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Introduction and Objectives Electromagnetic navigation bronchoscopy (ENB) is approved for use as an adjunct to conventional bronchoscopy, aiding the diagnosis of peripheral lung lesions. It is a modern technique which improves bronchoscopic yield, thereby potentially preventing unnecessary operations or high-risk procedures. Our objective was to assess the use of this technique in regular clinical practice, and to identify factors which may influence its success. Methods A retrospective data analysis of all ENB procedures carried out in a 120-bed speciality respiratory hospital in Solingen, Germany, between 2007 and 2011 revealed a total of 43 procedures. In each case, size and anatomical location of the tumour based on CT findings were noted. A positive result was documented if as a result of the procedure a clinical diagnosis could be reached. Results ENB reached a clinical diagnosis in 15 of 43 patients (34.9%); eight malignant tumours, seven benign lesions, 28 left unclear. Of these 28, further investigations revealed a malignant process in nine patients, mostly by surgical interventions (n=6). 35 patients had previously had a failed diagnostic bronchoscopy. Of these patients, the addition of ENB allowed a diagnosis in 14 cases. 8 underwent an ENB directly upon assessment of the clinical data. The anatomical positioning of the lesion was without consequence for the diagnostic yield. The diagnostic yield increased significantly with the size of the lesion (<2 cm: 15%, 2-3 cm: 37%, >3 cm: 50%, p<0.001). Conclusions ENB is a useful diagnostic method in the hands of a skilled interventional respiratory physician, particularly where conventional bronchoscopy has failed. Although the anatomical location does not affect the accuracy of the results, lesions over 2 cm in size are more likely to be amenable to this procedure. The overall diagnostic yield lies lower than those quoted in previous studies, so that selective use of this procedure should be considered. [ABSTRACT FROM AUTHOR]

Background: Our centre followed a stepwise approach in the nonpharmacological treatment of respiratory failure in COVID-19 in accordance with German national guidelines, escalating non-invasive measures before invasive mechanical ventilation (IMV) or extracorporeal membrane oxygenation (ECMO). The aim of this study was to analyse this individualized approach to non-pharmacologic therapy in terms of patient characteristics and clinical features that may help predict more severe disease, particularly the need for intensive care., Method: This retrospective single-centre study of COVID-19 inpatients between March 2020 and December 2021 analysed anthropometric data, non-pharmacological maximum therapy and survival status via a manual medical file review., Results: Of 1052 COVID-19-related admissions, 835 patients were included in the analysis cohort (54% male, median 58 years); 34% (n=284) received no therapy, 40% (n=337) conventional oxygen therapy (COT), 3% (n=22) high flow nasal cannula (NHFC), 9% (n=73) continuous positive airway pressure (CPAP), 7% (n=56) non-invasive ventilation (NIV), 4% (n=34) intermittent mandatory ventilation (IMV), and 3% (n=29) extracorporeal membrane oxygenation (ECMO). Of 551 patients treated with at least COT, 12.3% required intubation. A total of 183 patients required ICU treatment, and 106 (13%) died. 25 (74%) IMV patients and 23 (79%) ECMO patients died. Arterial hypertension, diabetes and dyslipidemia was more prevalent in non-survivors. Binary logistic analysis revealed the following risk factors for increased mortality: an oxygen supplementation of ≥2 L/min at baseline (OR 6.96 [4.01-12.08]), age (OR 1.09 [1.05-1.14]), and male sex (OR 2.23 [0.79-6.31])., Conclusion: The physician's immediate clinical decision to provide oxygen therapy, along with other recognized risk factors, plays an important role in predicting the severity of the disease course and thus aiding in the management of COVID-19., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Introduction:  The ambulantization of patient care that were previously provided as inpatient service is one of the goals of the current reform in the German healthcare system. In pulmonology, this particularly applies to endoscopic procedures. However, the real costs of endoscopic services, which form the basis for the calculation of a future so called hybrid DRG or in the AOP catalog, are unclear., Methods:  After selection of use cases including endoscopic procedures which can be performed on an outpatient basis by a committee of experts the appropriate DRGs were identified from the § 21-KHEntgG data for 2022 published by the Institute for the Hospital Remuneration System (InEK). The costs were calculated from the respective InEK cost matrix added by the calculated material costs., Results:  The use cases suitable for outpatient treatment were systematic endobronchial ultrasound (EBUS) with transbronchial needle aspiration (calculated costs € 2,175.60 without or € 3,315.60 including PET/CT), navigation-assisted bronchoscopy for peripheral lesions (depending on the methodology € 2,870.23 to €4,120.23) and diagnostic (flexible) bronchoscopy (€ 1,121.02)., Conclusion:  Outpatient treatment of endoscopic procedures that were previously performed inpatient is possible and necessary, and the costs calculated in this publication can form a reliable basis for appropriate reimbursement. Together with a structural quality that has been transformed to outpatient service and cross-sector cooperation, continued high-quality care for pneumological patients can be ensured., Competing Interests: Keiner der Autoren erklärte einen Interessenkonflikt. Die inspiring-health GmbH (M. Rathmayer, M. Tiefgraber, M. Wilke) hat als Berater für die Moderation der Arbeitsgruppensitzungen und die Durchführung der Kostenkalkulationen ein Beratungshonorar von der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e. V. erhalten., (Thieme. All rights reserved.)

