Search

Zusammenfassung Fragestellung Bislang sind nur wenige Daten über den Verlauf von Patienten mit COVID-19 im prolongierten Weaning vorhanden. Die aktuelle Arbeit vergleicht deshalb Patienten mit einem COVID-19-assoziierten ARDS (cARDS) mit Patienten mit einem ARDS anderer Genese (ncARDS), die aufgrund von prolongierter Beatmungspflichtigkeit auf einer spezialisierten Weaning-Station behandelt wurden. Methoden Es wurde eine retrospektive Analyse aller Patienten mit prolongierter Beatmungspflichtigkeit infolge eines ARDS vorgenommen, die vom 21. November 2013 bis zum 23. Juli 2021 auf die Weaning-Station der Uniklinik RWTH Aachen aufgenommen wurden. Dabei erfolgte ein Vergleich von Patienten mit und ohne SARS-CoV-2-Infektion. Ergebnisse Insgesamt wurden im untersuchten Zeitraum n=129 Patienten mit prolongierter Beatmungspflichtigkeit aufgrund eines ARDS auf der Weaning-Einheit betreut, davon n=38 mit cARDS und n=91 mit ncARDS. Insgesamt ergaben sich zwischen den Gruppen in Bezug auf demografische Parameter, chronische Nebenerkrankungen, den Schweregrad des ARDS und die Beatmungsdauer vor Verlegung auf die Weaning-Station keine wesentlichen Unterschiede. Patienten mit cARDS wurden allerdings auf der Intensivstation häufiger mit Steroiden und mit Lagerungstherapie behandelt. Bei Übernahme benötigten Patienten mit cARDS häufiger eine Therapie mit Katecholaminen (cARDS: 42,1% vs. ncARDS 12,1%; p=0,0003) und wiesen im Vergleich zu Patienten mit ncARDS eine geringere Urinausscheidung (cARDS: 1980 ml vs. ncARDS: 2600 ml; p=0,0037) auf. Der weitere Weaning-Prozess verlief dann in beiden Patientengruppen ähnlich, Komplikationen traten in ähnlichem Ausmaß auf und die Beatmungsdauer insgesamt und auf der Weaning-Station war nicht unterschiedlich. Insgesamt verstarben 5 Patienten (13,2%) mit cARDS und 15 Patienten mit ncARDS (16,5%) während des stationären Aufenthalts. Bei einem Patienten war eine außerklinische invasive Beatmung, bei n=4 Patienten eine Langzeit nicht-invasive Beatmung notwendig (alle in der ncARDS-Gruppe). Schlussfolgerung Die Prognose bezüglich Entwöhnbarkeit von der invasiven Beatmung nach COVID-19-assoziiertem ARDS ist nach überstandener akuter Phase als günstig zu betrachten. Wesentliche Unterschiede im Weaning-Prozess zu Patienten mit einem ARDS anderer Genese scheinen nicht zu bestehen.

Evidence from both animal and human studies now supports the development of ventilator-induced diaphragm dysfunction (VIDD) starting as early as 24 h after initiation of mechanical ventilation in the intensive care unit (ICU). However, although the concept of VIDD is now widely accepted, there remain several unanswered questions regarding its pathophysiology, rate of development, and (potentially) recovery after mechanical ventilation.This state-of-the-art opinion article briefly explains VIDD and provides an update on its clinical and prognostic relevance. It then focusses on state-of-the-art diagnostic approaches to determine diaphragm function, strength, and control (neural and peripheral), highlights knowledge gaps relevant to VIDD, and discusses the use of diaphragm pacing for VIDD prevention. It is suggested that future research projects in mechanically ventilated patients would ideally use both cortical and cervical phrenic nerve stimulation studies over time (including also diaphragm electromyography) as the gold standard techniques. This approach has not yet been utilized in a longitudinally designed study in the ICU. Application of these gold standard techniques would allow better understanding of the true pathophysiology and rate of development of VIDD. Notably, these techniques would be superior to diaphragm ultrasound, which yields surrogate markers of diaphragm function only without any direct measure of diaphragm strength or control. It is also suggested that such translational research would further advance understanding of diaphragm pacing as a very promising treatment option for VIDD.

Mobile (m) Health technology is well-suited for Remote Patient Monitoring (RPM) in a patient's habitual environment. In recent years there have been fast-paced developments in mHealth-enabled pediatric RPM, especially during the COVID-19 pandemic, necessitating evidence synthesis. To this end, we conducted a scoping review of clinical trials that had utilized mHealth-enabled RPM of pediatric asthma. MEDLINE, Embase and Web of Science were searched from September 1, 2016 through August 31, 2021. Our scoping review identified 25 publications that utilized synchronous and asynchronous mHealth-enabled RPM in pediatric asthma, either involving mobile applications or via individual devices. The last three years has seen the development of evidence-based, multidisciplinary, and participatory mHealth interventions. The quality of the studies has been improving, such that 40% of included study reports were randomized controlled trials. In conclusion, there exists high-quality evidence on mHealth-enabled RPM in pediatric asthma, warranting future systematic reviews and/or meta-analyses of the benefits of such RPM. Copyright © 2022 Elsevier Ltd. All rights reserved.

American journal of respiratory and critical care medicine : AJRCCM 207(8), 1012-1021 (2023). doi:10.1164/rccm.202206-1243OC, Published by American Thoracic Society, New York, NY

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) in patients with coronavirus disease 2019 (COVID-19) showed reasonable outcomes. However, recent studies indicated a negative trend and analysis is needed. METHODS: Baseline characteristics, laboratory parameters, and outcomes of ECMO-supported patients with COVID-19 were analyzed in a retrospective single-center study. We included hospital admissions until February 28, 2021; patients were followed until discharge/death. Eventually, we compared data between patients hospitalized before and after September 1, 2020. RESULTS: Median age of patients treated with ECMO (n=39) was 56 years; most patients were males (n=28, 72%). Median mechanical ventilation time (prior to ECMO) was 6 days, while the median ECMO duration was 19 days. Overall survival rate was 41%. In the sub-analysis, survival until discharge in the first and second epidemic waves was 53% (n=19) and 30% (n=20), respectively (P=0.2). At baseline, compared with patients of the first wave, those of the second wave had higher median body mass index (28.2 vs. 31.1 kg/m(2), respectively, P=0.02), bicarbonate (27 vs. 31.8 mmol/L, respectively, P=0.033), plasma free hemoglobin (36 vs. 58 mg/L, respectively, P=0.013), alanine aminotransferase (33 vs. 52 U/L, respectively, P=0.018), and pH (7.29 vs. 7.42, respectively, P=0.005), lower rate of pulmonary hypertension (32% vs. 0%, respectively, P=0.008), lower positive end-expiratory pressure (14 vs. 12 cmH(2)O, respectively, P=0.04), longer median ECMO duration (16 vs. 24.5 days, respectively, P=0.074), and more frequent major bleeding events (42% vs. 80%, respectively, P=0.022). CONCLUSIONS: ECMO-supported patients with COVID-19 had an overall survival rate of 41%. Similar to international registries, we observed less favorable outcomes during the second wave. Further research is needed to confirm this signal and find predictors for mortality.

