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Purpose: To compare the Therapeutic Intervention Scoring System (TISS) 28 in difficult to wean patients before and after transfer to a weaning center., Patients and Methods: Using TISS-28, the authors investigated the difference between regular intensive care units (ICUs) and the respiratory ICU (RICU) of their hospital in difficult to wean patients after long-term mechanical ventilation (MV). Special emphasis was placed on the appropriateness of TISS-28 to cover the specific weaning activities. 63 tracheotomized patients ventilated for more than 14 days were included., Results: In total, 15.9% of patients were not weaned, 20.6% of population was successfully weaned with noninvasive ventilation (NIV), and 63.5% of patients was successfully weaned without NIV. The transfer of patients from other ICUs to a weaning facility resulted in a significant reduction of total TISS-28 from 29.5 to 23.8 points (p<0.001) on average., Conclusion: The high weaning success rate in a specialized facility is associated with a significant reduction of TISS-28 scores. The use of TISS-28 in a weaning center for patients with prolonged MV to measure workload does not adequately mirror the efforts by physicians, nurses, physiotherapists, and other health-care personnel.

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

Objectives: Patients with severe emphysema from pink puffer type (PPT) are symptom-limited due to dyspnea even at low level of activity. In this study we investigated the clinical effect of oral morphine in this group of patients., Materials and Methods: Based on the analysis of medical records (n = 456 patients) and a currently answered questionnaire (n = 205 patients) we analyzed data of all patients with emphysema being treated from 1995-1999., Results: Dyspnea improved during the adaptation period on the ward in 59.4% of the whole population being treated with morphine and in 67.7% of the analyzed patients after discharge. Before discharge the treatment with morphine was finished by 38.9% of the population. In the group of long-term survivors approximately 50% of patients continued the treatment. In total, about 10% of the collective finished the treatment due to intolerable side effects. In the 5-year observation period morphine has been increasingly applied in an earlier stage of the disease., Conclusion: In patients with severe emphysema from pink puffer type a trial with morphine is justified. In particular the beneficial effect on dyspnea in the responder group and the acceptable rate of side effects underline this strategy.

Background: Imbalance of load-capacity relationship in severe COPD may lead to ventilatory failure. Additionally, in such patients, anemia may aggravate the ventilatory load. In this retrospective study we investigated whether anemia patients undergoing long-term ventilation benefit from transfusion., Case Reports: We studied 5 anemic patients (hemoglobin: 8.7 +/- 0.8 g/dl) with COPD in whom trials of weaning from the ventilator had been unsuccessful. After transferral to our regional weaning centre, blood was transfused to increase the hemoglobin value to approximately 12 g/dl or higher. Subsequently, all patients could be successfully weaned within a short period., Conclusion: We conclude that in difficult to wean anemic patients blood transfusion should be considered and may lead to successful weaning.

Background: In patients with disturbed gas-exchange (e.g. COPD) intratracheal oxygen insufflation (ITO2) improves oxygenation and reduces the minute ventilation. We use a bronchoscopic technique of intratracheal catheter placement in unintubated patients. In a patient with a pink-puffer emphysema after endoscopical insertion of the catheter ITO2 induced a "continuous flow apnoeic ventilation" (CFAV)., Case Report: A patient (female, 58 years) with a pink-puffer emphysema was admitted to the ICU with acute on chronic respiratory failure due to acute laryngitis. Because of laryngitis associated upper airway obstruction a non-invasive mechanical ventilation could not be performed. The ensuing high flow ITO2 (10 l/min) induced a CFAV characterized by no chest wall movement and adequate ventilation as reflected by stable, elevated PaCO2 (between 118 and 125 mm Hg), which could be maintained for 4 hours. After an ensuing short-term invasive mechanical ventilation and the administration of high dose glucocorticoids the patient was successfully extubated and the clinical status improved continuously., Conclusion: In a patient with an acute on chronic respiratory failure due to end-stage emphysema ITO2 induced CFAV and stabilized the clinical status. Especially in patients with end-stage emphysema, who are likely to be difficult to be weaned from the respirator ITO2 may be a feasible technique in order to bridge an emergency situation.