Hypoglossal nerve stimulation for obstructive sleep apnea - Updated position paper of the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery. Since the first statement of the German Society of Oto-Rhino-Laryngology, hypoglossal nerve stimulation (HNS) is meanwhile an established treatment option for obstructive sleep apnea (OSA). There are three HNS systems available in Germany which differ in their technical details of the underlying comparable basic principle. For the unilateral HNS with respiratory sensing, several comparative studies, high-volume register analysis and long-term reports exist. The continuous HNS without respiratory sensing does not require a sleep endoscopy for indication. For the bilateral continuous HNS as the single partially implantable device, a feasibility study exists. For indication, the assessment of positive airway pressure failure by sleep medicine is crucial, and the decision for HNS should be made in discussion of other treatment options for at least moderate OSA. The implantation center holds primarily responsibility among the interdisciplinary sleep team and is primary contact for the patient in problems. This depicts why structural processes are required to secure outcome quality and minimize complications. The aftercare of HNS patients can be provided interdisciplinary and by different medical institutions whereat minimal reporting standards to document outcome and usage are recommended., Competing Interests: Armin Steffen ist Berater für Merz Pharmaceuticals und Respicardia, Inc., und erhielt Forschungsunterstützung von Inspire Medicals sowie Vortragshonorare von Intersect Inc, Proveca Inc, Onyx Health sowie Panakes.Clemens Heiser war Berater für Inspire Medical Systems. Clemens Heiser erhielt Forschungsunterstützung von Inspire Medical Systems, Nyxoah, Löwenstein Medizintechnik. Clemens Heiser erhielt Vortragshonorare von Jazz Pharma, Neuwirth Medical Products.Joachim T. Maurer ist Berater für Nyxoah und erhielt Forschungsförderung und/oder Vortragshonorare von Inspire Medicals, ImThera/LivaNova, MedEl, NeuwirthMedical Products, Gramann Veranstaltungsorganisation sowie XM Consults.Günther Eck gibt Interessenskonflikte bzgl. ALK-Abelló Arzneimittel GmbH, Bencard Allergie GmbH Deutschland, Bionorica SE, Inspire Medical Systems, Inc. und Sanofi-Aventis Deutschland GmbH an.Holger Woehrle erhielt Forschungsunterstützung von ResMed und Weinmann, war Mitarbeiter bei Resmed als Medical Director und erhielt Vortragshonorare bzw. ist Berater bei Allergopharma, AstraZeneca, Bayer, GSK, Boehringer Ingelheim, Inspire Medical, ResMed, Novartis und VitalAir.Jan Löhler gibt einen Interessenskonflikt bzgl. der finanziellen Unterstützung durch den Deutschen Berufsverband der HNO-Ärzte e.V. an.Winfried Randerath hat Honorare für die Mitarbeit in einem Advisory Board der Firmen Philipps Respironics, SoClean, Bioprojet, Bayer Sleep Research sowie Honorare und Reisekosten für Vortragstätigkeiten der Firmen Boehringer Ingelheim, Philipps Respironics, Heinen und Löwenstein, Vanda Pharma und Night Balance erhalten. Wolfgang Galetke, Simon-Dominik Herkenrath geben keine Interessenskonflikte an., (Thieme. All rights reserved.)

