BACKGROUND AND OBJECTIVE:Incident airflow limitation is frequently diagnosed at advanced stages. Identifying individuals at risk through primary care spirometry may enable earlier intervention, yet validated, pragmatic frameworks remain lacking. METHODS:We applied a framework of three mutually exclusive spirometric at-risk phenotypes, termed Three-Phenotype Spirometry-Based Identification (hereafter TriSpi), to 6123 participants from two population-based cohorts: KORA (n = 1973, 3-year Follow-up, derivation) and SHIP (n = 4150, 5-year Follow-up, validation). TriSpi+ individuals were defined as meeting criteria for one of the three phenotypes: Early airflow limitation (EAL, FEV1/FVC > 0.7 and < 10th percentile or < 0.7 and > 5th percentile), small airway dysfunction (SAD) defined using FEF50- or FEF75-based thresholds; and preserved-ratio impaired-spirometry (PRISm). Associations with incident airflow limitation were tested using Firth's regression. RESULTS:EAL, PRISm, and SAD (defined using either FEF50 or FEF75-based thresholds) were significantly associated with incident airflow limitation across cohorts and follow-ups. TriSpi+ individuals accounted for 26%-36% of the population, identifying 74%-93% of future cases, while TriSpi+ was associated with a 10-25-fold increase in risk. Negative predictive values exceeded 95% across definitions, and the number needed to screen among TriSpi+ individuals ranged from 7 to 13. EAL showed the strongest individual association (OR up to 53.2), while SAD was more common in younger adults. CONCLUSION:Combining definitions for EAL, PRISm, and SAD enables robust prediction of incident airflow limitation. TriSpi may serve as a scalable, pragmatic approach for early risk stratification in primary care, in absence of post-BD spirometry.

Study objectives Sleep and physical fitness are interrelated, with cardiovascular risk factors potentially influencing this relationship. Sleep disturbances and reduced exercise capacity are linked to higher mortality. This study examined associations between sleep characteristics, cardiopulmonary exercise testing (CPET) measures and all-cause mortality, and assessed whether reduced exercise capacity mediates the link between impaired sleep and mortality. Methods We analysed 1001 participants from the population-based SHIP-TREND cohort (2008–2012) who underwent single-night polysomnography and symptom-limited CPET. Associations between sleep and CPET measures, as well as mortality, were assessed using multivariable linear and Cox regression models. Results The mean age of participants was 54 (range 44–63) years; 47.1% were women. The apnoea–hypopnoea index (AHI) was 4.9 (95% CI 1.4–13.7) events·h −1 and higher in men (7.9, 95% CI 2.6–18.8) than in women (2.6, 95% CI 0.7–9.2; p<0.001). Peak oxygen uptake ( V ′ O 2 peak ) was lower in women (22 (95% CI 18–25) mL·min −1 ·kg −1 ) than in men (27 (95% 22–32) mL·min −1 ·kg −1 ; p<0.001). Higher AHI and oxygen desaturation index were inversely associated with V ′ O 2 peak . Over a median 10.3-year follow-up, 73 deaths occurred. AHI was significantly associated with all-cause mortality across models (hazard ratio 1.31–1.72). Mediation analysis demonstrated a significant direct effect, whereas the indirect effect via V ′ O 2 peak was not statistically significant. Conclusions In the SHIP-TREND-0 cohort, elevated AHI is associated with reduced V ′ O 2 peak and increased all-cause mortality. Mediation analysis suggested a possible, but not statistically significant, contribution of impaired cardiopulmonary fitness to the relationship between sleep apnoea and mortality, highlighting a potential role of fitness that warrants further investigation.