Background: Nocturnal hypoventilation is associated with chronic ventilatory insufficiency (CVI). Noninvasive mechanical ventilation (NIV) performed overnight relieves symptoms of hypoventilation and improves daytime blood gases in CVI. In order to test whether the efficacy of NIV depends on its being applied during sleep we conducted a prospective case controlled study comparing daytime mechanical ventilation (DV) in awake patients with nocturnal mechanical ventilation (NV) given in equal quantities., Patients and Methods: We enrolled 34 clinically stable patients (age: 56.1 +/- 12.1 years, 20 female) with CVI due to both restrictive lung and chest wall disorders and neuromuscular disease. Using a prospective case-control design, matched subjects were allocated alternately to DV and NV., Results and Conclusions: There were no significant differences between the groups in the improvement of the measured parameters; (e.g. PaCO2; DV: from 57.6 +/- 4.3 to 44.0 +/- 4.6 mm Hg, NV: from 55.5 +/- 3.5 to 45.0 +/- 4.1 mm Hg, p < 0.0001). We conclude that in many respects, when compared to NV, DV in awake patients is equally effective for the treatment of CVI.

Background: Recently we could show that the daily activity in patients with hypercapnic respiratory failure as judged by the total amount of movements per day increased by 120% after 3 months of non-invasive mechanical ventilation. This study was designed to evaluate the reproducibility of the result of a movement detector in measuring daily activity of patients with COPD., Patients and Methods: 25 outpatients (11 females, 56 +/- 12 years old) with stable non-hypercapnic COPD (FEV1 = 47 +/- 9% predicted) were examined twice during a 7 days lasting interval, one month apart using a pedometer., Results and Conclusions: The repeatability of the activity counts in the non-hypercapnic COPD patients was high (1st study period: 3,781 +/- 2,320 movements/d, 2nd study period: 3,626 +/- 2,149 movements/d) and in these patients activity correlated significantly with FEV1 (r = 0.54, p = 0.006).

Background: The concept evolutionary quality assurance is a new, non-mandatory, open peer review process for in-patients settings., Method: Ten medical charts (with radiographs) from participating hospitals were randomly chosen and assessed using a prespecified questionnaire (total 134). Individual inadequacies had to be justified on a case by case level. Reviewer and reviewee are known by names, allowing subsequent discussions on content between reviewer and reviewee prior to a final judgement. The final analysis was performed anonymously and communicated to the participants after completion of the process. Patients had to give their consent to the review process. The report, however, is not part of the medical patient file, so that access is not warranted. For the first cycle, all lung clinics and departments throughout Germany were asked to participate. 35 chest hospital (approximately 50%) agreed to participate., Results: Data analysis revealed that almost all detected inadequacies were apparent, i.e. discussions on the discordant interpretation of diagnostic and therapeutic strategies rarely occurred (0.25%). Final analysis of the evaluation performance of reviewers judged less than 5% and 14% judged more than 30% of all quality inadequacies., Conclusions: The quality assurance process is comparably cheap and can be implemented without delay, because standards for reference values are not required. The structure allows adaptation in all areas of clinical medicine.

