Sarah Bettina Schwarz

Continuous non‐invasive PCO2 monitoring in weaning patients: Transcutaneous is advantageous over end‐tidal PCO2

Continuous partial pressure of carbon dioxide (PCO2) assessment is essential for the success of mechanical ventilation (MV). Non‐invasive end‐tidal PCO2 (PetCO2) and transcutaneous PCO2 (PtcCO2) measurements serve as alternatives to the gold standard arterial PCO2 (PaCO2) method, but their eligibility in critical care is unclear.

Interfaces and ventilator settings for long-term noninvasive ventilation in COPD patients

Introduction The establishment of high-intensity (HI) noninvasive ventilation (NIV) that targets elevated PaCO2 has led to an increase in the use of long-term NIV to treat patients with chronic hypercapnic COPD. However, the role of the ventilation interface, especially in more aggressive ventilation strategies, has not been systematically assessed. Methods Ventilator settings and NIV compliance were assessed in this prospective cross-sectional monocentric cohort study of COPD patients with pre-existing NIV. Daytime arterialized blood gas analyses and lung function testing were also performed. The primary end point was the distribution among study patients of interfaces (full-face masks [FFMs] vs nasal masks [NMs]) in a real-life setting. Results The majority of the 123 patients studied used an FFM (77%), while 23% used an NM. Ventilation settings were as follows: mean ± standard deviation (SD) inspiratory positive airway pressure (IPAP) was 23.2±4.6 mbar and mean ± SD breathing rate was 16.7±2.4/minute. Pressure support ventilation (PSV) mode was used in 52.8% of patients, while assisted pressure-controlled ventilation (aPCV) was used in 47.2% of patients. Higher IPAP levels were associated with an increased use of FFMs (IPAP <21 mbar: 73% vs IPAP >25 mbar: 84%). Mean compliance was 6.5 hours/day, with no differences between FFM (6.4 hours/day) and NM (6.7 hours/day) users. PaCO2 assessment of ventilation quality revealed comparable results among patients with FFMs or NMs. Conclusion This real-life trial identified the FFM as the predominantly used interface in COPD patients undergoing long-term NIV. The increased application of FFMs is, therefore, likely to be influenced by higher IPAP levels, which form part of the basis for successful application of HI-NIV in clinical practice.

Capillary PO 2 does not adequately reflect arterial PO 2 in hypoxemic COPD patients

Purpose To compare arterial (PaO2) with capillary (PcO2) partial pressure of oxygen in hypoxemic COPD patients because capillary blood gas analysis (CBG) is increasingly being used as an alternative to arterial blood gas analysis (ABG) in a non-intensive care unit setting, although the agreement between PcO2 and PaO2 has not been evaluated in hypoxemic COPD patients. Patients and methods Bland–Altman comparison of PaO2 and PcO2 served as the primary outcome parameter if PcO2 values were ≤60 mmHg and the secondary outcome parameter if PcO2 values were ≤55 mmHg. Pain associated with the measurements was assessed using a 100-mm visual analog scale. Results One hundred and two PaO2/PcO2 measurement pairs were obtained. For PcO2 values ≤60 mmHg, the mean difference between PaO2 and PcO2 was 5.99±6.05 mmHg (limits of agreement: −5.88 to 17.85 mmHg). For PcO2 values ≤55 mmHg (n=73), the mean difference was 5.33±5.52 mmHg (limits of agreement: −5.48 to 16.15 mmHg). If PaO2 ≤55 (≤60) mmHg was set as the cut-off value, in 20.6% (30.4%) of all patients, long-term oxygen therapy have been unnecessarily prescribed if only PcO2 would have been assessed. ABG was rated as more painful compared with CBG. Conclusions PcO2 does not adequately reflect PaO2 in hypoxemic COPD patients, which can lead to a relevant number of unnecessary long-term oxygen therapy prescriptions.

Is Outpatient Control of Long-Term Non-Invasive Ventilation Feasible in Chronic Obstructive Pulmonary Disease Patients?

Background: Long-term non-invasive ventilation (NIV) is an established and increasingly used treatment option for patients with chronic hypercapnic chronic obstructive pulmonary disease (COPD). Following inpatient NIV establishment, inpatient control visits regularly occur thereafter. However, it remains unclear whether such control visits can also be performed in an outpatient setting, which, in turn, would reduce costs, patient burden and the complications related to hospitalization. Objectives: To investigate an outpatient setting with predefined criteria for hospitalization for patients with chronic hypercapnic COPD. Methods: An outpatient clinic located within the hospital in the vicinity of the respiratory care unit provided predefined criteria for hospitalization of COPD patients receiving long-term NIV therapy. The results of this setting were retrospectively analysed. Results: A total of 130 outpatient visits (80 patients) were analysed. In 93 cases (71.5%), hospital admission was not necessary, while hospitalization was performed in 37 cases (28.5%). Out of these, 7 cases with acute conditions required prompt hospitalization. Patients without hospitalization had better PaCO2 values (45.40 ± 5.27 vs. 50.05 ± 8.04, p = 0.002) and Severe Respiratory Insufficiency Questionnaire Summary scores (55.54 ± 19.74 vs. 41.82 ± 19.59, p = 0.012). Conclusion: Outpatient control of long-term NIV in a hospital setting is feasible and has the capacity to identify stable COPD patients in whom NIV therapy is sufficient according to predefined criteria. These patients may not require hospitalization and may account for more than two thirds of cases.

