Lungenersatzverfahren – Welche Therapie für welchen Patienten? Wahl der Beatmungsstrategie im akuten Lungenversagen

Zusammenfassung

Die Entstehung eines beatmungsinduzierten Lungenschadens (VILI) trägt zur hohen Sterblichkeit des akuten Lungenversagens bei. Durch lungenprotektive Beatmung mit einem Tidalvolumen von 6 ml/kgIBW (Ideal Body Weight) und einem Plateaudruck <30 cm H₂O kann die Letalität nachweislich reduziert werden und wurde aus diesem Grund als einer von zehn Qualitätsindikatoren der Intensivmedizin in Deutschland ausgewählt. Über das optimale PEEP-Niveau herrscht gegenwärtig Unklarheit, allerdings scheinen Patienten mit schwerer Gasaustauschstörung von höheren PEEP-Werten zu profitieren.

Die Anpassung der Beatmungseinstellungen an die individuellen mechanischen Eigenschaften der Lunge wird die ARDS-Therapie in den nächsten Jahren verändern. Die Messung des transpulmonalen Drucks mittels einer Ösophagusdrucksonde oder die elektrische Impendanztomografie (EIT) sind vielversprechende Verfahren, müssen aber ihre Überlegenheit noch unter Beweis stellen.

Bis dahin muss es Ziel jedes Klinikers sein, die Empfehlungen der lungenprotektiven Beatmung auch tatsächlich in die tägliche Praxis umzusetzen.

Abstract:

Ventilator-induced lung injury (VILI) contributes to the high mortality of ALI/ARDS. Lung protective ventilation with a tidal volume of 6 ml / kgIBW (Ideal Body Weight) and a plateau pressure <30 cm H₂O has shown to reduce mortality and was thus selected as one of ten quality indicators for critical care in Germany. The optimal level of PEEP is currently unclear; however, patients with severe disorders of gas exchange seem to benefit from higher PEEP levels.

Adjusting the respirator settings to the mechanical properties of the individual patient will change the treatment of ARDS in the next few years. Measurements of transpulmonary pressure by an oesophageal probe or electrical impedance tomography (EIT) are promising approaches, but still need to proof their superiority. Until then, every clinician must aim to translate the recommendations of lung protective ventilation into daily practice.

Kernaussagen

• Die lungenprotektive Ventilation ist eine der wenigen evidenzbasierten Therapien beim akuten Lungenversagen.

• Die lungenprotektive Ventilation bei ALI / ARDS ist einer von 10 Qualitätsindikatoren für die Intensivmedizin.

• Niedrige Tidalvolumina (< 6 ml/kg IBW) und die Begrenzung des Plateaudrucks (< 30 cmH₂O) kennzeichnen die lungenprotektive Ventilation.

• Patienten mit einem schweren ARDS (PaO₂/FiO₂-Quotient < 150) profitieren von einem höheren PEEP.

• Tidalvolumen und Atemwegsdruck vernachlässigen die individuellen intrathorakalen Druckverhältnisse und geben die auf die Lunge einwirkenden Kräfte nur unzureichend wider.

• Die entscheidende Determinante der auf das Lungenparenchym einwirkenden Kraft ist der transpulmonale Druck.

• Der Pleuradruck unterliegt bei kritisch kranken Patienten großen Variabilitäten.

• Es gibt Hinweise, dass die Ermittlung des transpulmonalen Drucks und eine entsprechende Anpassung des PEEP der Festlegung der PEEP-Niveaus entsprechend der inspiratorischen Sauerstoffkonzentration nach ARDS-Network Studie überlegen sein könnte.

• Die EIT ist eine hochinteressante Technologie, die das Potenzial hat, dem Patienten eine individuelle Beatmungstherapie zukommen zu lassen.

• Extrakorporale Lungenunterstützungsverfahren bzw. Lungenersatzverfahren (ECMO) können nicht nur als „Rescue Therapy“ eingesetzt werden, sondern sollten bei Ausreizung der differenzierten Beatmungsstrategie rechtzeitig diskutiert werden.

• Die Therapie eines Lungenunterstützungssystems bzw. Lungenersatzverfahrens erfordert ein professionelles Team, das Komplikationen rechtzeitig erkennt und behandelt. Somit sollte diese Therapie speziellen Zentren vorbehalten sein und Patienten frühzeitig in ein solches Zentrum verlegt werden.

Schlüsselwörter:

ARDS - lungenprotektive Beatmung - Therapiealgorithmus - PEEP - transpulmonaler Druck

Key words:

ARDS - lung protective ventilation - therapy algorithm - PEEP - transpulmonary pressure - EIT

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