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To assess the sensitivity and negative predictive value of sputum examination for Pneumocystis carinii in HIV-positive patients, follow-ups were performed in HIV-infected patients who had been investigated for the presence of Pneumocystis carinii (376 examinations of sputum and 71 bronchoalveolar lavages). Pneumocystis carinii pneumonia was diagnosed 65 times in 64 patients (57 male and 7 female, median age 35 [23-67]years). In 52% of the cases (n = 34) the pathogen was identified in the sputum, in 48% (n = 31) by means of the bronchoalveolar lavage. Of 342 negative findings in sputum examination, five were definitely false negative since the subsequent lavage yielded pneumocysts. In nine further cases Pneumocystis carinii pneumonia could not be excluded because of the course of the disease. In patients from whom sputum samples were available the sensitivity of pathogen identification was at least 70.8% and the negative predictive value at least 95.9%. Since preceding prophylaxis did not render identification in the sputum more difficult, examination of spontaneous or provoked sputum is indicated as a first hand measure in all patients infected with HIV in whom Pneumocystis carinii pneumonia is suspected.

Von April bis August 1989 wurden 60 konsekutive Pneumocystis-carinii-Pneumonien bei 58 HIV-Infizierten (48 Manner, zehn Frauen, mittleres Alter 34 [22-53] Jahre) prospektiv ausgewertet, und der klinische Verlauf wurde verglichen mit demjenigen von 60 konsekutiven P.-carinii-Pneumonien bei 59 HIV-Infizierten (55 Manner, vier Frauen, mittleres Alter 37,5 [22-60] Jahre) in den Jahren 1981-88. Bis 1985 verliefen 50 % (acht von 16), von 1986 bis August 1988 20,5 % (neun von 44) und 1989 1,7 % (eine von 60) der P.-carinii-Pneumonien trotz Therapie innerhalb von 14 Tagen nach der Diagnose todlich. Der Schweregrad der Pneumonien zum Zeitpunkt der Diagnose war 1989 deutlich geringer als in den Jahren zuvor; das war anhand folgender Parameter erkennbar (Durchschnittswerte des Jahres 1989 im Vergleich mit den Werten der Jahre 1981-88): Lactatdehydrogenase 540 (250-1419) U/l gegenuber 680 (235-1920) U/l (nicht signifikant); alveolo-arterielle Sauerstoff-Partialdruckdifferenz p A-aO2 22,9 (0,5-73,5) mm Hg gegenuber 39,7 (19-70) mm Hg (P < 0,001); Score der radiologischen Befunde 1,4 (0-3) gegenuber 2,7 (0-4) (P < 0,001). Bei den im Jahre 1989 diagnostizierten P.-carinii-Pneumonien war vor allem die klinische Symptomatik mit trockenem Husten (57 von 60), Dyspnoe (44 von 60) und Fieber (43 von 60) diagnostisch leitend. Das Rontgenbild des Thorax war bei 13 Episoden unauffallig, die Lactatdehydrogenase bei 25 und die p A-aO2 bei 33. Die Medikamente der Wahl blieben seit 1981 nahezu unverandert. Die fruhe Diagnose war somit entscheidend fur die Verbesserung der Uberlebenswahrscheinlichkeit. The clinical presentation of 60 consecutive Pneumocystis carinii pneumonias in 58 HIV-infected patients (48 men, 10 women, mean age 34 [22-53] years) was prospectively evaluated from April to August 1989 and compared with 60 consecutive P. carinii pneumonias in 59 HIV-infected patients (55 men, 4 women, mean age 37.5 [22-60] years) between 1981-88. Mortality rates within 14 days after diagnosis of P. carinii pneumonia were 50% (8 of 16 patients) until 1985, 20.5% (9 of 44) between 1986 and August 1988, and 1.7% (one of 60) in 1989. The degree of severity of the pneumonias at time of diagnosis was markedly lower in 1989, as shown by following parameters (averages of 1989, compared with averages of 1981-88): lactate dehydrogenase 540 (250-1419) U/l versus 680 (235-1920) U/l (not significant); alveolo-arterial difference of partial oxygen tension (pA-aO2) 22.9 (0.5-73.5) mmHg versus 39.7 (19-70) mmHg (P less than 0.001); score of radiological findings 1.4 (0-3) versus 2.7 (0-4) (P less than 0.001). In 1989, mainly clinical symptoms (dry cough: 57 of 60 cases, dyspnea: 44 of 60 cases, fever: 43 of 60 cases) initiated the diagnostic procedure: chest radiographs, lactate dehydrogenase and pA-aO2 were normal in 13, 25 and 33 episodes, respectively. The lower mortality rate of P. carinii pneumonia could not primarily be explained by therapeutical progress since the treatment of choice did not change fundamentally since 1981. Above all, early diagnosis fundamentally determined the probability of survival.

