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Wahrend Erkrankungen der Lunge ursachlich zu einem Sauerstoffmangel, einer Hypoxamie, fuhren mit der Indikation, Sauerstoff zu geben, ist die Uberlastung der Atempumpe Ursache fur Hyperkapnie und Luftnot, die durch Beatmung zu behandeln sind. Fruhzeitige Diagnostik ermoglicht eine rechtzeitige nichtinvasive Beatmungstherapie und kann ein Atemversagen und eine akute invasive Beatmung vermeiden. Dafur stehen diagnostische Masnahmen zur Verfugung, sodass das Risiko fur ein zukunftiges Atemversagen fruhzeitig erfassbar ist. Auch die Therapie der Atempumpinsuffizienz, der ventilatorischen Insuffizienz, ist etabliert: die Entlastung der Atempumpe durch intermittierende Beatmung. Tausende Patienten mit ventilatorischer Insuffizienz nutzen eine intermittierende oder kontinuierliche Beatmung jeden Tag, um ihre Atemmuskulatur zu entlasten. Mehrere Studien haben eine Verlangerung der Lebenserwartung und eine Steigerung der Lebensqualitat belegt, wenn diese Entlastung zusammen mit einer Erniedrigung des pCO2 (Kohlendioxidpartialdruck) sowohl unter Beatmung als auch unter Spontanatmung erreicht wird. Wird dieses Ziel der pCO2-Erniedrigung nicht erreicht, so kann ein Effekt der Beatmung nicht nachgewiesen werden. Je schwerer die Erkrankung, desto schwerer ist es, Entlastung zu erreichen, weil die erheblichen Atemanstrengungen des Betroffenen durch nur unterstutzende Beatmung kaum entlastet werden konnen. Eine vollstandig passive Hyperventilation, sodass der Patient unterhalb der Apnoeschwelle nicht selbst atmen muss, garantiert die Entlastung. Dazu sind ein hohes Atemzugvolumen, eine ausreichende Atemfrequenz und eine ausreichend lange Inspirationszeit notwendig, um den pCO2 unter den Normbereich abzusenken und die passive Beatmung herbeizufuhren. Lungenschaden sind bei dieser an einer Vielzahl von Patienten eingesetzten Therapie nicht beobachtet worden.

Non-invasive ventilation has gained an increasingly pivotal role in the treatment of acute hypoxemic and/or hypercapnic respira-tory failure and offers multiple advantages over invasive mechanical ventilation. Some of these advantages include the preserva-tion of airway defense mechanisms, a reduced need for sedation, and an avoidance of complications related to endotracheal intubation. Despite its advantages, non-invasive ventilation has some contraindications that include, among them, severe encephalopathy. In this review article, the rationale, evidence, and drawbacks of the use of noninvasive ventilation in the context of hypercapnic and non-hypercapnic patients with an altered level of consciousness are analyzed.

Hintergrund: Die ambulante Pflege auserklinisch beatmeter Patienten stellt komplexe Anforderungen an die betreuenden Institutionen. Ebenso komplex sind die Vorgaben der Sozialgesetzgebung, welche die Rahmenbedingungen der Betreuung regeln. Die Deutsche Gesellschaft fur Pneumologie und Beatmungsmedizin (DGP) hat zusammen mit der Deutschen Interdisziplinaren Gesellschaft fur Auserklinische Beatmung (DIGAB) in ihrer Leitlinie hierzu Strukturempfehlungen publiziert und eine Akkreditierung von spezifisch qualifizierten Pflegediensten empfohlen. Rationale: Dieser Akkreditierung vorausgehend fuhrte die Projektgruppe „Pflegedienste“ der DIGAB eine Statuserhebung durch, um die aktuelle Struktur von in der Beatmungspflege tatigen Pflegediensten mit den Empfehlungen der Leitlinie zu vergleichen. Methode: Selbstauskunft uber einen einheitlichen Fragebogen mit insgesamt elf Fragen. Ergebnis: 37 Pflegedienste mit 78 Niederlassungen, die das gesamte Bundesgebiet betreuen, stellten ihre Fragebogen zur Auswertung zur Verfugung. Wahrend die von der Leitlinie geforderten Ausbildungsstrukturen weitgehend etabliert sind, waren insgesamt nur 43 % der 812 erfassten Patienten an ein Beatmungszentrum oder Weaningzentrum angebunden. 84 % dieser Patienten waren invasiv beatmet. Obwohl alle Pflegedienste invasiv beatmete Patienten betreuten, fehlten vereinzelt betriebseigene Standards zu spezifischen pflegerischen Masnahmen. Schlussfolgerung: Innerhalb dieser Umfrage weisen die Pflegedienste Organisationsformen auf, die in weiten Teilen den Empfehlungen der Leitlinie entsprechen, wahrend die Zentrumsanbindung und damit die arztliche Versorgung auserklinisch beatmeter Patienten unzureichend ist. Eine Akkreditierung von Beatmungspflegediensten sollte mit Nachdruck verfolgt werden, um bundesweit einheitliche Qualitatsstandards zu schaffen. Die Zahl invasiv beatmeter Patienten im auserklinischen Bereich wurde bisher wahrscheinlich unterschatzt und ist moglicherweise Folge fehlender Weaningkapazitaten.