Obstructive sleep apnea (OSA) and smoking are both prevalent and impactful health risks. While smoking may contribute to OSA through inflammatory and neuromuscular pathways, population-based evidence on this relationship remains limited and inconsistent. A sample (N = 1,206) from the population-based Study of Health in Pomerania with complete overnight polysomnography and smoking assessment was investigated in a cross-sectional study for an association between OSA and former as well as recent smoking status. Regression models adjusted for Age and BMI were applied. Current smoking was significantly associated with increased apnea-hypopnea-index (AHI) severity (OR = 1.75, 95% CI [1.27; 2.41], p < .001), with stratified analyses confirming the effect across younger and older participants. Former smokers also showed significantly elevated AHI severity compared to never-smokers (OR = 1.76, 95% CI [1.27; 2.43], p < .001). Both current and former smoking were significantly associated with greater OSA severity in this population-based sample, even after accounting for age and BMI. The findings underscore the long-term respiratory consequences of smoking and highlight the need for integrated approaches in smoking cessation and OSA screening.

Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder that is diagnosed more frequently in men. The aim of this population-based cross-sectional study was to describe sex-specific differences in sleep stage distribution and subjective daytime sleepiness in individuals with OSA. Special attention was given to the distribution of the apnea-hypopnea index (AHI) in rapid eye movement (REM) and non-REM sleep. This study analyzed data from the SHIP-TREND-0 cohort, a population-based study from northeastern Germany. Standardized polysomnography identified 604 participants with an AHI ≥ 5 (395 men, 209 women) who were included in this study. In addition, daytime sleepiness was recorded using the Epworth Sleepiness Scale (ESS). Sex differences were analyzed descriptively and evaluated according to effect sizes. Compared to males, females were on average older and had higher BMI values. Women showed descriptively higher AHI values in REM sleep than in non-REM sleep, whereas men exhibited a more balanced distribution of AHI across sleep stages. Women had a longer REM sleep latency (d = 0.36). Our results indicate sex-specific differences in the distribution of obstructive events across sleep stages. The AHI during REM sleep should receive greater consideration in the diagnosis and assessment of severity, particularly in women. Further population-based studies are needed to confirm these findings and evaluate their clinical relevance.

We investigated associations of movement behaviors (moderate-vigorous physical activity, light physical activity, and stationary time) with various parameters measured during cardiopulmonary exercise testing. We applied compositional data analysis to account for the relative contributions of different movement behaviors to the overall time budget of the waking day. We used data from 1,396 participants of the cross-sectional population-based Study of Health in Pomerania (SHIP-TREND-1), who provided valid accelerometer data worn on the hip for seven days during waking hours and participated in cardiopulmonary exercise testing on a cycle ergometer (n = 1,396 participants with a mean age of 57.1 (SD 13.2, 51% men). Linear regression models applying compositional data analysis were used to examine associations of proportions of movement behaviors (exposure) with parameters derived during cardiopulmonary exercise testing (outcome) normalized for body weight and stratified by sex. Models were adjusted for age, education, smoking, and partnership, except the %predicted VO2peak model, where age was omitted, as it is part of the calculation of the %predicted VO2peak. In models examining O2pulse or HRmax, individuals using beta blockers were excluded. In males and females, more time spent in moderate-to-vigorous physical activity was associated with greater VO2VT1, VO2peak, and VO2 recovery after 60 s (all p < 0.01). Greater moderate-to-vigorous physical activity was also related to higher %predicted VO2peak and maximum heart rate in males and to higher VO2/work in females (all p < 0.01). In both sexes, more time in stationary time was associated with less %predicted VO2peak (p < 0.01). More light intensity physical activity was associated to higher %predicted VO2peak in both sexes and with lower VO2/work in women (all p < 0.01). Greater stationary time was related to less VO2/work, VO2VT1, and VO2peak in males and to less VO2 recovery after 60 s and O2pulse in females (p values < 0.05). Moderate-to-vigorous physical activity (positive) and stationary time (inverse) influence parameters derived during cardiopulmonary exercise testing irrespective of age, smoking, and living in a relationship. The sex specific effects were rather small. Hence, promoting physical activity should be encouraged to increase cardiorespiratory fitness.

