Pneumologie最新文献

Malignant pleural effusion is a common diagnosis in metastasized cancers. It is always of palliative character. Main symptoms are dyspnoea and reduced quality of life. Diagnosis is made by ultrasound-guided puncture of the pleural effusion (cytology) and often video-assisted thoracic surgery with biopsy of the pleural surface (histology). The goal of treatment is a fast, sustainable, minimally invasive, patient-centred therapy that increases quality of life. Besides systemic therapy and best supportive care the patient can be treated with local therapy including either pleurodesis (via drainage or VATS) or an indwelling-pleural catheter (IPC). Decision for one of these procedures is made upon performance index (ECOG), expandability of the lung, prognosis and the patient's wish. For the first technique, the lung must be expandable. The latter one (IPC) can be implanted both with expandable and trapped lung. Both are similarly effective in symptom control.

Aim: Patients undergoing long-term ventilation often show anemia. The aim of the study was to investigate the duration and success of weaning from mechanical ventilation in patients with RBC transfusion.

Methods: A retrospective analysis of patient data from a weaning unit was performed. Transfused and non-transfused patients were matched using a propensity score. Of the 249 patients in the database, 31 transfused and the same number of non-transfused cases with similar disease severity as measured by the Simplified Acute Physiology Score (SAPS) could be analyzed. Additional sensitivity analyses were performed.

Results: In the group of transfused patients, the difference in weaning duration was longer than in non-transfused patients (1.35 days and 3.26 days, respectively). Weaning success also varied. The risk of weaning failure was twice as high in the group of transfused patients. The groups also differed in terms of mortality, 25.8% of the transfused patients died, while in the non-transfused patients the mortality rate was 6.5%. The risk of death was increased in patients who received RBC transfusion. The differences were not statistically significant.

Conclusion: A high proportion of patients with prolonged mechanical ventilation have anemia. RBC transfusion does not improve their prognosis. The need for transfusion is associated with higher mortality and longer duration of weaning in this population. The indication for RBC transfusion should therefore be restrictive.

Background: The optimal use of steroids in COVID-19 patients remains challenging. Current S3-guidelines "Recommendations for patients with COVID-19" recommend dexamethasone (DEX) for patients requiring respiratory support, remdesivir (RD) in the early disease phase and azythromycin (AZ) is no longer recommended. We investigated effects of DEX, RD and AZ in a lipopolysaccharide induced inflammation in lung cells in vitro and analyzed publicly available datasets with a focus on the Angiotensin-converting enzyme 2 (ACE2) to better understand drugs' mechanisms of action.

Methods: human bronchial (Calu) and alveolar (A549) lung epithelial cells were treated with DEX, AZ or RDV in the presence of lipopolysaccharides (LPS). Gene expression (GE) of ACE2, IL-6 and the IL-6 protein release were measured. Publicly available GE data from lung tissues of COVID-19 patients and from lung cells treated with DEX were analyzed for the GE of ACE2.

Results: DEX increased and RDV and AZ reduced the GE of ACE2 in LPS-stimulated bronchial and alveolar epithelial cells. Only DEX significantly reduced LPS-induced IL-6 releases in alveolar cells substantially. The database analyses showed an, albeit not always significant, increase in ACE2 for lung tissue or cell lines treated with DEX. Lung tissue from patients after COVID-19 infection as well as bronchial cell cultures after COVID-19 infection showed lower GEs of ACE2.

Discussion and conclusion: DEX can increase ACE2 expression in vitro and thereby the portal of entry of SARS-CoV-2 into lung cells during an LPS induced inflammation. Simultaneously the inflammatory marker IL-6 is reduced. Comparative database analyses indicate that these processes can also take place in vivo.

Bronchoscopy courses should be an integral part of bronchoscopy training. Course graduates should be familiar with the indications, prerequisites and technical possibilities of bronchoscopy. In addition to theoretical content, practical bronchoscopic skills are taught and trained in small supervised groups using various methods of simulation-based bronchoscopy training. The course content is based on the current guidelines and recommendations of the DGP as well as the applicable national directives and KRINKO recommendations. The standardization of central course elements serves to ensure quality assurance across the board, whilst explicitly supporting local site-specific focuses and preferences.