Evidence-based national and international guidelines are largely aimed to guide in the diagnosis and treatment of asthma or COPD, but none addresses sufficiently mixed disease states of both disorders, which are ill-defined but very common in the daily routine clinic. This is a consensus report of a workshop on mixed disease. Asthma is characterized by a classical clinical history and physical exam, reversible airflow limitation and a high degree of bronchial hyperresponsiveness. In contrast, history (mostly smoker) and findings in typical COPD are different: COPD patients have little if any bronchial hyperresponsiveness and reversibility of the airflow limitation, respectively. However, beyond the full reversible airflow limitation which excludes COPD or mixed disease, none of these criteria are fully discriminatory. Patients with some of the characteristics of both diseases should be classified as mixed disease. A definitive diagnosis however, should only be assigned in a dynamic process. Once diagnosed the patient should be continuously re-evaluated according to the strength of the diagnosis, since the consequent treatment is important: COPD patients with asthmatic phenotype need early inhaled corticosteroids, even if their FEV1 > 50 %. Moreover, allergen avoidance can be indicated. On the other hand, asthma patients with COPD phenotype could benefit from anticholinergics or--if indicated--pulmonary rehabilitation. Mixed disease should be diagnosed as the coexistence of two distinct entities, i. e. asthma (allergic or intrinsic asthma, whichever is appropriate) and COPD.

Bronchialasthma ist eine Erkrankung, die durch respiratorische Beschwerden gekennzeichnet ist, welche sich spontan oder aufgrund von therapeutischen Masnahmen rasch andern. Nicht immer sind alle Symptome der klassischen Asthma-Trias – Husten, Atemnot, pfeifende Atmung – vorhanden. Bei leichten Formen kann die klinische Untersuchung normal ausfallen. Aus klinischer Sicht konnen die verschiedenen Formen von Asthma entweder unter den Gesichtspunkten des Schweregrades der Erkrankung oder aufgrund atiologischer Aspekte unterschieden werden. Asthma kann sich in jedem Lebensalter erstmals manifestieren. Nicht haufig, aber von groser Bedeutung fur Prognose und Therapie sind besondere Formen von Asthma wie die allergische bronchopulmonale Aspergillose oder Asthma im Rahmen einer Churg-Straus-Vaskulitis.

Multicentric Castleman's disease (MCD) is a rare polyclonal lymphoproliferative disorder that is typically accompanied by an overproduction of circulating cytokines (mainly interleukin-6). We here report the case of a 40-year-old HIV-negative woman with pulmonary manifestation of MCD. There is no standard treatment for MCD. In our patient, various treatment courses with immunomodulatory drugs were unsuccessful. Finally, treatment with the interleukin-6 receptor antibody tocilizumab has resulted in continual clinical improvement over the last 5 years.

Reduced exposure to particulate matter with a 50% cut-off aerodynamic diameter of 10 microm (PM(10)) attenuated age-related lung function decline in our cohort, particularly in the small airways. We hypothesised that polymorphisms in glutathione S-transferase (GST) and haem oxygenase-1 (HMOX1) genes, important for oxidative stress defence, modify these beneficial effects. A population-based sample of 4,365 adults was followed up after 11 yrs, including questionnaire, spirometry and DNA blood sampling. PM(10) exposure was estimated by dispersion modelling and temporal interpolation. The main effects on annual decline in forced expiratory flow at 25-75% of forced vital capacity (FEF(25-75%)) and interactions with PM(10) reduction were investigated for polymorphisms HMOX1 rs2071746 (T/A), rs735266 (T/A) and rs5995098 (G/C), HMOX1 (GT)(n) promoter repeat, GSTM1 and GSTT1 deletions, and GSTP1 p.Ile105Val, using mixed linear regression models. HMOX1 rs5995098, HMOX1 haplotype TTG and GSTP1 showed significant genetic main effects. Interactions with PM(10) reduction were detected: a 10 microg.m(-3) reduction significantly attenuated annual FEF(25-75%) decline by 15.3 mL.s(-1) only in the absence of HMOX1 haplotype ATC. Similarly, carriers of long (GT)(n) promoter repeat alleles or the GSTP1 Val/Val genotype profited significantly more from a 10 microg.m(-3) reduction (26.5 mL.s(-1) and 27.3 mL.s(-1) respectively) than non-carriers. Benefits of a reduction in PM(10) exposure are not equally distributed across the population but are modified by the individual genetic make-up determining oxidative stress defence.

