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The outcome of patients with idiopathic pulmonary fibrosis (IPF), which represents the most common type of idiopathic pulmonary pneumonias, is poor. Breathlessness and coughing are usually progressive and about 50% of he patients die within 3 years after diagnosis. The effect of medical treatment in terms of survival is disappointing. Most of the currently available studies only focus on daytime diagnostics and therapy. The role of sleep quality and sleep disordered breathing in IPF is only investigated in a small number of papers, which can be summarized as follows: sleep fragmentation in IPF is very common. The reasons might be coughing, nocturnal oxygen desaturations, and increased respiratory drive. Sleep disorders in IPF have a profound impact on the quality of life. Oxygen desaturations often appear during sleep and can be predicted by the PaO(2) during wakefulness. There are no evidence-based recommendations concerning the indication for oxygen therapy and non-invasive ventilation during sleep in IPF. Obstructive sleep apnea (OSA) has no increased incidence with the exception of the IPF patients with an increased body mass index. If, however, OSA is present in IPF oxygen desaturations are more profound. The therapy of sleep disorders and sleep disordered breathing in IPF is individual. But in the absence of an effective treatment of IPF, optimization of sleep and life quality by the treatment of sleep disorders seems to be a primary goal. Further studies are needed to determine special sleep-related treatment effects.

Many patients with obstructive sleep apnea syndrome (OSAS) receiving continuous positive airway pressure (CPAP) complain of leaky masks or too high pressure during expiration. C-Flex is a breathing mode with a constant CPAP pressure during inspiration and a reduced pressure during expiration. We compared the leakage data between CPAP and C-Flex and their influence on patients' compliance. Thirty patients (22 men, 8 women, aged 55.4 +/- 11.7 yr, BMI 32.0 +/- 7.4 kg/m(2)) with polysomnographically diagnosed OSAS got a CPAP or C-Flex therapy in a randomized double-blind and cross-over design. After 6 weeks, an adjustment to the other mode followed. Leakage data were sampled during all polysomnographic examinations. Twelve patients dropped out of the study (7 after C-Flex, 5 after CPAP), 4 of them gave up CPAP therapy completely (2 after CPAP, 2 after C-Flex). The leakage in CPAP mode was 27.5 +/-11.5 l/min and in C-Flex mode 28.0 +/-10 l/min (ns). The average nightly use in CPAP mode was 350.0 +/- 70.2 min and in C-Flex mode 347.0 +/- 70.8 min (ns). In the final decision of therapy, 9 patients chose C-Flex and 4 patients CPAP (P=0.001). Five patients had no preference regarding the therapy mode. There is no difference in leakage and compliance between CPAP and C-Flex. But significantly more patients decided for a therapy with the C-Flex mode. There must be other unknown factors that influence the decision for the mode of therapy.

Patients with chronic obstructive pulmonary disease (COPD) present with impairments of their cognitive performance. It is still unknown whether cognitive deficits influence driving abilities in patients with COPD. The present study investigates driving performance in patients with COPD and healthy controls. Driving simulation was performed in 17 patients with COPD and 10 healthy controls. Patients with COPD demonstrated significantly worse results in terms of accident frequency in the simulated driving situation. No correlations existed between the severity of disease, assessed from the polysomnographical findings (e.g., lung function, blood gas analysis, sleep disturbance, nocturnal ventilation, and oxygen saturation), and driving performance. We conclude that impairments of driving performance in patients with COPD cannot be predicted on the basis of the severity of the disease. The impairment of driving performance in the simulated driving situation in COPD patients may have crucial consequences for driving licensing in these patients.

Several studies indicate an association between obstructive sleep apnea syndrome (OSAS) and diabetic autonomic neuropathy (DAN). Observed frequency of OSAS in diabetic patients with DAN varies between 26% and 30%. Excessive daytime sleepiness is one of the major clinical symptoms of sleep disordered breathing. Diabetics with autonomic neuropathy might have abnormal control of respiration during sleep, probably resulting in a reduced daytime sleepiness. We investigated the impact of autonomic diabetic neuropathy on clinical symptoms (e.g., daytime sleepiness, measured by Epworth Sleepiness Scale, ESS) in patients with suspected OSAS. We examined 196 patients suspected of sleep apnea (52 female, 144 male, mean age 58.7 yrs, mean BMI 30.57 kg/m2). All patients underwent overnight polysomnography and were tested for autonomic neuropathy by a method of measuring heart rate variabilty and heart rate response to the Valsalva maneuver, standing and deep breathing using a computerized data analysis system. Eighty diabetic subjects: 52 DAN-, 28 DAN+; 116 subjects without diabetes: 101 without autonomic neuropathy (AN), 15 AN+. The group of diabetics with DAN+ had a mean apnoea/hypopnea index (AHI) of 38.6/h, mean oxygen desaturation: 77.5%, mean ESS-Score: 9.86. Diabetic patients DAN-: mean AHI:30.4/h, mean oxygen desaturation: 79.3%, mean ESS-Score 9.73. Defining OSAS as AHI>5/h and ESS-Score>9, 46% of the diabetic patients DAN+ were positive, whereas in the DAN- group 61% met the criteria (non-diabetic patients without AN 50.5%; with AN: 60%). Although the group of diabetic patients with autonomic neuropathy had the lowest percentage of OSAS, statistical analysis showed no significance in comparisons between DAN-/DAN+ or diabetic/non-diabetic. In conclusion, although this study did not give statistical evidence, there is reason to assume that patients with diabetic autonomic neuropathy show fewer clinical symptoms of OSAS than those without it. The examination for OSAS might be indicated even without excessive daytime sleepiness because of elevated cardiovascular risk.

