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ZusammenfassungDas vorliegende Addendum zur Leitlinie zur Diagnostik und Therapie von Patienten mit Asthma (2017) ergänzt wichtige neue Erkenntnisse zur Diagnostik und Therapie von Asthma sowie zu neu für die Therapie des Asthmas zugelassenen Medikamenten. Es werden sowohl für Kinder und Jugendliche als auch für Erwachsene mit Asthma die aktuellen, Evidenz-basierten diagnostischen und therapeutischen Empfehlungen dargelegt.

ZusammenfassungDie vorliegende Leitlinie ist eine Neufassung und Aktualisierung der Leitlinie zur Diagnostik und Therapie von Patienten mit Asthma, welche die bisher für den deutschen Sprachraum gültige Version aus dem Jahr 2006 ablöst. Die Fülle an neuen Erkenntnissen zur Pathophysiologie und zu den Phänotypen von Asthma und das erweiterte Spektrum an diagnostischen und therapeutischen Möglichkeiten bei dieser Erkrankung machte eine Neufassung und Aktualisierung notwendig. Es werden sowohl für Kinder und Jugendliche als auch für Erwachsene mit Asthma die aktuellen, Evidenz-basierten diagnostischen und therapeutischen Empfehlungen dargelegt.

The present guideline is a new version and an update of the guideline for the diagnosis and treatment of asthma, which replaces the previous version for german speaking countries from the year 2006. The wealth of new data on the pathophysiology and the phenotypes of asthma, and the expanded spectrum of diagnostic and therapeutic options necessitated a new version and an update. This guideline presents the current, evidence-based recommendations for the diagnosis and treatment of asthma, for children and adolescents as well as for adults with asthma.Die vorliegende Leitlinie ist eine Neufassung und Aktualisierung der Leitlinie zur Diagnostik und Therapie von Patienten mit Asthma, welche die bisher für den deutschen Sprachraum gültige Version aus dem Jahr 2006 ablöst. Die Fülle an neuen Erkenntnissen zur Pathophysiologie und zu den Phänotypen von Asthma und das erweiterte Spektrum an diagnostischen und therapeutischen Möglichkeiten bei dieser Erkrankung machte eine Neufassung und Aktualisierung notwendig. Es werden sowohl für Kinder und Jugendliche als auch für Erwachsene mit Asthma die aktuellen, Evidenz-basierten diagnostischen und therapeutischen Empfehlungen dargelegt.

Die chronisch-obstruktive Lungenerkrankung (COPD) ist eine sehr haufige chronische Erkrankung mit steigender Pravalenz. Eine Exposition gegenuber inhalativen Noxen, v. a. Tabakrauch, fuhrt zu einer chronischen Entzundungsreaktion in den Atemwegen, begleitet von einer nicht voll reversiblen obstruktiven Ventilationsstorung. Die Zerstorung von Lungengewebe und damit eine Einschrankung des Gasaustauschs konnen folgen. Parallel wird eine Reihe von Komorbiditaten beobachtet. Die uberarbeitete COPD-Klassifizierung berucksichtigt neben der Lungenfunktion auch Symptome und die anamnestische Haufigkeit von Exazerbationen. Kurzlich wurden mehrere neue lang wirkende Bronchodilatatoren fur die Behandlung der COPD zugelassen. Kombinationspraparate, bestehend aus lang wirkenden β2-Sympathomimetika und Anticholinergika, sowie eine neue Kombination aus einem inhalierbaren Steroid und einem lang wirkenden β-2-Mimetikum werden folgen. Auch der Rauchentwohnung kommt eine entscheidende Bedeutung zu.

Die Substitutionstherapie bei Alpha-1 Antitrypsin-Mangel soll das Voranschreiten eines Lungenemphysems verzogern, die Exazerbationshaufigkeit reduzieren und die Lebensqualitat der Patienten verbessern. Dieses Expertenstatement fasst die wichtigsten Therapiestudien zur Substitutionstherapie bei Patienten mit schwerem Alpha-1 Antitrypsin-Mangel und Lungenemphysem kurz zusammen. Aus den verfugbaren Studienergebnissen werden Indikationen und Kontra­indikationen fur eine dauerhafte intravenose Substitutionstherapie mit humanem Alpha-1 Antitrypsin abgeleitet. Sicherheitsaspekte und die Kontroversen um das Thema werden ausfuhrlich diskutiert.

