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A 73-year-old female patient was admitted to our clinic for further clarification of a suspicious mediastinal lesion. Endosonographically, we performed a fine-needle aspiration biopsy. Clinical and radiological findings as well as cytology hardened the suspicion of a paraganglioma as being the cause of the mediastinal lesion. Finally, this diagnosis was confirmed histologically after complete surgical resection of the lesion. This case report on a mediastinal paraganglioma includes a concise summary of diagnostic procedures and therapeutic options for this rare disease., (© Georg Thieme Verlag KG Stuttgart · New York.)

The first set of German guidelines for diagnosis and treatment of patients suffering from acute or chronic cough was published in 2004. Scientific developments over the past five years necessitate an update. The purpose of this document is to assist in ascertaining underlying causes and treating cough, in order to eliminate or minimize impairments of patients' health. The guidelines aim to introduce scientifically founded, evidence-based steps for the diagnosis and treatment of cough and optimize cost-effectiveness. Recommendations are assessed through the GRADE system (The Grades of Recommendation, Assessment, Development and Evaluation). Cough as a symptom is categorized as either acute (lasting up to 8 weeks) or chronic (lasting more than 8 weeks) and attributed to distinct diseases. For acute and chronic cough the diagnostic algorithms are updated; cost effectiveness is also taken into account. Additionally, the most frequent diagnostic errors are highlighted. Finally, available therapeutic options are discussed.

Scleroderma is a generic term for autoimmunological diseases having thickened sclerotic skin lesions in common. Scleroderma belongs to a group of connective tissue diseases. The systemic form of scleroderma is called progressive systemic sclerosis (PSS) or systemic sclerosis (SSc). Lung impairments, namely interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH), are one of the most common manifestations in SSc. This article summarises the forms of lung impairment in SSc with special emphasis on interstitial lung diseases and draws attention to the so far identified pathogenetic mechanisms and the presently accepted therapeutic options., ((c) Georg Thieme Verlag KG Stuttgart-New York.)

Due to its high prevalence in patients with heart failure and its negative predictive value concerning morbidity and mortality, Cheyne-Stokes respiration (CSR) is a sleep disorders of major interest. CSR correlates with the degree of heart failure and is characterised by a typical crescendo/decrescendo breathing pattern combined with phases of central sleep apnoea, caused by pulmonary oedema and oscillation of ventilatory control. Thus, CSR is a marker of the severity of heart failure. Treatment of CSR first involves optimisation of heart failure therapy by cardiologists and then application of non-invasive means of ventilatory support. Treatment of patients with severe heart failure with non-invasive positive pressure ventilatory support leads to a significant reduction of CSR, sympathetic activity, and daytime sleepiness and improves cardiac output and 6-minute walking distance. At present, a prospective randomised, controlled intervention-study (Serve-HF study) is being conducted in order to show if therapy of CSR can improve patient survival. This review describes the pathophysiology, epidemiology, and therapeutic options of CSR with a special focus on the elevated cardiovascular risk of patients with CSR.

Introduction: Air quality is not only important for respiratory health but it also influences the homeostasis of the whole human organism. In the past years numerous violations of European Union particulate matter thresholds have been recorded., Methods: The present study is a selective literature analysis encompassing the epidemiology and pathophysiological effects of particulate matter., Results: Epidemiological studies point to an association between chronic particulate matter exposure and mortality. The most prominent effects on the human body are present in subjects with cardiovascular or respiratory conditions. However, the effects of air pollutants need to be examined critically and the plausibility of thresholds should be evaluated in detail., Discussion: The negative influences of chronic particulate matter exposure have been proven by a multitude of epidemiological and experimental studies. From the viewpoint of primary prevention, air quality plays a crucial role. This encompasses both the outdoor compartment with particulate matter and other pollutants and the indoor compartment with tobacco smoke.

COPD is a heterogenous disease caused by the interaction of genetic susceptibility and environmental influences. The best example to support this is tobacco smoke. Although cigarette smoking is the most important aetiological factor, only up to half of chronic smokers develop significant COPD. There are three main themes within the pathogenesis of COPD: 1) imbalance between proteases and anti-proteases, 2) oxidative stress, 3) inflammation. Disparity between levels of exogeneous oxidants, e. g., tobacco smoke, and endogeneous antioxidants leads to oxidative stress which, in turn, causes an inflammatory response involving pro-inflammatory mediators. The activated inflammatory cells release further proteases and oxidants, leading to chronic inflammation and irreversible destruction of connective tissue in the lung. Individual genetic variations influence these processes in many ways. This article summarises the results of recent candidate gene studies for COPD.

