Akutes Lungenversagen (ARDS) – Schritt für Schritt

Das akute Lungenversagen (acute respiratory distress syndrome, ARDS) ist mit einer Letalität von etwa 40% eine massiv lebensbedrohliche Erkrankung. Dennoch wird das Krankheitsbild häufig zu spät oder gar nicht erkannt. Zugleich kann durch eine adäquate Therapie das Outcome der Patienten deutlich verbessert werden. Der Beitrag stellt die wichtigsten Prinzipien für eine frühe Diagnose und eine leitliniengerechte Therapie des ARDS dar.

Publication History

Article published online:
21 November 2025

• Literatur

• 1 Imai Y, Kuba K, Neely GG. et al. Identification of oxidative stress and Toll-like receptor 4 signaling as a key pathway of acute lung injury. Cell 2008; 133: 235-249
• 2 Bhattacharya J, Matthay MA. Regulation and repair of the alveolar-capillary barrier in acute lung injury. Annu Rev Physiol 2013; 75: 593-615
• 3 Zemans RL, Matthay MA. Bench-to-bedside review: the role of the alveolar epithelium in the resolution of pulmonary edema in acute lung injury. Crit Care 2004; 8: 469-477
• 4 Huppert LA, Matthay MA, Ware LB. Pathogenesis of acute respiratory distress syndrome. Semin Respir Crit Care Med 2019; 40: 031-039
• 5 Coudroy R, Chen L, Pham T. et al. Acute respiratory distress syndrome: respiratory monitoring and pulmonary physiology. Semin Respir Crit Care Med 2019; 40: 66-80
• 6 Imai Y, Parodo J, Kajikawa O. et al. Injurious mechanical ventilation and end-organ epithelial cell apoptosis and organ dysfunction in an experimental model of acute respiratory distress syndrome. JAMA 2003; 289: 2104-2112
• 7 Bates JHT, Smith BJ. Ventilator-induced lung injury and lung mechanics. Ann Transl Med 2018; 6: 378-378
• 8 Tremblay LN, Slutsky AS. Ventilator-induced injury: from barotrauma to biotrauma. Proc Assoc Am Physicians 1998; 110: 482-488
• 9 Ranieri VM, Rubenfeld GD. ARDS Definition Task Force. et al. Acute Respiratory Distress Syndrome: The Berlin Definition. JAMA 2012; 307: 2526-2533
• 10 Bellani G, Laffey JG, Pham T. et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA 2016; 315: 788-800
• 11 Phua J, Badia JR, Adhikari NK. et al. Has mortality from acute respiratory distress syndrome decreased over time?: A systematic review. Am J Respir Crit Care Med 2009; 179: 220-227
• 12 Villar J, Blanco J, Anon JM. et al. The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation. Intensive Care Med 2011; 37: 1932-1941
• 13 Ferguson ND, Frutos-Vivar F, Esteban A. et al. Acute respiratory distress syndrome: underrecognition by clinicians and diagnostic accuracy of three clinical definitions. Crit Care Med 2005; 33: 2228-2234
• 14 Frohlich S, Murphy N, Doolan A. et al. Acute respiratory distress syndrome: underrecognition by clinicians. J Crit Care 2013; 28: 663-668
• 15 Adamzik M, Bauer A, Bein T. et al. S3-Leitlinie Invasive Beatmung und Einsatz extrakorporaler Verfahren bei akuter respiratorischer Insuffizienz. AWMF Leitlinien-Register Nr. 001/021. https://www.awmf.org/uploads/tx_szleitlinien/001–021l_S3_Invasive_Beatmung_2017–12.pdf
• 16 Antonelli M, Conti G, Moro ML. et al. Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med 2001; 27: 1718-1728
• 17 Westhoff M, Schönhofer B, Neumann P. et al. S3-Leitlinie Nicht-invasive Beatmung als Therapie der akuten respiratorischen Insuffizienz. AWMF Leitlinien-Register Nr. 020/004. https://www.awmf.org/uploads/tx_szleitlinien/020–004l_Nichtinvasive_Beatmung_ARI_2015–09-verlaengert.pdf
• 18 Laffey JG, Kavanagh BP. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury. N Engl J Med 2000; 343: 812-814
• 19 Tonelli AR, Zein J, Adams J. et al. Effects of interventions on survival in acute respiratory distress syndrome: an umbrella review of 159 published randomized trials and 29 meta-analyses. Intensive Care Med 2014; 40: 769-787
• 20 Raymondos K, Dirks T, Quintel M. et al. Outcome of acute respiratory distress syndrome in university and non-university hospitals in Germany. Crit Care 2017; 21: 122