The obstructive sleep apnoea syndrome (OSAS) is a highly prevalent sleep related breathing disorder associated with hypopnoea/apnoea, arousals and increased daytime sleepiness. OSAS has been shown to have damaging acute effects on the cardiovascular system and thus has been postulated to represent an independent cardiovascular risk factor. A causal relationship between OSAS and cardiovascular disease has currently only been established for hypertension and heart failure. Evidence that OSAS indeed plays a key role in the pathogenesis of heart attacks and stroke and that therapy of OSAS reduces cardiovascular morbidity and mortality is currently limited. The results of multiple ongoing international multi-centre studies investigating the effects of OSAS therapy on cardiovascular event rate and mortality are thus anxiously awaited.

The present study reports the case of a 43-yr-old very sporty male, who developed shortness of breath and expectorated bloody froth during aqua jogging. Pulmonary oedema was diagnosed clinically and by computed tomography of the chest. The patient made a full recovery and his echocardiography was entirely normal. Pulmonary oedema occurring in healthy scuba-divers and swimmers has been reported previously. However, this is the first case where pulmonary oedema was observed during aqua jogging.

Sensitivity and specificity of clinical findings for the diagnosis of pulmonary diseases is often poor, or information on test characteristics of particular findings is even missing. Nevertheless, a meticulous clinical exam remains a cornerstone in clinical practice. Quite often clear-cut findings may provide valuable diagnostic information. Furthermore, history taking and painstaking physical examination foster the confidence between patients and physicians, which is urgently needed in a time of machine-dominated medical practice.

Evidence-based national and international guidelines are largely aimed to guide in the diagnosis and treatment of asthma or COPD, but none addresses sufficiently mixed disease states of both disorders, which are ill-defined but very common in the daily routine clinic. This is a consensus report of a workshop on mixed disease. Asthma is characterized by a classical clinical history and physical exam, reversible airflow limitation and a high degree of bronchial hyperresponsiveness. In contrast, history (mostly smoker) and findings in typical COPD are different: COPD patients have little if any bronchial hyperresponsiveness and reversibility of the airflow limitation, respectively. However, beyond the full reversible airflow limitation which excludes COPD or mixed disease, none of these criteria are fully discriminatory. Patients with some of the characteristics of both diseases should be classified as mixed disease. A definitive diagnosis however, should only be assigned in a dynamic process. Once diagnosed the patient should be continuously re-evaluated according to the strength of the diagnosis, since the consequent treatment is important: COPD patients with asthmatic phenotype need early inhaled corticosteroids, even if their FEV150 %. Moreover, allergen avoidance can be indicated. On the other hand, asthma patients with COPD phenotype could benefit from anticholinergics or--if indicated--pulmonary rehabilitation. Mixed disease should be diagnosed as the coexistence of two distinct entities, i. e. asthma (allergic or intrinsic asthma, whichever is appropriate) and COPD.

Ein Lungenersatzverfahren soll die zentrale Aufgabe der Lunge — den Gasaustausch — ubernehmen konnen, um ein schwer geschadigtes Organ, das diese Funktion nicht mehr bewaltigt, temporar zu ersetzen oder mindestens zu unterstutzen.

Better recipient selection, sophisticated postoperative surveillance and new immunosuppressive and anti-infective regimens can improve the results of lung transplantation. We compared the results of lung transplants performed between 1992 and 1996 (early period; 47) and between 1997 and 2000 (recent period; 46) in a cohort study to assess which factors influenced survival. Estimates of relative hazards were adjusted for possible confounding effects with the use of Cox regression analysis. Overall 2-year survival was 70%. Survival by this time was significantly better in the recent period (82% vs. 60%; p = 0.0093). Acute rejection episodes and death due to BOS were less frequent in the recent period. There were no technical failures, and the cumulative incidence of BOS was low (34% at 5 years). The beneficial effect of the transplantation date 1997 or later at a hazard ratio of 0.33 (95% CI, 0.13-0.84) was materially changed only by the adjustment for ganciclovir prophylaxis (0.50; 95% CI, 0.09-2.91) and immunosuppression with mycophenolate mofetil (0.80; 95% CI, 0.27-2.36). After adjustment for both ganciclovir and mycophenolate mofetil, the beneficial time period effect was completely removed (1.24; 95% CI, 0.14-11.39). Immunosuppressive therapy with mycophenolate mofetil and use of ganciclovir prophylaxis in addition to careful postoperative surveillance and surgical expertise can lead to improved results after lung transplantation.

