Hans-Werner Duchna

Driving simulator and neuropsychological [corrected] testing in OSAS before and under CPAP therapy.

Patients with obstructive sleep apnoea syndrome (OSAS) have an increased car accident rate. Investigations on accident frequency are based on case history, insurance reports and driving simulator studies. The present study combines neuropsychological testing of different attention aspects engaged in driving a car and driving simulation to evaluate a suitable instrument for assessing therapeutic effects of continuous positive airway pressure (CPAP). Driving simulator investigation and neuropsychological testing of alertness, vigilance and divided attention were performed in 31 patients with polysomnographically confirmed OSAS (apnoea–hypopnoea index 24.8±21.5·h−1) before, and 2 and 42 days after initiation of CPAP. Divided attention and alertness improved significantly during CPAP, whereas vigilance remained unchanged. However, accident frequency (OSAS before therapy: 2.7±2.0; 2 days after CPAP: 1.5±1.4; 42 days after CPAP: 0.9±1.3) and frequency of concentration faults (OSAS before therapy: 12.4±5.1; 2 days after CPAP: 6.5±3.9; 42 days after CPAP: 4.9±3.3) decreased in the simulated driving situation after 2 and 42 days of therapy. There was no relation between accident frequency, concentration faults and daytime sleepiness, as measured by the Epworth Sleepiness Scale, and polysomnographic or neuropsychological findings, respectively. In conclusion, the present results suggest that driving simulation is a possible benchmark parameter of driving performance in obstructive sleep apnoea syndrome patients.

A fatal case of spinal tuberculosis mistaken for metastatic lung cancer: recalling ancient Pott's disease

BackgroundTuberculous spondylitis (Potts disease) is an ancient human disease. Because it is rare in high-income, tuberculosis (TB) low incidence countries, misdiagnoses occur as sufficient clinical experience is lacking.Case presentationWe describe a fatal case of a patient with spinal TB, who was mistakenly irradiated for suspected metastatic lung cancer of the spine in the presence of a solitary pulmonary nodule of the left upper lobe. Subsequently, the patient progressed to central nervous system TB, and finally, disseminated TB before the accurate diagnosis was established. Isolation and antimycobacterial chemotherapy were initiated after an in-hospital course of approximately three months including numerous health care related contacts and procedures.ConclusionThe rapid diagnosis of spinal TB demands a high index of suspicion and expertise regarding the appropriate diagnostic procedures. Due to the devastating consequences of a missed diagnosis, Mycobacterium tuberculosis should be considered early in every case of spondylitis, intraspinal or paravertebral abscess. The presence of certain alarm signals like a prolonged history of progressive back pain, constitutional symptoms or pulmonary nodules on a chest radiograph, particularly in the upper lobes, may guide the clinical suspicion.

Radiological Findings, Pulmonary Function and Dyspnea in Underground Coal Miners

Background: Respiratory disability induced by dust exposure in coal workers is assessed by pulmonary function tests and radiological evidence of pneumoconiosis. High-resolution computed tomography (HR-CT) improves the visibility of tissue changes, but the value of the findings for the clinical evaluation is controversial. Objectives: It was the aim of this study to evaluate the correlation between the International Labour Office (ILO) classification and the degree of emphysema in HR-CT with self-reported dyspnea and pulmonary function tests including diffusion capacity for CO (DL,CO). Methods: We investigated 87 coal miners (aged 67 ± 6 years), having worked underground for 26 ± 9 years, with pulmonary function tests and HR-CT. Univariate associations were tested with correlation coefficients, and multivariable analyses used a stepwise forward regression model. Results: No aspect of the ILO classification showed a univariate correlation with dyspnea or forced expiratory flow in 1 s (FEV1). Emphysema CT score was strongly associated with DL,CO (rs = –0.40; p < 0.001) and FEV1/maximal vital capacity (r = –0.38; p < 0.001) in univariate analysis, but not with the clinical grade of dyspnea (r = –0.14; p = 0.256). CT emphysema score but not ILO classification was associated with FEV1 in multivariable analyses (rs = –0.37; p < 0.001). Dyspnea was best approximated by DL,CO (r = –0.312; p = 0.008). Conclusion: The clinical grade of breathlessness was best approximated by DL,CO. HR-CT showed a good association with expiratory flow limitation. ILO classification of the chest radiograph may be a marker of exposure but conveys little information about the degree of respiratory impairment.

