W Windisch

Guidelines for Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure * Published by the German Society for Pneumology (DGP)

Martina Bogel, Weinmann GmbH, Hamburg Andreas Bosch, Heinen & Lowenstein GmbH, Bad Ems Jorg Brambring, Heimbeatmungsservice Brambring Jaschke GmbH, Unterhaching Stephan Budweiser, Klinik Donaustauf Dominic Dellweg, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg Peter Demmel, MDK Bayern, Munchen Rolf Dubb, Klinikum Stuttgart – Katharinenhospital Jens Geiseler, Asklepios Fachkliniken Munchen-Gauting Frank Gerhard, isb Ambulante Dienste gGmbH, Wuppertal Uwe Janssens, St.-Antonius-Hospital Eschweiler Thomas Jehser, Gemeinschaftskrankenhaus Havelhohe, Berlin Anne Kreiling, Deutsche Gesellschaft fur Muskelkranke e.V., Baunatal Thomas Kohnlein, Medizinische Hochschule Hannover Uwe Mellies, Universitatsklinikum Essen F. JoachimMeyer, Medizinische Universitatsklinik Heidelberg Winfried Randerath, Krankenhaus Bethanien gGmbH, Solingen Bernd Schonhofer, Klinikum Hannover Oststadt Bernd Schucher, Krankenhaus Groshansdorf Karsten Siemon, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg Helmut Sitter, Universitatsklinikum Giesen und Marburg GmbH (Vertreter der AWMF) Jan Hendrik Storre, Universitatsklinik Freiburg Stephan Walterspacher, Universitatsklinik Freiburg Steffen Weber-Carstens, Charite – Universitatsmedizin Berlin Wolfram Windisch, Universitatsklinik Freiburg MartinWinterholler, Krankenhaus Rummelsberg, Schwarzenbruck KurtWollinsky, Universitatsund Rehabilitationskliniken Ulm

Noninvasive Ventilation in COPD: Impact of Inspiratory Pressure Levels on Sleep Quality

BACKGROUND Although high-intensity noninvasive positive pressure ventilation (HI-NPPV) is superior to low-intensity noninvasive positive pressure ventilation (LI-NPPV) in controlling nocturnal hypoventilation in stable hypercapnic patients with COPD, it produces higher amounts of air leakage, which, in turn, could impair sleep quality. Therefore, the present study assessed the difference in sleep quality during HI-NPPV and LI-NPPV. METHODS A randomized, controlled, crossover trial comparing sleep quality during HI-NPPV (mean inspiratory positive airway pressure 29 ± 4 mbar) and LI-NPPV (mean inspiratory positive airway pressure 14 mbar) was performed in 17 stable hypercapnic patients with COPD who were already familiar with HI-NPPV. RESULTS Thirteen patients (mean FEV(1) 27% ± 11% predicted) completed the trial; four patients refused to sleep under LI-NPPV. There was no significant difference in sleep quality between the treatment groups (all P > .05), with a mean difference of -3.0% (95% CI, -10.0 to 3.9; P = .36) in the primary outcome, namely non-rapid eye movement sleep stages 3 and 4. However, nocturnal Paco(2) was lower during HI-NPPV compared with LI-NPPV, with a mean difference of -6.4 mm Hg (95% CI, -10.9 to -1.8; P = .01). CONCLUSIONS In patients with COPD, high inspiratory pressures used with long-term HI-NPPV produce acceptable sleep quality that is no worse than that produced by lower inspiratory pressures, which are more traditionally applied in conjunction with LI-NPPV. In addition, higher pressures are more successful in maintaining sufficient alveolar ventilation compared with low pressures. Thus, HI-NPPV is a very promising new approach, but still requires large, longer-term trials to determine the impact on outcomes such as exacerbation rates and longevity. TRIAL REGISTRY German Clinical Trials Register (DRKS); No.: DRKS00000520; URL: www.drks.de.

Diagnostik und Therapie der gestörten Zwerchfellfunktion

There are many reasons for an impairment of the diaphragmatic function potentially affecting all components of the respiratory pump. Particularly, diagnosis and treatment of unilateral and bilateral phrenic nerve paralysis are challenging. Neuromuscular disorders, trauma, iatrogenic conditions, tumor compression, but also infectious and inflammatory conditions in addition to neuralgic amyotrophy and idiopathic phrenic nerve paralysis are reasons for phrenic nerve paralysis. Primarily, diagnostic procedures include the anamnesis, physical examination, blood gas analysis, lung function testing and the diagnosis of the underlying disease. In addition, specific respiratory muscle testing and respiratory imaging are available today. Current established treatment options include respiratory muscle training, long-term non-invasive ventilation and surgical diaphragm plication in selected patients.

Empfehlungen der Deutschen Atemwegsliga zur Messung der Atemmuskelfunktion

Based on the tremendous impact of impaired respiratory muscle function, tests on their function play a significant role in respiratory and intensive care medicine. Besides differential diagnosing e.g. during prolonged weaning and quantification of impaired respiratory muscle function, e.g. in COPD, neuro-muscular diseases or ventilator-induced diaphragmatic dysfunction, those tests qualify for follow-up assessment, e.g. phrenic nerve lesions or specific respiratory muscle training. In general, (simple) volitional and (complex) non-volitional tests are available. Volitional tests aim at screening for potential respiratory muscle impairment, while non-volitional tests - including ultrasound application - are used to further specify low values assessed by volitional tests and to assess complex clinical conditions (e.g. intubated, sedated patients). Several tests are complementary or additive to each other. Complete assessment for respiratory muscle function, therefore, frequently requires the combination of different test regimes. The current recommendations include in-depth description and practical guidelines for the different tests and approaches to assess respiratory muscle function.

Checklists for the Assessment of Correct Inhalation Therapy.

Introduction For the long-term treatment of obstructive lung diseases inhalation therapy with drugs being delivered directly to the lungs as an aerosol has become the method of choice. However, patient-related mistakes in inhalation techniques are frequent and recognized to be associated with reduced disease control. Since the assessment of patient-mistakes in inhalation has yet not been standardized, the present study was aimed at developing checklists for the assessment of correct inhalation. Methods Checklists were developed in German by an expert panel of pneumologists and professionally translated into English following back-translation procedures. The checklists comparably assessed three major steps of inhalation: 1) inhalation preparation, 2) inhalation routine, and 3) closure of inhalation. Results Checklists for eight frequently used inhalers were developed: Aerolizer, Breezhaler, Diskus (Accuhaler), metered-dose inhaler, Handihaler, Novolizer, Respimat, Turbohaler. Each checklist consists of ten items: three for inhalation preparation, six for inhalation routine, and one for closure of inhalation. Discussion Standardized checklists for frequently used inhalers are available in German and English. These checklists can be used for clinical routines or for clinical trials. All checklists can be downloaded free of charge for non-profit application from the homepage of the German Airway League (Deutsche Atemwegsliga e. V.): www.atemwegsliga.de.