Asthma and atopy are strongly related conditions. The presence of specific IgE to perennial (arthropods, animal dander and other), seasonal (pollens, certain fungal spores) and occupational allergens is associated with the occurrence of asthmatic symptoms. Current therapy is based on combining three principles: Avoidance of trigger factors and of allergen exposure, drug therapy, and specific immunotherapy. Feasability and effectiveness of allergen avoidance (particularly of perennial allergens) have been proven. However, these measures must often be supplemented with drug therapy. Several classes of drugs are nowadays available for treatment of asthmatic symptoms and, most importantly, for control of the bronchial inflammatory process which underlies atopic asthma. Specific immunotherapy is a good treatment option in allergy to pollens, but its use is controversial in allergy to house dust mites and other perennial allergens. Finally, it should be kept in mind that the successful longterm management of patients with atopic asthma depends highly on the compliance of patients.

To evaluate the activity and evolution in the field of lung volume reduction surgery (LVRS) performed at surgical centers in Europe.LVRS is a novel surgical therapy with the potential to improve lung function, exercise performance, and quality of life in selected patients suffering from severe pulmonary emphysema.Questionnaire addressed to 75 European thoracic surgical centers presumed to perform LVRS, and review of the literature.Of 45 responding centers, 42 centers in 17 countries covering a population of 423 million reported performing LVRS. Until the end of 1998, 1,120 patients were reported to have undergone LVRS, corresponding to 2.6 patients/million inhabitants. Thirty-one of 40 centers (78%) perform the operation bilaterally. Most centers (83%) evaluate their activity prospectively. The average perioperative mortality rate of 4.1% is moderate. The most commonly utilized technique is video-assisted thoracoscopy, which is most frequently performed bilaterally. Two thirds of the centers treat patients with alpha(1)-antitrypsin deficiency, and half of the centers will consider patients with homogenous morphology of emphysema on CT scan for LVRS. Half of the centers also perform lung transplantation. The five largest centers have operated on 49% of all LVRS patients assessed by this survey.LVRS is performed at few thoracic surgical centers throughout Europe, with a large variation in the operative activity between different regions. Half of the centers also perform lung transplantation. Between 1995 and 1997, the number of LVRS procedures performed per year nearly tripled but has reached a plateau since then. As five centers perform nearly half the total number of operations, an optimal exchange of knowledge with smaller centers seems important.

We report on two patients with pulmonary arteriovenous malformations (PAVM). An almost asymptomatic young man and an elderly woman with severe dyspnoea illustrate paradigmatically various aspects of the clinical manifestation, diagnostic approach and treatment of this rare disorder. New aspects with respect to genetics, diagnosis and therapy are discussed. PAVM are often manifestations of hereditary teleangiectasia, which also affect blood vessels of the skin, mucous membranes, brain and liver. Transcatheter embolotherapy is a safe, effective and minimally invasive treatment option, which seems to be replacing surgical resection as first-line therapy in many cases.

Verschiedene Lungenkrankheiten gehen in einem weit fortgeschrittenen Stadium mit einer chronisch respiratorischen Insuffizienz einher. Die Anreicherung der einge- atmeten Luft mit Sauerstoff bildet in diesen Fallen einen zentralen Bestandteil der Therapie. Diese Art von Behandlung wird Langzeit-Sauerstofftherapie (LOT) genannt. Sie soil nicht verwechselt werden mit der kurzfristigen, d.h. nur wenige Tage bis Wochen dauernden Verabreichung von Sauerstoff bei spontan atmenden oder beatmeten Patienten, die an einer akuten respiratorischen Insuffizienz leiden.

Hospital-wide information systems may provide economical solutions for communication processes or for documentation by means of centralized digital medical records. Within a large university hospital, however, there may be too many diverse subspecialties and too many special medical procedures to be supported comprehensively by a single database information system. A peripheral modular system has been tailored to the specific needs of a sleep disorder clinic as an adjunct to the main clinical information system. The client server application allows for automatic data acquisition by on-line devices and by a graphical user interface. It supports administrative tasks for patient management, specific encounter interactions and data retrieval for research. Performance and acceptance of the system was assessed during clinical use, revealing positive response by the users, also with respect to significant time savings. Our experience suggests that the concept of peripheral database modules as "satellites" to a main clinical system provides flexibility in design and implementation of the specialized databases while providing access to data of more general relevance via the main database.

