Die außerklinische Beatmung über einen invasiven oder nichtinvasiven Beatmungszugang ist mittlerweile etablierter Standard. Entsprechend wurde bereits im Jahr 2010 unter der Federführung der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP) die Leitlinie „Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz“ publiziert. Die stetige Weiterentwicklung der technischen Methoden, neue wissenschaftliche Erkenntnisse sowie neue versorgungsrelevante Entwicklungen machen jedoch eine umfangreiche Revision der Leitlinie notwendig. Entsprechend wurde nun die revidierte Fassung der Leitlinie publiziert. Dabei finden sich in Bezug auf die aktuelle Literatur sowie auf die Versorgungslandschaft in Deutschland überarbeitete Empfehlungen zu den bereits in der Erstversion der Leitlinie aufgenommenen Themenbereichen der technischen Aspekte, der Organisationsstrukturen in Deutschland, der Qualifikationskriterien für die Versorgung außerklinisch beatmeter Patienten, für die einzelnen Krankheitsentitäten inklusive der Besonderheiten in der Pädiatrie sowie der ethischen Aspekte und der Palliativmedizin. Neu hinzugenommen sind zusätzlich die Themen der außerklinischen Beatmung nach erfolglosem prolongierten Weaning sowie die außerklinische Beatmung bei Querschnittlähmung. Neu ist auch die Zusammensetzung der beteiligten Fachgesellschaften, Fachverbände und Vereinigungen. Dabei werden die einzelnen Krankheitsbilder und Organsysteme übergreifend auch über die Deutsche Interdisziplinäre Gesellschaft für Außerklinische Beatmung e. V. (DIGAB) vertreten, während zusätzlich die Einbindung von Verbänden wichtig war, die direkt mit der Versorgung beatmeter Patienten im außerklinischen Setting konfrontiert sind. Zusätzlich wurde die Einbindung der Kostenträgerseite und der Patientenverbände für wichtig erachtet. Diese Leitlinie hat eine Gültigkeit von drei Jahren, beginnend mit dem Datum der Veröffentlichung auf der Homepage der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) Anfang Juli 2017. Ziel ist eine weitere zeitgerechte Überarbeitung der Leitlinie nach Fristablauf. Today, invasive and non-invasive home mechanical ventilation have become a well-established treatment option. Consequently, in 2010 the German Society of Pneumology and Mechanical Ventilation (DGP) has leadingly published the guidelines on “Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory Failure”. However, continuing technical evolutions, new scientific insights, and health care developments require an extensive revision of the guidelines. For this reason, the updated guidelines are now published. Thereby, the existing chapters, namely technical issues, organizational structures in Germany, qualification criteria, disease specific recommendations including special features in pediatrics as well as ethical aspects and palliative care, have been updated according to the current literature and the health care developments in Germany. New chapters added to the guidelines include the topics of home mechanical ventilation in paraplegic patients and in those with failure of prolonged weaning. In the current guidelines different societies as well as professional and expert associations have been involved when compared to the 2010 guidelines. Importantly, disease-specific aspects are now covered by the German Interdisciplinary Society of Home Mechanical Ventilation (DIGAB). In addition, societies and associations directly involved in the care of patients receiving home mechanical ventilation have been included in the current process. Importantly, associations responsible for decisions on costs in the health care system and patient organizations have now been involved. The currently updated guidelines are valid for the next three years, following their first online publication on the home page of the Association of the Scientific Medical Societies in German (AWMF) in the beginning of July 2017. A subsequent revision of the guidelines remains the aim for the future. ^* Erstmalig publiziert auf der Homepage der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) (http://www.awmf.org/leitlinien/detail/ll/020-008.html) am 07.07.2017.

Background: Bronchoscopic lung volume reduction (BLVR) with valves has been shown to improve lung function, exercise capacity, and quality of life in patients with emphysema, but only few patients with forced expiratory volume in 1 s (FEV1) ≤20% predicted have been included in former studies. Although the procedure can be performed safely, pneumothorax is a frequent complication, which can be critical for these very severely diseased patients. Objectives: The aim of the study was to assess the safety of BLVR in patients with a very advanced stage of emphysema, as indicated by FEV1 ≤20% predicted. Patients and Methods: Patients in whom BLVR was performed between January 2013 and August 2015 were included in this analysis if their baseline predicted FEV1 was ≤20%. BLVR, performed only if collateral ventilation was absent, achieved complete occlusion of the target lobe. All patients were closely monitored and were not discharged before the fourth day after BLVR. Results: Twenty patients with FEV1 ≤20% predicted were included in the analysis. Lung volume reduction was achieved in 65% of the cases. Pneumothorax occurred in 4 cases (20%). No patient died. Lung function and exercise tolerance improved after 1 and 3 months, respectively. Conclusions: BLVR with valves can be safely performed in patients with FEV1 ≤20% predicted when close postprocedural monitoring is provided. Improvement in lung function and exercise capacity can be achieved.