BackgroundThe optimal interface for the delivery of home non-invasive ventilation (NIV) to treat chronic respiratory failure has not yet been determined. The aim of this individual participant data (IPD) meta-analysis was to compare the effect of nasal and oronasal masks on treatment efficacy and adherence in patients with COPD and obesity hypoventilation syndrome (OHS).MethodsWe searched Medline and Cochrane Central Register of Controlled Trials for prospective randomised controlled trials (RCTs) of at least 1 month’s duration, published between January 1994 and April 2019, that assessed NIV efficacy in patients with OHS and COPD. The main outcomes were diurnal PaCO2, PaO2 and NIV adherence (PROSPERO CRD42019132398).FindingsOf 1576 articles identified, 34 RCTs met the inclusion criteria and IPD were obtained for 18. Ten RCTs were excluded because only one type of mask was used, or mask data were missing. Data from 8 RCTs, including 290 IPD, underwent meta-analysis. Oronasal masks were used in 86% of cases. There were no differences between oronasal and nasal masks for PaCO2 (0.61 mm Hg (95% CI −2.15 to 3.38); p=0.68), PaO2 (−0.00 mm Hg (95% CI −4.59 to 4.58); p=1) or NIV adherence (0·29 hour/day (95% CI −0.74 to 1.32); p=0.58). There was no interaction between the underlying pathology and the effect of mask type on any outcome.InterpretationOronasal masks are the most used interface for the delivery of home NIV in patients with OHS and COPD; however, there is no difference in the efficacy or tolerance of oronasal or nasal masks.

ZusammenfassungDie Langzeit-Sauerstofftherapie hat einen hohen Stellenwert sowohl zur Verminderung der Letalität als auch zur Verbesserung der Leistungsfähigkeit bei Patienten mit chronischen Lungenerkrankungen.Die Grundvoraussetzung für die Langzeit-Sauerstofftherapie ist die adäquate Diagnostik und Indikationsstellung. Sinnvoll ist eine kausale Unterscheidung in eine chronische hypoxämische oder hyperkapnische respiratorische Insuffizienz, aus der sich die Differentialindikation zur nichtinvasiven Beatmung ergibt.Die revidierte Leitlinie behandelt u. a. die Diagnostik und die Indikation bei chronischen Lungen- und Herzerkrankungen sowie den Einsatz in der Palliativmedizin und gibt eine detaillierte Beschreibung der verfügbaren Sauerstoffsysteme. Die Leitlinie soll dazu beitragen, die teilweise bestehende Unter-, Fehl- und Überversorgung zu vermeiden. Zudem wird im Kapitel „Postakute Sauerstofftherapie“ die im Alltag relevante, bisher nicht definierte Vorgehensweise für die Verschreibung einer Sauerstofftherapie am Ende eines stationären Aufenthaltes für den häuslichen Bereich diskutiert. Ein weiterer wichtiger Punkt, die korrekte Verordnung mobiler Sauerstoffsysteme, wird auch in der Leitlinie dargestellt. Die vorliegende aktualisierte Leitlinie zur Langzeit-Sauerstofftherapie löst die alte im Jahr 2008 publizierte Version ab.

BACKGROUND: Fiberoptic bronchoscopy (FOB) with broncho-alveolar lavage (BAL) is frequently performed in patients with hematological malignancies and pulmonary opacities. While the safety of the procedure in this patient population has been shown, data about the diagnostic yield widely differ between studies. Furthermore, data comparing diagnostic yield and safety of flexible bronchoscopy to narrow sources of pulmonary infections in patients with and without underlying hematological malignancy are lacking. METHODS: We carried out a retrospective analysis of bronchoscopies done for the diagnostic work-up of pulmonary infections. Diagnostic yield and the occurrence of complications in patients with and without hematological disease were compared. RESULTS: In total n=268 bronchoscopies were done in patients suffering from a hematological malignancy (HM) compared to n=408 bronchoscopies in patients without hematological malignancy (NHM). The overall diagnostic yield was similar and did not differ between the groups (HM: 67.2% vs. NHM: 64.7%; P=0.5622). However, when cultures positive for Candida were not considered as clinically relevant diagnostic yield was higher in the HM group (HM: 62.7% vs. NHM: 53.9%; P=0.0261) due to a higher detection rate of fungi and viruses (both P0.05). There was no difference in the complication rate between the groups and most complications were considered as minor. CONCLUSIONS: In summary, our data demonstrate similar diagnostic yield and safety of flexible bronchoscopy for diagnosing pulmonary infection in patients with and without underlying hematological malignancy.

International audience; Chronic Obstructive Pulmonary Disease (COPD) is a common disease associated with significant morbidity and mortality that is both preventable and treatable. However, a major challenge in recognizing, preventing, and treating COPD is understanding its complexity. While COPD has historically been characterized as a disease defined by airflow limitation, we now understand it as a multi-component disease with many clinical phenotypes, systemic manifestations, and associated co-morbidities. Evidence is rapidly emerging in our understanding of the many factors that contribute to the pathogenesis of COPD and the identification of "early" or "pre-COPD" which should provide exciting opportunities for early treatment and disease modification. In addition to breakthroughs in our understanding of the origins of COPD, we are optimizing treatment strategies and delivery of care that are showing impressive benefits in patient-centered outcomes and healthcare utilization. This special issue of Respiratory Medicine, "COPD: Providing the Right Treatment for the Right Patient at the Right Time" is a summary of the proceedings of a conference held in Stresa, Italy in April 2022 that brought together international experts to discuss emerging evidence in COPD and Pulmonary Rehabilitation in honor of a distinguished friend and colleague, Claudio Ferdinando Donor (1948-2021). Claudio was a true pioneer in the field of pulmonary rehabilitation and the comprehensive care of individuals with COPD. He held numerous leadership roles in in the field, provide editorial stewardship of several respiratory journals, authored numerous papers, statement and guidelines in COPD and Pulmonary Rehabilitation, and provided mentorship to many in our field. Claudio's most impressive talent was his ability to organize spectacular conferences and symposia that highlighted cutting edge science and clinical medicine. It is in this spirit that this conference was conceived and planned. These proceedings are divided into 4 sections which highlight crucial areas in the field of COPD: (1) New concepts in COPD pathogenesis; (2) Enhancing outcomes in COPD; (3) Non-pharmacologic management of COPD; and (4) Optimizing delivery of care for COPD. These presentations summarize the newest evidence in the field and capture lively discussion on the exciting future of treating this prevalent and impactful disease. We thank each of the authors for their participation and applaud their efforts toward pushing the envelope in our understanding of COPD and optimizing care for these patients. We believe that this edition is a most fitting tribute to a dear colleague and friend and will prove useful to students, clinicians, and researchers as they continually strive to provide the right treatment for the right patient at the right time. It has been our pleasure and a distinct honor to serve as editors and oversee such wonderful scholarly work.