Non-invasive ventilation is applied with increasing frequency in patients with chronic hypercapnic COPD and insufficiency of the ventilatory pump. In the few existing clinical trials on long-term use of NIV, no significant improvement on survival could be proven, mainly due to methodical reasons. The "National Task Force for Non-invasive ventilation and weaning" plans to study patients with severe COPD and hypercapnic ventilatory pump insufficiency in a prospective, randomised, multicentre clinical trial over one year. In the intervention group, NIV will be applied for at least six hours per day in addition to standard COPD-treatment. The target of mechanical ventilation is a reduction of PCO (2) during spontaneous breathing by at least 20 %, or into the normal range. The main outcome parameter is all-cause mortality, secondary outcome parameters are course of the disease, exercise capacity, quality of life and consumption of medical resources. The sample size is estimated on 300 patients (150 control group, 150 intervention group). The whole study will take approximately three years.

We investigated the effects of continuous positive airway pressure (CPAP) and pressure support ventilation (PSV) on the oxygen cost of breathing (VO2resp) for different states of pulmonary function. Additionally VO2resp was measured during spontaneous breathing.This was done in a controlled and prospective study. Ventilatory modes were applied randomly.Measurements were performed in a quiet room on volunteers (VOL) and inpatients treated for chronic obstructive pulmonary disease (COPD). Post-operative patients after aortocoronary bypass surgery (ACB) were studied on the cardio-thoracic intensive care unit just before and after extubation.Healthy volunteers (n = 14), postoperative patients after aorto-coronary bypass surgery (n = 15) and patients with COPD (n = 9, xFEV1 47.7%) were the objects of study.Demand flow CPAP (5 mbar) and PSV (7 mbar, PEEP 5 mbar), using the Hamilton Veolar ventilator, were investigated in comparison to spontaneous breathing.VO2 was measured by a Datex Deltatrac metabolic monitor. VO2resp was calculated by subtraction of total oxygen uptake (VO2tot) in controlled mode ventilation (CMV) from that in the respective spontaneous breathing mode. For VOL and COPD patients who were not intubated, a CPAP facemask connected to a short 7.5 mm tube was used as connection to the ventilator. Breathing spontaneously under a canopy system VOL showed a VO2resp of 4.5 +/- 4.0% compared to 9.2 +/- 3.5% for ACB and 15.4 +/- 7.7% for COPD. CPAP changed the VO2resp to 7.8 +/- 3.9%, 12.0 +/- 4.0% and 9.1 +/- 3.6% respectively. PSV reduced the VO2resp to 7.9 +/- 3.8% in ACB and 7.7 +/- 5.5% in COPD.This investigation confirms findings that postoperative patients have a mild increase in VO2resp. COPD exhibit the highest increase in VO2resp. Tracheal tubes, masks and CPAP on a demand flow apparatus increases VO2resp in volunteers and postoperative patients after cardiac surgery. The same amount of CPAP in contrary reduces VO2resp in patients with COPD. Pressure support ventilation can offset the additional VO2resp induced by CPAP but at the same level does not further reduce VO2resp in COPD patients.

Originating from centres charged with the care of patients with chronic respiratory insufficiency, noninvasive ventilation (NIV) has been used increasingly in chronic and acute respiratory failure during the last decade. Despite a considerable number of series and randomised studies advocating access to NIV for units that treat acute or chronic ventilatory failure, the number of units and the proportion of total ventilatory support remains poor. This is due to lack of education, as many units treat only a few patients per year. Indication, technique, education, monitoring and home care require special experience and a special environment and there is a wide range throughout Europe. With respect to home care in particular, there are many organisations, which range from totally private to hospital based or run for profit. A concerted action, funded by the European Union, will soon provide valuable information about the practice of home ventilation in Europe based on a European survey.

