Elektrische Atemwegsstimulation zur Therapie der obstruktiven Schlafapnoe

Obstructive sleep apnea (OSA) is characterized by recurrent episodes of pharyngeal collapse resulting from a decrease in tone of the dilatory musculature of the pharynx. Electrical stimulation of the hypoglossal nerve is a new clinical treatment modality for patients with moderate to severe OSA, who do not respond to standard therapy with continuous (CPAP) or automatically adjusted (APAP) positive airway pressure therapy or adjustable mandibular advancement devices. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation (HNS), the results of the large STAR multicenter prospective trial using the Inspire? device were recently published. The results show that HNS can prevent pharyngeal collapse without arousing patients from sleep and HNS with the Inspire? device led to a significant improvement of objective and subjective measurements of the severity of OSA. A limitation of available HNS remains the invasive procedure and the costs involved. Further research is required to define optimal patient selection and device performance and to investigate long-term effectiveness. The absence of a complete circular collapse at the level of the palate as documented during drug-induced sleep endoscopy can predict success with implanted HNS therapy and is therefore a requirement for the implantation of the Inspire? device, which is rarely effective in cases with complete concentric collapse at the level of the soft palate. It is strongly recommended that implantation of HNS devices is performed only in experienced centers with multidisciplinary sleep medicine teams. The recruitment of patients in clinical trials and enrollment in registries could help to control quality and costs.     

Auswirkungen der Schlafapnoe auf andere Organsysteme

Obstructive sleep apnea is characterized by repetitive apneas and hypopneas and respiratory efforts against the occluded pharynx. Its immediate pathophysiological sequelae include hypoxia, arousal from sleep, and repetitive surges of sympathetic activity, heart rate an arterial as well as pulmonary arterial pressure. This report outlines the long-term pathophysiological consequences of obstructive sleep apnea (e.g. hypertension, endothelial dysfunction, metabolic dysregulation and acceleration of atherosclerosis), which ultimately contribute to a threefold increase in the risk of cardio and cerebrovascular diseases such as myocardial infarction and stroke in patients with severe sleep apnea. Moreover, the role of sleep apnea in promoting the progression of heart failure is described.     

Moderne Therapie der Schlafapnoe

There are different treatment options for obstructive sleep apnea, which are selectively used based on severity of sleep apnea, physical structure of the upper airway, and other medical aspects including co-morbidities. Weight loss as well as avoidance of alcohol and other CNS depressants is generally recommended. Positional training, oral appliances and surgery of the upper airways are used in selected cases. CPAP is the most effective method for treating obstructive sleep apnea irrespective of disease severity. In patients with central sleep apnea or Cheyne-Stokes respiration (CSA/CSR) diagnosis and treatment of the underlying cause is mandatory. Adaptive servo-ventilation appears to be an effective treatment modality for patients with complex sleep apnea and with CSA/CSR that is resistant to CPAP.     

Kardiale Probleme in der Schwangerschaft

All women of child-bearing age suffering from congenital cardiac valve malformations or acquired valvular disease, pulmonary hypertension or arterial hypertension and who are at risk for coronary heart disease should receive early counseling and optimal treatment before pregnancy. They should be treated by an interdisciplinary team composed of gynecologists, cardiologists, geneticists and, if necessary, cardiac surgeons. This interdisciplinary approach should be used for all pregnant women with cardiac disease in order to minimize maternal and fetal mortality. As physicians will only rarely be confronted with such critically ill patients, guidelines and access to worldwide information from databanks are particularly important (http://www.safetus.com und http://www.emryotox.de).     

Kardiale Wirkungen der nicht-invasiven Beatmung

Noninvasive ventilation is becoming increasingly important in the treatment of acute and chronic respiratory failure. However, noninvasive ventilation not only influences respiratory failure but also cardiac (dys-)function. Furthermore, cardiac comorbidities are often present in systemic diseases with respiratory failure such as COPD or obesity hypoventilation syndrome. This review covers the (patho-)physiological causes of hypoxic and hypercapnic respiratory insufficiency and its treatment with noninvasive ventilation. A special focus on acute and chronic effects on cardiac function will be addressed.     

