Chronic noninvasive ventilation in COPD:Identifying targets and patients who benefit

Patients with severe COPD have an indication for chronic noninvasive ventilation (NIV) in case they suffer chronic hypercapnia (PaCO2 > 6.0 kPa). However, the precise mechanisms by which chronic NIV leads to improved outcomes are not well understood, and it remains unclear what the intended goals of NIV should be. Additionally, approximately 30% of patients subjectively do not experience a relevant benefit from the treatment. This thesis first summarizes the scientific evidence supporting chronic NIV. It also investigates the relationship between the improvement in hypercapnia and NIV outcomes (quality of life and survival). A final objective was to explore which COPD phenotype experiences the greatest improvement in quality of life.There is sufficient scientific evidence to support the use of chronic NIV in COPD patients with chronic hypercapnia, but there is considerable variation in the change in quality of life after initiating NIV. Chronic NIV results in the greatest improvement in quality of life in patients with severe airflow obstruction, frequent COPD exacerbations, comorbid mood disorders, and in patients who are able to maintain the improvement in hypercapnia during daytime spontaneous breathing.We concluded that it is insufficient to set the indication for chronic NIV solely based on the presence of chronic hypercapnia (a single PaCO2 value). To achieve a relevant improvement in quality of life, however, a significant reduction in hypercapnia must be targeted with NIV

Improvement in hypercapnia does not predict survival in COPD patients on chronic noninvasive ventilation

Purpose: It has recently been shown that chronic noninvasive ventilation (NIV) improves a number of outcomes including survival, in patients with stable hypercapnic COPD. However, the mechanisms responsible for these improved outcomes are still unknown. The aim of the present study was to identify parameters associated with: 1) an improved arterial partial pressure of carbon dioxide (PaCO2) and 2) survival, in a cohort of hypercapnic COPD patients treated with chronic NIV. Patients and methods: Data from 240 COPD patients treated with chronic NIV were analyzed. Predictors for the change in PaCO2 and survival were investigated using multivariate linear and Cox regression models, respectively. Results: A higher level of bicarbonate before NIV initiation, the use of higher inspiratory ventilator pressures, the presence of anxiety symptoms, and NIV initiated following an exacerbation compared to NIV initiated in stable disease were associated with a larger reduction in PaCO2. A higher body mass index, a higher FEV1, a lower bicarbonate before NIV initiation, and younger age and NIV initiation in stable condition were independently associated with better survival. The change in PaCO2 was not associated with survival, neither in a subgroup of patients with a PaCO2 >7.0 kPa before the initiation of NIV. Conclusion: Patients with anxiety symptoms and a high bicarbonate level at NIV initiation are potentially good responders in terms of an improvement in hypercapnia. Also, higher inspiratory ventilator pressures are associated with a larger reduction in PaCO2. However, the improvement in hypercapnia does not seem to be associated with an improved survival and emphasizes the need to look beyond PaCO2 when considering NIV initiation

Rezension: Roll, Heike; Baur, Rupprecht; Okonska, Dorota & Schäfer, Andrea (2017): Sprache durch Kunst. Lehr- und Lernmaterialien für einen fächerübergreifenden Deutsch- und Kunstunterricht. Münster/New York: Waxmann

Obwohl dank Migrationsbewegungen kulturelles Lernen als wichtiger denn je an-gesehen werden könnte, werden weiterhin Gelder für den Kunstunterricht gekürzt, außerschulische Aktivitäten für dieses Fach geraten ganz aus dem Fokus. Dabei kann im handlungsorientierten Unterricht mit Kunst nicht nur kulturelles, sondern auch soziales, kreatives und sprachliches Lernen stattfinden. Dies möchten auch Roll u.a. mit ihren 2017 erschienenen Handreichungen zeigen

Keying Process

The current process for setting guide keys into aluminum extrusions is performed manually. It is a tedious and unergonomic process. The team needs to evaluate the process for improvement or replacement

Population, Ecology, and the American Indian: A Native American Curriculum Unit for Middle High School. NATAM XII.

