Langzeitbeatmung und Entwöhnung vom Beatmungsgerät

Kernaussagen

Ursachen für Probleme bei der Entwöhnung vom Beatmungsgerät oder für eine Langzeitbeatmung sind höheres Alter, Polymorbidität und/oder eine Funktionsstörung der Atemmuskulatur. Eine Schwäche der Atemmuskulatur wird begünstigt durch eine schwere COPD, Adipositas permagna, Anämie oder auch durch neuromuskuläre Erkrankungen. Weitere wichtige Faktoren, die zu einer Langzeitbeatmung führen können, sind kardiale Dysfunktionen, eine Mangelernährung oder auch neurophysiologische Störungen.

Spezialisierte Beatmungszentren sind den regulären Intensivstationen bei der schwierigen Entwöhnung überlegen: die Erfolgsrate ist höher, die Kosten sind niedriger. Darüber hinaus bieten sie den Patienten einen höheren Komfort und eine bessere Sicherheit. Problematisch ist jedoch die nicht allgemeingültig geregelte Finanzierung dieser Zentren.

Zur Einschätzung des Entwöhnbarkeit werden Prädiktoren und feste Entwöhnungsprotokolle eingesetzt. Der Erhebung wichtiger Prädiktoren dient der T-Stück-Versuch. Protokollbasierte Entwöhnungsstrategien erhöhen die Erfolgsrate, ersetzen jedoch nicht ein erfahrenes Beatmungsteam.

Übliche Beatmungsformen zur Entwöhnung sind PSV und SIMV. Durch die Verringerung der Atemarbeit kann sich die erschöpfte Atemmuskulatur erholen. Oft wird der Strömungswiderstand eines Trachealtubus durch eine Druckerhöhung nur unzureichend ausgeglichen. Bei absehbaren Entwöhnungsproblemen sollte man daher immer großlumige Tuben verwenden. Standard zur längerfristigen Beatmung ist die Tracheotomie. Weitgehend durchgesetzt hat sich eine Frühtracheotomie in Punktionstechnik.

Die nichtinvasive Beatmung (NIV) spielt insbesondere beim hyperkapnischen Atemversagen eine Rolle. Bei Patienten mit schwerer COPD kann dadurch eine frühzeitige Extubation erreicht werden, nach Extubation wird das Risiko einer erneuten akuten Ateminsuffizienz vermindert. Wichtig ist allerdings, die NIV frühzeitig zu beginnen und nicht erst das manifeste Postextubationsversagen abzuwarten.

Ist eine Entwöhnung im präfinalen Stadium nicht möglich, muss das weitere Vorgehen mit dem Patienten und seinen Angehörigen abgestimmt werden. Dabei müssen auch eine Therapiebegrenzung oder ein Therapieabbruch angesprochen werden. Je nach Wunsch des Patienten kann eine Betreuung durch einen Seelsorger oder einen Psychologen hilfreich sein. Ist der Tod des Patienten absehbar, sollte es einen gesonderten Bereich geben, wo ihm im Beisein der Angehörigen ein würdiges Sterben ermöglicht wird.

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