Left Ventricular Geometry in Patients with Obstructive Sleep Apnea Coexisting with Treated Systemic Hypertension

Background: Left ventricular (LV) hypertrophy is a common consequence of systemic hypertension (SH) and obstructive sleep apnea (OSA). However, little is known about the degree of LV involvement in patients with OSA coexisting with treated SH. Objectives: Our study was designed in order to assess the prevalence of distinct types of LV geometry in treated hypertensive OSA patients. Methods: Patients: 183 patients with treated SH were enrolled to the study. Group 1 consisted of 38 patients with newly-diagnosed OSA and ineffectively treated SH. The remaining 145 patients with effectively treated SH were divided into three groups: group 2 – 70 patients with newly-diagnosed OSA, group 3 – 31 patients with OSA treated with continuous positive airway pressure (CPAP), and group 4 – 44 patients without OSA.Overnight sleep studies and M-mode echocardiography were performed. Results: LV mass index did not differ between the study groups. Mean values of LV end-diastolic diameter (LVED) were 55.4 ± 6.8 mm in group 1 and 53.6 ± 6.9 mm in group 2 and were significantly increased in comparison to subjects treated with CPAP and controls (49.8 ± 6.8 mm and 50.1 ± 64.7 mm, respectively; p = 0.001). LVED correlated positively with the apnea-hypopnea index and desaturation index. LV eccentric hypertrophy was the commonest type of LV geometry in newly-diagnosed OSA patients. Conclusions: The major finding of our study is the predominance of LV eccentric hypertrophy in newly-diagnosed OSA patients. We suggest that a relatively moderate degree of LV involvement in hypertensive OSA patients may depend on the cardioprotective effect of concomitant antihypertensive therapy, ameliorating OSA-dependent neurohumoral abnormalities.

Vascular endothelial dysfunction in patients with mild Obstructive Sleep Apnea Syndrome

ZusammenfassungHINTERGRUND: Untersucht wurde das Vorhandensein einer vaskulären endothelialen Dysfunktion, eine Frühform der Atherosklerose, bei Patienten mit leichtgradigem obstruktivem Schlafapnoe-Syndrom (OSAS) (5/h < AHI < 15/h). PATIENTEN UND METHODE: Wir testeten die endothelzellabhängige und -unabhängige Gefäßreagibilität bei 10 Patienten mit leichtgradigem OSAS, 12 Gesunden und 20 Patienten mit mittel- bis schwergradigem OSAS (AHI > 15/h) mit der Handvenen-Compliance Messtechnik. ERGEBNISSE: Patienten mit leichtgradigem OSAS wiesen eine signifikante Einschränkung ihrer maximalen endothelzellabhängigen Vasodilatation nach Bradykinin-stimulation (Emax: 68,6 ± 30,2 %) gegenüber der gesunden Kontrollgruppe (94,8 ± 9,5 %; p < 0,05) auf, unterschieden sich hierin jedoch nicht signifikant von Patienten mit mittel- bis schwergradigem OSAS (57,1 ± 23,4 %, p = 0,33). Die endothelzellunabhängige Vasodilation war jeweils ungestört. 7 Patienten mit leichtgradigem OSAS zeigten eine Normalisierung ihrer Endothelzellfunktion nach 160,7 ± 82,2 Nächten CPAP-Therapie (Emax 90,8 ± 23,8 %; p < 0,01 vs. Ausgangsmessung; p = 0,7 vs. Gesunde). SCHLUSSFOLGERUNGEN: Eine endotheliale Dysfunktion ist bereits bei Patienten mit leichtgradigem OSAS nachweisbar. Daher ist auch in dieser Patientengruppe ein erhöhtes kardiovaskuläres Risiko anzunehmen und eine CPAP-Therapie empfohlen.SummaryBACKGROUND: We investigated endothelial dysfunction, an early manifestation of atherosclerosis, in patients with mild obstructive sleep apnea syndrome (OSAS) (5/h < AHI < 15/h). PATIENTS AND METHODS: Endothelium-dependent and -independent vasodilatory function was tested in 10 patients with mild OSAS, 12 healthy controls and 20 subjects with moderate to severe OSAS using the hand vein compliance technique. RESULTS: Maximum endothelium-dependent vasodilation to bradykinin (Emax) was significantly blunted in patients with mild OSAS (68.6 ± 30.2 %) compared to healthy controls (94.8 ± 9.5 %; p < 0.05; moderate to severe OSAS: 57.1 ± 23.4 %; p = 0.33). Mean endothelium-independent venodilation was not altered. After 160.7 ± 82.2 nights of CPAP therapy, mean Emax was significantly improved to 90.8 ± 23.8 % (p < 0.01 vs. baseline; p = 0.7 vs. healthy controls) in 7 patients with mild OSAS. CONCLUSIONS: Systemic endothelium-dependent venodilation is markedly reduced in subjects with mild OSAS, which may imply adverse cardiovascular consequences. CPAP-treatment leads to a sustained restoration of endothelial dysfunction in these patients and is thus highly recommended.