BMJ Open Respiratory Research 9(1), 1-10 (2022). doi:10.1136/bmjresp-2022-001228, Published by BMJ Publishing Group, London

Background Extracorporeal membrane oxygenation (ECMO) is a potential treatment option in critically ill COVID-19 patients suffering from acute respiratory distress syndrome (ARDS) if mechanical ventilation (MV) is insufficient; however, thromboembolic and bleeding events (TEBE) during ECMO treatment still need to be investigated. Methods We conducted a retrospective, single-center study including COVID-19 patients treated with ECMO. Additionally, we performed a univariate analysis of 85 pre-ECMO variables to identify factors influencing incidences of thromboembolic events (TEE) and bleeding events (BE), respectively. Results Seventeen patients were included; the median age was 57 years (interquartile range [IQR]: 51.5–62), 11 patients were males (65%), median ECMO duration was 16 days (IQR: 10.5–22), and the overall survival was 53%. Twelve patients (71%) developed TEBE. We observed 7 patients (41%) who developed TEE and 10 patients (59%) with BE. Upper respiratory tract (URT) bleeding was the most frequent BE with eight cases (47%). Regarding TEE, pulmonary artery embolism (PAE) had the highest incidence with five cases (29%). The comparison of diverse pre-ECMO variables between patients with and without TEBE detected one statistically significant value. The platelet count was significantly lower in the BE group (n = 10) than in the non-BE group (n = 7) with 209 (IQR: 145–238) versus 452 G/L (IQR: 240–560), with p = 0.007. Conclusion This study describes the incidences of TEE and BE in critically ill COVID-19 patients treated with ECMO. The most common adverse event during ECMO support was bleeding, which occurred at a comparable rate to non-COVID-19 patients treated with ECMO.

At the 2020 “Luftschlösser” (castles in the air) conference, experts from a wide range of pneumological fields discussed technical innovations in pneumology, which can be seen in many different areas of the field, including e-health, screening, diagnostics, and therapy. They contribute to substantial advancements ranging from the innovative use of diagnostic tools to novel treatments for chronic lung diseases. Artificial intelligence enables broader screening, which can be expected to have beneficial effects on disease progression and overall prognosis. There is still a high demand for clinical trials to investigate the usefulness and risk-benefit ratio. Open questions remain especially about the quality and utility of medical apps in an inadequately regulated market. This article weighs the pros and cons of technical innovations in specific subspecialties of pneumology based on the lively exchange of ideas among various pneumological experts.

Chronic respiratory disease 18, (2021). doi:10.1177/1479973120986228, Published by Sage, London

ERJ Open Research 7(3), 00454 (2021). doi:10.1183/23120541.00454-2021, Published by European Respiratory Society, [S.l.]

Respiratory medicine case reports 34, 101560 (2021). doi:10.1016/j.rmcr.2021.101560, Published by Elsevier, Amsterdam

Background: Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role. Research Question: What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP? Study Design and Methods: This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups. Results: We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P =.021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P 50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics. Interpretation: Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage.

Background and objective: The clinical relevance and interrelation of sleep-disordered breathing and nocturnal hypoxemia in patients with precapillary pulmonary hypertension (PH) is not fully understood. Methods: Seventy-one patients with PH (age 63 ± 15 years, 41% male) and 35 matched controls were enrolled. Patients with PH underwent clinical examination with assessment of sleep quality, daytime sleepiness, 6-minute walk distance (6MWD), overnight cardiorespiratory polygraphy, lung function, hypercapnic ventilatory response (HCVR; by rebreathing technique), amino-terminal pro-brain natriuretic peptide (NT-proBNP) levels, and cardiac MRI (n = 34). Results: Prevalence of obstructive sleep apnea (OSA) was 68% in patients with PH (34% mild, apnea-hypopnea index [AHI] ≥5 to p < 0.01). Only 1 patient with PH showed predominant central sleep apnea (CSA). Nocturnal hypoxemia (mean oxygen saturation [SpO2] 2, self-reported sleep quality, 6MWD, HCVR, and lung and cardiac function between patients with moderate to severe OSA and those with mild or no OSA (all p > 0.05). Right ventricular (RV) end-diastolic (r = −0.39; p = 0.03) and end-systolic (r = −0.36; p = 0.04) volumes were inversely correlated with mean nocturnal SpO2 but not with measures of OSA severity or daytime clinical variables. Conclusion: OSA, but not CSA, is highly prevalent in patients with PH, and OSA severity is not associated with nighttime SpO2, clinical and functional status. Nocturnal hypoxemia is a frequent finding and (in contrast to OSA) relates to structural RV remodeling in PH.