Neuere Daten zur Epidemiologie der chronisch obstruktiven Lungenerkrankung (COPD) haben gezeigt, dass in Deutschland mehr als 10 % der uber 40-Jahrigen an einer COPD leiden. Trotz intensiver Forschungsbemuhungen ist die Pathogenese nur unzureichend verstanden, so dass die Entwicklung krankheitsspezifischer Therapiekonzepte immer noch schwierig ist. Fur die Diagnostik der COPD bleibt der lungenfunktionsanalytische Nachweis einer obstruktiven Ventilationsstorung der entscheidende Faktor; gleichzeitig gewinnt die technisch verbesserte Computertomographie der Lunge immer mehr an Bedeutung. Die inhalativ zu verabreichenden Wirkstoffe Indacaterol, Glycopyrronium und Aclidinium haben als lang wirksame Bronchodilatatoren die Zulassung zur Behandlung der COPD erhalten. Mit der Einfuhrung des selektiven Phosphodiesterase-4-Inhibitors Roflumilast erfolgte erstmals eine phanotypspezifische Zulassung (COPD mit chronischer Bronchitis und haufigen Exazerbationen), die primar auf der Senkung der Exazerbationsrate beruhte. Eine grose Herausforderung der Zukunft besteht in der Entwicklung neuer therapeutischer Algorithmen, die neben der Lungenfunktion auch die Parameter Symptome, Exazerbationsrate, Komorbiditaten und andere patientenrelevante Parameter berucksichtigen.

Daten uber die klinische Prasentation der chronisch-obstruktiven Lungenerkrankung (COPD) haben zu einer neuen Klassifikation der Erkrankung gefuhrt. Auser der spirometrischen Schweregradeinteilung werden das Ausmas der Symptome sowie die Exazerbationsrate berucksichtigt. Die Standardtherapie der stabilen COPD befindet sich im Umbruch, da in naher Zukunft Fixkombinationen aus langwirksamen Betamimetika und langwirksamen Anticholinergika eingesetzt werden konnen. Damit wird der Stellenwert von inhalativen Steroiden neu zu bewerten sein. Die Zulassung von Roflumilast hat die medikamentose Therapie um eine Option erweitert, mit Hilfe derer bei Patienten mit schwerer Obstruktion (FEV1

This observational study was designed to determine the importance of sterilization method and insert thickness as predictors of articular damage of cruciate-retaining polyethylene components used in total knee arthroplasty. Ninety-nine explanted tibial inserts were evaluated for surface damage. Severe damage modes were observed in 36 of 52 of γ-irradiated inserts but none of those sterilized by ethylene oxide. Articular damage significantly correlated to time in vivo but not to insert thickness. Inserts sterilized by ethylene oxide gas in gas-permeable packaging exhibited a significantly lower damage accumulation rate compared with inserts sterilized by γ radiation and stored in air or an inert environment. γ irradiation and storage in argon instead of air reduced the frequency of severe damage such as delamination but not the overall damage rate.