Lung volume reduction surgery is a novel operative concept, which may be applied in certain patients, who are severely handicapped by advanced pulmonary emphysema and suffer from dyspnea at minimal exercise despite optimal medical therapy. The most destroyed lung parts are resected by video-assisted thoracoscopy. This type of surgery has a surprisingly low morbidity and mortality at specialized centers. It improves symptoms by ameliorating lung function and exercise tolerance. Maximal functional improvement is observed and lung function starts to decline slowly within one to two years thereafter.

The dysbalance between proteolytic neutrophil elastase and its endogeneous inhibitor seems to be a pathogenetic key mechanism in the origin of pulmonary emphysema (elastase-antielastase hypothesis). This hypothesis is supported by the observation, that low serum levels of alpha 1-antitrypsin can be observed in smokers with premature pulmonary emphysema. alpha 1-proteinase inhibitor is an acute phase protein with known structural and moleculargenetic aspects, which is synthesized by the liver and reaches the lung by the circulation. Its role is the inactivation of excessive neutrophil elastase in the pulmonary parenchyma, which is liberated during inflammation and destroys elastin and other components of extra-cellular connective tissue matrix. This is an overview on epidemiology, clinical aspects, genetics and molecular biology of this particular disease which was described in 1963.

We investigated functional results, complications and survival of patients undergoing bilateral video-assisted thoracoscopic (VAT) lung volume reduction surgery (VRS) for severe, diffuse pulmonary emphysema [FEV1 28 +/- 0.8 (% pred.), RV/TLC 0.65 +/- 0.01, 12' walking distance 499 +/- 21 (m)]. From January 1994 to March 1998, 106 of 286 candidates were operated, 85 patients (mean age 64, range 38-78 years, 30 females) fulfilled the study criteria and were included in the prospective study. Hyperinflation decreased to an RV/TLC ratio of 0.51 +/- 0.01 after 3 months and 0.55 +/- 0.02 after 24 months, FEV1 increased to 43 +/- 1.6 (% pred.) after 3 months and 35 +/- 2.3 (% pred.) after 24 months, and the 12' walking distance was 687 +/- 29 (m) 3 months postoperative and 626 +/- 44 (m) after 24 months.

Sleepiness is a major cause of traffic accidents. Our purpose was to review determinants of accidents related to sleepiness and measures to prevent them. We performed a systematic literature review on the topic and studied official accident statistics and legislation regarding medical driving ability in Switzerland. In 1997, 79,178 road traffic accidents, each causing bodily injury or property damage in excess of 500 Swiss francs, occurred in Switzerland. According to official statistics, sleepiness accounted for only 1% of identified causes. However, scientific studies performed in other countries suggest that sleepiness is a contributing factor in up to 30% of traffic accidents. Causes of hypersomnolence are sleep restriction, sleep disturbance by external environmental factors, inappropriate sleep hygiene, and sleep disorders. Several reports suggest an increased crash rate in patients with obstructive sleep apnoea syndrome. At our clinic, every sixth sleep apnoea patient reports sleepiness-related driving problems which resulted in traffic accidents in one third of them. Long monotonous motorway drives, late night, early morning and late afternoon hours are associated with an increased crash rate. Drivers with excessive sleepiness should not drive until the cause of hypersomnolence is determined and treated appropriately. Medical assessment of driving ability in patients with sleep disorders involves a specific history including standardised questionnaires, sleep studies and vigilance tests. Swiss legislation authorizes physicians to report sleepy drivers to the authorities if they are thought to represent an accident risk for themselves or others. We conclude that sleepiness is a common but under-recognised cause of traffic accidents. Enhancing awareness of the problem in the public, early recognition and treatment of sleep disorders, and counselling of drivers with excessive sleepiness may contribute to prevention.