Introduction: Prolonged weaning from invasive mechanical ventilation remains a major clinical challenge. While outcomes from certified weaning centers are increasingly documented, data on long-term survival and post-discharge trajectories are limited. This study evaluated both in-hospital weaning outcomes and long-term survival in patients treated at two specialized weaning centers in Germany. METHODS:We conducted a retrospective cohort study using the WeanNet registry, focusing on patients admitted for prolonged weaning between 2016 and 2020 at two centers (Greifswald and Hemer). After data cleaning, 718 patients (Greifswald: 337; Hemer: 381) were included. The 3-year follow-up was performed using structured outpatient assessments, clinical records, and telephone interviews. RESULTS:In-hospital mortality was markedly lower in both centers (Greifswald: 6.2%; Hemer: 3.4%) compared to national WeanNet data (13.4%). Among discharged patients, increased age, discharge with invasive ventilation (hazard ratio [HR] 2.60; 95% confidence interval [CI]: 1.99-3.39), and tracheostomy without ventilation (HR 1.90; 95% CI: 1.40-2.60) were significantly associated with higher 36-month mortality. Comorbidities such as left heart failure, thoracorestrictive disease, chronic kidney disease, oncologic disease, and diabetes were also linked to poorer outcomes. CONCLUSION:Patients discharged with invasive ventilation or tracheostomy exhibit significantly reduced long-term survival, highlighting the urgent need for structured post-discharge care pathways. Regular re-evaluation of weaning potential and tracheostomy decannulation should be integrated into follow-up programs to improve outcomes in this vulnerable population. .

Background: The term preserved ratio impaired spirometry (PRISm) is defined as post-bronchodilator forced expiratory volume in 1 s (FEV1) <80% predicted and FEV1/forced vital capacity (FVC) ratio ≥0.7 or ≥lower limit of normal (LLN). The population prevalence is estimated to be between 3% and 20%. PRISm does not indicate a specific lung disease but is associated with functional limitations, respiratory symptoms, comorbidities, and mortality. The aim of this study is to analyze the PRISm prevalence in an excellently characterized epidemiological study, to obtain better insight into the influence of comorbidities on PRISm development and its impact on overall mortality. Methods: We included 3403 healthy subjects from the Study of Health in Pomerania (SHIP) and 507 individuals with PRISm. Data from lung function testing, cardiopulmonary exercise testing (CPET), and echocardiography were compared in both groups. Comorbidities, as well as cardiovascular and all-cause mortality data, were analyzed. Results: Individuals in the PRISm group reported more often a history of myocardial infarction, hypertension, type 2 diabetes, dyspnea, and lung disease, and had more unfavorable median values for most of the lung function, CPET, and echocardiographic parameters compared to the non-PRISm group. Furthermore, they were older, more often current smokers, and had higher body fat marker values. Likewise, all-cause and cardiovascular death were more frequently observed in the PRISm group. Conclusions: Future studies are warranted to identify the underlying mechanisms and longitudinal progression of PRISm. However, our findings reveal that PRISm is not only associated with cardiovascular comorbidities but also with increased dyspnea, an impaired exercise capacity, and mortality.

Rationale:Inspiratory capacity (IC) should increase during exercise to allow unrestrained tidal volume expansion, mitigating uncomfortable respiratory sensations. However, preliminary evidence suggests that this is not universally seen in healthy individuals. Whether this negatively impacts on inspiratory reserves and dyspnoea remains unclear. To gain novel insights on the regulation of operating lung volumes in community-dwelling individuals, we determined the association of a lack of increase in IC during incremental cardiopulmonary exercise testing (dynamic inspiratory capacity (ICdyn)) with demographic, anthropometric and respiratory functional data in a large population-based study. Methods:We reviewed general characteristics, pulmonary function and cycle ergometer data from 1065 healthy individuals (51.5% women, aged 20-86 years) with normal lung function. Measurements and main results:ICdyn remained unchanged or decreased from rest to peak exercise (Δ (peak-rest) ICdyn ≤0 L) in 245/1065 individuals (23.0%). Tidal volume increased to a lower extent after the ventilatory threshold compared to earlier exercise in these subjects; thus, peak end-inspiratory lung volume (EILV) and EILV/total lung capacity were similar to subjects showing ICdyn >0 L despite higher EILVs. Albeit statistically significant, between-group differences in peak dyspnoea scores were modest (p=0.049). Multivariable regression revealed that age (particularly in women), higher body mass index and higher resting airway resistance were independently associated with ΔICdyn ≤0 L (p<0.001). Conclusions:Elderly women and overweight/obese individuals may fail to increase ICdyn during incremental exercise due to dynamic hyperinflation. Careful regulation of tidal volume, however, avoids critically high inspiratory constraints and limiting exertional dyspnoea.