When caring for patients with respiratory diseases, always think of the heart! This is especially important for COPD patients, but also for a variety of other disorders of the respiratory system. At the workshop "Luftschlösser", held once more at Wiesbaden, Germany in February 2019 the many and important interactions of the lungs and the heart as well as the therapeutic implications were discussed. Based on pathophysiology, the psycho-social consequences of dyspnea, the leading symptom in patients with lung and heart disease became apparent. A particularly demanding diagnostic and therapeutic situation occurs in patients suffering simultaneously of lung and heart disease. It has been shown how frequently the diagnosis myocardial infarction is missed in COPD patients - and vice versa. Surprisingly, this is also the case in asthmatics with coronary heart disease or heart failure, a fact not readily known in clinical practice. In patients with emphysema and no apparent heart disease, hyperinflation leads to significantly restricted heart function. Reducing hyperinflation by inhaling broncholytics thus improves heart function. Biomarkers are increasingly being used for diagnostic purposes. Their role is being investigated in the large German COPD cohort COSYCONET. Lung patients suffering from more severe heart diseases pose a challenge for therapy in intensive care, especially when ventilated, and weaning from the ventilator is prolonged. Lung vessel diseases are "classic" examples of the intimate interaction of the lungs and the heart. In pulmonary arterial hypertension as well as in chronic thrombo-embolic pulmonary hypertension the lag time between the first symptoms and the definite diagnosis is often unacceptably long. For both diseases of the lung vessels therapeutic options have improved significantly over the last years. Pulmonologists should take care of this increasingly important patient group. Sleep-related breathing disorders and heart function are closely intertwined. Both conditions need special attention after the results of the SERVE-HF trial have been published. But there is no doubt that obstructive sleep apnea represents an independent and important risk factor for cardiovascular disease and needs to be treated according to existing guidelines.This workshop demonstrated impressively the multiple interactions of the respiratory system with cardiac function, resulting diagnostic and therapeutic problems, and means to overcome these problems. Guidelines for respiratory diseases should appropriately address cardiac comorbidity., Competing Interests: B. Jany erhielt Vortragshonorare und Reisekostenerstattung von Boehringer Ingelheim.R. Bals erhielt Forschungsmittel oder persönliche Bezüge von AstraZeneca, CSL Behring, Boehringer Ingelheim, Novartis, German Federal Ministry of Education and Research (BMBF), Competence Network Asthma and COPD (ASCONET), persönliche Bezüge von GlaxoSmithKline, Grifols. Weitere Förderung außerhalb dieser Publikation erfolgte durch die Wilhelm-Sander Stiftung, die Schwiete Stiftung, die Deutsche Krebshilfe und den Mukoviszidose e. V. M. Dreher erhielt Vortragshonorare von Actelion, Astra Zeneca, Bayer, Berlin Chemie, Boehringer, Chiesi, Hamilton, Heinen und Löwenstein, Intermune, Linde, Novartis, Pfizer, Philips Respironics, ResMed, Roche und Weinmann, Beraterhonorare von Almirall, Boehringer, Hamilton, Linde, Novartis, Pfizer, Philips Respironics, ResMed und Roche, Forschungsmittel von Linde, Philips Respironics und ResMed.M. Held gibt an Vortrags- und Beraterhonorare von folgenden Firmen erhalten zu haben: Actelion, Astra Zeneca, Bayer Healthcare, BMS, Boehringer Ingelheim, Berlin Chemie, Daichii Sanyo, MSD, OMT, Pfizer und Forschungsbeihilfen von der Firma Actelion.R. Koczulla hat Honorare von Grifols, CSL, Novartis, Roche, GSK, Boehringer, Astra Zeneca, Berlin Chemie, TEVA, Sanofi, Mundipharma, GSK, Chiesi erhalten.W. Randerath erhielt Vortragshonorare und Reisekosten der Firmen Boehringer Ingelheim, Berlin Chemie, Bayer, Novartis und Roche.H. Watz erhielt Honorare für Vortrags- und Beratungstätigkeit sowie die Durchführung von klinischen Studien und Reisekostenerstattungen von den Firmen AstraZeneca, Bayer, Boehringer Ingelheim, BerlinChemie, Chiesi, Novartis, GlaxoSmithKline, Takeda und SanofiAventis.H. Wilkens erhielt Honorare für Vorträge und/oder Beratertätigkeiten von Actelion, Bayer Health Care, Boehringer Ingelheim, MSD, Pfizer und Roche.G. Steinkamp erhielt Honorare für Medizinisch-wissenschaftliches Publizieren von Boehringer Ingelheim, Gilead Sciences, InfectoPharm, Novartis, Pari GmbH und Alpha1 Deutschland e. V. L. Jany und M. Pfeifer geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Despite the encouraging results of noninvasive ventilation (NIV) in chronic hypercapnic COPD patients, it is also evident that some patients do not tolerate NIV or do not benefit from it. We conducted a study in which COPD patients with stable, chronic hypercapnia were treated with NIV and nasal high-flow (NHF) to compare effectiveness., Methods: In a multi-centered, randomized, controlled, cross-over design, patients received 6 weeks of NHF ventilation followed by 6 weeks of NIV ventilation or vice-versa (TIBICO) between 2011 and 2016. COPD patients with stable daytime hypercapnia (pCO 2 ≥50 mmHg) were recruited from 13 German centers. The primary endpoint was pCO 2 changes from baseline blood gas, lung function, quality of life (QoL), the 6 min walking test, and duration of device use were secondary endpoints., Results: A total of 102 patients (mean±SD) age 65.3±9.3 years, 61% females, body mass index 23.1±4.8 kg/m 2 , 90% GOLD D, pCO 2 56.5±5.4 mmHg were randomized. PCO 2 levels decreased by 4.7% (n=94; full analysis set; 95% CI 1.8-7.5, P =0.002) using NHF and 7.1% (95% CI 4.1-10.1, P <0.001) from baseline using NIV (indistinguishable to intention-to-treat analysis). The difference of pCO 2 changes between the two devices was -1.4 mmHg (95% CI -3.1-0.4, P =0.12). Both devices had positive impact on blood gases and respiratory scores (St. George's Respiratory Questionnaire, Severe Respiratory Insufficiency Questionnaire)., Conclusions: NHF may constitute an alternative to NIV in COPD patients with stable chronic hypercapnia, eg, those not tolerating or rejecting NIV with respect to pCO 2 reduction and improvement in QoL., Competing Interests: Dr. Bräunlich reports grants and non-financial support from TNI Medical AG during the conduct of the study; and grants, personal fees and non-financial support from TNI Medical AG and personal fees from Fisher&Paykel, outside the submitted work. Prof. Kähler reports non-financial support from TNI Medical AG. Prof. Randerath reports grants from Heinen und Löwenstein, Weinmann, Philips Respironics, and Inspire, outside the submitted work. Prof. Wirtz reports personal fees and non-financial support from TNI Medical AG, during the conduct of the study. All other authors have nothing to disclose.