Sleep apnoea syndrome (SAS) is a known risk factor for vascular diseases and stroke. Structural brain damage, manifesting as an overt neurological deficit or more subtly as cognitive dysfunction, is a frequent symptom in SAS. The presence of a biochemical marker of cerebral injury would be of great benefit in SAS to screen for even small brain damage and to monitor efficiacy of therapy. Therefore, in 10 patients with mild SAS (age 50.8+/-9.9 yrs, respiratory disturbance index (RDI) 18+/-3.6, lowest arterial oxygen saturation (min Sa,O2) 80.5+/-4.06%) and nine patients with severe SAS (age 50.3+/-11.5 yrs, RDI 75.4+/-21.7, min Sa,O2 56.56+/-14.58%), serum concentrations of neuron-specific enolase (NSE), S-100beta protein, and beta-trace were measured just before and after sleep using commercially available assays. Only serum levels in the normal range could be found, independent of when the blood was taken or the degree of SAS. Structural cerebral injury caused by sleep apnoea syndrome in patients without neurological symptoms or previous cerebrovascular events may be too small to produce a measurable increase in S-100beta, neuron-specific enolase and beta-trace serum concentrations or subclinical cerebral damage may be outside the lower detection limits of the analytical methods which were used. There is a need for biochemical markers and more sensitive methods for detecting small cerebral injury in sleep apnoea syndrome.

Background: Noninvasive mechanical ventilation (NIPPV) has been used successfully for ventilator failure due to derangements of the respiratory pump. Its efficacy in pulmonary diseases is still a matter of contoversy: however, NIPPV is reported as being a means of bridging the period until lung transplantation (LTx) can be performed.

The introduction of the nasal airway access, as an alternative to the endotracheal or the tracheostomal tube, has extended the application of inspiratory positive pressure ventilation to patients in a chronic state of disease and outside the intensive care unit. Nasal mechanical ventilation is noninvasive and can be performed by patients whenever the necessity arises.

Dyspnea (breathlessness or shortness of breath) is a sensation that almost everyone has experienced and so intuitively understands. With respect to pathological dyspnea, several questions need to be answered: Is the pathological dyspnea of patients with respiratory disease the same as that experienced by those with cardiac disease? Are these sensations similar to dyspnea induced by increased ventilation or flow-resistive loading in normal subjects? Although there is disagreement about whether there is only one or different kinds of dyspnea [7], no difference in the dyspnea of normals and patients has been found [16]. It is now generally accepted that dyspnea means a sensation of labored or difficult breathing [1, 5, 7, 16]. This is almost identical to the definition given by J.C. Meakins in 1934, in a clinical lecture: “Dyspnoea is the consciousness of the necessity for increased respiratory effort” [27]. An increased respiratory effort indubitably involves the respiratory muscles, especially the inspiratory muscles, which contract stronger during increasing effort. A hypothesis to explain the mechanism of dyspnea by inspiratory muscle function is that of “length-tension inappropriateness” put forward initially by Campbell and Howell in 1963 [6]. They postulated that dyspnea arises in situations in which the ventilation achieved is inappropriately small in relation to the pressure developed by the inspiratory muscles.

7541 Background: In multimodal neoadjuvant therapy of stage III NSCLC, the potential impact of the sequencing of the different induction modalities on survival has not been evaluated. Methods: Patients (pts) with biopsy-proven stage III (PET obligatory) NSCLC were stratified (center/technical operability) and then randomized to (arm 1) 2–3 cycles paclitaxel 225 mg/m2 d 1 / carboplatin AUC 6 d 1, followed by hfRT at 1.5 Gy 2x/d (total 45 Gy) with concurrent paclitaxel 50 mg/m2 / carboplatin AUC 2 d 1, 8, 15 vs (arm 2) hfRT/PC followed by PC at identical dosages to arm 1, then restaging incl. PET and surgery. The primary (secondary) endpoint was median overall survival (mOS), the secondary endpoint was median progression-free survival (mPFS). Assuming a median survival advantage of 6 months (mo) for arm 2, 104 pts per arm would detect a difference with type I (type II) error ≤ 5% (20%). Results: 210 pts were randomized between 01/01 and 06/05, 207 were evaluable. Median follow-up was 35 mo. The pts were wel...