Some of the patients with SARS-CoV-2 infection (COVID-19) received invasive ventilation during inpatient care. Weaning from ventilation was difficult for some patients (so-called prolonged weaning). PATIENTS:Patients (n=751) with prolonged weaning (reason for ventilation "pneumonia" and "acute respiratory failure") from four centers for the period 2011-23 from the "WeanNet" registry were used as a matched group. RESULTS:The median duration of intensive medical care was 39 (25-68) days. In 19% (37/193) of patients, ECMO support was necessary for a median of 27 (18-51) days. In-hospital mortality was 8.3% (2.7% with vs. 9.6% without ECMO) and 6.8% died in the comparison group. At discharge, 84% (vs. 77% in the control group) were completely weaned and 2.6% (vs. 17.6% in the control group) of patients received non-invasive treatment. Invasive ventilation was still necessary in 7.8% (control group 15.7%). In the observation period of 6 months after discharge, 22.4% of patients required inpatient care and a further 14.1% after 12 months. The overall mortality at 12-month follow-up was 20,6% (5.6% with vs. 24.6% without ECMO). DISCUSSION:The mortality rate of ventilated patients with COVID-19 was very low at 8.3% in the four weaning centers studied. The mortality rate of patients with ECMO treatment was only 2.7%. The mortality rate in the control group was 7.3%. The lower mortality of patients with ECMO treatment was also evident at follow-up of up to 12 months.Patients with prolonged weaning who received invasive ventilation due to COVID-19 showed comparable results in terms of successful weaning and mortality compared to a control group from the WeanNet registry. The long-term results with a survival of more than 80% for the first year after discharge were encouraging.

Recently, the parameter internal work (IW) has been introduced as change in oxygen uptake (VO2) between resting and unloading workload in cardiopulmonary exercise testing (CPET). The proportional IW (PIW) was defined as IW divided by VO2 at peak exercise. A second option is to calculate the PIW based on the workload [PIW (Watt)] by considering the aerobic efficiency. The aim of our study was to investigate whether IW and PIW differ between patients with and without pulmonary hypertension and healthy controls. Our study population consisted of 580 patients and 354 healthy controls derived from the Study of Health in Pomerania. The PIW was slightly lower in patients (14.2%) than in healthy controls (14.9%; p = 0.030), but the PIW (Watt) was higher in patients (18.0%) than in the healthy controls (15.9%; p = 0.001). Such a difference was also observed, when considering only the submaximal workload up to the VAT (19.8% in patients and 15.1% in healthy controls; p < 0.001). Since the PIW (Watt) values were higher in patients with pulmonary hypertension, this marker may serve as a useful CPET parameter in clinical practice. In contrast to most of the currently used CPET parameters, the PIW does not require a maximal workload for the patient. Further studies are needed to validate the prognostic significance of the PIW.

Die Beeinträchtigung der Schlafqualität sowie unterschiedliche Schlafstörungen haben einen negativen Einfluss auf die kognitive und körperliche Leistungsfähigkeit. Bei länger bestehenden Störungen sind die kardiovaskuläre Morbidität und Mortalität erhöht.

Parameters of cardiopulmonary exercise testing significantly discriminate between healthy subjects and patients with pulmonary hypertension (PH), also according to the new 2022 definition of pulmonary hypertension (mean pulmonary arterial pressure mPAP > 20 mmHg). The cut-offs indicating on PH were peakVO2 ≤ 16.7 mL/min/kg (Youden-Index YI = 0.79), petCO2@AT ≤ 34 mmHg (YI = 0.67), and VE/VCO2@AT ≤ 30 (YI = 0.76).

