Organersatzverfahren - Lungenersatzverfahren

Zusammenfassung

Die lungenprotektive Beatmung gilt als Standardtherapie zur Sicherstellung des Gasaustauschs bei Patienten im akuten Lungenversagen. Eine Replikation der physiologischen Atmung und Herstellung eines optimalen Ventilations-/Perfusionsverhältnisses ist aufgrund einer passiven Zwerchfellbewegung mit der Präferenz nicht-abhängiger Lungenabschnitte jedoch nicht möglich. Zugleich besteht die Gefahr einer iatrogenen Schädigung der Lungen durch die mechanische Beatmung, der sog. „ventilatorassoziierten oder -induzierten Lungenschädigung“ (VILI). Ist die Sicherstellung eines suffizienten Gasaustauschs trotz invasiver mechanischer Beatmung nicht mehr möglich bzw. nur unter Inkaufnahme sehr hoher Tidalvolumina oder Beatmungsdrücke, sollte an den Einsatz eines extrakorporalen Lungenersatzverfahren gedacht werden. Die veno-venöse extrakorporale Membranoxygenierung (vvECMO) erlaubt eine nahezu vollständige Übernahme der Lungenfunktion und scheint bei gleichzeitiger Behandlung in einem ARDS-Zentrum das Outcome von Patienten mit schwerem ARDS zu verbessern.

Abstract

Mechanical ventilation is the most commonly used form of respiratory support to restore or maintain adequate gas exchange. However, mechanical ventilation does not provide a physiological form of breathing. Neither does it provide an optimal ventilation / perfusion ratio due to passive movement of the diagphragm favoring the non-dependent parts of the lung. Furthermore, patients are in danger of ventilator-associated/induced lung injury (VALI/VILI). Hence, lung protective ventilation is mandatory in patients with an acute respiratory distress syndrome (ARDS) and should likewise be used in the operating room. Extracorporeal pulmonary support is required in case mechanical ventilation is unable to secure sufficient gas exchange or VILI is imminent. Venovenous extracorporeal membrane oxygenation (vvECMO) acts as lung replacement therapy and may improve survival along with treatment in an ARDS-center.

Kernaussagen

• Ein akutes Lungenversagen (acute respiratory distress syndrome, ARDS) ist mit einer hohen Letalität vergesellschaftet, wobei sich das klinische Bild im Median 2 Tage nach Erstvorstellung im Krankenhaus entwickelt. Aktuelle Forschungsbemühungen zielen daher zunehmend auf die Prävention des ARDS ab.

• Beim schweren ARDS ist die frühzeitige Verlegung in ein Zentrum zu empfehlen, um die optimale Versorgung der Patienten sicherzustellen.

• Eine maschinelle Beatmung ist keine Replikation der physiologischen Atmung und bei kranken Lungen mit einem hohen Risiko von ventilatorassoziierten Lungenverletzungen (VILI) verbunden.

• Eine lungenprotektive Beatmung mit einem Tidalvolumen von 6 ml/kg idealisiertem Körpergewicht, einem Plateaudruck von < 30 cmH₂O sowie einem positiven endexspiratorischen Druck (PEEP) ist bei einem ARDS obligat. Sie sollte jedoch auch beim Lungengesunden angewandt werden.

• Die veno-venöse ECMO (vvECMO) kann als Lungenersatz die Oxygenierung und Dekarboxylierung des Blutes sicherstellen. Der vvECMO-Blutfluss ist hierbei die Determinante zur Steuerung der Oxygenierung. Die Höhe des Frischgasflusses bestimmt die CO₂-Elimination.

• Komplikationen einer ECMO-Therapie umfassen mechanische sowie patientenassoziierte Faktoren. Häufigste Komplikation im Verlauf der Therapie ist eine komplexe Störung der Hämostase.

• Absolute Kontraindikationen für einen extrakorporalen Lungenersatz existieren nicht.

Schlüsselwörter:

Beatmung - extrakorporale Membranoxygenierung - ventilatorassoziierte oder induzierte Lungenschädigung (VALI/VILI) - ARDS

Keywords:

mechanical ventilation - extracorporeal membrane oxygenation - ventilator-associated / induced lung injury (VALI/VILI) - ARDS

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