Background: A standard outcome parameter for pharmacological trials in COPD has not yet been defined. Therefore, it is the aim of this review to evaluate frequently used parameters for their eligibility as assessment and outcome parameters in COPD., Methods: A review of the actual scientific literature was performed., Results: It is recommended to continue to rely primarily on the FEV (1), which has been used as a primary variable in the vast majority of trials. In addition, further parameters, such as FVC and IC/TLC should be determined. If available, additional information is provided by RV/TLC, K (co), PaO (2) and PaCO (2). FEV (1) is not a surrogate parameter for dyspnoea, quality of life, and exercise tolerance, which should therefore be assessed separately. Frequency and severity of exacerbations and mortality are important outcome parameters in long-term trials. Complex indices, such as the BODE index, may be superior to single variables., Conclusions: No single additional parameter has been evaluated sufficiently in order to substitute FEV (1) as the standard parameter for the assessment and outcome in COPD.

Respiratory viruses trigger the majority of common colds, acute respiratory illnesses in children during the cold season as well as acute exacerbations of asthma and chronic obstructive pulmonary disease. They also play a role in community acquired pneumonia. Unfortunately their detection is still difficult. The aim of this review is therefore to introduce the methods of detection and to present the current knowledge of the clinical role of respiratory viruses in different diseases.

Background: Sleep-related breathing disorders (SDB), especially Cheyne-Stokes respiration (CSR), have prognostic relevance in patients with chronic heart failure (CHF). Thus, we investigated acute effects of cardiac resynchronization therapy on breathing during sleep., Methods: Beside a cardiopulmonary investigation, breathing during sleep was analysed polygraphically/polysomnographically on the night before and during the second night after implantation of a biventricular pacemaker for cardiac resynchronization., Patients: We investigated 16 consecutive patients with severe CHF (NYHA class III-IV) and widened QRS complexes (QRS > 150 ms) with the indication for cardiac resynchronization therapy independent of this study., Results: Cardiac resynchronization therapy shortened the QRS time in each and every patient (QRS: 167.3 +/- 21.7 ms to 113.0 +/- 19.0 ms; p < 0.001) as a marker for successful resynchronization. Initially, SDB were diagnosed in 11 of the 16 patients studied (69 %), with 7 patients having CSR (44 %) and 4 patients (25 %) having CSR and obstructive sleep apnoea. With cardiac resynchronization therapy, no significant acute changes were seen regarding nocturnal breathing/breathing disorder, heart frequency, or oxygen saturation., Conclusions: The established positive effects of cardiac resynchronization therapy are rather due to a chronic improvement of cardiopulmonary interactions (remodelling, circulatory time, or chemosensitivity) than to acute effects, as investigated in this study.

Sojourns in the high mountains have been recommended to patients with asthma for many decades. It is the aim of this contribution to summarise the published studies about the effects of a stay at > 1500 m above sea level on asthmatic patients. These data from 428 adolescent and adult patients indicate an improvement of asthma symptoms and lung function during sojourns at high altitude. In many patients a reduction of the steroid therapy was achievable. Profound changes in the immune system have been demonstrated at high altitude, with a reduction of B- and T-helper cell activation. Total and mite-specific immunoglobulin E antibodies decrease significantly during longer sojourns. These changes are associated with a reduction of airway inflammation (e. g., reduction of eosinophil activation, NO exhalation and bronchial hyper-responsiveness). The fact that also patients with non-allergic asthma demonstrate a reduction of their airway inflammation at high altitude suggests that the high altitude climate has beneficial effects on asthma beyond the effects of allergen avoidance. High UV exposure and low humidity could be important additional factors, to explain the reductions in asthma severity in the high mountain climate. Larger controlled studies should be performed to prove the positive effects of the high altitude climate on asthma.

Background: In patients with COPD and isolated night time hypoxemia, oxygen administration has not shown any effects on life expectancy and the development of pulmonal arterial hypertension. The aim of the present pilot study was to investigate the influence of nocturnal oxygen therapy on the quality of life in daytime normoxemic COPD patients with nocturnal oxygen desaturations., Patients and Methods: 19 patients with COPD, in a stable phase of the disease without need for oxygen supplementation under rest (PaO2 62.7 +/- 4.9 mmHg) and nocturnal hypoxemia (t90 = 55.5 +/- 33.4 % of registration time, mean SaO2 89.8 +/- 1.9 %, minimal SaO2 81.1 +/- 4.8 %) were randomly assigned to either oxygen or placebo treatment, both generated by identical concentrator devices. Each treatment period lasted 6 weeks, after six weeks a cross-over was performed by a technician. Quality of life was assessed before and at the end of each treatment period by the SF-36, Nottingham Health Profile and Saint George's Respiratory Questionnaire., Results: Significant differences for the comparison of placebo and verum were only seen for the dimension sleep (NHP), all other dimensions showed no differences between placebo and oxygen. However, both placebo and oxygen improved the majority of the quality of life items significantly., Conclusions: The prescription of supplemental oxygen in COPD patients with isolated nocturnal hypoxemia in the present pilot study is not able to improve the quality of life within 6 weeks after initiation of therapy. It cannot, therefore, be generally recommended, but may be indicated in patients with a documented improvement of sleep quality.