Background: Upper airway stimulation (UAS) is a treatment approach for patients with moderate-to-severe obstructive sleep apnea who cannot adhere to continuous positive airway pressure therapy., Objective: The objective was to evaluate added patient benefit and cost-effectiveness of UAS in the German health care system., Methods: We used a decision-analytic Markov model to project major adverse cardiovascular or cerebrovascular events (myocardial infarction [MI] or stroke), motor vehicle collision (MVC), mortality, quality-adjusted life years (QALYs), and costs. The assumed reduction in the apnea-hypopnea index with UAS compared to no treatment is based on German real-world data. Other input data were derived from the literature, public statistics, and multivariate regression. Cost-effectiveness was evaluated in Euros per QALY gained, both discounted at 3%., Results: UAS was projected to reduce event risks (10-year relative risk for stroke, MI, cardiovascular death, and MVC: 0.76, 0.64, 0.65, and 0.34, respectively), and to increase survival by 1.27 years. While the UAS strategy incurred an additional 1.02 QALYs within the patient lifetime, there were also additional costs of EUR 45,196, resulting in an incremental cost-effectiveness ratio of EUR 44,446 per QALY gained. -Conclusions: In the present model-based analysis, UAS therapy provides meaningful benefit to patient-relevant endpoints and is a cost-effective therapy in the German setting., (© 2019 S. Karger AG, Basel.)

Competing Interests: Jeder Autor ist Chefarzt einer pneumologischen Klinik.

