Zusammenfassung
Die nichtinvasive Beatmung hat sich in den letzten 15 Jahren zu einer unverzichtbaren
Therapieform bei Patienten mit restriktiven thorakalen Erkrankungen wie der Kyphoskoliose,
dem posttuberkulösem Syndrom und neuromuskulären Erkrankungen entwickelt. Bei Patienten
mit einer schwergradigen chronisch obstruktiven Bronchitis und einem Lungenemphysem
(COPD) ist der Nutzen für die akute ventilatorische Dekompensation im Rahmen einer
Exazerbation sehr gut belegt und gilt mittlerweile als Standardtherapie. Die nichtinvasive
Beatmung wird jedoch auch in zunehmendem Maße bei Patienten mit einer chronisch ventilatorischen
Insuffizienz eingesetzt, ist hier aber umstritten. Die nichtinvasive Beatmung führt
hier zu einer deutlichen Reduktion der Atemarbeit der stark belasteten Atemmuskulatur,
dies führte jedoch meist zu keiner Verbesserung der maximalen Inspirationskraft (Pimax). Eine Verbesserung der Schlafqualität konnte insbesondere in Studien nachgewiesen
werden, in denen höhere effektive Beatmungsdrücke verwendet wurden. Eine Verbesserung
der Gehstrecke ist bisher nur in Kurzzeitstudien belegt. Ein Anstieg der Lebensqualität
ist hingegen in fast allen Studien nachweisbar. Eine Senkung der Mortalität konnte
dagegen bisher nicht sicher bewiesen werden. Nach der vorliegenden Studienlage sollten
bevorzugt Patienten mit einer stark ausgeprägten Hyperkapnie ausgewählt werden, es
sollten überwiegend Beatmungsverfahren Anwendung finden, die hohe effektive Beatmungsdrücke
ermöglichen und somit eine vollständige Entlastung der Atemmuskulatur erreichen. Unter
diesen Vorraussetzungen ist es möglich, einen großen Teil der sorgfältig ausgewählten
und unter klinischen Bedingungen an die Beatmung adaptierten Patienten erfolgreich
in eine Langzeittherapie zu überführen. Patienten, die die Beatmung in der Klinik
akzeptieren zeigen im weiteren Verlauf eine hohe Therapiecompliance gemessen an der
dokumentierten täglichen Nutzungsdauer.
Abstract
Noninvasive positive pressure ventilation in patients with stable chronic obstructive
pulmonary disease. The role of non-invasive positive pressure ventilation (NIPPV)
is well documented in patients with restrictive thoracic diseases like kyphoscoliosis,
tuberculosis sequelae or neuromuscular disease. There is also a good evidence for
the use of NIPPV in acute respiratory failure in patients with an exacerbation of
COPD. The application of NIPPV in patients with chronic respiratory failure is growing,
but there is less evidence than in restrictive disorders. NIPPV can unload the respiratory
muscles in patients with chronic hypercapnic COPD and so alleviates fatigue of the
respiratory pump, but improvement in the maximal inspiratory pressure (Pimax) is small or even absent. An improvement of sleep quality has also postulated, there
was an increase in total sleep time and sleep effectiveness when using higher inspiratory
pressure. An increase of the walking distance was shown in short term studies, only.
In most studies, there was an increase in quality of life as a main topic. Mortality
was unchanged in the two long-term randomised controlled studies. Current data suggest
a possible role of NIPPV in patients with severe hypercapnia. A high effective inspiratory
pressure and a ventilator mode with a significant reduction in the work of breathing
should be choosen. NIPPV should be started in hospital, a close reassessment must
be performed. Patients who accepted NIPPV in the first weeks had a good compliance
for long-term use.
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Dr. med.
Bernd Schucher
Krankenhaus Großhansdorf · Zentrum für Pneumologie und Thoraxchirurgie
Wöhrendamm 80
22927 Großhansdorf
Email: bhschucher@aol.com