The prevalence of clinically relevant, obstructive sleep apnoea syndrome (OSAS) in the general population is 2% in women and 4% in men. With increasing age and onset of postmenopausal status, the prevalence of OSAS in women becomes comparable to that of males. However, compared to prevalence data, women are under-represented in clinical sleep laboratories. The present overview deals with the potential reasons for clinical under-recognition of OSAS in women. The fact that OSAS frequency is underestimated in women probably derives from the atypical clinical symptoms, dominated by difficulties of initiating and maintaining sleep and by a depressive mood. There are several protecting mechanisms in women that prevent or postpone OSAS development to higher age groups or until the onset of menopause. These factors include craniofacial morphology and function, gender-specific body-fat distribution and hormonal influences on ventilation and dilating muscles in the oropharynx. Physicians should be aware of the presence of sleep-disordered breathing in women and of their special features.

Background: Obstructive sleep apnea syndrome (OSAS) is a nocturnal breathing disorder with possibly negative consequences on daytime control of ventilatory drive. We therefore investigated ventilatory efficiency, defined as the ventilatory equivalent for CO2 (VaE/VaCO2), in patients with OSAS during exercise before and under treatment with continuous positive airway pressure (CPAP)., Patients and Methods: In 21 patients with untreated OSAS, ventilatory efficiency, described as the slope (DeltaVaE vs. VaCO2) and the lowest ratio (VaE/VaCO2 min) of the ventilatory equivalent for CO2, was determined below the anaerobic threshold using spiroergometry. A follow-up after at least 6 months of CPAP therapy was performed in 16 of these patients and in 5 CPAP-neglecting patients with OSAS, who served as controls., Results: In 21 patients with untreated OSAS, DeltaVaE vs. VaCO2 was significantly and VaE/VaCO2 min non-significantly lower, revealing better ventilatory efficiency, compared to normal values. In 16 patients, ventilatory efficiency did not change after on average 305.7 +/- 104.8 nights of CPAP-therapy, compared to 5 controls., Conclusions: OSAS is not associated with a disturbed ventilatory efficiency during exercise. Long-term CPAP-therapy does not change ventilatory efficiency during exercise in patients with OSAS. The improved ventilatory efficiency during exercise compared to normal controls may be due to differences concerning anthropometric data (e. g., obesity, hypertension) and cardiopulmonary exercise-test (45 degrees lying position).

Approximately 25 % of all patients suffering from obstructive sleep apnea syndrome (OSAS) discontinue CPAP-therapy in long-term follow-up. This study was conducted to investigate if there are any predictors signaling low compliance prior to initiation of CPAP-therapy. We used an open label longitudinal cohort study at an University hospital in-patient Sleep laboratory setting. In 85 consecutive patients with a diagnosis of OSAS confirmed by polysomnography a CPAP-therapy was initiated. Prior to CPAP-titration the subjects were interviewed using standardized, validated questionnaires (Nottingham Health Profile, von Zerssen's Depression Scale, State Trait Anxiety Inventory, IPC-Scale). On follow up (mean 16 +/- 8 month) 66 patients were still using CPAP regularly, 19 individuals had discontinued the therapy. Data of both groups were compared. There were no significant differences in polysomnographic parameters before CPAP except apnea-hypopnea-index (users: 30.72 +/- 20.68, rejecters: 18.43 +/- 10.43) and mean oxygen saturation (users: 91.65 +/- 3.32, rejecters 93.63 +/- 1.86). Depression and anxiety levels were normal in both groups. The subjects who discontinued CPAP had a significantly less external control belief. Internal control belief was normal in all patients. It is suggested that individuals who discontinued CPAP could not be convinced of the necessity of CPAP by physicians or nurses due to their reduced external control belief. Identifying patients with diminished external control belief prior to prescription of a device might be useful. In selected subgroups, different methods of motivation to maintain long-term acceptance for CPAP-therapy seems to be necessary.

Introduction: Patients with COPD present with impairments of their cognitive performance. The present study compares intelligence and memory performance as well as different aspects of attention in COPD patients and healthy controls. Additionally, potential factors influencing daytime performance are analyzed., Patients and Methods: Neuropsychological testing was performed in 32 patients with COPD and 10 normal controls. The following aspects were evaluated: memory, intelligence, simple, selective and divided attention, sustained attention under stress and under monotonous conditions., Results: There were no differences between COPD patients and normals with regard to divided attention, vigilance and memory. Patients with COPD demonstrated significantly worse results in terms of intelligence (p < 0.01) as well as simple (p < 0.01), selective (p < 0.05) and sustained attention (p < 0.01). No correlation existed between the severity of the disease (lung function, blood gas analysis, nocturnal oxygen saturation) and neuropsychological findings. Merely a relationship between memory function and slow-wave sleep or REM sleep was demonstrated., Conclusion: Impairments of cognitive performance in patients with COPD cannot be predicted on the basis of the severity of the disease. Therefore neuropsychological testing is recommended, especially when impairment of daytime function has to be quantified.

