Nasaler Highflow (NHF): Eine neue Therapiealternative zur Behandlung der respiratorischen Insuffizienz

Zusammenfassung

Die Therapie der hypoxämischen respiratorischen Insuffizienz (Typ 1) beruht auf der Gabe von 1 bis 15 l Sauerstoff pro Minute per Nasensonde oder Maske. Falls mit dieser Therapie keine ausreichenden Effekte zu erzielen sind oder falls primär ein hyperkapnisches Atemversagen (Typ 2) vorliegt, erfolgt eine nichtinvasive oder invasive Positivdruck-Beatmung. Seit einiger Zeit steht eine alternative Therapie zur Verfügung, die von der Pathophysiologie zwischen der Sauerstofftherapie und der Positivdruckbeatmung einzugruppieren ist. Die Therapie beruht auf der nasalen Applikation eines angewärmten und befeuchteten Luft/Sauerstoffgemisches mit einem Fluss bis etwa 60 l/min. Diese Therapie wird Nasale Highflow-Therapie genannt (NHF). Die genauen pathophysiologischen Wirkungen sind bisher nur zum Teil verstanden, jedoch sind verschiedene Teilaspekte gut untersucht: Es können hohe Sauerstoffkonzentrationen angeboten werden, eine Austrocknung der Atemwege wird vermieden, der Anteil der Totraumventilation wird reduziert, und der nasale Totraum wird ausgewaschen. Weiterhin baut sich ein endexspiratorischer positiver Atemwegsdruck auf, der einem Kollaps der Atemwege entgegenwirkt. Daraus folgen eine Steigerung der Atmungseffizienz und eine Reduktion der Atmungsarbeit. Aktuelle Studien zeigen eine Verbesserung des Gasaustausches und eine Reduktion von Reintubationen beim Einsatz von NHF in der akuten respiratorischen Insuffizienz. Demzufolge findet der NHF zunehmende Verbreitung in der Intensivmedizin. Die Einsatzgebiete in anderen Feldern wie der chronischen Ateminsuffizienz sind noch weniger geklärt.

Ziel dieser Übersichtsarbeit ist die Darstellung der grundlegenden pathophysiologischen Wirkmechanismen soweit diese bekannt sind und die Darstellung der aktuellen Studienlage.

Abstract

The therapy of choice in hypoxemic respiratory failure (type 1) is the application of supplemental oxygen at flow rates of 1 to 15 l/min via nasal prongs or mask. Non-invasive or invasive positive pressure ventilation will be initiated when the oxygen therapy effects are not sufficient or if hypercapnic respiratory failure (type 2) is the underlying problem. Recently, an alternative therapy option is available, from the pathophysiology it can be classified between oxygen therapy and positive pressure ventilation. The therapy called Nasal High Flow (NHF) is based on the nasal application of a heated and humidified air oxygen mixture with a flow range of up to 60 l/min. The precise pathophysiological principles of NHF are only partly understood, yet various aspects are well studied already: it is possible to deliver high oxygen concentrations, airway dryness can be avoided, dead space ventilation reduced and clearance of nasal dead space is achieved. Additionally, an end expiratory positive pressure is built up, which helps to prevent airway collapse, thus resulting in an improvement of respiratory efficiency and reduction of breathing work. Current studies demonstrate improvement in gas exchange and reduction of reintubation rate when applying the NHF treatment in acute respiratory failure. Thus the NHF therapy attracts attention in intensive care medicine. The application in other fields like chronic respiratory insufficiency is less well clarified. The objectives of this review are to present the pathophysiological effects and mechanisms of NHF, as far as understood, and to give an overview over the current state of relevant studies.

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