Abstract Background While physical activity and cardiorespiratory fitness are often considered as surrogates, their exact relationship remains unclear. Besides cardiorespiratory fitness (i.e., maximal oxygen consumption; VO2peak), other parameters can be measured by cardiopulmonary exercise testing (CPET). Information from these may lead to a better understanding of the systemic response to physical activity. Compositional data analysis is a novel method that accounts for the relative contribution of different movement behaviours to the overall time budget of the waking day. Purpose The aim was to investigate associations of moderate-vigorous physical activity (MVPA), light physical activity (LPA), and sedentary time (ST) with the following parameters: VO2 at rest, VO2 at the anaerobic threshold (VO2VT1), VO2peak, VO2 recovery 60s, predicted VO2peak, change of VO2 with increasing work (VO2/work), O2 pulse, and maximum heart rate. Methods In total, complete data was used from 1396 participants of the population-based Study of Health in Pomerania (SHIP-TREND-1) who wore ActiGraph GT3X+ accelerometers (Pensacola, FL) on the hip for seven consecutive days and performed CPET on a cycle ergometer. Linear regression models were used to examine associations of movement behaviours with CPET parameters, normalized for body weight and stratified by sex. Models were adjusted for age, smoking, education, and living in a partnership. According to compositional data analysis, MVPA, LPA, and ST were expressed as proportions of total accelerometer wear time and transformed into isometric log-ratios. Because regression coefficients and confidence intervals are not directly interpretable, they are omitted in the results section. Results Participants were on average 57.1 years old (SD 13.2) and 51 % were men. The mean accelerometer wear time was 14.4 hours/day (SD 1.5). The mean proportion of time spent in MVPA, LPA, and ST was 5 %, 24 %, and 71 %, respectively. In both men and women, the proportion of time spent in MVPA was positively associated with VO2VT1, VO2peak, predicted VO2peak, and VO2 recovery 60s. Higher MVPA was also related to higher maximum heart rate in men and to higher VO2/work in women. In both sexes, the proportion of time spent sedentary was inversely associated with predicted VO2peak. Higher ST was also related to lower VO2VT1, VO2peak, and VO2/work in men and to lower VO2 recovery 60s and O2 pulse in women. The proportion of time spent in LPA was inversely associated to VO2/work in women, only. All other associations were not statistically significant (p values > 0.05). Conclusion Proportions of MVPA, LPA, and ST were differently associated with various CPET parameters and these relations differed by sex. Our findings suggest that the relative amount of time spent in different movement behaviours contribute differently to systemic response to physical activity and ST.