CPAP (continuous positive airway pressure) is the therapy of choice for obstructive sleep apnea syndrome (OSAS). About 70 % of patients on CPAP use their device for at least 70 % of nights with an application-time of at least 4 hours per night. Severity of breathing disorder respectively disturbance of sleep architecture, degree of daytime sleepiness and patients' satisfaction with diagnostic and therapeutic procedures are good predictors of long-term CPAP-compliance. CPAP-compliance can be increased by intensive patient education. Alternative devices like for example Bilevel or auto-CPAP respectively cannot augment CPAP compliance.

We report about a male 50-year-old patient with known non-small cell lung cancer and tumor-associated stenosis of the right main bronchus already treated with Neodym-YAG-laser coagulation. Eight months later the patient was readmitted to hospital and revealed complete occlusion of the right main bronchus and subtotal stenosis of the distal trachea and the left main bronchus. Conventional tracheobronchoscopy failed to visualize the post-stenotic parts of the left main bronchus due to the length and degree of stenosis. Multidetector-CT-generated virtual tracheobronchoscopy was able to demonstrate complete intraluminal tumor extent thus making precise pre-interventional measurements for stent implantation possible. Furthermore, post-interventional re-evaluation by virtual tracheobronchoscopy confirmed correct position and patency of the stent located within the distal trachea and the left main bronchus. Our case report demonstrates a non-invasive and easy approach for evaluating the tracheobronchial system in a patient with tumor-associated airway stenosis including the possibility for viewing beyond post-stenotic segments.

Developing more effective and convenient inhalation devices for the treatment of obstructive pulmonary diseases is at least as important as designing new drugs. In recent years, existing inhalation systems have undergone many technical modifications and there have also been many new developments. All of these systems have their own particular attributes and characteristics. Two fundamentally different modes of operation are represented by propellant-driven metered-dose inhalers (pMDI) on the one hand and dry powder inhalers (DPI) on the other. However, none of the systems developed so far can be considered ideal. The Respimat Soft Inhaler (Respimat SI) was developed in the light of experience with previous systems and was launched in Germany at the beginning of 2004. The aim in developing this new type of inhaler was to avoid the well-known drawbacks typically associated with pMDI and DPI. The Respimat SI requires neither a chemical propellant nor batteries. The active ingredients are dissolved in water and the solution is atomised using mechanical energy only imparted by a spring which, when released, provides the power to force the solution through an extremely fine nozzle system. Two fine jets of liquid are produced. They converge at an optimised angle and the resulting impact generates a fine mist which is slow-moving and lasts for about 1.5 seconds; moreover, a high proportion of the droplets fall into the fine particle fraction. All of these features allow excellent lung deposition and reduced oropharyngeal deposition. Coordination between actuation and inhalation is less critical as compared with pMDI due to the fact that the mist is both slow-moving and long-lasting. A further advantage is that the mist is generated independently of the patient's inspiratory flow. The Respimat SI meets the requirements for an ideal inhaler better than any other previous device and must therefore be regarded as a significant new development.

Background: nCPAP-therapy is standard for patients with obstructive sleep apnea syndrome (OSAS). This study investigated, if nCPAP changed the patients lung function., Patients and Methods: Lung function of 228 OSAS patients without co-prevalent lung disease, who received nCPAP for the first time, was examined (whole body plethysmography, spirometry, and blood gas analysis). After 1, 2, and 3 years the results of the re-examined patients were compared with their individual starting results., Results: The results of the patients in the basic and in the follow-up examinations was within standard range. During reexamination, an improvement of inspiratory vital capacity was registered repetitively, especially in smokers. On the other hand, MEF 50 decreased within the first two years and FEV (1) %VC, but not FEV (1), decreased after 2 and 3 years of reexamination., Conclusions: Neither obstructive nor restrictive lung diseases were diagnosed under nCPAP-therapy within three years. This study with a retrospective design showed significant improvements of vital capacity (VC) in patients with OSAS, especially in smokers, under nCPAP-therapy. This increase can be explained by an effect of practice in the examination and by recruitment of formerly hypoventilated lung areas. As MEF 50 and FEV (1) %VC depend on VC, the decrease of both parameters may be caused by the increase of VC. In summary, nCPAP did not cause negative effects of lung function in the investigated patients over a period of 3 years.

