Aktuelle Therapieansätze bei schwerer hypoxischer respiratorischer Insuffizienz (ARDS/ALI)

Zusammenfassung

Eine lungenprotektive Beatmung mit niedrigen Tidalvolumina, Plateaudruck < 30 cm H₂O, Sauerstoffsättigung > 90% und permissiver Hyperkapnie führt bei Patienten mit „acute lung injury” (ALI) und „acute respiratory distress syndrome” (ARDS) zu einer Senkung der Sterblichkeit. Der PEEP ist abhängig vom Sauerstoffbedarf zu wählen. Die Hochfrequenzoszillationsventilation und die NAVA-Beatmung (Neurally Adjusted Ventilatory Assist) sind vielversprechende Verfahren. Weitere Studien mit harten Endpunkten müssen allerdings für eine abschließende Beurteilung abgewartet werden. Venovenöse extrakorporale Lungenunterstützungsverfahren (ECMO) können bei schwerstem, vital bedrohlichem Lungenversagen einen lebensnotwendigen Gasaustausch sichern, um Zeit für die Heilung der Lunge zu gewinnen und die Beatmungsaggressivität zu reduzieren. In der S3-Leitlinie zur Analgesie und Sedierung in der Intensivmedizin wird ein konsequentes Monitoring der Sedierungstiefe und der Schmerzintensität gefordert. Die Sedierung soll täglich unterbrochen werden, mit Aufwach- und, falls möglich, Spontanatmungsversuch. Unterstützende Therapieverfahren: Die Lagerungstherapie mit Bauchlagerung sowie die Anwendung von inhalativen Vasodilatantien können die Ventilations-Perfusionsstörungen und somit die Oxygenierung verbessern. Eine supportive Therapie mit Surfactant ist dagegen beim Lungenversagen des Erwachsenen nicht sinnvoll.

Abstract

Lung-protective ventilation with a low tidal volume, plateau pressure < 30 cm H₂O. oxygen saturation > 90% and permissive hypercapnia results in reduction of the mortality rate in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). The level of the positive end-expiratory pressure (PEEP) must be chosen in relation to oxygen requirement. High frequency oscillatory ventilation and neurally adjusted ventilatory assist are promising methods.However, further studies with firm end-points have to be awaited before a final judgment is possible. Veno-venous extracorporeal membrane oxygenation (ECMO) can ensure life-sustaining gas exchange in patients with severe vitally compromised pulmonary failure, to provide time for lung tissue to heal and reduce ventilatory stress. The latest guidelines for analgesia and sedation in intensive care medicine demand consistent monitoring of the level of sedation and the intensity of pain. The sedation should be interrupted daily, with phases of awakenings and, if possible, spontaneous breathing. Methods of supportive treatment: Positional treatment (prone position) and inhalation of vasodilators can improve ventilation/perfusion mismatch and thus oxygenation. However, administration of surfactant is currently not advised in adult respiratory failure.

Schlüsselwörter

ARDS - akutes Lungenversagen - Beatmung - extrakorporale Lungenunterstützung - Analgosedierung

Keywords

acute respiratory distress syndrome - acute lung injury - assisted ventilation - extracororeal lung assist - pain relief - sedation

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