Background Since December 2019 the novel coronavirus disease 2019 (COVID-19) has been burdening all health systems worldwide. However, pulmonary and extrapulmonary sequelae of COVID-19 after recovery from the acute disease are unknown. Material and methods Hospitalized COVID-19 patients not requiring mechanical ventilation were included and followed 6 weeks after discharge. Body plethysmography, lung diffusion capacity (DLco), blood gas analysis (ABG), 6-min walk test (6MWT), echocardiography, and laboratory tests were performed. Quality of life (QoL), depression, and anxiety were assessed using validated questionnaires. Results 33 patients with severe disease were included. Patients were discharged without prophylactic anticoagulation. At follow-up there were no thromboembolic complications in any patient. 11 patients (33%) had dyspnea, 11 (33%) had cough, and 15 (45%) suffered from symptoms of fatigue. Pulmonary function tests including ABG did not reveal any limitations (TLC: median = 94% of predicted [IQR:85–105]; VC: 93% [78–101]; FEV1: 95% [72–103]; FEV1/FVC 79% [76–85]; PaO2: 72 mmHg [67–79]; PaCO2: 38 mmHg (Xu et al., 2020; Tian et al., 2020; Huang et al., 2020; Ware, 2013) [35-38], except for slightly reduced DLco (77% [69–95]). There were no echocardiographic impairments. 6MWT distance was reduced in most patients without oxygen desaturation. According to standardized questionnaires, patients suffered from reduced QoL, mainly due to decreased mobility (SGRQ activity score: 54 [19–78]). There were no indicators for depression or anxiety (PHQ-9: 7 [4], [5], [6], [7], [8], [9], [10], [11]( Mizumoto et al., 2020; Kimball et al., 2020; Sakurai et al., 2020; Tabata et al., 2020; Wu and McGoogan, 2020; Richardson et al., 2020; Lewnard et al., 2020; Wang et al., 2020) [4], [5], [6], [7], [8], [9], [10], [11]4-11, GAD-7: 4 [1], [2], [3], [4], [5], [6], [7], [8], [9]( Lu et al., 2020; Zhou et al., 2020; Zhu et al., 2020; Mizumoto et al., 2020; Kimball et al., 2020; Sakurai et al., 2020; Tabata et al., 2020; Wu and McGoogan, 2020; Richardson et al., 2020) [1], [2], [3], [4], [5], [6], [7], [8], [9]1-9, respectively). Conclusions Hospitalized patients with severe COVID-19, who did not require mechanical ventilation, are unlikely to develop pulmonary long-term impairments, thromboembolic complications or cardiac impairments after discharge but frequently suffer from symptoms of fatigue., Highlights • Pulmonary impairment in hospitalized COVID-19 patients seems to be transient. • COVID-19 patients are unlikely to develop pulmonary impairments on follow-up. • Patients with COVID-19 often suffer from chronic fatigue following acute disease. • Exercise capacity is reduced 6 weeks after COVID-19.

Background: This document provides clinical recommendations for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). It represents a collaborative effort on the part of a panel of expert COPD clinicians and researchers along with a team of methodologists under the guidance of the American Thoracic Society.Methods: Comprehensive evidence syntheses were performed on all relevant studies that addressed the clinical questions and critical patient-centered outcomes agreed upon by the panel of experts. The evidence was appraised, rated, and graded, and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach.Results: After weighing the quality of evidence and balancing the desirable and undesirable effects, the guideline panel made the following recommendations: 1) a strong recommendation for the use of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance; 2) a conditional recommendation for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year; 3) a conditional recommendation for ICS withdrawal for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year; 4) no recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom ICS is conditionally recommended as an additive therapy; 5) a conditional recommendation against the use of maintenance oral corticosteroids in patients with COPD and a history of severe and frequent exacerbations; and 6) a conditional recommendation for opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy.Conclusions: The task force made recommendations regarding the pharmacologic treatment of COPD based on currently available evidence. Additional research in populations that are underrepresented in clinical trials is needed, including studies in patients with COPD 80 years of age and older, those with multiple chronic health conditions, and those with a codiagnosis of COPD and asthma.

In comparison to other chronically ill people, patients suffering from chronic obstructive pulmonary disease (COPD) have many additional difficulties to face and conquer. Due to the contribution of avoidable causes of their illness (“smokers’ lung”), society holds people with COPD responsible for their disease, which in return often leads to stigmatization and social isolation. In addition, COPD patients commonly belong to a less privileged social class, own a low socioeconomic status, and lower education. Their physical symptoms are easily observable and – by employing moderate adherence – treatable. Nonetheless, the influence of COPD on a patient’s psyche often plays an overly prominent role during therapy. “There is only half a patient laying on the examination table,” a revelation that sums up the current state of COPD research and the result of the expert meeting “Luftschlösser” (“castles in the clouds”), which took place in spring 2018. Within the limits of the meeting, participants identified practically applicable approaches aiming to enhance the patient management of this challenging patient group. These considerations are supposed to support healthcare professionals in their daily work and aim to improve the therapy as well as the outcome for COPD patients.

Background: Exercise intolerance in heart failure with reduced ejection fraction (HFrEF) or heart failure with preserved ejection fraction (HFpEF) results from both cardiac dysfunction and skeletal muscle weakness. Respiratory muscle dysfunction with restrictive ventilation disorder may be present irrespective of left ventricular ejection fraction and might be mediated by circulating pro-inflammatory cytokines. Objective: To determine lung and respiratory muscle function in patients with HFrEF/HFpEF and to determine its associations with exercise intolerance and markers of systemic inflammation. Methods: Adult patients with HFrEF (n = 22, 19 male, 61 ± 14 years) and HFpEF (n = 8, 7 male, 68 ± 8 years) and 19 matched healthy control subjects underwent spirometry, measurement of maximum mouth occlusion pressures, diaphragm ultrasound, and recording of transdiaphragmatic and gastric pressures following magnetic stimulation of the phrenic nerves and the lower thoracic nerve roots. New York Heart Association (NYHA) class and 6-min walking distance (6MWD) were used to quantify exercise intolerance. Levels of circulating interleukin 6 (IL-6) and tumor necrosis factor-α (TNF-α) were measured using ELISAs. Results: Compared with controls, both patient groups showed lower forced vital capacity (FVC) (p < 0.05), maximum inspiratory pressure (PImax), maximum expiratory pressure (PEmax) (p < 0.05), diaphragm thickening ratio (p = 0.01), and diaphragm strength (twitch transdiaphragmatic pressure in response to supramaximal cervical magnetic phrenic nerve stimulation) (p = 0.01). In patients with HFrEF, NYHA class and 6MWD were both inversely correlated with FVC, PImax, and PEmax. In those with HFpEF, there was an inverse correlation between amino terminal pro B-type natriuretic peptide levels and FVC (r = −0.77, p = 0.04). In all HF patients, IL-6 and TNF-α were statistically related to FVC. Conclusions: Irrespective of left ventricular ejection fraction, HF is associated with respiratory muscle dysfunction, which is associated with increased levels of circulating IL-6 and TNF-α.