The S3 guideline on non-invasive ventilation as a treatment for chronic respiratory failure was published on the website of the Association of the Scientific Medical Societies in Germany (AWMF) in July 2024. It offers comprehensive recommendations for the treatment of chronic respiratory failure in various underlying conditions, such as COPD, thoraco-restrictive diseases, obesity-hypoventilation syndrome, and neuromuscular diseases. An important innovation is the separation of the previous S2k guideline dating back to 2017, which included both invasive and non-invasive ventilation therapy. Due to increased scientific evidence and a significant rise in the number of affected patients, these distinct forms of therapy are now addressed separately in two different guidelines.The aim of the guideline is to improve the treatment of patients with chronic respiratory insufficiency using non-invasive ventilation and to make the indications and therapy recommendations accessible to all involved in the treatment process. It is based on the latest scientific evidence and replaces the previous guideline. This revised guideline provides detailed recommendations on the application of non-invasive ventilation, ventilation settings, and the subsequent follow-up of treatment.In addition to the updated evidence, important new features of this S3 guideline include new recommendations on patient care and numerous detailed treatment pathways that make the guideline more user-friendly. Furthermore, a completely revised section is dedicated to ethical issues and offers recommendations for end-of-life care. This guideline is an important tool for physicians and other healthcare professionals to optimize the care of patients with chronic respiratory failure. This version of the guideline is valid for three years, until July 2027.

Some of the patients with SARS-CoV-2 infection (COVID-19) received invasive ventilation during inpatient care. Weaning from ventilation was difficult for some patients (so-called prolonged weaning).

Patients: Patients (n=751) with prolonged weaning (reason for ventilation "pneumonia" and "acute respiratory failure") from four centers for the period 2011-23 from the "WeanNet" registry were used as a matched group.

Results: The median duration of intensive medical care was 39 (25-68) days. In 19% (37/193) of patients, ECMO support was necessary for a median of 27 (18-51) days. In-hospital mortality was 8.3% (2.7% with vs. 9.6% without ECMO) and 6.8% died in the comparison group. At discharge, 84% (vs. 77% in the control group) were completely weaned and 2.6% (vs. 17.6% in the control group) of patients received non-invasive treatment. Invasive ventilation was still necessary in 7.8% (control group 15.7%). In the observation period of 6 months after discharge, 22.4% of patients required inpatient care and a further 14.1% after 12 months. The overall mortality at 12-month follow-up was 20,6% (5.6% with vs. 24.6% without ECMO).

Discussion: The mortality rate of ventilated patients with COVID-19 was very low at 8.3% in the four weaning centers studied. The mortality rate of patients with ECMO treatment was only 2.7%. The mortality rate in the control group was 7.3%. The lower mortality of patients with ECMO treatment was also evident at follow-up of up to 12 months.Patients with prolonged weaning who received invasive ventilation due to COVID-19 showed comparable results in terms of successful weaning and mortality compared to a control group from the WeanNet registry. The long-term results with a survival of more than 80% for the first year after discharge were encouraging.

Treatment perspectives for non-small cell lung cancer (NSCLC) have been significantly expanded by the integration of immune checkpoint inhibitors into multimodal therapy concepts. Currently, combined, immune checkpoint-inhibitor-based therapy concepts are also advancing into early, resectable stages of NSCLC. Neoadjuvant and perioperative chemoimmunotherapy opened up a promising new preoperative treatment approach, but also raises some new questions and challenges. With the expanded perioperative treatment options and the perspective on a further improvement in the absence of recurrence after tumor resection, there is push towards comprehensively collecting therapy-relevant findings for imaging, molecular and histopathological diagnostics at an early stage. All patients with lung carcinoma, regardless of the therapy intention, should be presented to an interdisciplinary tumor board with thoracic oncological expertise. This is regularly given in certified lung cancer centers.A standardized procedure contributes to optimized pre-therapeutic diagnostics and facilitates coordination for the best possible multimodal approach in the interdisciplinary tumor board. In the case of centrally located resectable tumors, for example, neoadjuvant treatment increases the chances of a procedure that is as parenchymal sparing as possible. Some questions cannot yet be answered conclusively. Perioperative systemic therapy with molecular-targeted and immune checkpoint inhibitors is the subject of numerous ongoing studies. The considerable dynamics in newly approved therapies and the development of perioperative therapy concepts require continuous adaptation of diagnostic algorithms and standards. Integration into standard pre-surgical routine makes rapid classification of the relevant findings as well as close coordination between the diagnostic and interventional disciplines essential.

A 43-year-old quarry worker, after being exposed to fine quartz dust for 16 years in a German quarry, is on the waiting list for a lung transplant. The inhalation of the fine dust irreversibly damaged his lungs and facilitated the occurrence of fulminant mycobacterial and fungal infections, which have already led to a unilateral pneumonectomy and increasing respiratory failure. Despite regular monitoring by the occupational health and safety board, this dramatic development of silicosis could not be prevented.

Palliative medical care for patients with pulmonary diseases has improved significantly in recent years - particularly in the field of pneumooncology and in acute and intensive care medicine. For patients with non-malignant lung diseases, however, palliative care is often provided very late in the course of the disease. Our article is intended to provide incentives and explanations for the contemporary integration of palliative care - regardless of the underlying disease.