Aim of the Study:  Survey of specialist pulmonary medicine health care structures for patients with interstitial lung disease (ILD) in Nordrhein-Westfalen, Germany., Methods:  The Western German Respiratory Society initiated a voluntary registration of ILD expert centers. Structural quality and processes were evaluated by questionnaire., Results:  49 centers were registered, 46 allowed analysis of their center data (15 pulmonology specialist practices, 34 hospital pulmonology departments). Specialist practices saw a median of 360 ILD patients per year (26 % first diagnosis), hospital departments a median of 105 ILD patients per year (63 % first diagnosis). 10 centers diagnose more than 100 new ILD cases per year. Specialist practices report median 50 bronchoscopies per year, hospital departments median 1396. 78 % of the centers participate in a multidisciplinary ILD case conference., Conclusion:  Several ILD expert centers were identified in Nordrhein-Westfalen. Outpatient care mainly involves the monitoring of ILD patients, inpatient services focus on complex initial diagnostics or cases with unusual disease behaviour. ILD centers meeting regional health care needs should be supported in their development., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Positive effects of pulmonary rehabilitation on chronic obstructive pulmonary disease (COPD) are well known, and inpatient rehabilitation programs are the preferred modality in Germany. In this paper, we report on the recent results of a daily outpatient rehabilitation program offered at an acute hospital, the first of this kind in Germany. It is not known whether this kind of rehabilitation is an effective approach., Methods: 32 consecutive COPD patients GOLD-stage II-IV, phenotype B-D (mean 64.5±21.9 years; 18 male, 14 female) completed a rehabilitation program of 19 (15-21) days conducted according to the recommendations of the National Accociation for Rehabilitation. In this prospective observational study, data (walking distance in the 6-MWD, BODE-Index, HADS-, BDI/TDI-, CAT-questionnaire) were collected at the beginning (T1) and at the end (T2) of the program and the results are presented in a pre- vs. post-analysis., Results: We found significant positive effects for most of the measured parameters, except for body plethysmography, diffusion capacity and blood gas. Especially the increase in the 6 min walking distance (6-MWD) was remarkable (T1: 485.78±158.24, T2: 527.97±146.75 m, p=0.0212). There were no adverse events or complications. All participants were able to complete the program properly., Conclusion: Most of the measured parameters in COPD patients with stage II or worse disease improved significantly during the comprehensive outpatient rehabilitation program. A limitation of this study is the small number of cases, and further conclusions can only be made after examining a larger sample. The setting of this rehabilitation program in an acute hospital seems to be meaningful in an organisational and structural sense., (© Georg Thieme Verlag KG Stuttgart · New York.)

Malnutrition is a frequent problem for hospitalized patients. It is a relevant risk factor for morbidity and mortality. The aim of this study was to detect undernutrition and the risk of malnutrition (RM) in patients admitted to a university-affiliated respiratory care clinic. Undernutrition was assessed by body mass index (BMI<18.5 kg/m²) and RM by using the "Nutritional Risk Screening 2002" (NRS 2002) in 705 consecutive patients (BMI: measured in 689 patients/NRS: 680 patients assessed). Data was analysed with regard to age, sex, length of hospital stay as well as underlying pneumological disorders. In 14.3% of 680 patients, RM was detected by NRS. In 2.5% out of 689 patients, undernutrition was identified by BMI. In patients older than 65 years (n=365), these numbers were 19.6% (NRS) and 1.5% (BMI<18.5 kg/m²). Age was a significant risk factor for RM (OR 1.054 per year). Gender, however, was not associated with undernutrition or RM. In a sub-analysis, RM was more frequent in patients with pneumonia and chronic obstructive lung disease (23% and 16%, respectively). Patients with cancer were more frequently at RM as compared to patients with sleep-disordered breathing (OR: 2.33 in cancer, OR: 0.04 in sleep-disordered breathing). RM was associated with a significant increase in length of hospital stay (10.2 ± 9.5 vs. 5.4 ± 6.0 days). Besides the BMI, the NRS provides a valid tool for screening patients at RM., (© Georg Thieme Verlag KG Stuttgart · New York.)

Diagnosis and treatment of sleep disordered breathing (SDB) undergo substantial changes, both in terms of increasing scientific knowledge and also in terms of patient provision and socio-economic aspects. Increasing evidence shows the relevance of SDB on morbidity and mortality of affected patients. The precise differentiation of different phenotypes of SDBs has improved substantially in recent years. These proceedings influence the approach to the patients suspected of suffering from SDB. The scientific advances on the one hand are facing intentions to simplify diagnostical processes and treatment initiation and intentions to translate duties of physicians to non-medical personnel on the other hand. This consensus paper presents the principals of diagnosis, treatment initiation and provision, including the role of different participants of the healthcare system, and compares different treatment options. Major aspects include the differentiation of the diagnostical process in screening, affirmation of diagnosis and differential diagnosis. In addition, it focusses on the relevance of the pretest probability and describes a therapeutical algorithm., (© Georg Thieme Verlag KG Stuttgart · New York.)