Dyspnea is one of the most disturbing symptoms for patients with chronic obstructive pulmonary disease (COPD) or heart failure (HF). This study investigated dyspnea triggers and factors associated with worsening dyspnea in patients with COPD or HF. COPD support group members and HF patients with reduced ejection fraction (HFrEF) and no airway obstruction answered a questionnaire describing different weather conditions (rising/falling air pressure, sunny, foggy, rainy, windy, snowy, hazy, high ozone levels, and airborne pollen) and environmental circumstances (cooking, grilling, perfumes, cigarette smoke, gasoline odor, and flower scents) and were asked to estimate the occurrence and severity of dyspnea under these conditions using predefined scales. 230 patients with COPD and 90 with HFrEF (left ventricular ejection fraction 34 ± 10%, Tiffeneau index > 70%) were analyzed. COPD patients reported dyspnea more often than HF patients in almost all weather and environmental conditions (p = 0.004 to p

This study aimed to describe real-life microbiological testing of adults hospitalised with community-acquired pneumonia (CAP) and to assess concordance with the 2007 Infectious Diseases Society of America (IDSA)/American Thoracic Society (ATS) and 2011 European Respiratory Society (ERS) CAP guidelines. This was a cohort study based on the Global Initiative for Methicillin-resistant Staphylococcus aureus Pneumonia (GLIMP) database, which contains point-prevalence data on adults hospitalised with CAP across 54 countries during 2015. In total, 3702 patients were included. Testing was performed in 3217 patients, and included blood culture (71.1%), sputum culture (61.8%), Legionella urinary antigen test (30.1%), pneumococcal urinary antigen test (30.0%), viral testing (14.9%), acute-phase serology (8.8%), bronchoalveolar lavage culture (8.4%) and pleural fluid culture (3.2%). A pathogen was detected in 1173 (36.5%) patients. Testing attitudes varied significantly according to geography and disease severity. Testing was concordant with IDSA/ATS and ERS guidelines in 16.7% and 23.9% of patients, respectively. IDSA/ATS concordance was higher in Europe than in North America (21.5% versus 9.8%; p, Testing practices vary based on geography and disease severity, and IDSA/ATS/ERS testing recommendations are rarely followed http://ow.ly/80Iy30lxo1c

This report is a summary of a workshop focusing on using telemedicine to facilitate the integrated care of chronic obstructive pulmonary disease (COPD). Twenty-five invited participants from 8 countries met for one and one-half days in Stresa, Italy on 7-8 September 2017, to discuss this topic. Participants included physiotherapists, nurses, a nurse practitioner, and physicians. While evidence-based data are always at the center of sound inference and recommendations, at this point in time the science behind telemedicine in COPD remains under-developed; therefore, this document reflects expert opinion and consensus. While telemedicine has great potential to expand and improve the care of our COPD patients, its application is still in its infancy. While studies have demonstrated its effectiveness in some patient-centered outcomes, the results are by no means consistently positive. Whereas this tool may potentially reduce health care costs by moving some medical interventions from centralized locations in to patient's home, its cost-effectiveness has had mixed results and telemonitoring has yet to prove its worth in the COPD population. These discordant results should not be unexpected in view of patient complexity and the heterogeneity of telemedicine. This is reflected in the very limited support offered by the National Health Services to a wider application of telemedicine in the integrated care of COPD patients. However, this situation should challenge us to develop the necessary science to clarify the role of telemedicine in the medical management of our patients, providing a better and definitive scientific basis to this approach.

Background: Chronic obstructive pulmonary disease (COPD) and coronary heart disease (CHD) often occur together. However, COPD is underdiagnosed among CHD patients. Objectives: This study investigated the prevalence of COPD and relevant pulmonary function test (PFT) impairments in patients with acute myocardial infarction (AMI). Methods: Patients undergoing coronary angiography for AMI were prospectively included. Body plethysmography, lung diffusing capacity, blood gas analysis, and echocardiography were performed. The following patient subgroups were compared: with versus without COPD, ST elevation myocardial infarction (STEMI) versus non-STEMI (NSTEMI). The prevalence of PFT impairments was also recorded. Results: A total of 100 patients (51 with NSTEMI, 49 with STEMI) were included. Twenty patients had diagnosed COPD, of whom 15 were diagnosed for the first time; 80% of all COPD patients were not receiving COPD therapy. Patients with COPD had higher maximum creatine kinase (p = 0.008) and troponin T (p = 0.054) levels than those without COPD. Hypoxaemia was more common in COPD patients (lower oxygen saturation [p = 0.008] and partial pressure of oxygen [PaO2] [p = 0.005]). PaO2 was significantly lower in STEMI compared with NSTEMI (p = 0.017). Independent of a COPD diagnosis, 65 patients had relevant PFT impairments. Conclusions: The high prevalence of undiagnosed COPD and relevant pulmonary function impairments in this cohort of patients with AMI, and the fact that pulmonary disease was untreated in the majority of COPD patients, highlight the importance of a general pulmonary workup of patients with AMI. Furthermore, patients with CHD should undergo screening for COPD, given the fact that COPD patients had larger infarction size.

ZusammenfassungDie Lebensqualität und Prognose der COPD-Patienten lässt trotz erheblich verbesserter medikamentöser Therapieoptionen weiterhin zu wünschen übrig. Ziel des Workshops war es, COPD-spezifische Hindernisse auf dem Weg zur verbesserten Betreuung der Patienten zu beschreiben. Dazu zählen der Sozial- und Bildungsstatus der COPD-Patienten sowie die gesellschaftliche Stigmatisierung der Erkrankung als selbstverschuldete „Raucherkrankheit“. Die strenge sektorale Trennung trägt zu Defiziten in der Betreuung bei. Im zweiten Teil des Workshops wurden Möglichkeiten der Verbesserung dargestellt. Die Nutzung IT-basierter Hilfsmittel, verbesserte Kommunikation zwischen Patienten und Therapeuten und zwischen den Sektoren des Gesundheitswesens, verbesserte Integration von Rehabilitation sowie durch Strategien des Selbstmanagements, sind solche Möglichkeiten. Als Schlussfolgerung konnte festgehalten werden, dass ein integriertes Patientenmanagement mit Einbeziehung multiprofessioneller Teams die Betreuungsqualität nachhaltig verbessern könnte.

Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010, the German Respiratory Society (Deutsche Gesellschaft fur Pneumologie und Beatmungsmedizin, DGP) has leadingly published the Guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure." However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the Guidelines. For this reason, the updated Guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease-specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the Guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning. In the current Guidelines, different societies as well as professional and expert associations have been involved when compared to the 2010 Guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.

Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010, the German Respiratory Society (DGP) has leadingly published the guidelines on "Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure." However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines. For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease-specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning. In the current guidelines, different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved.

Background Inhaled agents are widely used in the treatment of chronic airway diseases. Correct technique is required to ensure appropriate drug deposition, but poor technique is common. This study investigated whether inhalation technique could be improved by patient training using short videos from the German Airway League. Methods Outpatients from a university hospital respiratory clinic who had incorrect inhalation technique were asked to demonstrate this again immediately after viewing the training videos, and after 4–8 weeks' follow-up. Inhalation technique was rated by a study nurse using specific checklists. Results One hundred and twelve patients with obstructive lung disease treated with inhaled bronchodilators or corticosteroids were included. More than half (51.8%) had at least one mistake in inhalation technique at baseline. Of these, most (88%) understood the training videos, 76% demonstrated correct device use immediately after training, and 72% were still able to demonstrate correct inhalation technique at follow-up (p = 0.0008 for trend). In addition, the number of mistakes decreased significantly after video training (by 1.82 [95% confidence interval 1.39–2.25]; p Conclusions German Airway League inhalation technique training videos were easy to understand and effectively improved inhalation technique in patients with airway diseases.