Background: Bronchial carcinoids are rare neuroendocrine tumors of the lung. Diagnosis is established by computed tomography (CT) and bronchoscopy-guided biopsy. Imaging features of carcinoids are highly characteristic including contrast enhancement and central intraluminal growth. Multislice-CT generated three-dimensional virtual bronchoscopy enables non-invasive and detailed view of the tracheobronchial system., Case Report: A 70-year-old male with known silicosis and chronic cough with hemoptysis showed hypertransparency of the left lung on conventional images. Axial CT scans revealed a solid tumor in the left lower lobe. Virtual CT-bronchoscopy based on surface rendering depicted an intraluminal mass occluding the bronchus of the anterobasal segment that was confirmed by conventional endoscopy. Conventional and virtual bronchoscopy showed almost identical imaging features. Histopathological evaluation of the bioptic specimen revealed a typical carcinoid tumor. The patient successfully underwent resection of the left lower lobe with mediastinal lymphadenectomy., Conclusions: Virtual Multislice-CT-bronchoscopy can add important information about an intraluminal tumor and its relation to surrounding structures. Further studies have to be undertaken to evaluate the potentials of this promising method as a tool to determine endoluminal growth in tumorous lung lesions.

We present the case of a 51-year old man with drug-resistant pneumonia in the upper right lobe, weight loss and a 50-pack year history of cigarette smoking who underwent bronchoscopy. By clinical and radiological findings bronchogenic cancer was assumed. Fiberbronchoscopy showed an exophytic tumor-like mass obliterating the right upper lobe. Biopsies revealed an epithelial pseudopapillomatous tumor with multiple mucosal dysplasia and metaplasia. A second bronchoscopy in order to remove the lesion revealed a foreign body embedded in the tissue which could be removed easily. The foreign body proved to be a cherry stone, after its removal pneumonia resolved completely. In the same patient this lesion was recurrent one year later after aspiration of a grape seed. We present this case to emphasize the relationship between foreign body aspiration and inflammatory pseudopapilloma as a sequela of the inflammatory insult provoked by foreign bodies. Bronchoscopy is mandatory and may obviate misdiagnosis and thoracotomy. The use of inhaled and systemic steroids can be used to facilitate successful endoscopic extraction.

Abstract. Patients with obstructive sleep apnea syndrome (OSAS) have an accident rate between two and seven times higher than normals. Investigations on accident frequency are based on case history, insurancy reports, and driving simulator investigations. The present controlled study was planned to test whether an increased accident risk could be demonstrated in patients with OSAS before and on CPAP (continuous positive airway pressure)-therapy using the driving simulator C.A.R. Driving simulator performance was investigated in 31 patients with polysomnographically confirmed OSAS (apnea-hypopnea-index 24.8 +/- 21.5/h) before, 2 and 42 days after initiation of CPAP and was compared to 10 healthy controls in whom OSAS was excluded by polysomnography. Driving simulator performance was significantly worse in OSAS as compared to normals especially in terms of accident frequency (OSAS: 2.7 +/- 2.0, controls: 1.3 +/- 1.5, p < 0.05) and concentration faults (OSAS: 12.4 +/- 5.1, controls: 7.1 +/- 3.2, p < 0.01). On CPAP accident frequency (OSAS before therapy: 12.4 +/- 5.1, 2 days CPAP: 1.5 +/- 1.4, p < 0.01; 42 days CPAP: 0.9 +/- 1.3, p < 0.001) and frequency of concentration faults (OSAS before therapy: 12.4 +/- 5.1, 2 days CPAP: 6.5 +/- 3.9, p < 0.001; 42 days CPAP: 4.9 +/- 3.3, p < 0.001) could be lowered significantly both in the short and medium term of therapy. The driving simulator C.A.R. is an adequate tool for the evaluation of an increased accident risk in OSAS-patients and demonstrates the efficiency of CPAP-therapy.

Background: Sleep related hypoxemia (SRH) in chronic obstructive pulmonary disease (COPD) can be easily detected by pulse-oximetry and may contribute to the development of pulmonary hypertension (PH). Since several parameters for the quantification of SRH are in use, we investigated which of these parameters has the strongest relation to the awake pulmonary arterial pressure (PAP) and is able to distinguish between patients without and with PH., Patients and Methods: 44 COPD-patients (awake PaO2 > or = 60 mm Hg) were investigated. PAP at rest (PAP; pathological threshold > 20 mm Hg) and under physical exercise (PAPB; p.t. > 28 mm Hg) were determined during daytime by Swan-Ganz-catheter. To quantify the degree of SRH the following parameters of nocturnal pulse-oximetry were used: mean nocturnal oxygen saturation (SaO2 m; p.t. < 90%), nadir SaO2 (SaO2 min; p.t. < 85%), and mean time of SaO2 < or = 90% in relation to total time of registration (t90; p.t. > 30%). Linear correlations and regressions as Chi 2-respectively Fisher-test were used for statistical analysis (p < 0.05)., Results: Generally there was only a weak relation between PAP and SRH. The best linear correlation at rest respectively under physical exercise was found between PAP and SaO2 min (r = -0.529 resp. -0.541, p < 0.001). Using the above defined thresholds for PAP and SaO2 patients could be most precisely separated into those without and with PH using SaO2 min with a threshold for the pathological range of < 85% (p = 0.030 resp. 0.002). t90 with a threshold > 30%, however, had a much worse selectivity (p = 0.487 resp. 0.057)., Conclusions: In COPD-patients with SRH the closest relation can be found between nadir SaO2 and PAP resp. PAPB. Furthermore nadir SaO2 (< 85%) could more precisely separate patients into those without and with pulmonary hypertension than t90. The overall weak relation between nocturnal oxygenation and pulmonary hypertension shows, however, that other factors such as daytime PaO2, hypercapnia or emphysema are involved in the development of pulmonary hypertension in COPD.