Background: In patients with disturbed gas-exchange intratracheal oxygen insufflation improves oxygenation and reduces the minute ventilation. Until now the intratracheal oxygen insufflation was performed using a tracheostomy or a percutaneous transtracheal technique. We studied the acceptance and efficacy of the intratracheal oxygen insufflation using a bronchoscopic technique of intratracheal catheter placement., Patients and Methods: Five COPD-patients (4 men, 55.2 +/- 10.3 years; FEV1: 0.9 +/- 0.31 = 30.3 +/- 5.5% debit, pO2: 56.2 +/- 10.3 mmHg, pCO2 +/- 43.1 +/- 4.8 mmHg). Procedure of catheter placement: Through a nasally passed bronchoscope a guide wire was inserted into the proximal part of one bronchus. When positioned at the point 2 to 3 cm proximal to the carina, the bronchoscope was marked with plaster at the nasal ostium in order to measure this distance. After removing the endoscope, the oxygen catheter was inserted proximal to the carina using the guide wire. Before and during the intratracheal oxygen insufflation (flow: 3 l/min) minute ventilation, tidal volume, breathing frequence, blood gases and the subjective scores (using a visual analogue scale) were measured., Results: Apart from one patient with a tolerable spontaneous declining urge to cough irritation the catheter was tolerated well during the study. Whereas pCO2 remained stable during the ITO2 (before ITO2: 43.1 +/- 4.8 mmHg; after 1 hour ITO2: 44.3 +/- 4.8 mmHg), the oxygenation improved (pO2: 56.2 +/- 10.3; 81.4 +/- 19.6 mmHg) and the minute ventilation decreased (7.5 +/- 1.8; 5.4 +/- 1.3 l/min) by approximately 28%., Conclusion: The bronchoscopic application of the intratracheal oxygen catheter was characterized by high acceptance, low invasiveness and immediate function. Furthermore, the minute ventilation and work of breathing respectively decreased to a relevant degree.

Background: Pulmonary diseases with marked disorders in gas exchange or chronic overload of the respiratory pump needs increased ventilatory requirements. Additionally in these patients anemic may aggravate the ventilatory load. We thereby evaluated whether in these patients treatment of anemia (red blood cell transfusion: RBCT) leads to an improvement of the ventilatory load in comparison to the anemic patients without pulmonary disease., Patients and Methods: We examined 21 patients with an anemia (Hb < 11 g%, 12 men). Fifteen patients had a pulmonary disease (group A), 6 patients suffered from anemia without pulmonary disease (group B). Subsequently within 8 hours the patients got 2 to 3 RBCT. We studied the patients on the day of admission and 24 to 36 hours after transfusion. The patients kept bed rest for spontaneous breathing 1 hour prior to the actual examination without supplemental oxygen. Hemoglobin, hematocrit, respiratory rate, respiratory minute volume and arterial blood gases were measured. On the following day we repeated the same procedures., Results and Conclusions: Anemia in patients with an increased ventilatory requirement causes an additional increase of work of breathing. In these patients-in contrast to patients without compromised lungs-2.2 red blood cell transfusions lead to an impressive reduction of VE (about 20%) and correspondingly also to a reduction of WOB.

Background: Nocturnal mechanical ventilation (NMV) can reduce symptoms of hypoventilation and improve gas exchange in patients with chronic respiratory failure but there is no data concerning the impact of nocturnal mechanical ventilation on daily activity. We prospectively measured daily activity as judged by total steps per day., Patients and Methods: Thirty stable patients (17 men, mean age 55.2 years, pCO2: 62.3 +/- 9.0 mmHg) with chronic respiratory failure., Diagnosis: Kyphoscoliosis (n = 11), COLD (n = 7), neuromuscular diseases (n = 6), post-tbc sequelae (n = 6). Applying a pedometer over a 7 day period before and 3 months after initiating nocturnal mechanical ventilation the steps per day were counted. We also obtained arterial blood gases and applied the St. George's Respiratory Questionnaire (scoring range from 0 = complete health to 100 = worst possible)., Results and Conclusions: The daily activity in patients with hypercapnic respiratory failure as judged by the total amount of steps per day increased by 120% after 3 months of nocturnal mechanical ventilation (from 1606.9 +/- 1341.3 to 3535 +/- 1813.8 steps per day, p < 0.0001). This was associated with a significant improvement in daytime blood gases and quality of life (QoL) as judged by questionnaire (total score: from 61.3 +/- 14.9 to 48.3 +/- 18.7, p = 0.0006). However no correlation between steps per day and QoL was found.