Akute Verschlechterungen der chronisch obstruktiven Lungenerkrankung (COPD) galten uber lange Zeit als vorubergehende, gelegentlich auch lebensbedrohliche Symptomverschlechterungen, die jedoch keinen Bezug zum Verlauf der Grunderkrankung haben. Erst Mitte des letzten Jahrzehnts wurde gezeigt, dass Patienten mit schweren, stationar behandlungsbedurftigen Exazerbationen in der Folge eine erheblich erhohte Sterblichkeit aufweisen. Diese Einsicht konnte 2012 durch eine grose, populationsbasierte Kohortenanalyse konsolidiert werden. Heute gilt die schwere Exazerbation als ein Hauptrisikofaktor fur die Krankheitsprogression. In der vorliegenden Zusammenfassung einer Expertentagung im Februar 2017 wird der aktuelle Stand der Kenntnisse zur Exazerbation der COPD dargestellt. Er umfasst die pathogenetischen Prozesse, die auslosenden Mechanismen, die Charakteristika der Patientengruppen mit haufigen Exazerbationen und die Pradiktoren einer schlechten Uberlebensprognose. Die Rolle von Komorbiditaten wird naher betrachtet. Die Darstellung der Pharmakotherapie der Exazerbation wird erganzt durch eine ausfuhrliche Betrachtung des ventilatorischen Supports. Zur Frage der Exazerbationspravention werden die verfugbaren Pharmaka analysiert. Die Bedeutung nicht medikamentoser Praventivmasnahmen wird im Einzelnen untersucht.

Home mechanical ventilation is increasingly used by people with chronic respiratory failure. However, there are few reports on attitudes towards treatment. A web-based survey in eight languages was disseminated across 11 European countries to evaluate the perception of home mechanical ventilation provision in ventilator-assisted individuals and caregivers. Out of 787 responders from 11 European countries, 687 were patients and 100 were caregivers. 95% of patients and 94% of caregivers were from only 4 countries (Germany, the Netherlands, Italy, Spain). The majority of respondents were male and aged 46–65 years. Obstructive lung diseases were proportionally more represented among respondent patients (46%), and neuromuscular diseases (65%) were more represented among patients of respondent caregivers. About 20% of respondent patients and caregivers were not sure of the modality of ventilation. Different interfaces were used, with a minority of respondents in all countries using invasive home mechanical ventilation by tracheostomy. These results may be useful for healthcare providers and policy makers to improve the quality of patients' daily lives., An @ERStalk/@EuropeanLung survey of European ventilator users http://ow.ly/u5e130csNFs

The respiratory intensive care Assembly of the European Respiratory Society is proud to present a summary of several important sessions held at the International Congress in Paris in 2018. For the highly esteemed reader who may have missed the Congress, a concise review was written on three topics: the state-of-the-art session on respiratory critical care, hot topics in weaning and the best abstracts in noninvasive ventilation., The respiratory intensive care Assembly of the European Respiratory Society is proud to present a summary of several important sessions from the 2018 #ERSCongress in Paris http://ow.ly/6Du830nFESK

Background Evaluating severity of illness of patients with prolonged mechanical ventilation (PMV) is important to adopt the best appropriate care management for each individual. Yet, no severity-of-illness scoring system has been specifically designed for this type of patients. The aim of this study was to develop and validate a new instrument, the Multi-INdependence Dimensions (MIND) questionnaire designed to comprehensively measure the severity of illness of patients under PMV. Methods The validation of the MIND questionnaire was performed during a longitudinal observational study conducted with PMV subjects in weaning facilities in three countries (Argentina, Colombia and Germany). The questionnaire validity was tested in 3 stages: 1) Specification of components, with description of item responses, inter-item and Cronbach alpha correlations; 2) Creation of the composite scores; 3) Measurement properties determination including test-retest reliability after 30 days, clinical validity (Medical Research Council (MRC) muscle strength score, Sepsis-related Organ Failure Assessment (SOFA), Glasgow Coma Scale (GCS), Dependence Nursing Scale and EuroQol-5 Dimension evaluated at inclusion), and ability to detect change. Results A total of 128 subjects participated in the validation study. Eleven component scores and four composite scores were created. MIND scores significantly correlated with MRC muscle strength, SOFA, DNS, GCS and EQ-5D, supporting the validity of the new scores. Intraclass Correlation Coefficient greater than 0.82 were observed for all composite scores, indicating good test-retest reliability. MIND scores were able to detect improvement in subject severity of illness. Conclusion The MIND questionnaire is a valid and reliable instrument for measuring comprehensively the multiple dimensions characterizing the severity of illness of PMV patients. Trial registration NCT02255058. Electronic supplementary material The online version of this article (10.1186/s12890-019-0870-2) contains supplementary material, which is available to authorized users.

Background and objective Patients with chronic obstructive pulmonary disease (COPD) and chronic hypercapnic respiratory failure (CHRF) characteristically have exercise intolerance and limitations in performing conventional training. Therefore, the aim of this study was to investigate the acute effects of non-invasive ventilation (NIV) as a supportive tool during exercise in CHRF. Methods Two cycle endurance tests (CET) at 60% of the peak work rate were performed. Patients were randomly assigned to cycle in two conditions: (i) high-pressure NIV (mean inspiratory positive airway pressure: 27 ± 3 cm H2 O) along with oxygen supplementation or (ii) control: oxygen-use only. Transcutaneously measured partial pressure of carbon dioxide (TcPCO2 ), oxygen saturation and heart rate were continuously recorded. Muscle oxygen availability of intercostal and vastus lateralis muscle was measured during exercise by near-infrared spectroscopy (NIRS). Results A total of 20 patients with CHRF (forced expiratory volume in 1 s (FEV1 ): 19 ± 4% predicted, partial pressure of oxygen (PaO2 ): 55 ± 9 mm Hg, partial pressure of carbon dioxide (PaCO2 ): 51 ± 7 mm Hg) were recruited in a randomized cross-over trial. On NIV, COPD patients increased cycle endurance time by 39% compared to oxygen-use only (663 ± 360 vs 477 ± 249 s, P = 0.013). On NIV, TcPCO2 was significantly lower at rest (44.9 ± 6.2 vs 50.7 ± 6.6 mm Hg, P Conclusion NIV with high pressures as add-on to oxygen supplementation increases cycle endurance time, mitigates exertional dyspnoea and limits exercise-induced hypercapnia in COPD patients with CHRF.