The bacterial index (BI) as defined by the sum of log10 colony-forming units (cfu) of microorganisms per milliliter of bronchoalveolar lavage (BAL) fluid, i.e., a multiplication of the single cfu/ml, has been used to distinguish between polymicrobial pneumonia (BIor =5) and colonization (BI5). Since many false-positive results are to be expected using this parameter, the diagnostic value of the BI was studied prospectively by obtaining bacteriologic cultures of BAL fluid in 165 consecutive unselected patients. In 27 cases the diagnosis of bacterial pneumonia was established on clinical criteria. In 133 patients pneumonia could be excluded, and in five patients the diagnosis remained unclear. Using a cut-off ofor = 10(5) cfu/ml BAL fluid, sensitivity and specificity for the diagnosis of pneumonia were 33% (9/27) and 99% (132/133), respectively. Sensitivity was mainly influenced by prior treatment with antibiotics, being 70% (7/10) in untreated and 12% (2/17) in treated patients. Applying the BI methodology at a cut-off ofor =5, however, resulted in an unacceptably high rate of 16 additional false-positive results, thus lowering the specificity to 87% (116/133; P0.0001) while increasing the sensitivity to only 41% (11/27; P = 0.77). In conclusion, given the high rate of false-positive results, the methodology of the BI is of doubtful value for the diagnosis of bacterial pneumonia by BAL in an unselected patient group. By applying the absolute number of cfu/ml BAL fluid, however, positive bacteriologic cultures of BAL fluid are highly specific for the diagnosis of pneumonia. Their sensitivity is limited by previous antibiotic therapy.

The presence of pulmonary hypertension in severe pulmonary emphysema has been considered a relative contraindication to lung volume reduction surgery (LVRS). There was concern that resection of lung tissue might further increase pulmonary artery pressure. To address this point, the prevalence of pulmonary hypertension in candidates for LVRS was investigated. The changes in pulmonary artery pressures after bilateral videoassisted thoracoscopic resection was studied in patients with homo- and heterogeneously destroyed emphysematous lungs.The pulmonary arterial pressures by right heart catheterization were prospectively assessed, before and 6 months after LVRS in 21 consecutive patients (15 males, six females, mean (+/- S.E.) age: 62 +/- 1.9, range 42-74 years). All were former smokers and three had ZZ-AT1 deficiency. The inclusion criteria were: (a) severe bronchial obstruction (FEV135% predicted); (b) pulmonary hyperinflation (RV/TLC0.60); and (c) absence of hypercapnia (PaCO250 mmHg).The FEV1 had increased from 28 +/- 2% to 35 +/- 3% of the predicted value (P0.05) 6 months after surgery. The RV/TLC had declined from 0.65 +/- 0.02 to 0.55 +/- 0.02; PaO2 increased (66 +/- 1 versus 71 +/- 2 mmHg, P = 0.04), PaCO2 (38 +/- 2 versus 36 +/- 1 mmHg, P = 0.26) did not change. The pulmonary artery mean pressure (PAPmean) remained unchanged (18 +/- 1 versus 19 +/- 1 mmHg, P = 0.26). In six patients PAPmean wasor = 20 mmHg (up to 24 mmHg) preoperatively. After 6 months, six patients had a PAPmeanor = 20 mmHg (up to 31 mmHg).In patients with severe emphysema who are candidates for LVRS (but have only mild to moderate hypoxemia and a PaCO250 mmHg) we found no relevant pulmonary hypertension and pulmonary artery pressure did not change significantly after surgery. Therefore, routine right heart catheterization is not mandatory for preoperative evaluation.

A 74-year-old man presented with shortness of breath and vague chest pain. A chest roentgenogram showed subtotal atelectasis of the upper lobe of the left lung and a CT scan revealed an occlusion of the bronchus of the upper lobe of the left lung by an intraluminal tumor. A well-circumscribed yellow tumor obstructing the bronchus of the upper lobe of the left lung was seen by fiberoptic bronchoscopy. Biopsies revealed mature fat tissue and small areas with bone consistent with the diagnosis of an endobronchial predominantly lipomatous hamartoma.

We investigated functional results, complications and survival of patients undergoing bilateral video-assisted thoracoscopic (VAT) lung volume reduction surgery (VRS) for severe, diffuse pulmonary emphysema [FEV1 28±0.8 (% pred.), RV/TLC 0.65 ±0.01, 12′ walking distance 499±21 (m)]. From January 1994 to March 1998, 106 of 286 candidates were operated, 85 patients (mean age 64, range 38–78 years, 30 females) fulfilled the study criteria and were included in the prospective study. Hyperinflation decreased to an RV/TLC ratio of 0.51±0.01 after 3 months and 0.55±0.02 after 24 months, FEV1 increased to 43±1.6 (% pred.) after 3 months and 35±2.3 (% pred.) after 24 months, and the 12′ walking distance was 687±29 (m) 3 months postoperative and 626±44 (m) after 24 months.

