Durch die Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) wurde der Auftrag erteilt, die seit 2008 bestehende S2-Leitlinie „Lagerungstherapie zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen“ zu revidieren. Aufgrund zunehmender klinischer und wissenschaftlicher Relevanz wurde die Leitlinie um den Themenkomplex „Frühmobilisation“ erweitert. Damit bezieht sie sich auf folgende thematische Schwerpunkte: Einsatz von Lagerungstherapie und Frühmobilisation zur Prophylaxe pulmonaler Funktionsstörungen, Einsatz von Lagerungstherapie und Frühmobilisation zur Therapie pulmonaler Funktionsstörungen, unerwünschte Wirkungen und Komplikationen von Lagerungstherapie und Frühmobilisation sowie praktische Aspekte beim Einsatz von Lagerungstherapie und Frühmobilisation. Diese Leitlinie ist das Ergebnis einer systematischen Literaturrecherche sowie der anschließenden kritischen Evidenzbewertung mit wissenschaftlichen Methoden. Das methodische Vorgehen des Leitlinienentwicklungsprozesses entspricht den Anforderungen an die evidenzbasierte Medizin, wie sie von der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften als Standard definiert wurden. Bezüglich der Lagerungstherapie wurden neu publizierte Arbeiten ab 2005 untersucht; der neu aufgenommene Aspekt der Frühmobilisation umfasst die gesamte bisher publizierte Literatur bis einschließlich 06/2014. Der vorliegende Beitrag gibt die Kurzversion der Leitlinie wieder.

The German Society of Anesthesiology and Intensive Care Medicine (DGAI) commissioneda revision of the S2 guidelines on "positioning therapy for prophylaxis or therapy of pulmonary function disorders" from 2008. Because of the increasing clinical and scientificrelevance the guidelines were extended to include the issue of "early mobilization"and the following main topics are therefore included: use of positioning therapy and earlymobilization for prophylaxis and therapy of pulmonary function disorders, undesired effects and complications of positioning therapy and early mobilization as well as practical aspects of the use of positioning therapy and early mobilization. These guidelines are the result of a systematic literature search and the subsequent critical evaluation of the evidence with scientific methods. The methodological approach for the process of development of the guidelines followed the requirements of evidence-based medicine, as defined as the standard by the Association of the Scientific Medical Societies in Germany. Recently published articles after 2005 were examined with respect to positioning therapy and the recently accepted aspect of early mobilization incorporates all literature published up to June 2014.

Darstellung der Atemtherapie als Bestandteil im Therapiekonzept bei Bronchiektasen.

A new experimental technique (repeated load annealing of flat wedge shaped specimens) was proposed for characterization of microstructural degradation under creep conditions. This technique was applied to investigate the microstructural degradation of the nickel-base superalloy CMSX-4 in a wide range of temperatures and stress levels. The results obtained allowed to describe analytically the kinetics of rafting, which is important to predict the reduction of fatigue lifetime and yield stress.

Assisted coughing and mechanical cough aids compensate for the weak cough flow in patients with neuromuscular diseases (NMD). In cases with preserved respiratory muscles also breathing techniques and special devices, e. g., flutter or acapella can be used for secretion mobilisation during infections of the airways. These means are summarised as oscillating physiotherapy. Their mechanisms are believed to depend on separation of the mucus from the bronchial wall by vibration, thus facilitating mucus transport from the peripheral to the central airways. In mucoviscidosis and chronic obstructive pulmonary disease their application is established, but there is a paucity of data regarding the commitment in patients with neuromuscular diseases. The effective adoption of simple oscillation physiotherapeutic interventions demands usually a sufficient force of the respiratory muscles--exceptions are the application of the percussionaire (intrapulmonary percussive ventilator, IPV) or high frequency chest wall oscillation (HFCWO). In daily practice there is evidence that patients with weak respiratory muscles are overstrained with the use of these physiotherapeutic means, or get exhausted. A general recommendation for the adoption of simple oscillating physiotherapeutic interventions cannot be made in patients with NMDs. Perhaps in the future devices such as IPV or HFCWO will prove to be more effective in NMD patients.

Visitations (audits) are considered an instrument of external quality assurance by which the structural and organizational set-up of health facilities can be assessed on site by external experts. The Deutsche Rentenversicherung Bund (including the former Bundesversicherungsanstalt für Angestellte, BfA, the statutory pension insurance agency for white collar employees) is the largest body responsible for rehabilitation in Germany, and it regularly carries out visitations in the approximately 650 rehab centres it sends its patients to. The project presented in this article aimed at developing a manual with detailed descriptions of the procedures and criteria of the assessment, as well as at checking the inter-rater-reliability of the assessment. The manual was developed in cooperation with experts of the Deutsche Rentenversicherung Bund. It contains a description of the areas to be assessed during a visitation as well as leading questions and criteria for the evaluation of single features. The manual was examined in "test visitations" in 10 centres, each of which was visited by three visitation teams (1 medical and 1 administrative expert) simultaneously. When the resulting 30 assessments were compared, the criterion "overall quality of the centre" (which was assessed on a 10-point scale) showed precise agreement in 47 %, and a deviation by 1 point in 33 % of the cases. Single features assessed on a three-point scale (no improvement needed/improvement recommended/immediate improvement obligatory) resulted in precise agreement in between 80 % ("medical and therapeutic processes") and 86 % ("structural features") of the cases. Two-point scales (condition fulfilled or not fulfilled) showed an agreement between 89 % ("internal quality management") and 97 % ("single structural features"). In order to maintain and further develop this good inter-rater-reliability, the visitors of Deutsche Rentenversicherung Bund are continually trained in applying the visitation manual. In addition to transferring knowledge, these internal training courses are aimed at exchanging views and experience in order to enhance consensus among the visitors. This approach of Deutsche Rentenversicherung Bund could be regarded as "internal quality assurance" of its visitation procedure.

