[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]

Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.

48-jähriger Triathlet mit schwerer COVID-19-Pneumonie: erfolgreiche und sichere Behandlung mit Sauerstoff und CPAP

Wir präsentieren den Fall eines 48-jährigen Patienten und Triathleten mit einer schweren COVID-19- und beidseitiger ausgedehnter Pneumonie. Der Patient präsentierte sich an Tag 7 seit Symptombeginn mit Fieber, Husten, Gliederschmerzen, progredienter Dyspnoe sowie einer schweren hypoxämischen Insuffizienz (PaO2 49,9 mmHg, PaCO2 35,7 mmHg, Horovitz-Index 130). In der CT des Thorax zeigten sich ausgedehnte beidseitige Milchglasinfiltrate. Formal waren die Kriterien eines ARDS nach Berlin-Definition erfüllt.

Es erfolgte entlang eines vorbestehenden definierten Behandlungskonzeptes zunächst eine Therapie mit Sauerstoff und nach zwischenzeitlicher Verschlechterung eine CPAP-Behandlung. Der Patient stabilisierte sich und konnte nach 12 Tagen stationärer Behandlung mit einer Normoxämie unter Raumluft entlassen werden. Belastbarkeit, Lungenfunktion und die CT des Thorax waren bei einer Nachuntersuchung 6 Wochen nach der Entlassung wieder normal.

Dieser Fall zeigt, dass auch bei einer schweren Hypoxämie infolge einer beidseitigen COVID-19 Pneumonie eine invasive Beatmung erfolgreich vermieden werden kann.

[Position Paper for the State of the Art Application of Respiratory Support in Patients with COVID-19 - German Respiratory Society]

Against the background of the pandemic caused by infection with the SARS-CoV-2, the German Society for Pneumology and Respiratory Medicine (DGP e.V.), in cooperation with other associations, has designated a team of experts in order to answer the currently pressing questions about therapy strategies in dealing with COVID-19 patients suffering from acute respiratory insufficiency (ARI).The position paper is based on the current knowledge that is evolving daily. Many of the published and cited studies require further review, also because many of them did not undergo standard review processes.Therefore, this position paper is also subject to a continuous review process and will be further developed in cooperation with the other professional societies.This position paper is structured into the following five topics:1. Pathophysiology of acute respiratory insufficiency in patients without immunity infected with SARS-CoV-22. Temporal course and prognosis of acute respiratory insufficiency during the course of the disease3. Oxygen insufflation, high-flow oxygen, non-invasive ventilation and invasive ventilation with special consideration of infectious aerosol formation4. Non-invasive ventilation in ARI5. Supply continuum for the treatment of ARIKey points have been highlighted as core statements and significant observations. Regarding the pathophysiological aspects of acute respiratory insufficiency (ARI), the pulmonary infection with SARS-CoV-2 COVID-19 runs through three phases: early infection, pulmonary manifestation and severe hyperinflammatory phase.There are differences between advanced COVID-19-induced lung damage and those changes seen in Acute Respiratory Distress Syndromes (ARDS) as defined by the Berlin criteria. In a pathophysiologically plausible - but currently not yet histopathologically substantiated - model, two types (L-type and H-type) are distinguished, which correspond to an early and late phase. This distinction can be taken into consideration in the differential instrumentation in the therapy of ARI.The assessment of the extent of ARI should be carried out by an arterial or capillary blood gas analysis under room air conditions and must include the calculation of the oxygen supply (measured from the variables of oxygen saturation, the Hb value, the corrected values of the Hüfner number and the cardiac output). In principle, aerosols can cause transmission of infectious viral particles. Open systems or leakage systems (so-called vented masks) can prevent the release of respirable particles. Procedures in which the invasive ventilation system must be opened, and endotracheal intubation must be carried out are associated with an increased risk of infection.The protection of personnel with personal protective equipment should have very high priority because fear of contagion must not be a primary reason for intubation. If the specifications for protective equipment (eye protection, FFP2 or FFP-3 mask, gown) are adhered to, inhalation therapy, nasal high-flow (NHF) therapy, CPAP therapy or NIV can be carried out according to the current state of knowledge without increased risk of infection to the staff. A significant proportion of patients with respiratory failure presents with relevant hypoxemia, often also caused by a high inspiratory oxygen fraction (FiO2) including NHF, and this hypoxemia cannot be not completely corrected. In this situation, CPAP/NIV therapy can be administered under use of a mouth and nose mask or a respiratory helmet as therapy escalation, as long as the criteria for endotracheal intubation are not fulfilled.In acute hypoxemic respiratory insufficiency, NIV should be performed in an intensive care unit or in a comparable unit by personnel with appropriate expertise. Under CPAP/NIV, a patient can deteriorate rapidly. For this reason, continuous monitoring with readiness to carry out intubation must be ensured at all times. If CPAP/NIV leads to further progression of ARI, intubation and subsequent invasive ventilation should be carried out without delay if no DNI order is in place.In the case of patients in whom invasive ventilation, after exhausting all guideline-based measures, is not sufficient, extracorporeal membrane oxygenation procedure (ECMO) should be considered to ensure sufficient oxygen supply and to remove CO2.