Das obstruktive Schlafapnoe-Syndrom: Ein kardiovaskulärer Risikofaktor?

Introduction Obstructive sleep apnea syndrome (OSAS) is frequently associated with cardiovascular disease. We investigated endothelium-dependent and endothelium-independent nitric oxide-mediated vasodilatory function in normotensive patients with OSAS using the hand vein compliance technique. Patients and methods Dose-response curves to the endothelium-dependent vasodilator bradykinin were obtained in 23 male subjects with OSAS and 12 male control subjects of comparable age, height, and weight. Results Mean (±SD) maximum dilation (Emax) to bradykinin was significantly lower in OSAS patients than in controls (59.8±26.0 vs. 94.8±9.5%, p<0.0001). Mean vasodilation with nitroglycerin was not diminished in the OSAS group (90.7±30.5 vs. 100.3±12.9% in controls; n.s.). In 11 OSAS patients, a follow-up investigation was performed after at least 2 months of treatment with nasal continuous positive airway pressure (CPAP): Emax to bradykinin rose from 54.5±19.2% to 111.5±25.1% after treatment (p<0.001). Mean vasodilation to nitroglycerin was unchanged. Conclusions These results suggest that endothelium-dependent nitric oxide-mediated vasodilation is impaired in patients with OSAS due to an impaired function in the endothelial cells. This impairment is reversible with CPAP treatment. Einleitung Das obstruktive Schlafapnoe-Syndrom (OSAS) ist häufig mit kardiovaskulären Erkrankungen assoziiert. Zur Erkennung möglicher pathophysiologischer Zusammenhänge zwischen OSAS und kardiovaskulären Erkrankungen untersuchten wir daher die Gefäßreagibilität bei normotensiven OSAS-Patienten. Patienten und Methodik Bei 23 männlichen OSAS-Patienten und 12 gesunden männlichen Kontrollprobanden mit vergleichbarem Alter, Größe und Gewicht wurden Dosis-Wirkungskurven nach Gabe des endothelabhängigen Vasodilatators Bradykinin und einer Einzeldosis des endothelunabhängig wirkenden Nitroglycerins mit der Handvenen-Compliancetechnik in vivo bestimmt. Ergebnisse Die mittlere (±Standardabweichung) maximale Gefäßdilatation (Emax) nach Gabe von Bradykinin war bei den OSAS-Patienten signifikant niedriger als in der Kontrollgruppe (59,8±26,0 vs. 94,8±9,5%, p<0,0001). Hingegen war die mittlere Gefäßdilatation nach Gabe von Nitroglycerin in der OSAS-Gruppe nicht signifikant erniedrigt (90,7±30,5 vs. 100,3±12,9% in der Kontrollgruppe; n.s.). Bei 11 der OSAS-Patienten konnte eine Verlaufsuntersuchung nach mindestens zweimonatiger Behandlung mit einer nasalen Überdruck (CPAP)- Therapie durchgeführt werden. Bei diesen Patienten wurde eine Verbesserung der Emax-Werte nach Bradykiningabe von initial 54,5±19,2% auf 111,5±25,1% unter CPAP-Therapie erreicht (p<0,001). Die Vasodilatation nach Nitroglycerin blieb hingegen im Mittel unverändert. Schlussfolgerungen Es konnte gezeigt werden, dass die endothelabhängige Vasodilatation bei Patienten mit OSAS aufgrund einer Dysfunktion der Gefäßendothelzellen gestört ist. Diese endotheliale Dysfunktion ist unter nCPAP-Therapie reversibel.