Background: Volume controlled intermittent ventilation (IPPV) via face mask is a treatment of proven efficacy for chronic respiratory failure (CRF). Pressure support ventilation has recently been introduced in the treatment of CRF. In this study we investigated whether pressure constant ventilation (PCV) via face mask could be an adequate long term alternative to IPPV., Patients and Methods: We studied 30 (24 male, age: 52.2 +/- 15.9 years) patients with CRF. We measured the following parameters at baseline, after 1, 2 and 6 months, respectively: blood gas analysis, oxygen saturation, vital capacity, forced exspiratory volume, breathing frequency, tidal volume, inspiratory mouth occlusion pressure, maximal inspiratory pressure, subjective symptom scores and ventilator acceptance scores. In all patients, we attempted to treat with IPPV over 1 month, followed by 1 month's trial of PCV. If PCV, compared to IPPV, was adequate, PCV was continued for a follow-up period of 4 months' duration. If patients deteriorated after PCV they were treated the following 4 months with IPPV., Results: In 28 out of 30 patients CRF improved concerning subjective and objective parameters. After IPPV 18 out of 28 patients changed to PCV, with an equal quality of treatment (PCV-responder). Ten patients were PCV-nonresponders since compared to IPPV the subjective scores deteriorated and the PaCO2 increased again. In all patients of either therapy group, subjective and objective parameters remained constant for another 4 months period. At baseline the PCV-nonresponders had significantly higher degree of hypercapnia and oxygen desaturation; no other parameters were found to be of predictive value concerning the efficacy of PCV., Conclusions: PCV proved to be an alternative to IPPV in the treatment of chronic respiratory insufficiency in approximately 60% of the patients with CRF. However there is a subgroup with more severe CRF at baseline in whom PCV is inadequate.

Background: Recently intra- and extraoral devices are increasingly used in order to treat obstructive sleep apnea (OSA) and snoring. We examined the value of some devices according to the literature and our own results., Patients and Methods: The mandibular advancing devices aim at increasing upper airway diameter. The active part of the tongue extending device (SnorEx) is a stamp connected to a piston which exerts pressure at the base of the tongue causing its forward displacement; we studied 23 patients. The principle of an optically stimulating system ("eye-cover", Snore-Stop) consists of a microphone and light diods which are integrated in the eye-cover. After detecting acoustic signals (for example snoring) optical stimuli are generated in front of the eyes, which are thought to induce arousals causing a change of body position and the reduction of the snoring and apneas; we measured 24 patients. The principle of the tongue-retainer (Snore-Master) is the fixation of the tongue in a ventral position, which is thought to enlarge the mesopharyngeal area; we studied 14 patients. The nose plaster (Breathe-Right) contains an elastic spine that pulls the alae nasi cranial. This manipulation is thought to increase the diameter of the nostril and reduce the airway resistance. We measured 30 patients with obstructive sleep apnea and 20 snoring subjects without obstructive sleep apnea., Results: Regarding the mandibular advancing due to different appliance designs and study protocols variable success rates have been documented. In patients with mild to moderate obstructive sleep apnea a reduction of the sleep related breathing disorder could be shown. Non compliance (NC) to the tongue extending device was 75% (17/23). Non-compliance-patients were characterized by unacceptable local-side-effects of the prosthesis, lacking improvement of symptoms and of the respiratory disturbance index. Both tongue-retainer and -extensor are characterized by a high incidence of local side effects. Neither the eye-cover nor the nose plaster could improve the severity of obstructive sleep apnoe or snoring. In contrast to another study we could not show a significant effect of the tongue-retainer., Conclusions: Neither the nose plaster nor the optical stimulating device influenced the degree of obstructive sleep apnea and snoring. There are conflicting data regarding the tongue retainer. The high rate of non-compliant subjects and the low efficacy of the tongue extending prosthesis precludes large-scale use of this treatment modality in patients with obstructive sleep apnoe and snoring. In selected individuals suffering from a mild to moderate degree of obstructive sleep apnea with CPAP-inefficiency and -incompliance the mandibular advancing principle may be an therapeutic alternative to CPAP.