[The Role of Air Pollutants for Health - A Reply to the Expert Opinion of the International Society for Environmental Epidemiology (ISEE) and the European Respiratory Society (ERS)]

In Deutschland gibt es regionale Fahrverbote für ältere Dieselfahrzeuge ohne SCR-Katalysator bei Überschreitung der Grenzwerte für NO2. Dies hat zu einer intensiven Diskussion über die Rolle der Luftschadstoffe für die Gesundheit geführt. In der Replik wird dargestellt, dass die Daten zur Wirkung von Stickstoffdioxid (NO2) und Feinstaub (PM10 und PM2,5) nicht ausreichen, um die Fahrverbote zu begründen.

Für NO2 gibt es passagere Reaktionen bei unbehandelten Asthmatikern ab 500 µg/m3. Die deutschen Grenzwerte (Jahresmittelwert 40 µg/m3) fußen im Wesentlichen auf einer Metaanalyse von 9 Studien aus Innenraumbelastungen wobei nur in 4 Studien NO2 gemessen wurde. In der großen europäischen Escape-Studie von 2014 wurde kein Einfluss von NO2 auf die Mortalität gefunden.

Als Surrogatparameter für andere Schadstoffe ist NO2 ebenfalls nicht mehr geeignet, da seit Einführung der Partikelfilter bei Dieselautos (etwa ab 2000) der KFZ-Anteil am Feinstaub an der Straße unter 10 % liegt. Der Feinstaub besteht im Wesentlichen aus Aufwirbelung von mineralischen, organischen Bodensubstanzen sowie Reifenabrieb und wird am stärksten durch Wetterphänomene, vor allen Dingen durch Sonneneinstrahlung beeinflusst.

Die Grenzwerte für NO2 und Feinstaub werden errechnet aus epidemiologischen Beobachtungsstudien. Es findet sich zumeist eine schwache Assoziation zwischen der Konzentra-tion und zahlreichen Erkrankung sowie der Mortalität. Epidemiologische Beobachtungsstudien erlauben nur die Bildung einer Hypothese. Permanente Wiederholungen der Beobachtungsstudien betätigen nur, dass manche gefundenen Phänomene nicht zufällig sind. Eine Kausalität kann daraus nicht abgeleitet werden, da es zahlreiche Erklärungsmodelle neben dem NO2 und Feinstaub gibt. Dazu wären Interventionsstudien im Niedrigdosisbereich sowie Tierexperimente erforderlich. Diese Daten fehlen nahezu komplett bzw. sind, soweit vorhanden, allesamt negativ.

Nie diskutiert wird eine starke Widerlegung der Hypothese der Gefährdung von NO2 und Feinstaub im Grenzwertbereich durch das Inhalationsrauchen. Die Raucher stellen quasi einen inhalationstoxikologischen Großversuch dar. Der Zigarettenrauch enthält sehr hohe Feinstaub-, Stickstoffmonoxid- (NO) und NO2-Konzentrationen, die vom Organismus erstaunlich gut toleriert werden. Das hängt damit zusammen, dass NO ein Naturstoff ist, der in den Zellen oder auch in den Nasennebenhöhlen in z. T. sehr hohen Konzentrationen (über 30 000 µg/m3) vorkommt. Eines der Abbauprodukte von NO ist NO2, was im Wasser zu Nitrat und Nitrit disproportioniert wird. Ein Teil von NO2 wird zur Synthese von Fettsäuren verwendet.

