Klinischer Stellenwert von Rekruitmentmanövern bei Patienten mit akutem Lungenversagen

Zusammenfassung

Die Anwendung von Rekruitmentmanövern wird als additive Therapiestrategie in der Behandlung des akuten Lungenversagens empfohlen, um eine rasche Öffnung atelektatischer Lungenkompartimente zu erzielen und danach die rekrutierten Alveolen durch Applikation eines adäquat hohen positiven endexpiratorischen Drucks (PEEP) offen zu halten. Die schnelle Rekrutierung von Atelektasen durch Rekruitmentmanöver führte mitunter zu einer deutlichen Verbesserung der Oxygenierung mit konsekutiver Reduktion der Beatmungsinvasivität. Obwohl in mehreren Studien über eine Verbesserung des Gasaustausches nach einem Rekruitmentmanöver berichtet wurde, bleibt diese Intervention nach wie vor Gegenstand kontroverser Diskussionen, vor allem im Zusammenhang mit einer lungenprotektiven Beatmungsstrategie. In diesem Übersichtsartikel diskutieren wir den pathophysiologischen Hintergrund, begünstigende Faktoren für die Effektivität eines Rekruitmentmanövers und dessen klinischen Stellenwert im Lichte aktueller Publikationen. Die Effektivität eines Rekruitmentmanövers ist vor allem abhängig von der Höhe des Rekrutierungsdrucks und des applizierten PEEP vor und nach dem Rekruitmentmanöver, der Ätiologie und dem Stadium des akuten Lungenversagens, der Atemmechanik des respiratorischen Systems bzw. der Höhe des transpulmonalen Drucks sowie von der Lagerung des Patienten. Vor dem Hintergrund der derzeitigen Literatur sind Rekruitmentmanöver als eine „Rescue-Therapie” in der Frühphase eines lebensbedrohenden hypoxämischen Lungenversagens anzusehen, wenn trotz einer lungenprotektiven Beatmungsstrategie und additiver Maßnahmen wie Lagerungstherapie und Applikation von inhalativen Vasodilatatoren kein adäquater Gasaustausch zu erzielen ist.

Abstract

In patients with acute respiratory distress syndrome (ARDS), recruitment maneuvers have been proposed as an adjunct to mechanical ventilation to open up atelectasis and to keep these alveoli open by the application of adequate high levels of positive end-expiratory pressure (PEEP). Though several studies reported that the responsiveness to recruitment maneuvers resulted in a marked improvement of oxygenation with a concomitant decrease in airway pressure and/or inspiratory fraction of oxygen, the performance of recruitment maneuvers still remains a matter of dispute, especially in patients ventilated with a lung protective ventilation strategy. In this review we discuss the pathophysiological background, factors affecting the responsiveness to recruitment maneuvers and their clinical impact in the light of recently published studies. Successful recruitment depends on several factors like the applied recruitment pressure, the level of PEEP set before and after the recruitment maneuver, the stage and the underlying disease of the ARDS, chest wall mechanics and the transpulmonary pressure as well as the positioning of the patient. Regarding the current literature, recruitment maneuvers may be considered as a rescue therapy in the early stage of severe hypoxemic lung failure, if a lung protective ventilation strategy and other additive adjuncts like prone positioning or the application of inhaled vasodilators failed to induce adequate gas exchange.

Schlüsselwörter

Akutes Lungenversagen · alveoläres Rekruitment · Rekruitmentmanöver · Konzept der offenen Lunge · lungenprotektive Beatmung

Key words

Acute respiratory distress syndrome · alveolar recruitment · recruitment maneuver · open lung approach · lung protective ventilation

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