Heinen/Löwenstein erhalten zu haben. Wolfram Windisch gibt an, Reisekostenunterstützung und Vortragshonorare von Firmen erhalten zu haben, welche Beatmungsgeräte vertreiben., (© Georg Thieme Verlag KG Stuttgart · New York.)