Zigaretten haben ein Kondensat von ca. 7 – 10 mg. Nimmt man als Vergleich eine lebenslange Dauerbelastung durch Feinstaub und NO2 in den Grenzwertkonzentrationen an, müssten alle Raucher nach wenigen Tagen bis Monaten zahlreiche Erkrankungen entwickeln, die dem Feinstaub und NOx angelastet werden. Auch die Mortalität müsste drastisch erhöht sein; nahezu alle Raucher müssten bereits nach 1 packyear verstorben sein. Der Unterschied wird noch größer, wenn man die nachgewiesene Toxizität und Kanzerogenität des Zigarettenrauchs im Vergleich zu dem i. d. R. deutlich weniger gefährlichen Feinstaub an der Straße ins Verhältnis setzt.

Lazarus-type tumour response to therapy with nivolumab for sarcomatoid carcinomas of the lung

Pulmonary sarcomatoid carcinoma (psc) is a rare subtype of non-small-cell lung carcinoma with a poor prognosis and poor response to chemotherapy and radiotherapy. A previous study reported that psc expresses high levels of PD-L1, suggesting the potential efficacy of immune checkpoint inhibitors in these tumours. We report 2 cases of patients with a lung sarcomatoid carcinoma. Both patients initially underwent curative lung resection, but developed early recurrent disease. Because PD-L1 was highly expressed in the tumour cells, we initiated therapy with nivolumab, which showed good efficacy, almost complete radiologic tumour remission, and a remarkable improvement in the condition of those patients. Immune checkpoint inhibitors targeting PD-1 might be a valuable therapy option for pscs.

[Positionpaper on Telemonitoring in Sleep-Related Breathing Disorders]

The use of telemonitoring in the care of patients with Sleep-related Breathing Disorders (SBD) can enhance medical support significantly. Telemonitoring aims at helping physicians to detect therapy problems early and thus improve patients' therapy adherence. Diagnostics and therapy decisions in the telemonitoring process nevertheless remain the responsibility of sleep specialists. The selection of data monitored, their evaluation and resulting consequences fall to the physician, who makes decisions and prescribes therapy in consultation with the patient. In light of professional legal and ethical requirements, it must be ensured that the extensive changes to the process flow in sleep medicine are designed in a way to guarantee high-quality patient care. In this position paper, the German Sleep Society, the German Respiratory Society, the Association of Pneumological Hospitals and the Federal Association of German Pneumologists comment on important aspects for implementation of telemonitoring for SRBD and describe the basic conditions required for its use.

[Standardization of spirometry: 2015 update. Published by German Atemwegsliga, German Respiratory Society and German Society of Occupational and Environmental Medicine]

Spirometry is a simple test and considered the gold standard in lung function. An obstructive ventilatory defect is a disproportionate reduction of maximal airflow from the lung in relation to the maximal volume that can be displaced from the lung. It implies airway narrowing and is defined by a reduced FEV1/FVC ratio below the 5th percentile of the predicted value (lower limit of normal, LLN). A restrictive disorder may be suspected when vital capacity (FVC) is reduced and FEV1/FVC is normal. It is definitely proven, however, only by a decrease in TLC below the 5th percentile of predicted value (LLN). The measurement of TLC by body plethysmography is necessary to confirm or exclude a restrictive defect or hyperinflation of the lung when FVC is below the LLN. 2012 a task force of the ERS published new reference values based on 74,187 records from healthy non-smoking males and females from 26 countries. The new reference equations for the 3-95 age range are now available that include appropriate age-dependent mean values and lower limits of normal (LLN). This presentation aims at providing the reader with recommendations dealing with standardization and interpretation of spirometry.

[Foreign body removal with Roth-Net®]

There are different tools for the removal of endobronchial foreign bodies. The Roth-Net® is a further development of the Dormia basket. It enables an easy and sure retraction of a foreign body from the bronchial system. This will be presented in a case report.

[Effect of Inhalation of Tobramycin for 12 Months on Reduction of Hospitalisation Rate in Severe COPD]

INTRODUCTION

Bacterial colonisation in stable disease of severe COPD and bronchiectasis can cause recurrent hospital treatment, which has a negative impact on the patient's prognosis. A multicentre study has investigated if daily inhalation of tobramycin for one year would lower the number of hospitalisations in severe COPD.

METHODS

44 patients with severe COPD [FEV1 % of predicted value: 42.8 ± 7,1 tobramycin group (T) and 33.5 ± 10.3 placebo group (P)] and a minimum of two hospitalisations in the year before inclusion were randomly assigned to inhale twice daily for 12 months 80 mg tobramycin or isotonic saline (placebo). Concomitant therapy was according to the GOLD guidelines. Primary end point was the number of hospitalisations in the period of study, secondary end points were pulmonary function test and 6 MWD.

