Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. While COPD is a mainly chronic disease, a substantial number of patients suffer from exacerbations. Severe exacerbations are related to a significantly worse survival outcome. This review summarises the current knowledge on the different aspects of COPD exacerbations. The impact of risk factors and triggers such as smoking, severe airflow limitation, bronchiectasis, bacterial and viral infections and comorbidities is discussed. More severe exacerbations should be treated with β-agonists and anticholinergics as well as systemic corticosteroids. Antibiotic therapy should only be given to patients with presumed bacterial infection. Noninvasive ventilation is indicated in patients with respiratory failure. Smoking cessation is key to prevent further COPD exacerbations. Other aspects include choice of pharmacotherapy, including bronchodilators, inhaled corticosteroids, phosphodiesterase-4 inhibitors, long-term antibiotics and mucolytics. Better education and self-management as well as increased physical activity are important. Influenza and pneumococcal vaccination is recommended. Treatment of hypoxaemia and hypercapnia reduce the rate of COPD exacerbations, while most interventional bronchoscopic therapies increase exacerbation risk within the first months after the procedure.

https://err.ersjournals.com/content/errev/27/147/170103.full.pdf

Exacerbations of COPD

Aim of the study was to compare the short-term effects of oxygen therapy via a high-flow nasal cannula (HFNC) on functional and subjective respiratory parameters in patients with acute hypoxic respiratory failure in comparison to non-invasive ventilation (NIV) and standard treatment via a Venturi mask. Fourteen patients with acute hypoxic respiratory failure were treated with HFNC (FiO2 0.6, gas flow 55 l/min), NIV (FiO2 0.6, PEEP 5 cm H2O Hg, tidal volume 6–8 ml/kg ideal body weight,) and Venturi mask (FiO2 0.6, oxygen flow 15 l/min,) in a randomized order for 30 min each. Data collection included objective respiratory and circulatory parameters as well as a subjective rating of dyspnea and discomfort by the patients on a 10-point scale. In a final interview, all three methods were comparatively evaluated by each patient using a scale from 1 (=very good) to 6 (=failed) and the patients were asked to choose one method for further treatment. PaO2 was highest under NIV (129 ± 38 mmHg) compared to HFNC (101 ± 34 mmHg, p <0.01 vs. NIV) and VM (85 ± 21 mmHg, p <0.001 vs. NIV, p <0.01 vs. HFNC, ANOVA). All other functional parameters showed no relevant differences. In contrast, dyspnea was significantly better using a HFNC (2.9 ± 2.1, 10-point Borg scale) compared to NIV (5.0 ± 3.3, p <0.05), whereas dyspnea rating under HFNC and VM (3.3 ± 2.3) was not significantly different. A similar pattern was found when patients rated their overall discomfort on the 10 point scale: HFNC 2.7 ± 1.8, VM 3.1 ± 2.8 (ns vs. HFNC), NIV 5.4 ± 3.1 (p <0.05 vs. HFNC). In the final evaluation patients gave the best ratings to HFNC 2.3 ± 1.4, followed by VM 3.2 ± 1.7 (ns vs. HFNC) and NIV 4.5 ± 1.7 (p <0.01 vs. HFNC and p <0.05 vs. VM). For further treatment 10 patients chose HFNC, three VM and one NIV. In hypoxic respiratory failure HFNC offers a good balance between oxygenation and comfort compared to NIV and Venturi mask and seems to be well tolerated by patients. German clinical trials register: DRKS00005132
 .

/pdf/nasal-high-flow-oxygen-therapy-in-patients-with-hypoxic-3s7d6g5j3w.pdf

Nasal high-flow oxygen therapy in patients with hypoxic respiratory failure: effect on functional and subjective respiratory parameters compared to conventional oxygen therapy and non-invasive ventilation (NIV).

Sepsis and septic shock are major causes of mortality during chemotherapy-induced neutropenia for malignancies requiring urgent treatment. Thus, awareness of the presenting characteristics and prompt management is most important. Improved management of sepsis during neutropenia may reduce the mortality of cancer therapies. However, optimal management may differ between neutropenic and non-neutropenic patients. The aim of the current guideline is to give evidence-based recommendations for hematologists, oncologists, and intensive care physicians on how to manage adult patients with neutropenia and sepsis.