Background A large proportion of COPD patients do not achieve the recommended level of physical activity. It is suggested that feedback on the level of activity by using an activity monitoring device (PAM) increases awareness and may stimulate patients to increase their physical activity in daily life. Our objective was to assess the validity and usability of a simple and low-cost physical activity monitor (Polar A300™) when compared with the validated and established Bodymedia-SenseWear™ (SWA) device. Methods To assess the diagnostic equivalent, two different PAM devices were used in parallel in 20 COPD patients GOLD I to IV during 3 consecutive days of daily life. Both systems were compared in terms of steps, calories burned, daily activity time and metabolic equivalents using linear regression analysis and Bland-Altman plots. Practical usability was examined by a 16-item-questionnaire. Results High correlations of both devices were observed with regard to the sensed step count (r = 0.96; p < 0.01) and calories burned (r = 0.74; p < 0.01), and a lower correlation of daily activity (r = 0.25; p < 0.01) was found. Data analysis over 3 days showed that 90% of the steps (95% CI -4223 to 1887), 100% of the calories (95% CI -2798 to 1887), 90% of the daily activity data (95% CI -12.32, 4065) and 95% of the MET (95% CI -3.11 to 2.75) were within the limits of agreement. A favorable usability (system-, information- and interface quality) of the A300™ device was shown (p < 0.01). Conclusion The A300™ device with easy practical usability was shown not to be inferior for assessment of physical activity time, step count and calorie consumption in COPD patients when compared with the SWA. It is suggested to consider widespread available devices as commonly used for monitoring recreational sporting activities also in patients for assessment of physical activity in daily life.

Introduction: Decline in health status, lung function, and exacerbations are important determinants of disease progression of COPD patients (pts). CID has been proposed as a composite endpoint to evaluate COPD treatment effects. We report effect of IND/GLY on CID in pts with moderate COPD, after direct switch from LABA+ICS, or a LABA or a LAMA monotherapy. Methods: CRYSTAL, a 12-week, prospective, multicentre, randomised, open-label, pragmatic trial, evaluated the effect of IND/GLY or GLY after a direct switch from previous treatments in moderate COPD pts. CID was defined as a ≥100 mL decrease in trough FEV 1 or a ≥1 point decrease in transition dyspnoea index (TDI) or a ≥0.4 point increase in clinical COPD questionnaire (CCQ) score or a moderate/severe exacerbation. Results: Of 2,159 pts analysed in the IND/GLY treatment arms, 1,622 switched to IND/GLY and 537 continued their baseline treatment. The percentage of pts experiencing a CID was significantly lower in pts who switched to IND/GLY vs pts who continued on LABA+ICS, or on a LABA or a LAMA, using different CID definitions (Table) . Subgroup analyses according to different baseline characteristics were consistent with the overall results. Conclusion: Indacaterol/glycopyrronium significantly reduced the risk of CID in moderate COPD patients, after direct switch from LABA/ICS, or a LABA or a LAMA.

Systematic review of literature on patient-reported voice handicap following T1 glottic squamous cell carcinoma treatment using transoral laser microsurgery or radiation therapy.PubMed, Web of Science, and Scopus (1997-2013).These data sources were searched for papers reporting Voice Handicap Index (VHI) after treatment of early glottic carcinoma. Review and reference cross-checking were performed using a priori selection criteria. Study data were abstracted and publication quality categorized independently by 2 authors. Corresponding authors were contacted to maximize data for analysis. Meta-analysis was performed only with studies that included both treatment modalities, to reduce heterogeneity and maximize rigor; random effects modeling was used to pool results.Eighteen publications were identified that reported VHI data following surgery and radiotherapy for T1 glottic carcinoma. No studies were randomized. When studies that reported multiple T-stages or systematic treatment selection bias were excluded, 8 retrospective cohort studies describing 362 patients were suitable for meta-analysis. Follow-up time (mean, 47 months; range, 1-298 mo) and extent of surgical excision varied across studies. Six studies showed no VHI difference between treatment arms; 2 favored radiotherapy over surgery (1 of which reported transmuscular cordectomy for all surgical patients); and none favored surgery. Meta-analysis showed no significant difference in posttreatment VHI between radiotherapy and surgery (mean difference, -5.52; 95% confidence interval, -11.40, 0.36; heterogeneity I (2) = 61%, P = .01).VHI scores were comparable following transoral laser microsurgery and radiation therapy for T1 glottic carcinoma in the current literature, suggesting no clinically significant difference in functional voice outcomes between treatment types.

