ARDS – Ein Update – Teil 2: Therapie und Outcome

Zusammenfassung

Das Acute respiratory Distress Syndrome (ARDS) ist nunmehr seit über 50 Jahren als gravierende Komplikation verschiedener Grunderkrankungen bekannt [1]. Trotz intensiver Forschung in all dieser Zeit gibt es hinsichtlich der bestmöglichen Therapie des ARDS auch heute noch viele offene Fragen – insbesondere zur maschinellen Beatmung. Der zweite Teil des Update ARDS gibt einen aktualisierten Überblick zu Therapie und Outcome des ARDS.

Abstract

The Acute Respiratory Distress Syndrome (ARDS) is defined by hypoxemic respiratory failure due to inflammatory response within the lung usually requiring invasive mechanical ventilation. Despite more than 50 years of scientific research numerous issues especially regarding mechanical ventilation as the most important treatment option remain unclear. Most important, adjustment of mechanical ventilation is challenging due to desirable beneficial effects on pulmonary gas exchange on the one hand and deleterious effects in terms of ventilator-associated lung injury on the other. Specifically, optimal settings of positive end-expiratory pressure and the role of spontaneous breathing activity are still controversial. Because no specific pharmacological therapy revealed beneficial effects until today, adjunctive treatment is actually limited to prone positioning and restrictive fluid balance. Long-term outcome of ARDS survivors is often affected by anxiety and mental health disorders.

Kernaussagen

• Zentrale Behandlungsstrategie beim ARDS ist neben der Behandlung der Grunderkrankung die maschinelle Beatmung.

• Die Einstellung der maschinellen Beatmung muss einen suffizienten Gasaustausch sicherstellen, ohne einen ventilatorassoziierten Lungenschaden zu verursachen.

• Die Einstellung des positiven endexspiratorischen Drucks (PEEP) ist dabei von zentraler Bedeutung – allerdings gibt es bis heute keine Evidenz für eine bestimmte Strategie zur Adjustierung des PEEP. Tendenziell sollte vor allem in der Frühphase des schweren ARDS ein hoher PEEP eingestellt werden.

• Einfache Hilfsmittel zur orientierenden PEEP-Einstellung sind die PEEP-Tabelle sowie die Kontrolle des Driving Pressure.

• Der mögliche Nutzen und Schaden von Spontanatmungsaktivität ist für die Frühphase des ARDS umstritten, nach erster Stabilisierung des Gasaustausches überwiegen jedoch eindeutig deren Vorteile.

• Bei therapierefraktärer Hypoxämie stellen extrakorporale Gasaustauschverfahren eine wichtige Therapieoption im Rahmen eines Gesamtbehandlungskonzeptes dar.

• Das wichtigste adjuvante Verfahren ist die Bauchlagerung für mindestens 16 Stunden. Zudem sollte eine restriktive Flüssigkeitsbilanz angestrebt werden.

• Eine gezielte medikamentöse Therapieoption gibt es nicht.

Schlüsselwörter

akute respiratorische Insuffizienz - maschinelle Beatmung - beatmungsinduzierte Lungenschädigung - Langzeit-Outcome

Key words

acute respiratory failure - mechanical ventilation - ventilator-induced lung injury - long-term outcome

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