PNEUMOLOGE最新文献

An increasing number of patients require prolonged weaning from mechanical ventilation as a result of advanced age, patient comorbidities, technical progress in surgery and intensive care medicine. The data of the WeanNet register show that more than half (64%) of patients transferred from the intensive care unit (ICU) to a specialized weaning center could definitely be weaned from the respirator. Weaning failure was associated with prolonged ventilation prior to transfer to a weaning center, low body mass index, pre-existing neuromuscular diseases and advanced age. The number of patients with out of hospital ventilation who had to be re-hospitalized because of ventilation control or as part of emergency management quadrupled in Germany between 2006 and 2016. Invasive out-of-hospital ventilation and long-term noninvasive ventilation are associated with a significant loss of autonomy and with low quality of life. Therefore, the initiation must be carefully reviewed and regularly re-evaluated in the context of patient comorbidities and, if necessary, decisions should be made with respect to changing treatment targets. Specialized weaning centers have been established for patients in whom weaning on the ICU was unsuccessful. In cases of persisting weaning failure the adequate transition to out-of-hospital ventilation should be managed by a weaning unit. Weaning centers are responsible for outpatient invasive or noninvasive ventilation strategies and control of treatment quality. Depending on the infrastructure and networking of the respective weaning center, it is basically also possible to provide outpatient care for clinically stable patients in a cooperation model together with pulmonologists in private practice experienced in respiratory medicine.

Pneumonia is a common and severe disease in older people. In this group of patients pneumonia is among the four most frequent diseases leading to death. The diagnosis can often be difficult due to an atypical clinical presentation. Therefore, pneumonia should always be considered as the cause of any deterioration in an older person. Geriatric problems, such as frailty, physical and psychological limitations should be recorded as well as the social situation, as all these factors are of prognostic importance. Pneumonia acquired in a nursing home or by people in need of long-term care has a less favorable prognosis. Although this type of pneumonia is considered to be community acquired, special attenion is required. The treatment of pneumonia does not fundamentally differ from the treatment of younger patients but should take special situations into account, such as the patient's wishes documented in a living will when planning therapy. Older people in particular often show atypical clinical pictures with a coronavirus disease 2019 (COVID-19) infection. Therefore, in any acute change in the health condition of an older person COVID-19 should be considered.

The conventional X‑ray image is the method of choice for suspected pneumonia. Computed tomography (CT) is indicated for treatment refractory or recurrent infiltrates, difficult differential diagnostics, suspected complications and in immunocompromised patients. Thoracic sonography can be used as an alternative method for initial diagnostics and in the intensive care unit to monitor progress. In addition to the detection of infiltrates the radiological classification can help to limit the pathogen spectrum. Radiologically, three forms of pneumonia can principally be differentiated: lobar pneumonia, bronchopneumonia and interstitial pneumonia. Furthermore, there are special forms of pneumonia with certain pathogens, such as aspergilloma, invasive mycosis, postprimary tuberculosis and nontuberculous mycobacteriosis or in a specific clinical context, such as aspiration pneumonia, postinfarction pneumonia, retention pneumonia and septic emboli. The most frequent complications of pneumonia are lung abscesses and pleural empyema. Both can sometimes but not always be seen in the X‑ray image. If clinically suspected the indications for CT should be generously applied. Certain pre-existing diseases, such as immunodeficiency or structural alterations of the lungs can predispose to pulmonary infections, frequently with unusual pathogens or manifestation forms and must be taken into account in the diagnostics.

Diseases of the lung result in oxygen deficiency, hypoxemia, with the indications for oxygen supplementation, whereas hypercapnia and dyspnea are consequences of disorders and failure of the ventilatory pump, which need to be treated by mechanical ventilation. Early diagnostics enable a timely noninvasive ventilation treatment and can prevent overt ventilatory failure and avoid acute invasive ventilation. Diagnostic measures are available, so that the risk of developing overt respiratory failure can be ascertained in time. Treatment of respiratory pump insufficiency, i.e. ventilatory insufficiency, is also established. Many patients with ventilatory insufficiency use intermittent or continuous ventilation every day in order to relieve the respiratory musculature. Many studies have confirmed an extension of life expectancy and a better quality of life, when this relief together with a lowering of the pCO₂ is achieved under ventilation and more importantly while breathing spontaneously. If the target of lowering the pCO₂ is not achieved, an effect of intermittent ventilation cannot be detected. The more severe the disease, the more difficult it is to achieve relief, because the substantial effort needed for breathing by the patient can hardly be relieved by assisted ventilation alone. The relief is always guaranteed by a total passive mechanical ventilation below the apnea threshold so that the patient does not need to independently breathe. A high tidal volume, an adequately high respiratory rate and a prolonged inspiration time are necessary in order to reduce the pCO₂ to below the normal range and to induce passive ventilation. No lung damage has been observed with this treatment strategy in a large number of patients.

Pneumonia causes the highest mortality of all infectious diseases worldwide. The most common pathogens are bacteria but there are also epidemic or pandemic lung infections caused by influenza or coronaviruses, such as the current pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In addition to the occurrence of antibiotic resistance and immune pathologies, such as in sepsis, important challenges lie in considering the susceptibility of individual patients. Here, age, medication and comorbidities are considered; however, there is also clear evidence of genetic influences on the individual risk of developing pneumonia or developing a severe course of the disease. This article discusses the genetic influences on pneumonia and the clinical significance.

In addition to lung function testing and radiological imaging, bronchoscopy is the most important diagnostic tool in patients with bronchial and pulmonary diseases. Through the combined use of flexible and rigid bronchoscopes, nowadays bronchoscopy can be increasingly used as an endoscopic treatment procedure for pulmonary diseases. In cases of thoracic tumors interventional bronchoscopy provides palliative and curative treatment modalities. Apart from bronchoscopic tumor treatment, techniques for endoscopic lung volume reduction have increasingly come into focus in recent years. Furthermore, treatment options for asthma and chronic bronchitis as well as airway stenosis and fistulas are available.

Pulmonary rehabilitation (PR) is an evidence-based multidisciplinary treatment for patients with chronic respiratory diseases. The indications for applying for PR are given if there is an appropriate rehabilitation capability, need for rehabilitation and favorable rehabilitation prognosis. The aims of PR are the reduction of symptoms and improvement of the quality of life and physical resilience. The efficiency of PR is well proven for patients with chronic obstructive pulmonary disease (COPD) with the highest evidence grade and for non-COPD patients with an increasing level of evidence based on randomized controlled trials and meta-analyses. The treatment content of PR is individually adapted to the patients' needs by a multidisciplinary treatment team. In order to sustainably maintain the success of PR there is the possibility to participate in outpatient aftercare programs (e.g. breathing exercises) and to utilize digital technologies as supporting measures.