Zusammenfassung Bei einem Teil der Patienten mit SARS-CoV-2-Infektion (COVID-19) erfolgte während der stationären Betreuung eine invasive Beatmung. Die Entwöhnung von der Beatmung gestaltete sich bei einigen Patienten schwierig (sog. prolongiertes Weaning). Patienten Wir haben retrospektiv Patientencharakteristika und Outcome von 193 Patienten mit COVID-19-assoziierter invasiver Beatmung mit prolongiertem Weaning an vier deutschen Weaning-Zentren erfasst. Als Vergleichsgruppe wurden Patienten (n=751) mit prolongiertem Weaning (Grund der Beatmung „Pneumonie“ und „Akutes Lungenversagen“) aus diesen vier Zentren aus den Jahren 2011–2023 aus dem „WeanNet“-Register herangezogen. Ergebnisse Im Median betrug die intensivmedizinische Betreuung 39 (25–68) Tage. Bei 19% (37/193) der Patienten war im Median für 27 (18–51) Tage eine ECMO-Unterstützung notwendig. Die Sterblichkeit im Krankenhaus betrug 8,3% (2,7% mit vs. 9,6% ohne ECMO) und in der Vergleichsgruppe verstarben 6,8%. Bei Entlassung waren 84% (Vergleichsgruppe 77%) komplett entwöhnt, bei 2,6% (Vergleichsgruppe 17,6%) der Patienten erfolgte eine NIV-Behandlung. Bei 7,8% (Vergleichsgruppe 15,7%) war weiterhin eine invasive Beatmung notwendig. Im Beobachtungszeitraum von 6 Monaten nach Entlassung war bei 22,4% und nach 12 Monaten bei weiteren 14,1% der Patienten eine stationäre Betreuung notwendig. Die Gesamtsterblichkeit im Follow-up nach 12 Monaten betrug 20,6% (5,6% mit vs. 24,6% ohne ECMO). Diskussion Die Sterblichkeit von beatmeten Patienten mit COVID-19 war in den vier untersuchten Weaning-Zentren mit 8,3% sehr gering. Die Sterblichkeit der Patienten mit einer ECMO-Behandlung lag bei lediglich 2,7%. Die Sterblichkeit in der Vergleichsgruppe wurde mit 7,3% ermittelt. Die geringere Sterblichkeit der Patienten mit einer ECMO-Behandlung zeigte sich auch bei Nachbeobachtung mit bis zu 12 Monaten. Die aufgrund von COVID-19 invasiv beatmeten Patienten mit prolongiertem Weaning zeigten sowohl hinsichtlich erfolgreicher Entwöhnung als auch im Hinblick auf die Sterblichkeit vergleichbare Ergebnisse im Vergleich zu einer Kontrollgruppe aus dem WeanNet-Register. Die Langzeitergebnisse mit einem Überleben von mehr als 80% für das erste Jahr nach Entlassung waren ermutigend.

ZusammenfassungAktuell ist ein breites Spektrum von Substanzen zur Behandlung von Patienten mit pulmonaler arterieller Hypertonie verfügbar. Die aktuellen Empfehlungen orientieren sich bei der initialen medikamentösen Therapie an dem Risiko der Patienten. Bei Patienten mit hohem Risiko wird schon initial eine Triple-Kombination verschiedener Substanzen unter Einbeziehung von Prostanoiden empfohlen. In der prospektiven, einarmigen, unverblindeten Studie sollte geklärt werden, ob PAH-Patienten unter einer Triple-Therapie von der Umstellung von Selexipag auf intravenöses Treprostinil profitieren. Primärer Endpunkt war das Erreichen eines „Low-Risk“-Status nach 6 (12) Monaten. Es wurden 27 PAH-Patienten (45 [37; 61] Jahre, 77,8% Frauen) eingeschlossen. Bei Studienbeginn wurden sie einem „Low-Risk“- (n=1), „Intermediate“- (n=12) oder „High-Risk“-Status (n=14) zugeordnet. Eine Verlaufsbeobachtung erfolgte im Mittel über 8 (Spanne 5–11) Monate bei 22 Patienten. Ein Patient wurde nach 4 Monaten erfolgreich transplantiert, weitere 4 Patienten verstarben (in 1 Fall septische Komplikationen unklarer Genese; in 3 Fällen progredientes Rechtsherzversagen). Der primäre Endpunkt (Erreichen des „Low-Risk“-Status) wurde von 12/21 (57,1%) Patienten erreicht (ein weiterer Patient verblieb im „Low-Risk“-Status). Diese Daten geben (trotz der geringen Zahl von Patienten) einen Hinweis darauf, dass auch bei etablierter Triple-Therapie durch den Wechsel von Selexipag auf intravenöses Treprostinil eine klinische Verbesserung einzelner Patienten möglich ist.

Jüngst wurde über neue Parameter bei der Spiroergometrie, CPET ("Internal work, IW" bzw. "Proportional IW, PIW") aus der Framingham Kohorte berichtet. Diese Werte charakterisieren den "Arbeitsaufwand" beim Wechsel von Ruhe in den Zustand der Bewegung. Erste Ergebnisse weisen darauf hin, dass diese Parameter eine gute Assoziation zu bekannten kardiovaskulären Risikofaktoren aufweisen. Wir haben zeigen können, dass diese Parameter bei Gesunden eine zusätzliche unabhängige prognostische Bedeutung haben.