Atemwegsbeteiligung bei Rezidivierender Polychondritis

Zusammenfassung. Es wird über den schweren Verlauf einer Lungenbeteiligung bei einer 41jährigen Patientin mit einer langjährigen primären Rezidivierenden Polychondritis berichtet. Die Patientin stellte sich mit einer akuten respiratorischen Insuffizienz vor, die eine endotracheale Intubation erforderlich machte. In der Bronchoskopie zeigt sich eine Trachealstenose mit drohendem Trachealkollaps sowie entzündliche Stenosen der großen und mittleren Atemwege mit dynamischem Atemwegskollaps. Wir beschreiben ein multimodales Therapiekonzept, bestehend aus einer immunsuppressiven Therapie, bronchoskopischer Implantation von endobronchialen Stents bei ausgedehnter entzündlicher Bronchusstenosierung und Bronchialkollaps sowie einer Tracheotomie. Zudem berichten wir erstmalig über die Effektivität einer oralen Cyclophosphamidtherapie bei einer pulmonalen Manifestation einer Rezidivierenden Polychondritis nach primärem oder sekundärem Versagen anderer Immunsuppressiva. Die Problematik schwerer respiratorischer Komplikationen bei Patienten mit Rezidivierender Polychondritis und die Notwendigkeit eines interdisziplinären Vorgehens wird diskutiert.Summary. We report the case of a 41-year-old female patient with relapsing polychondritis and severe respiratory involvement. The patient presented with acute respiratory failure requiring endotracheal intubation. Bronchoscopy revealed tracheal collapse and inflammatory stenoses with dynamic collapse of the major airways. We describe a multidisciplinary therapeutic approach, consisting of immunosuppressive treatment, bronchoscopic placement of self-expandable stents into the collapsing bronchi, and tracheotomy. In addition, we report the effectiveness of oral cyclophosphamide for treatment of relapsing polychondritis with severe respiratory involvement after failure of other immunosuppressive agents. The problem of severe respiratory complications in patients with relapsing polychondritis and the need for a multidisciplinary approach is discussed.

[Cardiac structure and function in patients with obstructive sleep apnea syndrome and co-prevalent arterial hypertension. Influence of CPAP therapy].

ZusammenfassungHintergrund und Ziel:Ein koprävalentes obstruktives Schlafapnoesyndrom (OSAS) wird bei ca. 30% der Patienten mit einer arteriellen Hypertonie (AH) angenommen. Untersucht wurde daher der Einfluss einer CPAP-(„continuous positive airway pressure“-)Therapie auf die Herzfunktion und -struktur bei Patienten mit medikamentös behandelter AH und OSAS.Patienten und Methodik:Alle Patienten hatten eine seit mindestens 5 Jahren medikamentös behandelte AH. Es wurden „matched pairs“ hinsichtlich anthropometrischer Daten, Dauer und Therapie der AH sowie Ausprägungsgrad des OSAS gebildet: 20 Patienten hatten ein unbehandeltes OSAS versus 20 Patienten mit CPAP-Therapie (≥6 Monate). Weitere kardiopulmonale Erkrankungen wurden ausgeschlossen. Die kardiale Funktion und Struktur wurden echokardiographisch bestimmt.Ergebnisse:Patienten mit OSAS und koprävalenter, behandelter AH hatten in dieser Studie unter 6-monatiger CPAP-Therapie echokardiographisch eine signifikant bessere diastolische linksventrikuläre Funktion, einen niedrigeren linksventrikulären Massenindex sowie signifikant weniger häufig Zeichen einer linksventrikulären (exzentrischen) Hypertrophie als Patienten mit unbehandeltem OSAS und behandelter AH. Des Weiteren signifikant waren die Unterschiede bezüglich der Rechtsherzhypertrophie und des mittleren pulmonalarteriellen Drucks.Schlussfolgerung:Die CPAP-Therapie hat einen positiven Einfluss auf die links- und rechtskardiale Funktion und Struktur additiv zu einer bestehenden antihypertensiven Therapie bei Patienten mit AH und koprävalentem OSAS.AbstractBackground and Purpose:30% of patients with arterial hypertension (AH) are supposed to have a coprevalent obstructive sleep apnea syndrome (OSAS). Hence, the influence of CPAP (continuous positive airway pressure) therapy on cardiac structure and function was investigated in medically treated patients with AH and coprevalent OSAS.Patients and Methods:In all patients AH was treated for at least 5 years. Matched pairs concerning anthropometric data, medical therapy and duration of AH, and severity of OSAS were investigated: 20 patients with untreated OSAS were compared to 20 patients with CPAP therapy for at least 6 months. Further cardiopulmonary diseases were excluded. Cardiac structure and function were assessed echocardiographically.Results:Patients under CPAP therapy had significantly better diastolic left ventricular function, a lower left ventricular mass index, and significantly less frequent signs of left ventricular (eccentric) hypertrophy than patients with untreated OSAS. Furthermore, differences were significant concerning right ventricular wall thickness and mean pulmonary artery pressure.Conclusion:CPAP therapy positively influences left and right cardial structure and function in addition to antihypertensive medication in patients with AH and coprevalent OSAS.