Noninvasive positive pressure ventilation (NPPV) using effective pressure levels to reduce chronic hypercapnia improves survival in stable hypercapnic COPD. However, the underlying mechanisms remain unclear. This study investigated the influence of effective NPPV on a panel of cytokines and established cardiovascular biomarkers.Peripheral blood samples were drawn before and three months after the initiation of NPPV and analyzed by flow cytometric bead array and ELISA.Twenty COPD patients (forced expiratory volume in 1 s 31 ± 17% predicted) were included. NPPV (inspiratory positive airway pressure 23 ± 4 mbar; breathing frequency 17 ± 2/min) significantly improved arterial carbon dioxide pressure (PaCO2), both during daytime spontaneous breathing (p = 0.005) and nighttime ventilation (p0.001). Serum interleukin (IL)-10 levels were slightly reduced (p = 0.016), whereas IL-1 (p = 0.073) and IL-12 (p = 0.089) showed only a tendency towards change over time. Pro-brain natriuretic peptide (proBNP) significantly decreased by a mean of 578 ± 1332 ng/L after three months' NPPV (p = 0.017 vs baseline). No other significant changes in cardiovascular biomarkers occurred. The decrease in PaCO2 during daytime spontaneous breathing was positively correlated with the reduction in proBNP (correlation coefficient 0.613; p = 0.0197).Effective NPPV impacts on systemic inflammation in COPD patients. Furthermore, reductions in PaCO2 during NPPV were associated with decreases in proBNP levels. Future studies are needed to clarify these findings in a larger cohort of COPD patients.DRKS00007644 (German Clinical Trials Register; https://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?navigationId=resultsExt).

Background: Non-invasive positive pressure ventilation (NPPV) in addition to supplemental oxygen improves arterial oxygenation, walking distance and dyspnea when applied during exercise in stable hypercapnic COPD patients. The aim of the current study was to investigate whether NPPV without supplemental oxygen is capable of preventing severe exercise-induced hypoxemia in these patients when applied during walking. Methods and Results: 15 stable hypercapnic COPD patients (FEV1 29.9 ± 15.9%) performed two 6-minute walk tests (6MWT) with a rollator in a randomized cross-over design: using either supplemental oxygen(2.4 ± 0.7 L/min) or NPPV (inspiratory/expiratory positive airway pressure of 28.2 ± 2.8 / 5.5 ± 1.5 mbar) without supplemental oxygen. Results: 10 patients were able to complete both 6MWT. 6MWT with supplemental oxygen resulted in no changes for PO2 (pre: 67.3 ± 11.2 mmHg vs. post: 65.6 ± 12.0 mmHg, p = 0.72) whereas PCO2 increased (pre: 50.9 ± 8.1 mmHg vs. post: 54.3 ± 10.0 mmHg (p < 0.03...

Background Pneumonia and septic pneumonic shock are the most common indications for long-term mechanical ventilation and prolonged weaning, independent of any comorbidities. Multidrug resistant (MDR) bacteria are emerging as a cause of pneumonia or occur as a consequence of antimicrobial therapy. The influence of MDR bacteria on outcomes in patients with prolonged weaning is unknown. Methods Patients treated in a specialized weaning unit of a university hospital between April 2013 and April 2016 were analyzed. Demographic data, clinical characteristics, length of stay (LOS) in the intensive care unit (ICU) and weaning unit, ventilator-free days and mortality rates were determined in prolonged weaning patients with versus without MDR bacteria (methicillin-resistant Staphylococcus aureus bacteria, [MRSA]; extended spectrum beta lactamase [ESBL]- and Gyrase-producing gram negative bacteria resistant to three of four antibiotic groups [3 MRGN]; panresistant Pseudomonas aeruginosa and other carbapenemase-producing gram-negative bacteria resistant to all four antibiotic groups [4 MRGN]). Weaning failure was defined as death or discharge with invasive ventilation. Results Of 666 patients treated in the weaning unit, 430 fulfilled the inclusion criteria and were included in the analysis. A total of 107 patients had isolates of MDR bacteria suspected as causative pathogens identified during the treatment process. Patients with MDR bacteria had higher SAPS II values at ICU admission and a significantly longer ICU LOS. Four MRGN P. aeruginosa and Acinetobacter baumanii were the most common MDR bacteria identified. Patients with versus without MDR bacteria had significantly higher arterial carbon dioxide levels at the time of weaning admission and a significantly lower rate of successful weaning (23% vs 31%, p

Background: Pulmonary rehabilitation (PR) has a positive impact on functional status and quality of life in patients with interstitial lung disease (ILD). Objectives: This study investigated the effects of PR in hypercapnic ILD patients receiving nighttime noninvasive positive pressure ventilation (NPPV). Methods: Consecutive ILD patients referred to a specialized inpatient PR center were included. All participated in a PR program. Those with hypercapnia received NPPV (NPPV group; n = 29); the remaining patients served as comparison group (n = 319). Results: PR improved the 6-min walk distance by 64.4 ± 67.1 m versus baseline (p < 0.0001) in NPPV patients and by 43.2 ± 55.1 m (p < 0.0001) in the comparison group (difference 21.1 m, 95% confidence interval 0.5-41.8; p = 0.045). There was no change in total lung capacity during PR in NPPV recipients or the comparison group. Forced vital capacity significantly increased from baseline in the comparison, but not the NPPV group. NPPV recipients were significantly more likely than the comparison group to have improved dyspnea during PR (p = 0.049). There was no improvement in the 36-item Short Form (SF-36) physical component score in the NPPV group after PR, but there was in the comparison group. PR improved the SF-36 mental component score versus baseline in both groups. Conclusion: An individually tailored PR plus nighttime NPPV appears feasible in hypercapnic ILD patients and significantly improves exercise capacity and quality of life.