This overview presents data that take advantage of a new step of insight into COPD. Large population-based retrospective studies and intensively investigated prospective cohorts are two important sources of knowledge that have been recently developed. One of the contributions introduces the German COSYCONET which is on its way shortly after the American ECLIPSE cohort. The vast amount of new data has also contributed to some corrections of the recommendations of the international GOLD committee. Clinically important are the waiver of the reversibility test for the diagnosis of COPD, the inclusion of sympotom scores to evaluate quality of life and the estimation of exacerbations. The COPD types I through IV were originally the result of expert opinion, but their impact on prognosis has recently been evaluated empirically.The top issues of the expert meeting were cardiovascular aspects of COPD. Besides the comorbidity of two significant chronic diseases, it became clear that cardiovascular events have an outstanding significance for COPD patients. Inversely, advanced COPD is an important risk factor in cardiac and vascular diseases. The mutual influence of both disease entities does not only affect the long term progression but also the outcome of acute events like myocardial infarction and COPD exacerbation. The following contributions investigate the topic with regard to epidemiology, the biology of vessels, and especially with regard to acute COPD exacerbations and pharmakotherapy. Recent evidence enables a fresh view on the cardiovascular toxicity of COPD medication and on possible protective effects of cardiovascular drugs (i.e. statins and ß-receptor antagonists) for patients with COPD., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Bacterial colonisation in stable disease of severe COPD and bronchiectasis can cause recurrent hospital treatment, which has a negative impact on the patient's prognosis. A multicentre study has investigated if daily inhalation of tobramycin for one year would lower the number of hospitalisations in severe COPD., Methods: 44 patients with severe COPD [FEV1 % of predicted value: 42.8 ± 7,1 tobramycin group (T) and 33.5 ± 10.3 placebo group (P)] and a minimum of two hospitalisations in the year before inclusion were randomly assigned to inhale twice daily for 12 months 80 mg tobramycin or isotonic saline (placebo). Concomitant therapy was according to the GOLD guidelines. Primary end point was the number of hospitalisations in the period of study, secondary end points were pulmonary function test and 6 MWD., Results: Inhalation of T changed the number of hospitalisations from 2.8 ± 0.5 per year to 3.5 ± 2.7, P from 3.0 ± 1,4 to 2.3 ± 2.2. These differences and the results for secondary endpoints did not reach significance. The dropout rate was high, only 6 patients (T) and 14 patients (P) finished the study per protocol., Conclusion: Inhalation with 160 mg tobramycin by means of a nebuliser over a 12-month period did not reduce the number of hospitalisations for patients with severe COPD and a minimum of two hospitalisations compared to placebo. The severity of the disease was the main reason for the high dropout rate., (© Georg Thieme Verlag KG Stuttgart · New York.)

Amyloidosis is a rare disorder within the field of pneumology, however, it is estimated that there are a relevant number of unreported cases. In routine clinical practice, the disease is seldom considered in the diagnostic work-up of unclear respiratory symptoms and radiological findings. For amyloidosis to be considered as a differential diagnosis, the clinician must be aware of the broad variety of its clinical manifestations. In cases where amyloidosis is suspected, it is important to obtain an early tissue biopsy. If the diagnosis can be confirmed by Congo red staining, further subtyping of the amyloid protein is necessary in order to identify a treatable cause of the disease. The amyloidoses are classified according to the type of amyloid protein, with clinical subclassifications distinguishing hereditary from acquired forms and localised from generalised manifestations. Apart from causal therapy of the primary disease, the treatment of generalised amyloidosis includes specific systemic therapy. The majority of localised forms are treated with specific local interventions showing good long-term results. This review outlines the pathophysiology, classification, diagnostic pathways and therapeutic modalities in amyloidosis. Furthermore, typical manifestations of amyloidosis of the lung and the specific treatment options are discussed., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: At present health-care at home for the majority of patients with invasive ventilation is mainly provided by nursing personnel. The reason for this unsatisfying condition is the lack of a basic medical supply for patients with invasive ventilation outside of hospitals. In contrast, current guidelines recommend a follow-up care by the weaning centres that applies for patients with invasive ventilation at home. In an case the practical implementation of the follow-up care is not specified., Material and Methods: In this paper we attempt to balance the reasons for the need of follow-up care for ventilated patients by the weaning centre on the basis of 6 cases. Furthermore, we want to report our experience with a weekly visitation of these patients as a basic structure of the follow-up care., Results and Conclusions: The necessity for a regular consultation by a pneumologist that can be established by weekly rounds has been demonstrated. In addition, it can be expected to reduce the costs of public health markedly if one takes data from ventilated patients living in specialised institutions into account. Nevertheless prospective studies are necessary to objectify the financial and medical benefits arising from this form of medical supply. These studies should be designed as multicentre studies because of the heterogenous population of ventilated patients and the fact that home ventilation is in general a seldom occurrence., (© Georg Thieme Verlag KG Stuttgart · New York.)