Obstructive Sleep Apnea and Hypopnea Efficacy and Safety of a Long-Acting β2-Agonist

The effect of inhaled long-acting β2-agonists in obstructive sleep apnea syndrome (OSAS) is unknown, although from the pharmacological point of view both therapeutic and adverse effects need to be considered. The purpose of this study was to obtain data on the efficacy and safety of salmeterol in patients with OSAS. In a randomized, double-blind, placebo-controlled, cross-over study, effects of salmeterol on respiration during sleep and sleep quality were investigated in 20 patients with OSAS. Of these, 4 patients were female, 16 male; the average age was 53.0 ± 7.8 years, with average body mass index 28.0 ± 3.0 kg· m-2 and average apnea hypopnea index 35.6 ± 17.8 h-1. Patients with asthma, chronic obstructive pulmonary disease (COPD), and left heart failure were excluded. Placebo or verum (50 μg salmeterol) was administered at 7 pm by meter dose inhaler and spacer device. All patients underwent full polysomnography during baseline, placebo, and verum night. Statistical analysis was performed by Student’s t-test (p > 0.05). Between the placebo and verum there were no differences in total sleep time, sleep stages, apnea index (AI), apnea hypopnea index (AHI), and nadir oxygen saturation. There was, however, 1) a significant deterioration of mean oxygen saturation (SaO2m; placebo 93.1 ± 2.0 vs. verum 92.5 ± 2.2%; p = 0.01), 2) of percent of time spent with an oxygen saturation (SaO2) ≤ 90% (placebo 13.1 ± 14.5 vs. verum 19.5 ± 20.8%; p = 0.02), and 3) a significant increase in heart rate (placebo 63.1 ± 9.2 vs. verum 65.6 ± 9.3 h-1; p = 0.01). In patients with OSAS, salmeterol had no adverse effect on quality of sleep, AI or AHI. The slight increase in heart rate and the deterioration of oxygen saturation probably have no clinical relevance; the latter condition might be due to ventilation-perfusion-mismatch. This study excluded any influence of salmeterol on obstructive sleep apnea and hypopnea; on the other hand, salmeterol turned out to be safe in terms of OSAS. This might be of special importance in patients suffering from both OSAS and obstructive airway disease.

Der schwere Asthmaanfall im Erwachsenenalter

ZusammenfassungDie Ursachen für einen schweren bzw. lebensbedrohlichen Asthmaanfall sind Infektionen mit pneumotropen Viren oder Mycoplasma pneumoniae, weniger häufig bakterielle Infekte, darüber hinaus Allergene, unspezifische Reize, Medikamente sowie eine inadäquate Langzeittherapie. Die Basistherapie des schweren Asthmaanfalls stellen hochdosierte inhalative β2-Agonisten, systemische Glukokortikosteroide und Sauerstoff dar. Bei unzureichender Wirkung ist eine Krankenhauseinweisung erforderlich. Hier sind eine kontinuierlich überwachte intravenöse Medikamentenapplikation möglich, notfalls eine Gabe von Sedativa, bei zunehmender Störung der Atempumpfunktion mit alveolärer Hypoventilation auch eine nicht-invasive oder invasive Beatmung. Ist letztere erforderlich, reduziert die Anwendung einer permissiven Hyperkapnie die Komplikationsrate. Die Bronchoskopie einschließlich Bronchiallavage findet im Falle steigender Beatmungsdrucke sowie bei Atelektasenbildung Anwendung.AbstractThe underlying causes of acute severe or life threatening asthma are infections with respiratory viruses or Mycoplasma pneumoniae, rather than bacterial infections. In addition, exposure to various agents such as allergens, non-specific irritants or drugs, and inadequate long-term treatment may be responsible. High flow oxygen therapy, high dose topic β2-agonists and systemic glucocorticosteroids should be used as baseline therapy in outpatients. In hospital, intravenous therapy—eventually including sedatives—can be administered under controlled or intensive care conditions. In patients with increasing respiratory pump weakness and alveolar hypoventilation, non-invasive and/or invasive mechanical ventilation may be required. In ventilated asthma patients permissive hypercarbia has been shown to reduce complications such as pneumothorax. Bronchoscopy and bronchial lavage are recommended for patients ventilated with increasing pressures or when atelectasis occurs.