Continuous positive airway pressure ventilation (CPAP) and non-invasive positive pressure ventilation (NPPV) are accepted treatments in acute cardiogenic pulmonary edema (ACPE) and acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The aim of the study was a comparison of effectiveness, safety, and management of NPPV in ACPE and AECOPD trying to find an approach for standard management in intensive care. Thirty patients with acute respiratory failure (14 due to ACPE, 16 due to AECOPD) were prospectively included into the study. If clinical stability could not be achieved by standard therapy (pharmacological therapy and oxygen) patients were treated by non-invasive ventilation (NPPV) using a BiPAP-Vision device in S/T-mode. During the first 90 min after the onset of NPPV respiratory and vital parameters were documented every 30 min. Additional relevant outcome parameters (need for intubation, duration of ICU stay, complications and mortality) were monitored. We found that 85.7% of the ACPE patients and 50.0% of the AECOPD patients were treated successfully with NPPV. Intubation rate was 31.2% in the AECOPD group and 14.3% in the ACPE group. 78.6% of the ACPE patients and 43.8% of the AECOPD patients were regularly discharged from hospital in a good condition. In the first 90 min of NIV, there was a significant amelioration of respiratory and other vital parameters. In ACPE patients there was a significant increase in PaO2 from 58.9 mmHg to 80.6 mmHg and of oxygen saturation (SaO2) from 85.1% to 93.1% without changing the inspiratory O2 concentration. This effect was comparable in the AECOPD group, but only could be achieved by increasing the inspiratory ventilation pressure. In the ACPE group inspiratory ventilation pressure could be reduced. In conclusion, in acute respiratory failure, ACPE patients comparably profit from NPPV as do patients with AECOPD, but the algorithm of titration for non-invasive ventilation pressure is different.

The objective of this investigation was to assess the association between the presence of sleep disordered breathing (SDB) and daytime sleepiness, body mass index, hospitalisation, and survival. To this end, a prospective longitudinal study was conducted in the elderly population consisting of 80 patients of either sex over the age of 65 years admitted to a city hospital in Germany without any history of SDB. All patients met the following exclusion criteria: age <65 yr, heart failure, and chronic obstructive lung disease. Baseline anthropometric and cardiorespiratory (one-night portable polygraphic recording) data, and a standardized sleep and sleepiness-questionnaires (Epworth Sleepiness Scale, ESS) were obtained in 1999. A second screening was conducted in 2003. Thirty one women and 34 men completed the follow-up after 3 years. These patients were divided into two subgroups: (i) no clinically relevant SDB and (ii) SDB (apnea-hypopnea index, AHI, >or=5 plus excessive day time sleepiness, ESS, >9). Six men and 3 women fulfilled the criteria of SDB. Thirty three percent of patients with SDB and 20% of patients without SDB died during the follow-up period. Duration of hospital stay was 35 days for the SDB patients and 20 days for patients without it. Body weight and sleepiness did not change significant over the 3-year period between the two cohorts. We conclude that the presence of SDB was associated with a 1.5-fold higher mortality and longer hospital stay in elderly patients over a period of 3 years even in persons without previous history of SDB. Daytime sleepiness was a better predictor than AHI or BMI for death.

The prevalence of obstructive sleep apnea syndrome in patients up to the age of 60 is known to be two times higher in men then in women. Hormonal changes during menopause might underlie changes in this relationship in the elderly. This study was designed to detect differences in the type and frequency of sleep-disordered breathing between women and men over the age of 65 years, having the same body mass index. The study was conducted using a matched-pair approach consisting of a sample population of 40 pairs of patients over the age of 65. All patients met the following exclusion criteria: age below 65, heart failure, chronic obstructive lung disease. Polygraphy was conducted by means of a portable recorder. All measured indices were higher in men than in women. The apnea index was 2.8 +/-4.1 in men and 0.6 +/-1.4 in women. The apnea/hypopnea index was 10.2 +/-11.4 and 4.8 +/-3.9, respectively. These differences were significant (P<0.05). Significant differences also were observed when central (men 8.1 +/-13.1, women 3.1 +/-8.2), mixed (men 5.1 +/-11.4, women 0.4 +/-1.3), and obstructive (women men 8.6 +/-20.1, 1.0 +/-4.3) apnea indices were compared. In conclusion, the study demonstrates that elderly patients showed gender-dependent differences in the type and frequency of sleep-related breathing disorders. Men suffered from all kinds of apnea more frequently than women.

Non-invasive ventilation (NIV) via nasal or full face mask can be applied in respiratory failure due to chronic obstructive pulmonary disease (COPD) both in the acute and long-term settings. In acute exacerbation of COPD with respiratory failure it may be considered as a standard treatment. There is strong evidence that NIV might reduce intubation, complication, and mortality rate in patients with acute hypercapnia (PaCO(2) >45 mmHg). The method is cost effective and reduces hospital stay. NIV might be also useful in the weaning of COPD patients from invasive ventilation. On the other hand, for severe stable disease the data concerning a positive effect of NIV are less convincing. Preliminary evidence suggests that NIV improves gas exchange, sleep quality and quality of life and might reduce the need for hospitalization. Especially, COPD patients with substantial chronic hypercapnia (PaCO(2) >55 mmHg) and/or nocturnal hypoventilation, and those with repeated exacerbations may profit from NIV. In any case, NIV is a very valuable and effective tool in the non-pharmacological treatment of COPD. Every clinician who is involved in the management of COPD patients with respiratory insufficiency should be able to apply this technique.