When physicians encounter pregnant patients with respiratory complaints, they face a challenging set of clinical problems. To understand the clinical cardiopulmonary manifestations of diseases occurring during pregnancy, knowledge of the basic physiologic changes during pregnancy is necessary. The most prevalent chest related complaint in pregnant women is shortness of breath, which is in most cases due to an unpleasant awareness of physiological gestational hyperventilation. Lung diseases which are frequently seen in young people, such as bronchial asthma, occur with comparable prevalence in pregnant women. Clinical symptoms, diagnosis and treatment of most diseases do not differ from those in the nonpregnant state. However, pharmacotherapy presents unique aspects, since not only may pharmacokinetics differ, but the fetus must also be assumed to be a recipient of the drug.

Lung volume reduction surgery (LVRS) is performed to alleviate dyspnoea of selected patients with severe pulmonary emphysema, and to improve their pulmonary function, performance in daily activity and quality of life. By resection of targeted emphysematous lung tissue, the achievable changes in pulmonary function consist of: 1) an increase in expiratory flow rate and airway conductance; 2) a reduction in hyperinflation accompanied by an augmentation in vital capacity; and 3) possibly, an improvement in gas exchange. Recent studies indicate that these changes are attributable to an increase of the lung's elastic recoil pressure. The consequences of an augmented recoil pressure consist of: 1) a reduction of pulmonary hyperinflation together with an amelioration of diaphragm and chest wall mechanics; 2) larger driving pressures; and 3) better airway stability. The combination of these factors is responsible for the improved pulmonary mechanics.

Forms of sleep apnea syndrome: Interrupted breathing and hypoventilation during sleep lead to sleep disorders and to cardiovascular sequelae. In the common obstructive sleep apnea syndrome (OSAS) apneas are related to intermittent obstruction of the upper airways. In the rarer central sleep apnea syndrome certain cardiovascular or central nervous system disorders lead to disturbed regulation of respiration connected with periodic breathing. Signs indicating OSAS: Loud, cyclic snoring, interrupted by cessation of breathing during sleep observed by relatives and excessive daytime to diurnal sleepiness indicate OSAS. Furthermore alteration of personality, headache in the morning, non-refreshing sleep and nocturnal choking sensations may indicate OSAS. When is evaluation necessary? Patients with complaints possibly induced by OSAS should be further evaluated since nocturnal application of continuous positive airway pressure (CPAP) by means of a nose mask and other treatment forms often lead to significant improvement of OSAS. In addition patients with untreated OSAS have an increased risk for car accidents and premature death as consequence of cardiovascular diseases. The type and extent of a supposed respiratory disorder is evaluated by means of a sleep study.

Bronchiectasis is pathologically defined as an abnormal and permanent dilatation of one or several bronchi. There are localized and generalized types of bronchiectasis. A vicious circle hypothesis, including an initial insult to the lower airways, impaired mucociliary clearance, microbial colonization/infection, bronchial obstruction and a local inflammatory response, has been proposed to explain the damage to the bronchial tree and the adjacent lung parenchyma. The clinical picture is variable and affected individuals might be asymptomatic or suffer from severe respiratory failure. Daily sputum production is the most common, though unspecific symptom of bronchiectasis. Other common symptoms are hemoptysis and recurrent episodes of sputum purulence, fever and pleurisy. Occasionally, major, life-threatening hemoptysis from a ruptured bronchial artery occurs. Infectious complications, e.g. lung abscess, empyema, brain abscess, and secondary amyloidosis are rarely seen today. The chest radiograph reveals changes suggestive of bronchiectasis in the majority of patients with clinically important disease. High resolution computed tomography of the lung has almost completely replaced bronchography for diagnosis, the latter rarely being of value if surgery is contemplated. No etiology is identified in about one- to two-thirds of the patients, although there are many diseases eventually associated with bronchiectasis. Prevention and therapy of underlying diseases are most important. Traditionally, the therapy of symptomatic bronchiectasis is based on antibiotics, antibronchoobstructive medication, and chest physical therapy. Surgical resection is the treatment of choice for localized symptomatic disease. Bilateral lung transplantation should be considered in younger patients with severe, generalized bronchiectasis and respiratory failure. Prospective, randomized, largescale trials supporting any of the different treatment strategies are not available, but antibiotics and surgery probably have improved the long-term outcome of many patients with bronchiectasis. In this review, some recent findings regarding the classification, pathogenesis, pathology, etiology, diagnosis, treatment, and prognosis of bronchiectasis are discussed.