Objectives:Systematic review of literature on patient-reported voice handicap following T1 glottic squamous cell carcinoma treatment using endoscopic surgery or radiation therapy.Methods:PubMed, Web of Science, and Scopus (1988-2013) were searched for papers reporting Voice Handicap Index (VHI) after treatment of early glottic carcinoma. Review and reference cross-checking were performed using a priori selection criteria. Study data were abstracted and publication quality categorized independently by 2 authors. Corresponding authors were contacted to maximize data for analysis. Meta-analysis was performed using a random-effects model.Results:Twenty-three studies with VHI data following surgery (n = 7), radiation (n = 4), or both (n = 12) were reviewed. Meta-analysis was then pursued with studies that included both modalities. Excluding studies reporting multiple T-stages or systematic treatment selection bias, 5 retrospective cohort studies describing 238 patients in total were suitable for meta-analysis....

Augmentation therapy in Alpha-1 Antitrypsin Deficiency aims to reduce the progression of lung emphysema, to reduce exacerbation frequency, and to improve quality of life. This expert statement briefly summarizes the most important treatment studies performed in patients with Alpha-1 Antitrypsin Deficiency and severe lung emphysema. Indications and contraindications for long-term intravenous augmentation therapy with human Alpha-1 Antitrypsin are derived from the available study results. Safety issues and the controversies of this topic are discussed in detail.

Chronic obstructive pulmonary disease (COPD) is a very common chronic disease with increasing prevalence. Inhaled particles and gases (in particular tobacco smoke) induce chronic inflammation of the airways accompanied by a not fully reversible airflow limitation. Destruction of lung tissue and deterioration of gas exchange may follow. In parallel, several comorbidities can be observed. The COPD assessment was revised and now takes into account lung function, the patients' symptoms, and history of exacerbations. More recently, several new long-acting bronchodilators received approval. Combination products, consisting of long-acting β2-agonists and long-acting anticholinergics, and a new combination of a long-acting β-agonist and an inhaled corticosteroid will follow in the near future. Smoking cessation is of central importance.

A major problem associated with COPD is exacerbation. Symptoms include increased shortness of breathing, coughing, wheezing and sputum production. The frequency and severity of exacerbations are associated with a higher mortality risk. Early recognition and treatment have been shown to reduce severity of exacerbations, consecutive morbidity and hospital admissions. Telemonitoring of (nocturnal) lungsounds, oxygen saturation and frequency of breathing may offer the opportunity to detect symptoms of exacerbations very early. Therefore further research is needed to clarify precisely the role of telemonitoring in patients with COPD and exacerbations.

Data about the clinical presentation of chronic obstructive pulmonary disease (COPD) have resulted in a new classification of the disease. The degree of airflow limitation has been amended by symptoms and exacerbation rate. The standard pharmacotherapy of stable COPD is in transition, as fixed combinations of long acting beta agonists and long acting anticholinergics are in the late stages of clinical development. On this background inhaled corticosteroids will need to be re-evaluated. Roflumilast is a recently approved therapeutic option that primarily diminishes exacerbation frequency in patients with chronic bronchitis and severe airflow obstruction (FEV(1)50%). In COPD patients with acute exacerbations procalcitonin levels can be used to guide antibiotic therapy. Comparable clinical outcomes can be achieved while using significantly less amounts of antibiotics.

Allergic diseases of the lungs may affect the airways, the pulmonary parenchyma and the pulmonary vessels. The most relevant representatives are allergic asthma, hypersensitivity pneumonitis, bronchopulmonary aspergillosis and the Churg-Strauss syndrome. The type of allergic reaction and the pathophysiological consequences vary considerably between these entities. New drugs target specific mechanisms based on new insights into the pathogenetic processes of the underlying disease.

