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Radical systematic mediastinal lymphadenectomy does not influence disease-free or overall survival in patients with NSCLC and without overt lymph node involvement. However, a small subgroup of patients with limited mediastinal lymph node metastases might benefit from a systematic lymphadenectomy.

The non-invasive ventilation (NIV) is widespread in the clinical medicine and has attained meanwhile a high value in the clinical daily routine. The application of NIV reduces the length of ICU stay and hospitalization as well as mortality of patients with hypercapnic acute respiratory failure. Patients with acute respiratory failure in context of a cardiopulmonary edema should be treated in addition to necessary cardiological interventions with continuous positive airway pressure (CPAP) or NIV. In case of other forms of acute hypoxaemic respiratory failure it is recommended the application of NIV to be limited to mild forms of ARDS as the application of NIV in severe forms of ARDS is associated with higher rates of treatment failure and mortality. In weaning process from invasive ventilation the NIV reduces the risk of reintubation essentially in hypercapnic patients. A delayed intubation of patients with NIV failure leads to an increase of mortality and should therefore be avoided. With appropriate monitoring in intensive care NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency. Furthermore NIV can be useful within palliative care for reduction of dyspnea and improving quality of life. The aim of the guideline update is, taking into account the growing scientific evidence, to outline the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.

The value of radical systematic lymphadenectomy in the treatment of bronchial carcinoma is controversial. In a randomized controlled clinical trial, radical lymphadenectomy was compared with conventional node dissection in 182 patients with non-small cell lung cancer. Comparison of short-term results revealed a sigdflcantly longer operating time in those undergoing systematic lymphadenectomy, but overall morbidity and mortality rates were comparable between groups. However, there were compli-The only treatment with a chance of cure for patients with localized non-small cell lung cancer is a radical operation such as classical lobectomy or pneumonectomy. To what extent lymphadenectomy contributes to the chance of cure remains controversial.Some authors' ' advocate radical systematic mediastinal lymphadenectomy as a conditio sine qua non; it is even claimed3s4 that pulmonary resection without mediastinal lymph node dissection has to be considered a palliative operation, denying the patient a chance of cure. In some centres this treatment policy has led to ultraradical operations, mostly in left-sided lung cancers, where bilateral mediastinal lymphadenectomy via a median sternotomy is combined with the classical tumour operation3s5. Other surgeons, such as those of the American Lung Cancer Study Group, have advocated nodal sampling onlyG8 to avoid increasing the morbidity and mortality rates because of the extent of operation. A firm rational basis for extensive systematic lymph node dissection of the ipsilateral thoracic cavity does not emerge from the literat~re~.'~. Benefit has been shown only against historical controls or patients who were excluded from the treatment for other medical reasons3. Since it is unclear which patient categories will benefit from this extensive operation, McKneallyg has emphasized the need for a randomized controlled trial to evaluate the therapeutic efficacy of systematic lymph node dissection. Such a trial was devised to compare the results of conventional lymph node dissection with those of radical systematic lymphadenectomy in patients undergoing curative resection of non-small cell lung cancer. Patients and methodsThe trial was approved by the Ethical Research Committee of the Medical Faculty, University of Munich. Patients were evaluated, randomized, treated and followed up at the Department of Surgery, University of Munich, and the Division of Thoracic Surgery and Department of Pulmonary Medicine, Central Hospital Gauting.Paper accepted 11 July 1993 cations associated with radical lymphadenectomy such as prolonged air leakage and haemorrhage. Interim analysis of results at a median follow-up of 26.8 months showed no significant influence of radical lymphadenectomy on local recurrence-free interval, metastasis-free interval or cancer-related survival. In conclusion, radical systematic lymphadenectomy is a safe operation that leads to a better staging of non-small cell lung cancer, but its prognostic benefit k questionable. Eligibility criteriaPatients of any age and sex with a c...

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