The prognostic value of improvement endpoints that have been used in clinical trials of treatments for pulmonary arterial hypertension (PAH) needs to be further investigated. Using the COMPERA database, we evaluated the prognostic value of improvements in functional class (FC) and absolute or relative improvements in 6-min walking distance (6MWD) and N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP). In addition, we investigated multicomponent endpoints based on prespecified improvements in FC, 6MWD and NT-proBNP that have been used in recent PAH trials. Finally, we assessed the predictive value of improvements determined by risk stratification tools. The effects of changes from baseline to first follow-up (3-12 months after initiation of PAH therapy) on consecutive survival were determined by Kaplan-Meier analysis with Log-Rank testing and Cox proportional hazard analyses. All analyses were based on 596 patients with newly diagnosed PAH for whom complete data were available at baseline and first follow-up. Improvements in FC were associated with improved survival, whereas absolute or relative improvements in 6MWD had no predictive value. For NT-proBNP, absolute declines conferred no prognostic information while relative declines by ≥35% were associated with better survival. Improvements in multicomponent endpoints were associated with improved survival and the same was found for risk stratification tools. While sole improvements in 6MWD and NT-proBNP had minor prognostic relevance, improvements in multicomponent endpoints and risk stratification tools based on FC, 6MWD, and NT-proBNP were associated with improved survival. These tools should be further explored as outcome measures in PAH trials.

Background: Robust clinical evidence on the efficacy and safety of endoscopic lung volume reduction (ELVR) with one-way valves in patients with severe lung emphysema with chronic hypercapnic respiratory failure is lacking. Objective: The aim of this study was to compare patient characteristics, clinical outcome measures, and incidences of adverse events between patients with severe COPD undergoing ELVR with one-way valves and with either a partial pressure of carbon dioxide (pCO₂) of ≤45 mm Hg or with pCO₂ >45 mm Hg. Methods: This was a multicentre prospective study of patients with severe lung disease who were evaluated based on lung function, exercise capacity (6-min walk test [6-MWT]), and quality-of-life tests. Results: Patients with pCO₂ ≤45 mm Hg (n = 157) and pCO₂ >45 mm Hg (n = 40) showed similar baseline characteristics. Patients with pCO₂ ≤45 mm Hg demonstrated a significant increase in forced expiratory volume in 1 s (p < 0.001), a significant decrease in residual volume (RV) (p < 0.001), and significant improvements in the quality of life and 6-MWT at the 3-month follow-up. Patients with pCO₂ >45 mm Hg had significant improvements in RV only (p < 0.05). There was a significant decrease in pCO₂ between baseline and follow-up in hypercapnic patients, relative to the decrease in patients with pCO₂ ≤45 mm Hg (p = 0.008). Patients who were more hypercapnic at baseline showed a greater reduction in pCO₂ after valve placement (r = −0.38, p < 0.001). Pneumothorax was the most common adverse event in both groups. Conclusions: ELVR with one-way valves seems clinically beneficial with a remarkably good safety profile for patients with chronic hypercapnic respiratory failure.

COVID-19, ausgelöst durch Coronavirus SARS-CoV-2, ist eine neue, sich pandemisch ausbreitenden Infektionserkrankung, welche aktuell weltweit zu einer erheblichen Belastung der Gesundheitssysteme geführt hat. Krankenhausmitarbeiter stellen in Ländern mit hoher Krankheitsaktivität, wie China oder Italien, einen signifikanten Anteil der an COVID-19 Erkrankten und Verstorbenen dar. Bronchoskopische Untersuchungen führen beim untersuchten Patienten zu Hustenreiz und Aerosolbildung und beinhalten daher ein erhöhtes Infektionsrisiko für das Untersuchungsteam und für andere Patienten. In der aktuellen Pandemie sind daher besondere Maßnahmen bei der Durchführung bronchoskopischer Untersuchungen zu beachten, um das Infektionsrisiko zu senken. COVID-19, caused by coronavirus SARS-CoV-2 is a new and ongoing infectious disease affecting healthcare systems worldwide. Healthcare worker are at high risk for COIVD-19 and many have been infected or even died in countries severely affected by COVID-19 like China or Italy. Bronchoscopy causes cough and aerosol production and has to be considered a significant risk for the staff to get infected. Particular recommendations should guide to prevent spreading COVID-19 and to protect healthcare worker when performing a bronchoscopy.