Disabilities of patients with coal-workers' pneumoconiosis (CWP) are currently estimated by changes in lung function at rest and the degree of dust equivalents in chest x-ray (ILO-classification 1980). Functional disturbances during exercise are not taken into consideration on a regular basis. We assumed that standardised sub-maximal exercise tests might be useful even in disabled patients to give additional information on functional disabilities of patients with CWP. The impact of low-grade anthracosilicosis on ventilation and gas exchange during exercise was assessed in 20 patients (all male, age 64.55 +/- 3.78 years) and 24 healthy volunteers (all male, age 58.13 +/- 4.68 years, never dust exposed). Data were also analysed according to ILO classification subgroups (group 1: ILO-classification 1/0 to 1/2, n = 11; group 2: ILO-classification 2/1 to 2/2, n = 9). Heart rate (HR), minute ventilation (VE), ventilatory equivalent for O2 (VE/VO2), ventilatory equivalent for CO2 (VE/VCO2), O2 uptake (VO2)CO2 output (VCO2), end-tidal oxygen partial pressure (PetO2), end-tidal carbon dioxide partial pressure (petCO2) and estimated dead space to tidal volume ratio (VD/VT) were determined breath-by-breath during a 50 watts constant work load protocol on an exercise bicycle. The VE/VO2 (patients: 32.9 +/- 4.2; controls: 25.7 +/- 2.9; p < 0.001), the VE/CO2 (patients: 39.4 +/- 4.6; controls; 31.0 +/- 3.9), the VE (patients: 30.1 +/- 5.6, controls: 23.5 +/- 3.0; p < 0.001) and the PetO2 (patients 115.6 +/- 4.8; controls: 99.1 +/- 27.4; p < 0.05) at an exercise of 50 watts were significantly higher in the patients' group, the PetCO2 (patients: 38.4 +/- 4.5; controls: 44.0 +/- 4.1) were significantly lower in the patients' group. The comparison of patients subgroups did not reveal any significant differences between group 1 and group 2. A higher VE/VO2 during 50 watts of exercise is attributable to an increased ventilation/perfusion mismatch. There was no correlation between the radiological grade of the CWP (ILO classification) and the ventilation and gas exchange during exercise. We conclude that a sub-maximal spiroergometry with a 50 watts constant work load might serve as a sensitive and easy to apply procedure add information about the functional impairment in CWP. The exercise test should be included in the evaluation for disability benefits.

Introduction: Allergies caused by metallic implants are often thought to be a reason for postoperative complications like bone necrosis or loosening of the prosthesis., Patients and Methods: In a prospective study, we investigated allergic sensitivity against components of stainless steel implants, including titanium, in 112 patients shortly before surgical operation. The same tests were then repeated in 100 of these patients exactly one year after operation. There were three different kinds of procedures: 1. titanium implants, mainly total hip replacements, 2. regular steel implants, 3. surgery without any implants (control group). Any differences from the process of regular healing were regarded as postoperative complications., Results: A sensitivity against nickel (Ni) was diagnosed in three of these 100 patients (3%) before surgery. These patients, of whom two received a nickel-containing implant and one a titanium arthroplasty, did not show any postsurgical complications. Furthermore, three patients (3%) acquired a new sensitivity against metals during the study-interval of one year. Two of these three patients were women, who developed a postsurgical sensitivity against nickel or chrome but got titanium arthroplasties, which did not contain any nickel. These two women wore metal-containing jewelry, which might be the reason for the newly acquired metal-sensitivities, and both showed postsurgical complications. The third patient, who has developed a postsurgical sensitivity against components of his steel arthroplasty, did not reveal any complications., Discussion: We conclude that the rate of allergic sensitization against metal-components of arthroplasties is low in our patients. Additionally, skin-sensitivity against components of alloys and platings was not associated with a higher rate of postsurgical complications in our patients. We did not see any sensitivity against titanium. In conclusion, metallic implants are not a cause of allergies to a relevant extent, nowadays.