Nickel-base superalloys are used as blade material for gas turbines. They are solidified by dendritic growth, which results in the segregation of the alloying elements, i.e. in differences in the chemical composition between the dendrite arms (DAs) and the interdendritic regions (IRs). Because the segregation of the slowly diffusing refractory elements rhenium, tungsten, tantalum and molybdenum can not be fully removed within an acceptable homogenization time, superalloys are used with a significant residual segregation. This chemical inhomogeneity influences the structural stability and consequently the mechanical behavior of superalloys. One effect of the segregation are residual stresses within the dendritic cell which arise due to the different thermal contraction of DAs and IRs during cooling. The occurrence of these stresses in heat treated CMSX-4 has been proved by independent methods: scanning electron microscopy (SEM) of the microstructure, dilatometric analysis, finite element (FE) modeling and X-ray diffraction (XRD).

a (10 0) Dislocations are observed in nickel-base superalloys after creep deformation at high temperatures and low stresses. They are formed in the gamma/gamma' interfaces by a three step mechanism. First, primary dislocations with Burgers vector a/2 < 101 > and 60 degrees character are left behind in the interfaces when dislocation loops glide through the gamma channels. The 60 degrees dislocations move into edge orientation and react forming secondary dislocations a/2 < 110 >. In the third step, new primary dislocations are knit into the already existing meshes of primary and secondary dislocations, which results in hexagonal misfit dislocation networks consisting of secondary dislocations a/2 < 110 > and tertiary dislocations a < 100 >, both of edge type. This self-organisation process is explained by dislocation theory and crystallography. Creep deformation accelerates when the a < 100 > interfacial dislocations enter the gamma' phase. During their climb towards the opposite interface, they attain a characteristic rectangular shape. This shape and the importance of the a < 100 > super dislocations for creep deformation are discussed. (c) 2005 Elsevier B.V. All rights reserved.

Residual stresses in the dendritic structure of single-crystal nickelbase superalloys were investigated. Dilatometric measurements showed that the thermal contraction of the dendrite arms (DAs) is larger than that of the interdendritic regions (IRs). The reason is, that the J’ phase, precipitating during cooling, has a smaller lattice

The influence of small rhenium additions on the lattice spacing of a nickel solid solution was investigated using a nickel–rhenium single crystal with an axial macrosegregation of rhenium. The effect of rhenium on the lattice spacing of the nickel solid solution was found to be similar to that of tungsten.

The response of the structural parameters to applied stress was investigated in a conic single-crystal specimen of nickel-base superalloy CMSX-4 crept at 1100°C for 300 hours. The investigation was performed by Fourier analysis of scanning electron microscope images and by X-ray diffraction. Measurement of the period of the y/y'-microstructure (total thickness of the γ- and γ'-rafts) and the γ/γ'-misfit along the specimen axis showed clear correlations of these parameters with the change of applied stress along the specimen axis. At stress levels > 40 MPa the measured change of misfit was described by a model proposed by the authors earlier. It is intended to continue the investigation to develop a method for the estimation of stresses acting in turbine blades during operation at high temperatures.

In undeformed superalloys, the disordered γ-solid solution of nickel is hardened by coherently embedded small cuboids of the ordered γ′-phase (Ni3Al). During high-temperature creep the γ′-phase coalesces, coarsens and finally surrounds the γ-phase, i.e., it becomes topologically the matrix. The kinetics of this so-called topological inversion during creep of the superalloy SRR99 at 980°C and 200 MPa has been investigated quantitatively by analysis of scanning electron microscope images. The topological state of the γ/γ′-microstructure was characterized by the parameter R: the ratio of area densities of transverse terminations of γ- and γ′-lamellae. The topological inversion is explained by the formation of junctions connecting neighbouring γ′-rafts and separating the γ-phase. One reason is the generation of dislocations in the γ-channels during primary creep. Another reason is the dissolution of γ′-edges in the γ-phase, which is more diffusionally penetrative. The released γ′-forming atoms move along the interface towards dislocation concentrations, resulting in the formation of junctions between the γ′-rafts.

Mechanisms of creep deformation of single-crystal superalloys at low and high temperature are considered. Rupture life time of a single-crystal superalloy during creep is described in a wide temperature-stress range as a function of temperature and stress taking into account a change of creep mechanism with rising temperature. This phenomenological description is confirmed by creep tests. Anisotropy of creep behavior of single-crystal superalloys is discussed with respect to a choice of the optimal crystallographic direction for solidification of the turbine blades.