• 21 Amato MB, Meade MO, Slutsky AS. et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med 2015; 372: 747-755
• 22 Guerin C, Papazian L, Reignier J. et al. Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials. Crit Care 2016; 20: 384
• 23 Toufen Junior C, De Santis Santiago RR, Hirota AS. et al. Driving pressure and long-term outcomes in moderate/severe acute respiratory distress syndrome. Ann Intensive Care 2018; 8: 119
• 24 Lachmann B. Open up the lung and keep the lung open. Intensive Care Med 1992; 18: 319-321
• 25 Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs. low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA 2017; 318: 1335-1345
• 26 Brower RG, Lanken PN, MacIntyre N. et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004; 351: 327-336
• 27 Walkey AJ, Del Sorbo L, Hodgson CL. et al. Higher PEEP versus lower PEEP strategies for patients with acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc 2017; 14 (Suppl. 04) S297-S303
• 28 Gainnier M, Roch A, Forel JM. et al. Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome. Crit Care Med 2004; 32: 113-119
• 29 Papazian L, Forel JM, Gacouin A. et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 2010; 363: 1107-1116
• 30 Putensen C, Zech S, Wrigge H. et al. Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 2001; 164: 43-49
• 31 Sassoon CS, Zhu E, Caiozzo VJ. Assist-control mechanical ventilation attenuates ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med 2004; 170: 626-632
• 32 Wrigge H, Zinserling J, Neumann P. et al. Spontaneous breathing improves lung aeration in oleic acid-induced lung injury. Anesthesiology 2003; 99: 376-384
• 33 Yoshida T, Fujino Y, Amato MB. et al. Fifty years of research in ARDS. Spontaneous breathing during mechanical ventilation. Risks, mechanisms, and management. Am J Respir Crit Care Med 2017; 195: 985-992
• 34 Guerin C, Reignier J, Richard JC. et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368: 2159-2168
• 35 Sud S, Friedrich JO, Taccone P. et al. Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Med 2010; 36: 585-599
• 36 Charron C, Bouferrache K, Caille V. et al. Routine prone positioning in patients with severe ARDS: feasibility and impact on prognosis. Intensive Care Med 2011; 37: 785-790
• 37 Bein T, Bischoff M, Brückner U. et al. S2e-Leitlinie Lagerungstherapie und Frühmobilisation zur Prophylaxe oder Therapie von pulmonalen Funktionsstörungen AWMF Leitlinien-Register Nr. 001/015. https://www.awmf.org/uploads/tx_szleitlinien/001–015l_S2e_Lagerungstherapie_Fr%C3%BChmobilisation_pulmonale_Funktionsst%C3%B6rungen_2015–05.pdf
• 38 Kalisch BJ, Dabney BW, Lee S. Safety of mobilizing hospitalized adults: review of the literature. J Nurs Care Qual 2013; 28: 162-168
• 39 Lewis SR, Pritchard MW, Thomas CM. et al. Pharmacological agents for adults with acute respiratory distress syndrome. Cochrane Database Syst Rev 2019;
• 40 Gao Smith F, Perkins GD, Gates S. et al. Effect of intravenous beta-2 agonist treatment on clinical outcomes in acute respiratory distress syndrome (BALTI-2): a multicentre, randomised controlled trial. Lancet 2012; 379: 229-235
• 41 Gebistorf F, Karam O, Wetterslev J. et al. Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults. Cochrane Database Syst Rev 2016;
• 42 Silversides JA, Major E, Ferguson AJ. et al. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and metaanalysis. Intensive Care Med 2017; 43: 155-170
• 43 Bein T, Weber-Carstens S, Goldmann A. et al. Lower tidal volume strategy (approximately 3 ml/kg) combined with extracorporeal CO2 removal versus ‘conventional’ protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study. Intensive Care Med 2013; 39: 847-856
• 44 Fitzgerald M, Millar J, Blackwood B. et al. Extracorporeal carbon dioxide removal for patients with acute respiratory failure secondary to the acute respiratory distress syndrome: a systematic review. Crit Care 2014; 18: 222
• 45 Barbaro RP, Odetola FO, Kidwell KM. et al. Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry. Am J Respir Crit Care Med 2015; 191: 894-901