/pdf/management-of-sepsis-in-neutropenic-cancer-patients-2018-3n71fqmkpj.pdf

Management of sepsis in neutropenic cancer patients: 2018 guidelines from the Infectious Diseases Working Party (AGIHO) and Intensive Care Working Party (iCHOP) of the German Society of Hematology and Medical Oncology (DGHO)

Die nicht-invasive Beatmung (NIV) ist in der klinischen Medizin weit verbreitet und hat mittlerweile einen hohen Stellenwert im klinischen Alltag erlangt. Der Einsatz der NIV reduziert die Intensiv- und Krankenhausaufenthaltsdauer sowie die Mortalitat von Patienten mit akutem hyperkapnischen Atemversagen. Patienten mit akuter respiratorischer Insuffizienz im Rahmen eines Lungenodems sollten neben den notwendigen kardiologischen Interventionen mit CPAP oder NIV behandelt werden. Bei anderen Formen des akuten hypoxamischen Atemversagens wird empfohlen, den Einsatz der NIV auf lediglich mildes ARDS zu begrenzen, da eine NIV bei schweren Formen mit hoheren Raten von Therapieversagen und Mortalitat assoziiert ist. Im Weaning von invasiver Beatmung reduziert die NIV die Reintubationsraten im Wesentlichen bei hyperkapnischen Patienten. Eine verzogerte Intubation bei Auftreten eines NIV-Versagens fuhrt zu einem Anstieg der Mortalitat und sollte deshalb vermieden werden. Bei entsprechendem Monitoring auf der Intensivstation kann die NIV auch bei padiatrischen Patienten mit akuter respiratorischer Insuffizienz erfolgreich eingesetzt werden. Weiterhin kann im Rahmen der Palliativmedizin die NIV hilfreich bei der Reduktion von Dyspnoe und Verbesserung von Lebensqualitat sein. Ziel des Updates dieser Leitlinie ist es, unter Berucksichtigung der zunehmenden aktuellen wissenschaftlichen Evidenz, sowohl die Vorteile als auch die Limitationen der NIV in der Behandlung der akuten respiratorischen Insuffizienz in der taglichen klinischen Praxis und bei verschiedenen Indikationen aufzuzeigen.

/pdf/nicht-invasive-beatmung-als-therapie-der-akuten-2a5dlhii7n.pdf

Nicht-invasive Beatmung als Therapie der akuten respiratorischen Insuffizienz

Das vorliegende Dokument ist eine Neufassung und Aktualisierung der Leitlinie zur Diagnostik und Therapie von Patienten mit COPD, die die bisherige Version aus dem Jahr 2007 ablost. Die Fulle an neuen Erkenntnissen zu Risikofaktoren, Diagnostik, Schweregradeinschatzung, Pravention und medikamentosen sowie nicht medikamentosen Therapiemasnahmen machten eine umfassende Uberarbeitung erforderlich. Die neue Leitlinie baut auf das GOLD-Dokument unter Berucksichtigung von Besonderheiten in Deutschland und Osterreich auf.

Leitlinie zur Diagnostik und Therapie von Patienten mit chronisch obstruktiver Bronchitis und Lungenemphysem (COPD)

Background Scientific evidence is accumulating that non-invasive ventilation (NIV) may be beneficial for different patient groups with acute respiratory insufficiency (ARI). The aim of the new S3 guidelines is to propagate evidence-based knowledge about the indications and limitations of NIV in clinical practice. Methods A total of 28 experts from 12 German medical societies were involved in the process of development of the present guidelines. These experts systematically analyzed approximately 2,900 publications. Finally, the recommendations were discussed and approved in two consensus conferences. Results In hypercapnic ARI, NIV reduces the length of stay and mortality during intensive care treatment [grade A recommendation (A)]. Patients with cardiopulmonary edema should be treated with continuous positive airway pressure (CPAP) or NIV (A). For immunocompromized patients with ARI, NIV reduces the mortality (A). In patients with postextubation respiratory failure and during weaning from mechanical ventilation, NIV reduces the risk of reintubation (A). For patients who decline to be ventilated invasively, NIV may be an acceptable alternative (B). Non-invasive ventilation can also successfully be used in pediatric patients with ARI caused by different reasons (C). In acute respiratory distress syndrome (ARDS) NIV cannot generally be recommended because the failure rate is relatively high. Conclusion Non-invasive ventilation is still not as widely implemented in clinical medicine as would be expected on the basis of the scientific literature. The aim of the present guidelines is to further propagate NIV for the treatment of ARI.