Training Center for Community Programs; College of Education, Training of Teacher Trainers Program; and Minnesota Federation of Teachers

Cardinal IG: Keying Process

The current process for setting guide keys into aluminum extrusions is performed manually. It is a tedious and unergonomic process. The team needs to evaluate the process for improvement or replacement. The keying process is done by hand. Each key has to be placed in a channel one by one. Then keys are secured into the channels by using a wooden block which is smashed against the keys. This process is taking too much time, and it is hard on the employee’s hands. When attempting to secure the keys in the channels, a hole begins to wear into their gloves. The employee attempted to fix this problem by placing a piece of cardboard into their glove. Currently, they only have two employees completing this task. One of these employees rarely does this task. This problem needs to be addressed because the person completing it is currently a manager and could be doing more important things. This task is also disliked by the employees and by reducing time completing this task, it would also increase their morale

Social and environmental factors modulate leucocyte profiles in free-living Greylag geese (Anser anser)

Background. Blood parameters such as haematocrit or leucocyte counts are indicators of immune status and health, which can be affected, in a complex way, by exogenous as well as endogenous factors. Additionally, social context is known to be among the most potent stressors in group living individuals, therefore potentially influencing haematological parameters. However, with few exceptions, this potential causal relationship received only moderate scientific attention. Methods. In a free-living and individually marked population of the highly social and long-lived Greylag goose, Anser anser, we relate variation in haematocrit (HCT), heterophils to lymphocytes ratio(H/L) and blood leucocyte counts to the following factors: intrinsic (sex, age, raising condition, i.e. goose- or hand-raised), social (pair-bond status, pair-bond duration and parental experience) and environmental (biologically relevant periods, ambient temperature) factors. Blood samples were collected repeatedly from a total of 105 focal birds during three biologically relevant seasons (winter flock, mating season, summer). Results. We found significant relationships between haematological parameters and social as well as environmental factors. During the mating season, unpaired individuals had higher HCT compared to paired and family individuals and this pattern reversed in fall. Similarly, H/L ratio was positively related to pair-bond status in a seasonally dependent way, with highest values during mating and successful pairs had higher H/L ratio than unsuccessful ones. Also, absolute number of leucocytes tended to vary depending of raising condition in a seasonally dependent way. Discussion. Haematology bears a great potential in ecological and behavioural studies on wild vertebrates. In sum we found that HTC, H/L ratio and absolute number of leucocytes are modulated by social factors and conclude that they may be considered valid indicators of individual stress load

Home ventilation for patients with end-stage chronic obstructive pulmonary disease

Purpose of the review The number of patients with end-stage chronic obstructive pulmonary disease (COPD) treated with chronic non-invasive ventilation (NIV) has greatly increased. In this review, the authors summarize the evidence for nocturnal NIV and NIV during exercise. The authors discuss the multidisciplinary and advanced care of patients with end-stage COPD treated with NIV. Recent findings Nocturnal NIV improves gas exchange, health-related quality of life and survival in stable hypercapnic COPD patients. Improvements in care delivery have been achieved by relocating care from the hospital to home based; home initiation of chronic NIV is feasible, non-inferior regarding efficacy and cost-effective compared to in-hospital initiation. However, the effect of NIV on symptoms is variable, and applying optimal NIV for end-stage COPD is complex. While exercise-induced dyspnoea is a prominent complaint in end-stage COPD, nocturnal NIV will not change this. However, NIV applied solely during exercise might improve exercise tolerance and dyspnoea. While chronic NIV is often a long-standing treatment, patient expectations should be discussed early and be managed continuously during the treatment. Further, integration of advance care planning requires a multidisciplinary approach. Summary Although chronic NIV is an effective treatment in end-stage COPD with persistent hypercapnia, there are still important questions that need to be answered to improve care of these severely ill patients.Peer reviewe