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

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

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

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

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

Homecare for mechanically ventilated patients is complex and challenging for homecare institutions. The framework conditions of homecare are regulated by a likewise complex social legislation. The German Respiratory Society (DGP) and the German Interdisciplinary Society for Home Care Ventilation (DIGAB) have published recommendations on the structure of homecare for ventilated patients in their recent guideline and recommended a certification of homecare nursing services.Prior to a certification process, the homecare task force of the DIGAB conducted a survey in order to compare the current structures with the guideline recommendations.Voluntary disclosure of information by means of a written questionnaire consisting of eleven items was requested.37 homecare institutions with a total of 78 subsidiaries providing service all over Germany returned their questionnaires. While educational standards are mostly in line with the guideline recommendation, it was found that only 43 % of 812 recorded patients followed up with a specialised weaning centre or centre for ventilation. 84 % of these patients were ventilated invasively. In spite of the fact that all homecare institutions took care of invasively ventilated patients, there was a lack of company-owned standards for specific nursing measures.Homecare for ventilated patients in Germany has reached a decent degree of organisation, while follow-up with specialised centres for ventilation, and with that medical specialist care appears to be underserved. The certification process for homecare institutions should be pursued with emphasis in order to create uniform quality standards. The number of invasively ventilated patients in homecare settings is probably higher than previously estimated and could be the result of a lack of weaning capacity.

We attempted to decrease PCO2 during noninvasive ventilation (NIV) and studied he effects of this therapy both in acute exacerbations of chronic obstructive pulmonary disease (COPD) and in its chronic state. Ninety six patients (63% male) with COPD and hypercapnia above 6.7 kPa were investigated. The mode and setting of the ventilator had to be chosen to achieve normocapnia. The subgroup of acute exacerbated COPD was separated by pH (7.35=acute), by HCO3- (26 mmol/l=acute), and by history (acute=history of recent deterioration). Ventilator settings were the following: tidal volume-972+/-137 ml and frequency-20+/-2.2 (volume preset). Inspiratory pressure was 33.6+/-14.2 mbar and frequency-19.7+/-5.1 (pressure preset). The preference of volume preset ventilators resulted from insufficient maximal pressures of the pressure preset devices. Eighty three percent of the patients became normocapnic while on NIV after 6.8+/-5.7 days. The mean PCO2 decreased from 64+/-13 mmHg to 41+/-6 mmHg (P0.001). After 4 weeks, 72% of the patients were normocapnic while breathing spontaneously (P0.001). The subgroups of acute exacerbation were the following: pH 28%, HCO3- 3.1%, and history 68%. All three indicators together were present in 2% of patients. Normocapnia under ventilation and during spontaneous breathing was independent from the subgroup. In conclusion, the study showed that normocapnia can be achieved in COPD under the ventilator and while breathing spontaneously in chronic and acute disease.

Patients suffering from advanced chronic thoracic disorders are at higher risk to develop respiratory failure, requiring mechanical ventilation. Forty seven patients acutely decompensated were investigated. Twenty nine of them were primarily ventilated noninvasively, 7 were intubated and 11 had been intubated and tracheotomized prior to arriving at the weaning center. All intubated patients were transferred to noninvasive ventilation within 24 h after arrival. Ten of the 11 tracheotomizd patients were transferred to noninvasive ventilation before discharge. One remained tracheotomized because of severe tracheal stenosis, despite being able to breathe spontaneously for several hours. Mortality was 14.2% in the intubated, 9% in the tracheotomized, and 10.2% in the primarily nasally ventilated. One patient refused to go on with mechanical ventilation and died. Hospital stay ranged between 4 and 24 days in the nasally ventilated. The intubated were ventilated invasively between 3 and 16 days and thereafter 4 to 17 days noninvasively on a regular ward. Tracheotomized patients were treated in intensive care for 7 to 32 days and in the weaning unit for 7 to 39 days. We conclude that patients either ventilated nasally or intubated or tracheotomized can be prepared for home mechanical ventilation in a weaning unit with similar outcome. Noninvasive ventilation is highly important in such patients as only one remained on invasive ventilation. This may implicate that transfer to noninvasive ventilation prior to tracheotomy might be appropriate.

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