/pdf/non-invasive-ventilation-as-treatment-for-acute-respiratory-2bnm4k95bc.pdf

[Non-invasive ventilation as treatment for acute respiratory insufficiency. Essentials from the new S3 guidelines].

Nichtinvasive Beatmung als Therapie der akuten respiratorischen Insuffizienz

Hintergrund
Der zunehmende Stellenwert der nichtinvasiven Beatmung (NIV) in der Therapie der akuten respiratorischen Insuffizienz (ARI) ist durch klinische Studien untermauert. Eine neue S3-Leitlinie macht das evidenzbasierte Wissen uber Indikationen und Grenzen der NIV bei ARI in der Praxis verfugbar.

https://link.springer.com/content/pdf/10.1007%2Fs00390-008-0015-y.pdf

ZusammenfassungHintergrundDer zunehmende Stellenwert der nichtinvasiven Beatmung (NIV) in der Therapie der akuten respiratorischen Insuffizienz (ARI) ist durch klinische Studien untermauert. Eine neue S3-Leitlinie macht das evidenzbasierte Wissen über Indikationen und Grenzen der NIV bei ARI in der Praxis verfügbar.MethodenAn der Entwicklung der Leitlinie beteiligten sich 28 Experten aus 10 medizinischen Fachgesellschaften. Zirka 2900 Veröffentlichungen wurden systematisch analysiert. In 2 Konsensuskonferenzen wurden die Kernaussagen verabschiedet.ErgebnisseBei hyperkapnischer ARI verkürzt NIV die Aufenthaltsdauer und verringert die Letalitätsrate auf der Intensivstation [Empfehlungsgrad A (A)]. Patienten mit kardialem Lungenödem sollten mit NIV (bzw. „Continuous positive airway pressure“, CPAP) behandelt werden (A). Bei immunsupprimierten Patienten mit ARI senkt NIV die Letalitätsrate (A). In der Postextubationsphase und im „Weaning“ bei hyperkapnischer ARI senkt NIV das Risiko der Reintubation (A). Patienten, die eine Intubation ablehnen, können mit NIV behandelt werden (B). In der Pädiatrie wird NIV bei verschiedenen Indikationen eingesetzt (C). Bei Patienten mit „Acute respiratory distress syndrome“ (ARDS) ist NIV wegen der hohen Misserfolgsrate nicht generell zu empfehlen.FazitNoch ist die NIV an die Akutmedizin nicht so fest verankert, wie es aufgrund der wissenschaftlichen Evidenz zu erwarten wäre. Diese Leitlinie soll dazu beitragen, die NIV als Therapie der ARI breiter zu etablieren.AbstractBackgroundScientific evidence is accumulating that non-invasive ventilation (NIV) may be beneficial for different patient groups with acute respiratory insufficiency (ARI). The aim of the new S3 guidelines is to propagate evidence-based knowledge about the indications and limitations of NIV in clinical practice.MethodsA total of 28 experts from 10 German medical societies were involved in the process of development of the present guidelines. These experts systematically analyzed approximately 2,900 publications. Finally, the recommendations were discussed and approved in two consensus conferences.ResultsIn hypercapnic ARI, NIV reduces the length of stay and mortality during intensive care treatment [grade A recommendation (A)]. Patients with cardiopulmonary edema should be treated with continuous positive airway pressure (CPAP) or NIV (A). For immunocompromized patients with ARI, NIV reduces the mortality (A). In patients with hyper-capnic postextubation respiratory failure and during weaning from mechanical ventilation, NIV reduces the risk of reintubation (A). For patients who decline to be ventilated invasively, NIV may be an acceptable alternative (B). Non-invasive ventilation can also successfully be used in pediatric patients with ARI caused by different reasons (C). In acute respiratory distress syndrome (ARDS) NIV cannot generally be recommended because the failure rate is relatively high.ConclusionNIV is still not as widely implemented in clinical medicine as would be expected on the basis of the scientific literature. The aim of the present guidelines is to further propagate NIV for the treatment of ARI.

[Non-invasive mechanical ventilation in acute respiratory failure].

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Nicht-invasive Beatmung als Therapie der akuten respiratorischen Insuffizienz

[Non-invasive ventilation as treatment for acute respiratory insufficiency. Essentials from the new S3 guidelines].

Nichtinvasive Beatmung als Therapie der akuten respiratorischen Insuffizienz

Nichtinvasive Beatmung als Therapie der akuten respiratorischen Insuffizienz

[Non-invasive mechanical ventilation in acute respiratory failure].