Chronic diseases of the respiratory organs have, besides restrictions of lung function, also physical, mental and social consequences. The chronic disease impacts negatively not only the patient's own quality of life but also that of his/her partner and/or relative. As treatment modalities, besides drug therapy, above all outpatient rehabilitation measures have proved to be effective. In this pilot study we sought answers to three questions: (i) How is the quality of life of the patient's partner and/or relative influenced by the disease? How does the partner/relative assess the effect of the disease on the chronically ill patient? How does the partner/relative assess the effect of lung sports on the chronically ill patient?A specially conceived questionnaire was given to the partners/relatives of 25 patients with chronic pulmonary diseases. The patients, 23 with chronic obstructive pulmonary disease and 2 with pulmonary fibrosis, have been participating in lung sports once a week for more than three years. The average age of the patients was 67 years.The patients' illness also negatively influenced the quality of life of the partner to a considerable extent. The impact of the patients' pulmonary disease on the healthy partner was assessed as being rather moderate. Restrictions of social life were essentially influenced by the amount of assistance required by the pulmonary patient. The therapeutic effects of lung sports on the well-being of the patient were aways considered to be positive by the respective partner/relatives.A chronic pulmonary illness also has a negative influence on the partner/relative's quality of life. The necessity for extensive assistance in daily life is accompanied by a considerable negative impact on the partner's quality of life. According to the opinion of the partner/relative, lung sports have positive effects in all of the chronically ill patient's fields of life.

A 46-year-old patient was frequently seen with a medically treated Anti-Jo-1 syndrome. The patient had already been treated with azathioprine and oral corticosteroids on account of decreasing lung function, dyspnoea, fatigue, and beginning signs of myositis. Although high doses of steroids and azathioprine were administered, the muscleskeletal syndromes increased steadily. The patient used to be an active long-distance runner (20 km), but now was unable to perform that kind of physical exercise. It was decided to start a treatment with the GalileoTM training device for active muscle training of the lower extremities. Before and after three months of training the following assessment was performed: measurement of health-related quality of life (St. Georges respiratory questionnaire, SGRQ), ultrasound measurement of the cross-sectional area of the quadriceps muscle, 6 minute walk test (6 MWT), lung function testing, and assessment of serum markers of inflammation (TNF-alpha, interleukin-8, CRP, CK, myoglobin). After only two months, training with the GalileoTM five times a week has improved the patient's conditions dramatically. The training will be continued.

Chronic obstructive pulmonary disease (COPD) is defined as a progressive, usually only partially reversible, obstruction of the airways The disease is associated with an inflammatory response of the lungs to noxious particles, particularly cigarette smoke. Numerous epidemiological studies have shown a significant association between impaired lung function and the presence of cardiovascular, metabolic or other extrapulmonary comorbidities. Systemic inflammation may be the missing link between COPD and its extrapulmonary manifestations, although the exact mechanism of this relationship remains unclear. The development and validation of score systems that classify COPD severity, not only by changes in lung function, is an important step. The BODE score (body-mass index, airways obstruction, dyspnea, exercise capacity) is such a system. Based on the concept of COPD as a systemic disease, a concept is needed which describes in detail the pharmacological treatment of the pulmonary and extrapulmonary manifestations of the disease. In addition, the part of the disease that is treatable with physiotherapy and rehabilitation must be fully taken into account. Such multimodal treatment regimens have so far not been implemented into clinical guidelines.

alpha-1-Antitrypsin deficiency (AATD) is a rare condition with a prevalence of about 1/4000 individuals in Germany. The clinical manifestations are the early development of pulmonary emphysema or of liver cirrhosis. The low prevalence of AATD suggested the establishment of a registry with the aim to learn more details about the natural history and the quality of care for these patients.Since 2004 the German registry for individuals with AATD is maintained in Marburg. Up to May 2008, 548 individuals were registered, 455 with the genotype PiZZ and 46 with PiSZ. The age range of the registered individuals extends from 2 to 82 years (mean 55, SD 20; men 54 [SD 19] years, women 55 [SD 21] years). Most patients are affected by chronic obstructive pulmonary disease (COPD, distribution to the GOLD stages: GOLD I = 16 %, GOLD II = 30 %, GOLD III = 33 %, GOLD IV = 21 %). Currently 109 subjects are under substitution therapy. The time period between the first symptom and the establishment of the correct diagnosis was on average 5.6 years.The data of the registry allow a detailed characterisation of the natural course of the disease and the levels of the patient care.