Gehauchte Diagnosen? Zum Potenzial von Atemkondensatuntersuchungen

Nicht-invasive Diagnostik in der Pneumologie

Zu den neueren Entwicklungen in der Pneumologie gehören nicht-invasive Methoden der Informationsgewinnung aus den Atemwegen und dem Lungenparenchym. Zu diesen Methoden zählen das induzierte Sputum und das Atemkondensat sowie die Online-Messung von flüchtigen Substanzen in der Expirationsluft [1]. Diese Methoden stellen den Beginn einer Entwicklung dar, deren Ziel es ist, auf einfache Weise weitergehende Informationen über die Lunge zu erhalten und damit invasivere Diagnostik sparsam, ökonomisch und zielgerichtet einzusetzen. Gleichzeitig soll damit aber auch eine Screeningdiagnostik ermöglicht werden, die auf einen wesentlich größeren Kreis von potenziell Erkrankten ausgedehnt werden kann, als dies bisher für Erkrankungen der Lunge möglich war, von der rein funktionellen Möglichkeit der Atemflussanalyse einmal abgesehen.

Technisch einfacher noch als die Gewinnung von Sputum nach vorheriger Inhalation von 3 %iger Kochsalzlösung ist die Messung von Substanzen, die entweder gasförmig oder eingeschlossen in aerosolisierte Tröpfchen in der Ausatemluft enthalten sind. Dabei entstehen keinerlei Auswirkungen auf das Bronchialsystem, zumal diese Messungen am ruhig atmenden Patienten stattfinden können.

Zu den Mediatoren, die online (also ohne vorherige Sammlung und spätere Messung) bestimmbar sind, gehören Stickstoffmonoxid (NO) und Kohlenmonoxid (CO). Gegenwärtig gibt es vor allem Daten zum Stickstoffmonoxid [2] [3]. In verschiedenen Untersuchungen wurde ein Zusammenhang zwischen der NO-Konzentration in der Ausatemluft und dem Asthma bronchiale gefunden [4] [5] [6] [7] [8]. Mehrere Arbeiten haben sich mit der Standardisierung der Methode befasst [9] und festgelegt, dass die Ausatmung bei der Online-NO-Messung gegen einen fixen Widerstand stattfinden muss, wodurch sich das Gaumensegel verschließt und eine Kontamination des aus der Lunge stammenden Gases durch Nasenluft mit hoher Stickstoffmonoxid-Konzentration vermieden wird.

Das Exhalat enthält neben gasförmigen Bestandteilen auch eine Aerosolfraktion und vor allem Wasserdampf. Anteile dieser letzten beiden Bestandteile der Ausatemluft stellen den Hauptanteil des so genannten Atemkondensates (AK entspricht exhaled breath condensate: EBC) dar. In der Aerosolfraktion sind auch größere Moleküle wie Protein und DNA enthalten. Diesem Umstand verdankt das Atemkondensat seine potenzielle Bedeutung als Methode für Screening und Diagnostik von Lungenkrankheiten. Nachfolgende Übersicht soll darstellen, welche Möglichkeiten und Grenzen der Methode derzeit gegeben sind.

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