RESULTS

Inhalation of T changed the number of hospitalisations from 2.8 ± 0.5 per year to 3.5 ± 2.7, P from 3.0 ± 1,4 to 2.3 ± 2.2. These differences and the results for secondary endpoints did not reach significance. The dropout rate was high, only 6 patients (T) and 14 patients (P) finished the study per protocol.

CONCLUSION

Inhalation with 160 mg tobramycin by means of a nebuliser over a 12-month period did not reduce the number of hospitalisations for patients with severe COPD and a minimum of two hospitalisations compared to placebo. The severity of the disease was the main reason for the high dropout rate.

[Therapy for small airways disease: basic principles and therapeutic implications]

This paper describes the possibility of targeting the small airways. In addition to aiding in the therapy for chronic obstructive lung diseases this may prove to be invaluable in the development of treatment strategies for diseases of the bronchioli. Essential factors in peripheral lung deposition include extra-fine particles, a slow and controlled inspiratory flow and an endexspiratory breathhold of 5 - 10 sec (especially for steroids). Due to methodological difficulties, clinical data comparing steroids with larger or extra-fine particles are limited in the field of asthma therapy. However, research suggests a trend for reduced symptoms, positively affected biomarkers and decreased lung hyperinflation when steroids with extra-fine particles are used.

[Comparison of endobronchial ultrasound (EBUS) and mediastinoscopy (MS) for staging lung cancer]

Diagnostic findings of mediastinal metastasis are an important factor for the prognosis of and therapy for lung cancer. In this retrospective study we examined the role of endobronchial ultrasound with transbronchial needle aspiration (EBUS) and mediastinoscopy (MS) in patients with confirmed lung cancer. Between 01/2009 and 07/2011 we performed 111 EBUS procedures [partly in combination with transoesophageal endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA)] and 88 mediastinoscopies. The diagnostic accuracy of EBUS (94%) was superior to that of MS (86%) (p < 0.05). The negative predictive value of EBUS and MS was 83% for both, the sensitivity was 94% vs. 58%, the prevalence of N2 /N3 was 84% vs. 32% and the rate of complications was 0% vs. 3%. Due to the at least similar accuracy the EBUS should be the first diagnostic procedure for histological staging of the mediastinum in patients with lung cancer.

[Lung function diagnostics for the small airways]

In the recent years growing interest has focused on the involvement of the distal airways (internal diameter < 2 mm) in obstructive lung diseases and other pulmonary conditions. Inflammation in the small airways seems to play a major role in severe and uncontrolled asthma as a major determinant of airflow obstruction. Thus, small airways represent an important target for inhalation therapy. Currently there is no accepted single lung function parameter to detect small airway dysfunction. Various invasive and non-invasive techniques have been described. In future, non-invasive lung function testing will gain more importance. Using spirometry or body plethysmography, lung function parameters such as the ratio of forced vital capacity to slow vital capacity (FVC/SVC) and the residual volume (RV) can provide information about air trapping in small airway disease. Recent data show that techniques such as impulse oscillometry, nitrogen washout testing and analysis of exhaled nitric oxide are promising tools to assess involvement of the small airways. Impulse oscillometry is a sensitive method to calculate peripheral airway resistance, nitrogen washout allows one to detect air trapping and inhomogeneous ventilation in the distal lung, and the alveolar nitric oxide concentration represents a marker of peripheral inflammation. Further studies are needed to validate these functional tests or their combination for diagnosis and assessment of treatment response in pulmonary diseases involving small airways.

[Bronchiolitis]

Due to the variability in respect to aetiology, histopathology, lung function, imaging and clinical presentation, as well as overlapping parenchymal processes, bronchiolar disorders are generally difficult to diagnose. Thus, diseases of the small airways should generally be considered in the differential diagnostic approach to respiratory conditions. The diagnostic approach can be devided into several steps: in steps 1 (history and physical examination) and 2 (plain chest radiographs and pulmonary function tests) may point towards a bronchiolar pulmonary process. High-resolution CT (HR-CT) scanning of the chest provides three distinct HR-CT patterns (tree-in-bud sign, ill-defined centrilobular ground-glass nodules and/or pattern of mosaic attenuation, especially visible on expiratory images) which confirm a bronchiolic involvement and help to narrow down a likely diagnosis or more specific bronchiolitic diseases. In inconclusive cases, a histological diagnosis may be required. The paper presents a clinically useful algorithmic approach to diagnosis and differential diagnosis of bronchiolar disorders.

