Schweres hyperkapnisches Atmungsversagen bei akuter COPD-Exazerbation: Stellenwert von Beatmung und ECCO₂R

Zusammenfassung

Bei akut exazerbierter COPD (AE-COPD) mit hyperkapnischem Atmungsversagen und einem pH 7,25 – 7,35 gilt der primäre Einsatz der nicht-invasiven Beatmung (NIV) als Goldstandard. Absolute und relative Kontraindikationen sind zu beachten. Der Einsatz der NIV bedarf, insbesondere bei schwerer respiratorischer Azidose, eines geschulten, erfahrenen Beatmungsteams und eines engmaschigen Monitorings, um ein NIV-Versagen zu vermeiden bzw. frühzeitig zu erkennen. In diesem Fall stellt die Initiierung einer invasiven Beatmung grundsätzlich auch weiterhin die Therapie der Wahl dar. Beatmungseinstellungen müssen darauf abzielen, eine weitere Überblähung und Zunahme des intrinsischen PEEP zu vermeiden. Bei schwerster und beatmungstechnisch nicht beherrschbarer Hyperkapnie und ausgeprägter respiratorischer Azidose sind extrakorporale Verfahren zur CO2-Elimination eine Option. Vereinzelt liegen auch Berichte über ihren Einsatz bei wachen Patienten zur Intubationsvermeidung vor. Ein genereller und primärer Einsatz bei Hyperkapnie ohne vorherige Optimierung der medikamentösen Therapie und Beatmung ist nicht indiziert. Der Stellenwert extrakorporaler Verfahren zur CO2-Elimination bei COPD mit akutem hyperkapnischem Atemversagen ist noch experimentell und demzufolge unklar. Eine Anwendung kommt allenfalls für Einzelfälle und aufgrund potentiell schwerwiegender Komplikationen nur durch ein erfahrenes und geschultes Team in Frage.

Abstract

In acute exacerbations of COPD with acute hypercapnic respiratory failure and a pH 7.25 – 7.35, the initiation of non-invasive ventilation is the gold standard. However, absolute and relative contraindications have to be taken into account. The implementation of non-invasive ventilation in case of a severe respiratory acidosis necessitates a skilled therapeutic team and a close monitoring in order to avoid or perceive a NIV failure in time. In this case, the intubation and invasive mechanical ventilation is recommended. Ventilator settings have to aim at the prevention of an overinflation and increase of intrinsic PEEP. If severe hypercapnia and respiratory acidosis cannot be managed by mechanical ventilation, extracorporeal CO2 removal (ECCO2R) is a new treatment option. There are some reports about its use in awake patients in order to avoid an intubation. However, its general and primary use without optimizing medical therapy and mechanical ventilation is not indicated. ECCO2R is an experimental therapy in COPD with acute hypercapnic respiratory failure, its significance is still ambiguous. Therefore, it should only be applied in individual situations by a specialist team trained in its use.

Schlüsselwörter

hyperkapnisches Atemversagen - Beatmung - extrakorporale CO2-Elimination - COPD - akute Exazerbation

Keywords

acute hypercapnic respiratory failure - mechanical ventilation - extracorporeal CO2-removal - COPD - acute exacerbation

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