Inhaliertes Stickstoffmonoxid zur Behandlung refraktärer Hypoxämie bei ARDS–Patienten

Zusammenfassung

Das schwere akute Lungenversagen (acute respiratory distress syndrome, ARDS) ist durch eine Fehlverteilung des pulmonalen Blutflusses in nicht ventilierte, atelektatische Lungenareale charakterisiert, welche ihrerseits die Ursache für einen ausgeprägten intrapulmonalen Rechts–links–Shunt mit der Konsequenz einer arteriellen Hypoxämie bildet. Eine therapeutische Intervention zur selektiven Beeinflussung des pulmonalen Blutflusses, mit der sowohl der Gasaustausch verbessert als auch der pulmonalarterielle Druck gesenkt werden kann, steht mit der Anwendung von inhaliertem Stickstoffmonoxid (iNO) zur Verfügung. Obwohl randomisierte kontrollierte Studien bisher keinen signifikanten Effekt auf die Überlebensrate ergaben, stellt iNO dennoch derzeit eine klinisch relevante Option zur Notfallbehandlung von therapierefraktärer Hypoxämie dar und ist daher wichtiger Bestandteil eines Gesamtkonzeptes der ARDS–Behandlung in spezialisierten Zentren.

Abstract

The acute respiratory distress syndrome (ARDS) is characterized by a maldistribution of pulmonary blood flow towards non–ventilated atelectatic lung areas being the main reason for intrapulmonary right–to–left shunt with the consequence of severe arterial hypoxemia. The application of inhaled nitric oxide (iNO) is a therapeutic option to selectively influence pulmonary blood flow in order to improve arterial oxygenation and to decrease pulmonary artery pressure without relevant systemic side effects. Although randomized controlled trials demonstrated no survival benefit in patient populations covering the entire severity range of acute lung injury, iNO represents a feasible rescue treatment for ARDS patients with severe refractory hypoxemia and is, therefore, an important option for ARDS therapy in specialized centers.

ARDS - refraktäre Hypoxämie - pulmonaler Gasaustausch - selektive pulmonale Vasodilatation - iNO

ARDS - refractory hypoxemia - pulmonary gas exchange - selective pulmonary vasodilation - iNO

Kernaussagen

• Die selektive pulmonale Vasodilatation mit iNO ermöglicht bei Patienten mit akutem Lungenversagen eine Umverteilung des Blutflusses von Shunt–Arealen zu ventilierten Lungenbereichen.

• Inhaliertes NO verbessert in der akuten Phase der Anwendung die arterielle Oxygenierung sowie die Hämodynamik und erlaubt die Reduktion von Beatmungsdrücken und FiO₂.

• Zur Verbesserung des Gasaustausches sollte iNO in Konzentrationen < 10 ppm appliziert werden.

• Bei ARDS–Patienten mit gegenüber konventionellen Therapieoptionen refraktärer Hypoxämie stellt iNO eine sinnvolle Notfallmaßnahme dar.

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