Background: Correct measurement of PO2 and PCO2 is essential to establish appropriate therapy such as long-term oxygen therapy (LTOT) in patients suffering from respiratory failure. Objectives: We aimed to compare common invasive and noninvasive methods for assessing blood gas components for spot check analysis. Methods: Arterial (PaO2, PaCO2) and capillary blood gas (PCBGO2, PCBGCO2) measurements were taken consecutively in a randomized order and were compared with noninvasive measurements obtained from the transcutaneous monitoring of PO2 and PCO2 (PtcO2, PtcCO2, sensor-temperature 44°C). Capillary samples were taken from both arterialized earlobes, where samples of right earlobes were defined as a reference value. Pain assessment of all measurements was evaluated by each subject using the 100-mm visual analogue scale. Results: 83 patients and 17 healthy subjects were included. The mean difference between PaO2 and PtcO2 was 11.9 ± 15.0 mm Hg, with lower limits of agreement (LLA) of -17.4 mm Hg (95% confidence interval (CI) -22.5 to -12.3 mm Hg), and upper limits of agreement (ULA) of 41.1 mm Hg (95% CI 36.0-46.2 mm Hg). The comparison of PaO2 with PCBGO2 showed a mean difference of 5.6 ± 7.2 mm Hg (LLA -11.0; ULA 19.6 mm Hg). The mean difference between PaCO2 and PtcCO2 was 1.1 ± 4.9 mm Hg (LLA -8.6; ULA 10.8 mm Hg) and that between PaCO2 and PCBGCO2 was 0.7 ± 2.0 mm Hg (LLA -3.3; ULA 4.8 mm Hg). The analysis of capillary blood gases (36.2 ± 22.3 mm) was rated as more painful than the analysis of arterial blood gases (26.1 ± 20.6 mm), while transcutaneous measurement was rated as the least painful method (1.9 ± 7.4 mm; all p < 0.0001). Conclusions: The comparison of different methods for blood gas measurements showed substantial differences between capillary and arterial PO2 and between transcutaneous and arterial PO2. Therefore, arterial PO2 analysis is the essential method evaluating indication for LTOT. Nevertheless, comparative analysis further indicated capillary PCO2 as an adequate surrogate for arterial PCO2.

Background There are currently no data on the prevalence of sleep-disordered breathing (SDB) in patients with newly-diagnosed lung cancer. This might be of interest given that SDB is associated with increased cancer incidence and mortality. Furthermore, intermittent hypoxia has been linked with tumor growth and progression. The aim of the current study was to investigate the prevalence of SDB in patients with newly-diagnosed lung cancer. Methods Patients with newly-diagnosed lung cancer from three centers in Germany were screened for SDB using a two-channel screening system (ApneaLink™). SDB was defined as an apnea-hypopnea index of > 5/h, and was classified as mild if the AHI was 5–15/h whereas an AHI ≥15/h was classified as severe SDB. The presence of SDB-related symptoms was assessed using the Epworth Sleepiness Scale (ESS) and the Pittsburgh Sleep Quality Index (PSQI). Results A total of 100 patients were included. The overall prevalence of SDB was 49%; 32 patients (32%) had mild SDB with a median AHI of 7.7/h (quartile [Q1 5.4/h, Q3 10.4/h]) and a median oxygen desaturation index of 8.5 [Q1 4.2/h; Q3 13.4/h] and seventeen patients (17%) had moderate to severe SDB with a median AHI of 25.2 [Q1 18/h, Q3 45.5/h] and a median oxygen desaturation index of 20.6/h [Q1 9.6/h, Q3 36.6/h]. Patients with moderate to severe SDB had mild daytime sleepiness (ESS score 8.24 ± 3.96 vs. 5.74 ± 3.53 in those without SDB vs. 6.22 ± 2.72 in those with mild SDB; p = 0.0343). The PSQI did not differ significantly between the three groups (p = 0.1137). Conclusions This study showed a high prevalence of SDB in patients with newly-diagnosed lung cancer. In these patients SDB was associated with intermittent hypoxia and increased daytime sleepiness. Additional research is needed to determine whether SDB influences prognosis and morbidity in patients with lung cancer. Trial registration NCT02270853 (ClinicalTrials.gov), date of registration: 14th October 2014.

BACKGROUND: High-intensity noninvasive ventilation (HI-NIV) is the most effective means of improvingseveralphysiologicalandclinicalparametersinsubjectswithchronichypercapnicCOPD. Whether the newer hybrid mode using target tidal volume noninvasive ventilation (target V T NIV) provides additional benefits remains unclear. METHODS: Subjects with COPD successfully established on long-term HI-NIV were switched to target VT NIV. Optimal target VT settings according to nocturnal transcutaneous PCO2 measurements were achieved following a randomized crossover trial using 8 mL/kg ideal body weight and 110% of individual VT during HI-NIV, respectively. The following parameters were compared at the beginning of the trial while subjects were on HI-NIV, and after 3 months on optimal target VT NIV: sleep quality by polysomnography, overnight gas exchange, subjects’ tolerance, overnight pneumotachygraphic measurements during NIV, healthrelated quality of life (severe respiratory insufficiency questionnaire), exercise capacity (6-min walk test), and lung function. RESULTS: Ten of 14 subjects completed the study. There were no differences between HI-NIV and target VT NIV in any of the above-mentioned parameters. Specifically, the mean overnight transcutaneous PCO2 was equivalent under each form of ventilation (both 45 5 mm Hg, P .75). CONCLUSIONS: Switching subjects from well-established HI-NIV to target VT NIV shows no clinical benefits in chronic hypercapnic COPD. In particular, sleep quality, the control of nocturnal hypoventilation, daytime hypercapnia, overnight ventilation patterns, subjects’ tolerance, health-related quality of life, lung function, and exercise capability were all similar in subjects who underwent HI-NIV and target VT NIV. Nevertheless, target VT NIV might offer some physiological advantages in breathing pattern and might be beneficial in some individual patients. (German Clinical Trials Register [www.drks.de] Registration DRKS00000450.) Key words: Chronic obstructive pulmonary disease, mechanical ventilation, sleep quality, target volume, ventilation mode [Respir Care 2014;59(9):1–. © 2014 Daedalus Enterprises]

As seen in this CME online activity (available at http://journal.cme.chestnet.org/copd-hot-hmv), acute exacerbations of COPD are associated with significant levels of morbidity and mortality. Acute noninvasive ventilation has been demonstrated its clinical efficacy and cost-effectiveness in reducing intubation rate and mortality and in patients with acute decompensated hypercapnic exacerbations of COPD. However, those patients with evidence of chronic hypercapnic respiratory failure have worse long-term outcomes compared with patients who have only transient hypercapnia during the acute phase returning to eucapnia in the recovery stage. Indeed, there are limited options available to improve the clinical outcome in these COPD patients with persistent hypercapnia. The Home Oxygen Therapy-Home Mechanical Ventilation (HOT-HMV) trial investigated admission-free survival in patients with persistent hypercapnia following a life-threatening exacerbation requiring acute noninvasive ventilation. Phenotyping patients to ensure chronic hypercapnia enriched the trial population to identify those patients at highest risk of readmission or death following an exacerbation. The addition of home noninvasive ventilation to home oxygen therapy in patients with persistent hypercapnia led to improved admission-free survival. The noninvasive ventilation was titrated to overnight measures of transcutaneous CO2 to achieve control of nocturnal hypoventilation, which improved daytime chronic respiratory failure. Home noninvasive ventilation is a complex intervention requiring a multidisciplinary team and long-term patient follow-up to maximize the clinical benefit to the patient.