In superalloys the loss of coherency during creep results in the increase of misfit of the γ/γ′-interface. The kinetics of this process were measured locally by TEM (Moiré fringes) and X-ray diffraction. Two materials were creep tested (SRR99 and CMSX-4) in two temperature ranges (stable γ′-morphology and rafting), and the morphology changes were quantified. A microstructural model allows calculation of the equilibrium misfit and the increase of plastic strain on the basis of these data. At high temperatures and low stresses the model describes quantitatively creep kinetics up to 30h. Here the processes controlling primary creep are propagation of dislocation loops along matrix channels and thickening of the matrix channels orientated perpendicular to the load direction.

The evolution of the γ/γ′ microstructure of the superalloy SRR99 during creep at 980°C and 200 MPa has been characterised by Fourier analysis of scanning electron microscope images. Different kinetics of this process were found in the primary and secondary dendrite arms. Changes of the structure period and interface tilt are correlated with the accumulated creep strain. Possible mechanisms for the correlation of microstructural evolution and high-temperature creep deformation are discussed.

Changes in the structure of single-crystal (SC) superalloy SRR99 during creep at 980 °C and 200 MPa were investigated. Geometrical parameters of the y/y'-microstructure, y/y'-misfit, stresses in the phases and local misorientation of the structure were determined at defined points of the dendritic structure by use of X-ray diffraction (XRD), wavelength dispersive X-ray spectroscopy (WDXS), scanning (SEM) and transmission (TEM) electron microscopy. Correlation of the microstructural period and local misorientation of the structure with creep strain were found.

By copolymerization of trioxane with 1,3-dioxacycloheptane (DOCH) or 1,3-dioxacyclooctane (DOCO) acetal copolymers were synthesized with comonomer units which, in contrast to customary 1,3-dioxolane/trioxane copolymers, consist of sequences with four or five methylene groups, respectively. In comparison with 1,3-dioxolane/trioxane copolymers these copolymers show a significantly higher thermal stability due to the larger sequences of thermically stable C—C-bonds. Torsion pendulum measurements show that the difference of the comonomer nature influences the storage modulus, G′, which is a measure for the rigidity of the material, and the loss tangent tan δ. Obviously, G′ is dependent on the crystallinity of the sample, which again is influenced by the kind and concentration of the incorporated comonomer. Also the peak locations of the α- and γ-relaxation indicate a direct connection to the comonomer nature and content in the different copolymers. The α-maxima are shifted to lower temperatures with increasing number of methylene groups as well as with growing comonomer content. However, the γ-maxima appear at higher temperatures with increasing comonomer content, but at lower temperatures with growing length of the comonomer unit. Additionally, branched acetal copolymers were synthesized by using comonomers in which the hydrogen atom at the 4-position of 1,3-dioxolane has been substituted by alkyl groups of different length (methyl to tetradecyl). In these copolymers the nature of comonomer neither improves the thermal stability of the copolymers nor influences the α- and γ-relaxation. Durch Copolymerisation von 1,3-Dioxacycloheptan (DOCH) bzw. 1,3-Dioxacyclooctan (DOCO) mit Trioxan wurden Acetalcopolymere hergestellt, deren Comonomereinheiten im Gegensatz zu den herkömmlichen 1,3-Dioxolan/Trioxan-Copolymeren vier bzw. fünf aufeinanderfolgende Methylengruppen enthalten. Im Vergleich zu den 1,3-Dioxolan/Trioxan-Copolymeren besitzen diese Copolymeren, bedingt durch die größere Anzahl von thermisch stabileren C—C-Sequenzen, eine deutlich höhere Thermostabilität. Torsionsschwingungsmessungen zeigen, daß die unterschiedliche Comonomerstruktur den Speichermodul G′, der ein Maß für die Steifigkeit des Materials ist, sowie den mechanischen Verlustfaktor tan δ beeinflußt. G′ hängt dabei ganz offensichtlich von der Kristallinität der Proben ab, welche wiederum stark von der Art und Konzentration des eingebauten Comonomeren beeinflußt wird. Auch die Lage der α- und γ-Relaxationsmaxima steht in direktem Zusammenhang mit der Comonomerstruktur und dem Comonomergehalt. Die α-Maxima verschieben sich sowohl mit wachsender Anzahl von Methylengruppen als auch mit steigendem Comonomergehalt zu tieferen Temperaturen. Die γ-Maxima hingegen erscheinen mit steigendem Comonomergehalt bei höheren Temperaturen, mit zunehmender Länge der Comonomereinheit aber treten sie bei tieferen Temperaturen auf. Außerdem wurden durch Verwendung von Comonomeren, bei denen ein Wasserstoffatom in 4-Position des 1,3-Dioxolans durch Alkylreste unterschiedlicher Länge ersetzt wurde (Methyl bis Tetradecyl), verzweigte Acetalcopolymere hergestellt. Die Art des Comonomeren verbessert bei diesen Copolymeren weder deren thermische Stabilität, noch beeinflußt sie die α- und γ-Relaxation.