Zusammenfassung.
Patienten mit bronchialer Hyperreagibilität haben ein erhöhtes Risiko eines Bronchospasmus
bei Manipulation ihrer Atemwege im Rahmen einer In- oder Extubation sowie Bronchoskopie,
so dass eine Prophylaxe sinnvoll ist. Die Wirksamkeit der Prophylaxe einer Reflexbronchokonstriktion
ist sowohl für inhalativ und intravenös appliziertes Lidocain auch für das β2- Mimetikum Salbutamol als Aerosol nachgewiesen. Beide erhöhen die Histaminschwelle
um mehr als das doppelte (2,2- bzw. 2,6-fach) und sind damit ähnlich effektiv. Darüber
hinaus hat die kombinierte Applikation von Lidocain und Salbutamol einen additiven
Effekt auf die Histaminschwelle (Anhebung auf das 4,8 fache). Der Einsatz von Lidocain
ist demnach auch bei Patienten von Nutzen, die wegen einer Atemwegserkrankung mit
β2-Mimetika therapiert werden. Inhalativ und intravenös appliziertes Lidocain ist bei
unterschiedlich hohen Plasmakonzentrationen wirksam, nämlich nach Inhalation bei 0,7
µg/ml, nach intravenöser Gabe bei ca. 2 µg/ml. Die Inhalation hat den Vorteil der
niedrigeren Plasmakonzentration, als Nachteil oft eine initiale Bronchokonstriktion
sowie eine Sensibilitätsstörung im Pharynx und Larynx. Demgegenüber ist die intravenöse
Applikation einfach, führt aber zu höheren Plasmakonzentrationen mit häufigeren systemischen
Nebenwirkungen. Zur Wirksamkeit von Lokalanästhetika in der Therapie von Bronchospasmen
liegen dagegen bislang keine kontrollierten Studien vor. Insgesamt bereichert die
prophylaktische Anwendung von Lokalanästhetika bei Patienten mit vermuteter oder nachgewiesener
bronchialer Hyperreagibilität das Spektrum der perioperativen Pharmakotherapie.
Local Anesthetics and Bronchial Hyperreactivity.
Patients with bronchial hyperreactivity are at increased risk for bronchospasm particularly
during airway instrumentation such as with intubation, extubation, or bronchoscopy.
Pretreatment with either lidocaine or salbutamol is suggested, since application of
lidocaine intravenously or salbutamol as an aerosol has been shown to be similarly
effective in increasing the (2,2 resp. 2,6 fold) threshold for histamine evoked bronchoconstriction.
Furthermore, combined salbutamol and lidocaine pretreatment has an additive effect
and increases 4,8 fold the histamine-threshold. Thus, lidocaine treatment can be applied
to patients with airway disease treated with β2-mimetics also. Inhaled and injected lidocaine is equally effective in decreasing
histamine threshold although at different plasma concentrations, i. e., lidocaine
is effective at approx. 0,7 µg/ml after inhalation but at up to 2 µg/ml after injection.
While inhaled lidocaine results in lower plasma concentrations it can evoke an initial
bronchoconstriction. Furthermore, local anesthesia of pharynx and larynx associated
with inhalation may not be tolerable in some patients. Intravenous lidocaine, in contrast,
results in higher plasma concentrations and side-effects are seen more often. While
several case reports have described beneficial effects of lidocaine in the treatment
of bronchospasm no clinical studies have been performed. Overall, both inhaled and
injected local anesthetics are effective in mitigating reflex mediated bronchoconstriction.
Schlüsselwörter:
Bronchiale Hyperreagibilität - Lokalanästhetika - Lidocain - Salbutamol
Key words:
Airways - Bronchial hyperreactivity - Bronchospasm - Local anesthetics - Lidocaine
- Salbutamol
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Prof. Dr. med. J. Peters
Abteilung für Anästhesiologie und Intensivmedizin
Universitätsklinikum Essen
Hufelandstraße 55
45122 Essen
eMail: juergen.peters@uni-essen.de