Background: Weaning from the mechanical ventilator often proves to be difficult after prolonged ventilation due to excessive load or decreased capacity of the respiratory muscles. In the present retrospective study we examined the impact of the nocturnal mechanical ventilation during the "post-weaning-period" of long-term ventilated patients., Patients and Methods: We studied 43 patients (23 men, 59.1 +/- 14.6 years) with chronic respiratory failure who were transmitted from external ICUs after a mechanical ventilation period of 57.5 +/- 60.3 days. The weaning regime consisted of an individually adapted volume-cycled ventilation. If the patients were hypercapnic (pCO2 > 48 mm Hg) after the first 24-hour-period of spontaneous breathing without supplemental oxygen nocturnal mechanical ventilation was initiated., Results and Conclusions: In a retrospective study we could show that the decision to initiate invasive or noninvasive nocturnal mechanical ventilation after successful weaning primarily depends on the question whether a chronic hypercapnic respiratory failure persisted also after weaning from long-term mechanical ventilation. In about 40% of unselected patients nocturnal mechanical ventilation stabilized the weaning success whereas 60% of the patients did not need any further nocturnal mechanical ventilation.

Background: In patients with hypercapnic respiratory failure due to restrictive lung diseases home mechanical ventilation leads to improvement of daytime blood gases and symptoms. In this paper we regard the possible pitfalls and complications associated with intermittent mechanical ventilation in patients with kyphoscoliosis., Patients and Methods: From 1990 to 1994 we treated 30 patients suffering from severe kyphoscoliosis with home mechanical ventilation., Results and Conclusions: 1. As our cases show in the prehospital phase before initiating home mechanical ventilation there is still room for the outpatient pneumologists to improve their knowledge and awareness of symptoms and treatment of chronic respiratory failure. 2. In the subsequent inpatient phase and specialised center must be aware and experienced in regarding possible problems inherent with home mechanical ventilation. 3. After discharge during chronic home mechanical ventilation a good cooperation between the center, patient, relatives, general services and general pulmolgists is necessary. The centers should offer training courses for the caring persons and general pneumologists.

Background: Chronic hypercapnia seems to preserve the overloaded respiratory pump from manifest muscle failure. In order to get information about the regulation of the ventilation under exercise we investigated clinical stable hypercapnic patients., Patients and Methods: Twenty-one patients (20 males, 53.7 +/- 13.2 years) with obesity-hypoventilation syndrome (8), chronic obstructive lung disease (4), scoliosis (3), myopathy (2) and post-Tbc (2) were examined. Ventilation parameters (fb, Vt, VO2), respiratory muscle strength (PImax, PEmax), arterial blood gases (pO2, pCO2), respiratory quotient (RQ) and lactate were measured at rest and at the end of 5 minutes of maximal bicycle exercise. The control group consisted of 10 healthy persons., Results and Conclusions: A significant augmentation of the pre-existing hypercapnia under exercise (reflecting hypoventilation in relation to the predicted value) was observed in all patients with chronically overloaded respiratory muscles. This mechanism seems to be wise because it protects the respiratory pump from failure.

Background: In many cases, respiratory muscle failure is the reason for unsuccessful weaning attempts after long-term ventilation. Therapeutic measures must therefore be aimed at unloading the respiratory pump. In this present study we examined whether, in particular, the transtracheal O2-insufflation (TTO2) results in a change of breathing patterns and unloads the respiratory muscles., Patients and Methods: We examined 6 patients (5 males, age 65.6 +/- 3.9 years, diagnosis: chronic obstructive lung disease), who received long-term mechanical ventilation in outward intensive care units. Baseline resting data (arterial blood gas analysis, the breathing frequency and the minute volume) were obtained with the patients breathing room air for 1 hour. After receiving TTO2 with a flow of 21/min for another 1-hour-period the measurements were repeated., Results and Conclusion: In our study we could show that the TTO2 leads to an impressive decrease in inspiratory work of breathing-relative to the minute ventilation by about 28%. Therefore TTO2 is of great importance in the weaning phase subsequent to prolonged mechanical ventilation due to the respiratory muscle failure.