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Anästhesiol Intensivmed Notfallmed Schmerzther 2016; 51(06): 378-385
DOI: 10.1055/s-0041-109186
Fachwissen
Intensivmedizin
© Georg Thieme Verlag Stuttgart · New York

Weaning - Mehr als nur Beatmung beenden

Weaning: more than terminating mechanical ventilation
Johannes Bickenbach
1   Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen
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Publication History

Publication Date:
30 June 2016 (online)

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Zusammenfassung

Maschinelle Beatmung ist ein essentieller Bestandteil der modernen Intensivtherapie. Sie kommt bei Patienten mit akuter respiratorischer Insuffizienz zum Einsatz und hat – je nach Art des respiratorischen Versagens – unterschiedliche Einsatzformen. Vor allem die invasive maschinelle Beatmung sollte so rasch wie möglich beendet werden, um dessen Risiken zu vermeiden.

Der überwiegende Anteil beatmeter Patienten kann nach kurzfristiger Behandlungsdauer unproblematisch von der Beatmung entwöhnt werden. Bei etwa 20% aller beatmeten Patienten kann jedoch ein äußerst protrahierter und komplexer Entwöhnungsprozess beobachtet werden, auch wenn die zur Beatmung geführte Ursache längst behoben ist. Neben dem einzelnen Vorgang des Trennens vom Beatmungsgerät werden in diesem Artikel insbesondere die pathophysiologischen Vorgänge, die zum prolongierten Weaning führen, adressiert.

Abstract

Mechanical ventilation is an essential part of modern intensive care. It is used in patients with acute respiratory failure and, depending on the type of respiratory failure, different modes of application. In particular, invasive mechanical ventilation should be terminated as raidly as possible to avoid the associated risks.

The major proportion of ventilated patients can be weaned from mechanical ventilation without problems after a short treatment period. In about 20% of ventilated patients, however, an extremely protracted and complex weaning process can be observed, even though the cause necessitating ventilation has long since been eliminated. In addition to the stages in the process of weaning from the ventilator, in particular the pathophysiological processes that lead to prolonged weaning are addressed in this article.

Kernaussagen

  • Die akute respiratorische Insuffizienz subsummiert die beiden Leitsymptome „Hyperkapnie“ und „Hypoxie“, aus denen sich unterschiedliche Strategien in der Beatmungstherapie ableiten.

  • Die unterschiedlichen Weaning-Gruppen und deren Definitionskriterien reflektieren unterschiedliche Schweregrade der Beatmungsentwöhnung. Insbesondere die Patienten der Gruppen 2 und 3 haben oftmals eine komplexe protrahierte Intensivtherapie hinter sich, sodass auch das Weaning sehr viel aufwendiger ist und diverse pathophysiologische Veränderungen nach Intensivtherapie berücksichtigt werden müssen.

  • Das Risiko für beatmungsassoziierte Komplikationen gilt es zu reduzieren, indem so früh wie möglich die Spontanatemaktivität des Patienten untersucht wird. Sedierungs- und Weaningprotokolle können den Prozess strategisch sinnvoll systematisieren. Zur Vermeidung einer Dyssynchronie am Beatmungsgerät können modifizierte Spontanatmungsverfahren wie Proportional Assist Ventilation (PAV) und Neurally Adjusted Ventilatory Assist (NAVA) günstig sein, weil sie die eigentliche Zwerchfellaktivität des Beatmeten berücksichtigen. Große klinische Daten fehlen uns allerdings hierzu.

  • Das prolongierte Weaning ist v. a. von der äußerst ausgeprägten muskulären Schwäche beeinflusst. Die muskuläre Rekonditionierung ist aufwendig und erfordert systematische physikalische und logopädische Maßnahmen.

  • Häufige Komorbiditäten wie die Herzinsuffizienz müssen differenzialdiagnostisch berücksichtigt werden.

Schlüsselwörter:

Weaning - maschinelle Beatmung - Intensivtherapie - akute respiratorische Insuffizienz

Keywords:

mechanical ventilation - weaning - modern intensive care - acute respiratory failure
 

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