The effect of inhaled long-acting beta 2-agonists on obstructive sleep apnoea syndrome (OSAS) is unknown, though from the pharmacological point of view both therapeutic and adverse effects might be discussed. The purpose of this study was to obtain data on the efficacy and safety of Salmeterol in patients with OSAS. In a randomised, double-blind, placebo-controlled, crossover study effects of Salmeterol were investigated in 20 patients with OSAS: 4 female, 16 male; age 53.0 +/- 7.8 years, body mass index (BMI) 28.0 +/- 3.0 kg.m-2; apnoea hypopnoea index (AHI) 35.6 +/- 17.8 h-1. Patients with asthma, chronic obstructive pulmonary disease (COPD), and left heart failure were excluded. Placebo or verum (50 micrograms Salmeterol) were administered at 7 p.m. by metered dose inhaler and spacer device. All patients underwent full polysomnography during baseline, placebo, and verum night. Statistical analysis was performed by Student's t-test (p < 0.05). Between placebo and verum there were no differences in total sleep time, sleep stages, apnoea index (AI), AHI, and nadir SaO2. There was, however, a significant deterioration of mean SaO2 (placebo 93.1 +/- 2.0 vs Salmeterol 92.5 +/- 2.2%) and of relative time spent with SaO2 < or = 90% (placebo 13.1 +/- 14.5 vs Salmeterol 19.5 +/- 20.8%), as well as a significant increase in heart rate (placebo 63.1 +/- 9.2 vs Salmeterol 65.6 +/- 9.3 h-1). Thus, in patients with OSAS Salmeterol had no adverse effect on quality of sleep, AI or AHI. The slight increase in heart rate and the deterioration of oxygen saturation are clinically irrelevant. The latter might be due to ventilation-perfusion-mismatch. This study demonstrates that Salmeterol has no influence on obstructive sleep apnoea and hypopnoea, but on the other hand provides an acceptable safety profile in OSAS. This might be of special importance in patients suffering from both OSAS and obstructive airway disease.

The ILO classification of small and large opacities is the basis for the compensation of patients with pneumoconiosis. In order to validate the radiological findings, we compared the ILO classification with the gradings of pneumoconiosis in the post mortem investigation (n = 126). An ILO classification of 1/0 used as the threshold value for accepting the diagnosis of a pneumoconiosis was 100% sensitive with a specificity of 2%. With a value of 2/3 the sensitivity decreased to 60% and specificity increased to 74%. The grading of large opacities in the radiograph correlated well with the post mortem findings (rs = 0.71; p < 0.001). For accepting the diagnosis pneumoconiosis from the radiograph alone a threshold value of 1/0 is not specific. The ROC-plot revealed that specificity reached acceptable levels with an ILO classification of at least 2/3.

A skin prick test was performed in 75 patients with an obstructive sleep apnea syndrome (OSAS) to test allergic skin reactivity to 18 common inhalant allergens. Additionally, anterior rhinomanometry was performed. Results were compared with a group of 21 patients with chronic obstructive pulmonary disease and with 198 workers of the chemical industry. A positive (> or = 4 mm wheal diameter) skin test to at least one allergene was present in 49 per cent of the OSAS patients, compared to 14 per cent in COPD patients and 28 per cent in industrial workers (p < 0.05; chi 2-test)-33 per cent (n = 25) of the OSAS patients with a sleep apnea syndrome showed skin reactivity to house dust mite (D. ph., D. f.) compared to 9.5 per cent in COPD patients and 12.6 per cent in industrial workers (p < 0.05 chi 2-test). No difference was found between anthropometric, polysomnographic, or rhinomanometric data comparing OSAS patients with positive skin reactions against house dust mites (n = 25) and those without any allergic skin reactivity (n = 38).

This study was conducted to investigate the clinical value of blood gas analysis during exercise in patients with COPD and healthy controls using the new criteria of the Deutsche Gesellschaft für Pneumologie (DGP) for performance and interpretation of blood gas analysis during exercise. A total of 64 patients with COPD (age: 63.7 +/- 10.1 years) and 35 healthy controls (age: 35.0 +/- 14.3 years) exercised on a bicycle ergometer to their submaximal capacity under steady state conditions (patients: 44.4 +/- 24.6 watt vs. 102.4 +/- 32.1 watt; p < 0.01). A pathological response for PaO2 occurred in 3 of 35 controls (8.6%) and 14 of 64 patients (21.9%; p < 0.01). A decrease in PaO2 yielded a sensitivity of 28% and a specificity of 92% in respect of patients with emphysema. Significant associations of lung function parameters at rest and blood gases under exercise were found by linear regression analysis (airway resistance (Rt): beta = -0.48; p < 0.001) and PaCO2 (FEV1: beta = -0.27; p < 0.05). This study demonstrates that in patients with COPD parameters of lung function and blood gas analysis at rest are already good predictors of gas exchange under exercise conditions. In individual cases, however, prediction may not be possible. This underlines the importance of the exercise test to investigate gas exchange under diagnostic (i.e. dyspnoea, medical opinion) and therapeutic aspects (i.e. therapy control). For COPD patients, the rule of the DGP yielded a poor sensitivity, but an excellent specificity in the diagnosis of emphysema, which yields confirmation of the diagnosis only in conjunction with, and complementary to, other methods.