Sleep-related breathing disorders are common adult illnesses in Western countries and classified as either dominant obstructive sleep apnoea or dominant central sleep apnoea. Cheyne-Stokes Respiration is part of the spectrum of CSA. The earliest descriptions of patients who presumably suffered from sleep apnoea were made in the 19th century. The term ''Pickwickian'' in connection with sleepy patients was introduced in 1889. The first electrophysiological sleep recordings of Pickwickian patients and the understanding of the syndrome as disordered breathing in sleep, were made during the late 1950s and 1960s at the universities of Heidelberg and Freiburg in Germany. The term sleep apnoea syndrome was introduced by Guilleminault from Stanford. The introduction of continuous positive airway pressure (CPAP) therapy by C. E. Sullivan and co-workers gave an enormous impetus to the field of sleep-disordered breathing. Its recognition as a public health problem was facilitated by the Wisconsin study, investigating the prevalence of sleep apnoea in the middle-aged general population. Nowadays obstructive sleep apnoea (OSA) is recognised as an independent risk factor for a wide range of clinical conditions, such as atherosclerosis, hypertension, heart failure, arrhythmias, stroke, diabetes, and depression. This article focuses on issues related to OSA and CSA/CSR, their pathogenesis, interaction with other comorbidities including cardiovascular diseases. Future research will focus on treatment effects on cardiovascular and metabolic outcomes in sleep apnoea and on the pathophysiological mechanisms responsible for the inflammatory state and cardiovascular morbidity in the syndrome. Other potential areas of research include biochemical markers, new diagnostic and therapeutic modalities., (Copyright Georg Thieme Verlag KG Stuttgart . New York.)

The advances in intensive and critical care medicine have not only improved the prognosis of patients with acute respiratory failure but have also increased the number of ventilator-dependent patients. The continuously increasing number of patients, the differentiation of care-giving institutions and the technical progress make it necessary to re-evaluate the quality of health care in weaning centres and outpatient care of patients on long-term ventilation. Therefore, the German medical associations of pneumology and ventilatory support, "Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V." and the "Arbeitsgemeinschaft für Heimbeatmung und Respiratorentwöhnung e. V.", wish to present this actual position paper. However, scientific guidelines are in preparation.

Many patients with the obstructive sleep apnea syndrome (OSAS) look for alternative conservative or surgical therapies to avoid to be treated with continuous positive airway pressure. In view of the high prevalence and the relevant impairment of the patients lots of methods are offered which promise definitive cure or relevant improvement of OSAS. The working group "Apnea" in the German Society of Sleep Medicine and Research established a task force to evaluate the scientific literature on non-CPAP therapies in the treatment of OSAS according to the standards of evidence-based medicine. This paper summarizes the results of the task force. The data were unsatisfactorily for most of the methods. Sufficient data were available for intraoral appliances (IOA) and the maxillomandibular osteotomy (MMO). IOA's can reduce mild to moderate respiratory disturbances, MMO are efficient in the short and long term but are performed only in special situations such as craniofacial dysmorphias. Weight reduction and body positioning cannot be recommended as a single treatment of OSAS. Most surgical procedures still lack sufficient data according to the criteria of evidence based medicine. Resections of muscular tissue within the soft palate have to be strictly avoided. But even success following gentle soft palate procedures is difficult to predict and often decreases after years. Results in other anatomical regions seem to be more stable over time. Today combined surgeries in the sense of multi-level surgery concepts are of increasing interest in the secondary treatment after failure of nasal ventilation therapy although more data from prospective controlled studies are needed. There is no evidence for any other treatment options.