Pathophysiologie der chronisch obstruktiven Lungenerkrankung

Zusammenfassung Die chronisch obstruktive Lungenerkrankung (chronic obstructive pulmonary disease, COPD) gehört neben Asthma bronchiale zu den sozioökonomisch bedeutsamsten Lungenerkrankungen. Trotz dieser sozioökonomischen Bedeutung und der hohen Prävalenz gibt es noch immer eine Vielzahl ungeklärter Fragen bezüglich Pathogenese und Pathophysiologie. Diesbezüglich konnten wesentliche neue Erkenntnisse in jüngsten Arbeiten gewonnen werden. Die vorliegende Analyse bietet eine Zusammenfassung dieser Erkenntnisse und unterscheidet dabei tierexperimentelle und präklinische humane Studien zur Pathophysiologie der Erkrankung.     

Neue Methoden der nasalen Überdrucktherapie bei der Schlafapnoe

Today, we can differentiate between various forms of sleep apnea and sleep-related hypoventilation syndrome. These can be treated with different modes of nasal positive pressure therapy. Bi-level systems are used for patients with a combination of obstructive sleep apnea and obesity hypoventilation syndrome. In patients with obstructive sleep apnea with high pressures, modern pressure relief systems may be employed to ease expiration and reduce mouth leakage. With auto-continuous positive airway pressure (CPAP) systems, the mean treatment pressure may be significantly reduced, especially in patients with positional sleep apnea. Special ventilation modes such as adaptive servo-ventilation are increasingly used, for instance in patients with chronic heart failure and Cheyne-Stokes respiration or “complex sleep apnea”. Such modern differential treatment requires adequate differential diagnostics based on profound pathophysiological understanding.     

Bedeutung der Sputumantibiogramme bei der Behandlung der chronisch obstruktiven Bronchitis

The interpretation of the results in sputum antibiograms is often difficult, due to the questionable importance of individuel bacterial strains in chronic bronchitis. In 90% of the cases studied, Tetracylin gave good clinical results, in spite of “Tetracylin resistance”. In emergency cases previously treated with Tetracylin, one cannot await the results of an antibiogram. With renewed severity of chronic upper-respiratory infection, despite a long course of Tetracylin, immediate Chloramphenicol therapy is recommended, as in these cases it gives the most dependable success. If marked improvement does not occur within two or three days, one should seek a specific chemotherapeutic agent through repeated sputum antibiograms.     

Kardiale Magnetresonanztomographie in der Diagnostik des akuten Koronarsyndroms

In contrast to chronic myocardial infarction, data concerning the value of cardiac magnetic resonance imaging in patients with acute onset of chest pain are still rare. Even in the presence of characteristic clinical parameters, cardiac magnetic resonance imaging might provide independent evidence especially in the absence of typical ECG alterations and prior to biomarker elevation. Besides the ability to demonstrate wall motion abnormalities cardiac magnetic resonance imaging gains additional potential as to the detection of myocardial edema, microvascular obstruction (no-reflow) and myocardial necrosis. However, cardiac magnetic resonance imaging is expensive and time-consuming, and therefore may not be cost-effective. At present, a lack of sufficient diagnostic and prognostic data would make cardiac magnetic resonance imaging unsuitable for routine stratification of chest pain patients in an emergency department.     

Die Differentialdiagnose der obstruktiven Lungenkrankheiten mittels Ganzkörperplethysmographie

Whole body plethysmography has turned out to be a suitable method for simple and speedy differentiation of the several forms of obstructive lung diseases. For this purpose pressure-flow-diagrams are compared with changes of intrathoracic gas volume as a function of time as well as with the influences of drugs on bronchial size. The practical value of this procedure is demonstrated in cases of simple bronchial asthma, asthmatic bronchitis with pulmonary emphysema, emphysema without bronchitis, and subtotal stenosis of one main bronchus caused carcinoma.     

Kardiale Resynchronisationstherapie

Cardiac resynchronization therapy (CRT) is a new concept in the treatment of patients with drug-refractory heart failure (HI). Candidates for CRT are HI patients with NYHA class III-IV, left bundle branch block and QRS width ≥0.12 s. CRT leads to improvements in hemodynamics both acutely and during long-term follow-up, resulting in better cardiopulmonary exercise tolerance. In addition, patients receiving CRT have a better survival rate with or without implantable cardiac defibrillator (ICD) back-up. CRT is possible in patients with atrial fibrillation. CRT with ICD back-up is indicated in patients with HI, low left ventricular function (EF), indication for CRT and coronary artery disease, whereas this question is not fully resolved in patients with dilated cardiomyopathy. CRT patients must be followed up; home monitoring is a very promising approach for quick and safe surveillance of these patients.