There is evidence that bronchial responsiveness to allergen is quantitatively correlated with bronchial responsiveness to nonspecific stimuli in subjects with allergic asthma. This association has been questioned in occupational asthma due to low molecular weight substances. It was the aim of this study to assess the quantitative association of bronchial responsiveness to methacholine (MCH) and platinum salts (Pt), in the form of hexachloroplatinic acid, in workers with occupational asthma due to Pt salts. Fifty-seven subjects with exposure to Pt, work-related asthma, and a positive bronchial challenge with Pt underwent skin prick test with Pt and bronchial challenge with MCH. Using the provocation concentration causing a > or = 50% fall in specific airway conductance (PC50sGaw(Pt)) as a dependent variable, anamnestic data (period from first symptoms to removal, period between removal from exposure and diagnosis, and smoking), season of the investigation, skin prick tests with environmental allergens, total immunoglobulin E (IgE), skin reactivity to Pt (Pt concentration causing a 2 mm wheal), and PC50sGaw(MCH) were included as independent variables for regression analysis. Fifty-two subjects (91%) showed a PC50sGaw(MCH) < 8 mg.mL-1 (geometric mean for all subjects 1.6 mg.mL-1). Responsiveness to Pt varied widely between subjects (geometric mean of PC50sGaw(Pt) 9 x 10(-5) mol.L-1, range 2 x 10(-7) to 10(-2) mol.L-1). There was no univariate correlation between bronchial responsiveness to MCH and Pt, but there was a correlation between skin reactivity to Pt and PC50sGaw(Pt) (r = 0.6). This association could not be improved by considering PC50sGaw(MCH), the period from first symptoms to removal, or the period between removal from exposure and diagnosis. The parameters that showed the highest (negative) associations with PC50sGaw(Pt) were skin reactivity to Pt and the period between removal from exposure and diagnosis (r = 0.65). We conclude that there is a moderate association between bronchial responsiveness to platinum salts and skin reactivity to platinum salts. However, there is no association between methacholine responsiveness and bronchial responsiveness to allergen in occupational asthma due to platinum salts.

Data concerning the occurrence of chronic-obstructive pulmonary disease (COPD) in patients with obstructive sleep apnea syndrome (OSAS) vary between 11 and 20% due to the underlying definition of COPD. We investigated the frequency of COPD in 202 patients with OSAS. The obstructive pattern was defined by bodyplethysmography (Rt > 0.35 kPa x 1(-1) x s(-1)), flow-volume-curve (MEF50 < 50% pred.), Tiffeneau-index (FEV1/IVC < 70% pred.) and anamnesis (cough and/or sputum). Prevalence of COPD in our 202 patients with OSAS was 16.3%. Patients with OSAS and COPD had a higher body-mass-index (BMI), lower PaO2 and spent more time in an oxygen saturation < or = 90% in relation to total recording time (t90). Polysomnographically there was no difference between the two groups with regard to the ventilatory parameters apnea-index (AI) and apnea-hypopnea-index (AHI). As there is a high risk of developing hypercapnia, pulmonary arterial hypertension and cor pulmonale in patients with OSAS and COPD there is need for early diagnosis of the combination of both diseases.

In order to develop an efficient antioxidant therapeutic regime for inflammatory disease in the lung N-acetylcysteine (NAC) and reduced glutathione (GSH) were tested to inhibit O2 and H2O2 in vitro and ex vivo. NAC and GSH inhibited both at > or equal to 10(-4)M significantly H2O2 (5 x 10(-8)) mol/ml; p < 0.05). In contrast, in an assay consisting of xanthine/xanthine oxidase/ferricytochrome c Cu++/Zn++ superoxide dismutase (SOD), but not NAC and GSH had an anti-O2 effect (SOD: at > or equal to 10(-5)M, p < 0.01 when compared with 0). In accordance with these results, NAC and GSH had good anti-H2O2 efficacy in freshly isolated and ex vivo cultured mononuclear (MN) and polymorphonuclear cells (PMN) derived from patients with COPD (smoker, n = 30). Both drugs reduced H2O2 significantly when used in concentrations already at > or equal to 10(-9)M (p < 0.05). However, neither GSH nor NAC influenced O2 produced by these inflammatory cells effectively. Antioxidative properties of NAC are well explained by the SH-group within the molecular structure which can be oxidized by certain oxygen radicals. Good H2O2 scavenger function ex vivo, which seems to contradict the results obtained in vitro, illustrates additional cellular GSH-precursor efficacy of both substances in cell dependent assay systems. Thus, to achieve direct anti-H2O2 efficacy in vivo high local NAC concentrations (10(-4)M)) are necessary.