In a prospective study, we investigated the functional results, complications, and survival of patients who underwent bilateral video-assisted thoracoscopic (VAT) lung volume reduction surgery (VRS) for severe, diffuse pulmonary emphysema (FEV1 0.77 +/- 0.03 [1], RV/TLC 0.65, 12' walking distance 482 +/- 26 [m]). From January 94 to March 97, 67 of 179 candidates underwent the operation, and 58 patients (mean age 64 +/- 1.1, range 42-78 years; 17 women) fulfilled the study criteria. There was no 30-day mortality; hyperinflation decreased to an RV/TLC ratio of 0.52 +/- 0.01 after 3 months; FEV1 increased to 1.2 +/- 0.08 [1]; and the 12' walking distance was 687 +/- 29 [m].

Lower airway infections are very common. A distinction should be made between acute tracheobronchitis, exacerbation of chronic bronchitis and pneumonia, since prognosis and therapy of these diseases are different. Community-acquired pneumonia has to be treated without delay by an antibiotic which is efficient against pneumococci.

Resection of large bullae to decompress adjacent lung tissue with the goal of improving pulmonary function has been an accepted surgical approach for many years. However, the indication for lung volume reduction is not bullous disease but diffuse emphysema and the surgical approach is based on an entirely different concept. The resection of the most affected parts of the emphysematous parenchyma aims at a reduction of the over expansion of the chest with the goal of improving respiratory mechanics. This concept was introduced by Brantigan in 1959, but has failed to gain widespread acceptance until recently. Based on the extensive experience in lung transplantation for patients with end stage emphysema J. D. Cooper reevaluated the idea successfully. He reported remarkable improvements in FEV1 and a reduction in hyperinflation after performing bilateral lung volume reduction through a median sternotomy. During the last 2 years we performed bilateral lung volume reduction in more than 30 patients with diffuse emphysema using video assisted thoracoscopy (VAT) and studied the results prospectively. In the first 20 patients preoperative mean forced expiratory volume in 1 second (FEV1) was 765 ml/sec and improved by a mean of 42% (0-100%) three months postoperatively. This gain in FEV1 was already observed at the end of hospitalisation approximately two weeks after surgery. The 12 minute walking distance improved over 40%. In our highly selected study population we had no perioperative mortality. Lung volume reduction is a palliative treatment of severe pulmonary emphysema. Currently no data is available on the duration of the improvement. In this selected group of patients dyspnea is reduced and pulmonary mechanics are improved, with a resulting increase in quality of life.

High resolution computed tomography (HRCT) of the lungs uses thin-section CT (1- to 2-mm collimation scans) combined with a targeted reconstruction with a high-spatial frequency algorithm. HRCT is currently the most sensitive non-invasive imaging method for parenchymal and bronchoscopically inaccessible bronchial abnormalities of the lung. The following indications for HRCT of the pulmonary parenchyma are established: (1.) complementary examination in symptomatic patients with normal chest radiographs and/or normal pulmonary function testing; (2.) morphologic characterization of a nonspecific radiographic pattern; (3.) assessment of the activity and follow-up of a parenchymal disease; (4.) localization of a lung biopsy; (5.) localization of bronchiectasis.

Continuous positive airway pressure (CPAP) is the treatment of first choice for obstructive sleep apnea syndrome (OSAS). The effect of this treatment is highly dependent on patient compliance. To identify factors associated with compliance, a questionnaire was sent to 53 patients with OSAS for whom CPAP treatment had been prescribed. Response rate was 96%. 45 of 51 patients (88%) stated they had been on CPAP for a period of 30 to 2340 (median 292) days. 43 of the 51 patients (84%) who used CPAP regularly, defined as at least 4 hours nightly on 5 nights per week, were considered as compliant with the prescribed treatment. They did not differ from non-compliant patients either in initial symptom score or in apnea/hypopnea index at initial presentation. The most consistent factor associated with compliance was symptomatic improvement with CPAP. Side effects were more common in non-compliant patients. Symptomatic improvement during an initial trial with CPAP should be considered when starting definitive treatment, in order to optimize compliance.

Lung volume reduction is a novel surgical concept and may be applied in certain patients, who suffer from dyspnea and are limited in their daily activity due to severe emphysema associated with considerable pulmonary hyperinflation. Careful evaluation of patients aims at selecting those candidates, who profit most from this type of surgery and are at low risk for perioperative complications. Some of the inclusion and most of the exclusion criteria are rather arbitrary and are the topic of this review.

Excessive daytime somnolence is the main symptom of the obstructive sleep apnea syndrome (OSAS). Repetitive upper airway obstructions during sleep are followed by arousals and consequent sleep fragmentation. Furthermore, obstructive apneas or hypopneas and arousals are accompanied by fluctuations of blood pressure and heart rate. Several recent studies have found OSAS to be an independent risk factor for arterial hypertension and cardiovascular diseases.