Using web-based videos to improve inhalation technique in COPD patients requiring hospitalization: A randomized controlled trial

Background Inhalation errors frequently occur in patients receiving inhalation treatment, which can significantly impair treatment success. While this underscores the importance of inhalation training, the role of modern web-based instructional videos has not yet been investigated. Methods A randomized controlled trial using standardized checklists (10 items: preparation, N = 3, inhalation routine, N = 6, and closure of inhalation, N = 1) was carried out to determine the relative effects of web-based, device-specific videos versus standard personal instruction on reducing multiple (≥2) inhalation errors in severe COPD patients requiring hospitalisation. Investigators assessing inhalation errors were blinded to the intervention. Results Multiple handling errors were recorded at baseline in 152 out of 159 patients (95.6%). Each teaching method led to a similar reduction in errors (videos: from 4.2±1.6 to 1.5±1.5 errors; personal instruction: from 3.8±1.5 to 1.3±1.6; p<0.0001), although non-inferiority of web-based video teaching could not be confirmed statistically due to an unpredictably high number of patients in both groups still making multiple handling errors (44.0% versus 40.3%, mean difference 3.7%; 95%CI [-12.0–19.4%]). Conclusion Multiple inhalation errors regularly occur in severe COPD patients requiring hospitalisation. Web-based video teaching is capable of reducing inhalation errors. However, compared to personal instruction non-inferiority could not be established. This was due to an unexpectedly high number of patients with persisting inhalation errors despite training. Trial registration Clinical trial Registration: German Clinical Trial Register, DRKS 00004320.

Home noninvasive ventilatory support for patients with chronic obstructive pulmonary disease : patient selection and perspectives

Long-term or home mechanical noninvasive ventilation (Home-NIV) has become a well-established form of therapy over the last few decades for chronic hypercapnic COPD patients in European countries. However, meta-analyses and clinical guidelines do not recommend Home-NIV for COPD patients on a routine basis. In particular, there is ongoing debate about Home-NIV in chronic hypercapnic COPD regarding the overall effects, the most favorable treatment strategy, the selection of eligible patients, and the time point at which it is prescribed. The current review focuses on specific aspects of patient selection and discusses the various scientific as well as clinical-guided perspectives on Home-NIV in patients suffering from chronic hypercapnic COPD. In addition, special attention will be given to the topic of ventilator settings and interfaces.

Lunge und Atempumpe müssen als Ursache differenziert werden

ZusammenfassungBei einer respiratorischen Insuffizienz kann sowohl die Lunge als auch die Atempumpe betroffen sein, die unabhängig voneinander von unterschiedlichen Pathologien beeinflusst werden können. Bei der COPD wird je nach Art der respiratorischen Insuffizienz entweder die Sauerstofflangzeittherapie oder eine außerklinische Beatmung empfohlen, abhängig davon, ob eine pulmonale Insuffizienz und/oder eine ventilatorische Insuffizienz vorliegen/t.

Die Auskultation bei COPD hat noch immer ihren Stellenwert

Die Auskultation der Lunge ist einfach, schnell, gut verfügbar und informativ. Durch die hohe Untersucherabhängigkeit und dadurch bedingt geringe Sensitivität und Spezifität wird sie allerdings zunehmend aus der in den Leitlinien empfohlenen Basisdiagnostik verdrängt. Neue computergestützte Techniken bieten zudem neue Perspektiven.

Oxygenierungsstörung und disseminierte peribronchiale pneumonische Infiltrate

Bei einer 41 Jahre alten Patientin wird zunächst die Diagnose einer Pneumonie gestellt. Es kommt zu einer fortschreitenden Verschlechterung mit ausgeprägter Hypoxie trotz der eingeleiteten Therapiemaßnahmen. Als erneut eine Computertomografie des Thorax durchgeführt wurde, wird die Diagnose in Frage gestellt.

Talkose als tödliche SpÄtfolge langjÄhrigen intravenösen Drogenkonsums

Ein 53-jÄhriger ehemaliger Raucher lebt schon lange mit der Diagnose COPD. Als sich seine Atmungssituation zunehmend verschlechtert, lÄsst eine erneute Evaluation der Thorax Röntgenaufnahmen Zweifel an der Ätiologie der chronischen respiratorischen Insuffizienz aufkommen...