Herz und Weaning

Zusammenfassung

Der Beginn einer maschinellen Beatmung und die Rückkehr zur Spontanatmung (Weaning) induzieren erhebliche Änderungen des intrathorakalen Drucks mit Konsequenzen für die Herz-Kreislauf-Funktion. Trotz dieser bekannten pathophysiologischen Zusammenhänge wird die kardiovaskuläre Situation der Patienten häufig vor und beim Weaning nicht ausreichend beachtet. Die publizierten und in Leitlinien empfohlenen Kriterien für Beginn des Weanings, Extubation und Reintubation sind notgedrungen allgemein gehalten. Die Erkenntnis, dass eine kardiale Dysfunktion ein erfolgreiches Weaning verhindern kann, basiert auf Studien bei Patienten mit bekannter kardiovaskulärer Erkrankung. Tatsächlich haben viele Intensivpatienten eine latente oder noch nicht diagnostizierte kardiale Dysfunktion. Zudem limitiert die intensivmedizinische Grunderkrankung häufig die kardiovaskulären Kompensationsoptionen. Daher scheitert das Weaning bei nicht wenigen Intensivpatienten an einer ungenügenden hämodynamischen Reserve. Diese Arbeit stellt die klinisch relevanten Grundlagen für das erfolgreiche Weaning mit besonderer Berücksichtigung der kardiovaskulären Situation des Patienten dar.

Abstract

The initiation of and weaning from mechanical ventilation with extubation cause significant changes in intrathoracic pressures and have profound consequences for the cardiovascular function. However, in spite of the known pathophysiological relationships, frequently little attention is paid to the cardiovascular situation during the weaning period. The currently available guidelines concerning weaning and extubation/reintubation are based on only limited evidence and are thus rather general. Moreover, recommendations for the cardiovascular management during weaning reflect mainly the pathophysiological rationale. In patients with known cardiac disease, studies have demonstrated the necessity for a prolonged weaning process. On the contrary, many intensive care patients have subclinical or undiagnosed cardiac disease, and cardiovascular compensation mechanisms are frequently hampered by the underlying critical illness. Therefore, in a significant proportion of patients, weaning and extubation attempts fail due to the patient’s limited cardiovascular reserves. This review summarises the relevant information for a successful weaning and extubation with special respect to the cardiovascular function.

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