Prognosefaktoren bei Patienten mit COPD mit chronisch-hyperkapnischer respiratorischer Insuffizienz und außerklinischer Beatmungstherapie

Zusammenfassung

Die Prävalenz der Patienten mit schwerer COPD und chronisch hyperkapnischer respiratorischer Insuffizienz (CHRI), die einer außerklinischen Beatmung zugeführt werden, hat erheblich zugenommen. Im Hinblick auf die Schwere der Erkrankung erscheint eine multidimensionale Betrachtung sinnvoll. Der Basenüberschuss (BE) reflektiert die langfristige metabolische Kompensation der chronischen Hyperkapnie und stellt einen vielversprechenden, leicht fassbaren und integrativen Parameter der CHRI dar. Dieser konnte zusätzlich zu Ernährungsstatus und Lungenüberblähung als unabhängiger Prädiktor des Langzeitüberlebens detektiert werden. Darüber hinaus sind in Zusammenschau mit der Literatur sowohl zur Krankheitseinschätzung als zur Verlaufsbeurteilung weitere Marker sowie häufige Komorbiditäten zu berücksichtigen. Dementsprechend sollte auch die Entscheidung für eine außerklinische Beatmung nicht nur auf der Basis von Symptomen bzw. der chronischen Hyperkapnie erfolgen, sondern auch Faktoren einbeziehen, welche die Schwere der Erkrankung in spezifischer Weise abbilden. Retrospektive Daten deuten zudem daraufhin, dass auch COPD-Patienten mit wiederholten hyperkapnischen Dekompensationen oder nach prolongierter Beatmungsentwöhnung für eine außerklinische Beatmung infrage kommen. Dies ist allerdings noch in prospektiven Studien weiter zu evaluieren.

Abstract

The prevalence of patients with severe COPD and chronic hypercapnic respiratory failure (CHRF) receiving non-invasive home ventilation has greatly increased. With regard to disease severity, a multidimensional assessment seems indicated. Base excess (BE), in particular, reflects the long-term metabolic response to chronic hypercapnia and thus constitutes a promising, easily accessible, integrative marker of CHRF. Infact, BE as well as nutritional status and lung hyperinflation have been identified as independent predictors of long-term survival. In addition and in a review with the literature, a broad panel of indices including frequent comorbidities are helpful for assessment and monitoring purposes of patients with CHRF. Accordingly, in view of the patients' individual risk profile, the decision about the initiation of NIV should probably not rely solely on symptoms and chronic persistent hypercapnia but include a spectrum of factors that specifically reflect disease severity. Owing to the physiologically positive effects of NIV and according to retrospective data, patients with COPD and recurrent hypercapnic respiratory decompensation and patients with prolonged mechanical ventilation and/or difficult weaning could also be considered for long-term non-invasive ventilation. This, however, has to be corroborated in future prospective trials.

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