[Bronchiolitis. Part 1--anatomic features, classification, clinical presentation and imaging]

The term "bronchiolitis" refers to a broad spectrum of common conditions related to the small airways associated with a miscellaneous aetiology, histology, clinical features and course. Due to their variability, bronchiolar disorders are generally difficult to diagnose. History (smoking, collagen vascular disease, inhalational injury, medication usage, and organ transplant) may point towards a bronchiolar process. In addition, signs of systemic and pulmonary infection and evidence of air trapping may provide diagnostic hints. Although clinical presentation, physical examination, pulmonary function tests (obstructive ventilatory defect), and plain chest radiographs may demonstrate abnormalities suggesting small airways involvement, they are often non-specific and rarely diagnostic. In contrast, the high-resolution CT (HR-CT) scanning of the chest provides three distinct HR-CT patterns that assist in the diagnosis and differential diagnosis of bronchiolar conditions: (i) a tree-in-bud pattern, (ii) ill-defined centrilobular ground-glass nodules, and (iii) a mosaic attenuation pattern (best visible on expiratory images). The present paper summarises the current knowledge, the classification, imaging, and the clinical presentation of bronchiolar disorders.

What the pulmonary specialist should know about the new inhalation therapies

A collaboration of multidisciplinary experts on the delivery of pharmaceutical aerosols was facilitated by the European Respiratory Society (ERS) and the International Society for Aerosols in Medicine (ISAM), in order to draw up a consensus statement with clear, up-to-date recommendations that enable the pulmonary physician to choose the type of aerosol delivery device that is most suitable for their patient. The focus of the consensus statement is the patient-use aspect of the aerosol delivery devices that are currently available. The subject was divided into different topics, which were in turn assigned to at least two experts. The authors searched the literature according to their own strategies, with no central literature review being performed. To achieve consensus, draft reports and recommendations were reviewed and voted on by the entire panel. Specific recommendations for use of the devices can be found throughout the statement. Healthcare providers should ensure that their patients can and will use these devices correctly. This requires that the clinician: is aware of the devices that are currently available to deliver the prescribed drugs; knows the various techniques that are appropriate for each device; is able to evaluate the patient's inhalation technique to be sure they are using the devices properly; and ensures that the inhalation method is appropriate for each patient.

Guidelines of the German Respiratory Society for diagnosis and treatment of adults suffering from acute or chronic cough

The first set of German guidelines for diagnosis and treatment of patients suffering from acute or chronic cough was published in 2004. Scientific developments over the past five years necessitate an update. The purpose of this document is to assist in ascertaining underlying causes and treating cough, in order to eliminate or minimize impairments of patients' health. The guidelines aim to introduce scientifically founded, evidence-based steps for the diagnosis and treatment of cough and optimize cost-effectiveness. Recommendations are assessed through the GRADE system (The Grades of Recommendation, Assessment, Development and Evaluation). Cough as a symptom is categorized as either acute (lasting up to 8 weeks) or chronic (lasting more than 8 weeks) and attributed to distinct diseases. For acute and chronic cough the diagnostic algorithms are updated; cost effectiveness is also taken into account. Additionally, the most frequent diagnostic errors are highlighted. Finally, available therapeutic options are discussed.

[Health effects of particulate matter exposure: current scientific knowledge]

INTRODUCTION

Air quality is not only important for respiratory health but it also influences the homeostasis of the whole human organism. In the past years numerous violations of European Union particulate matter thresholds have been recorded.

METHODS

The present study is a selective literature analysis encompassing the epidemiology and pathophysiological effects of particulate matter.

RESULTS

Epidemiological studies point to an association between chronic particulate matter exposure and mortality. The most prominent effects on the human body are present in subjects with cardiovascular or respiratory conditions. However, the effects of air pollutants need to be examined critically and the plausibility of thresholds should be evaluated in detail.

DISCUSSION

The negative influences of chronic particulate matter exposure have been proven by a multitude of epidemiological and experimental studies. From the viewpoint of primary prevention, air quality plays a crucial role. This encompasses both the outdoor compartment with particulate matter and other pollutants and the indoor compartment with tobacco smoke.