Supportive und adjunktive Therapiemaßnahmen bei akutem Lungenversagen

Zusammenfassung

Trotz einzelner positiver Ergebnisse hinsichtlich der Oxygenierung und physiologischer Variablen in meist kleineren, observationellen Untersuchungen, konnte bislang für keine der untersuchten adjunktiven und supportiven Therapiestrategien (z.B. pulmonale Vasodilatatoren, Glukokortikoide, Surfactant, Lagerungstherapie u.a.) eine Effektivität hinsichtlich der Verbesserung der Überlebensrate des akuten Lungenversagens in entsprechend dimensionierten und strukturierten Untersuchungen dargestellt werden.

Summary

Various supportive and adjunctive therapies to conventional mechanical ventilation have been evaluated in patients with acute lung injury and acute respiratory distress syndrome (e.g. nitric oxide, prone position, surfactant, glucocorticoids). Although some investigations have shown promising improvements in oxygenation and physiological variables, large randomized trials of adjunctive and supportive therapies showed no impact on survival.

akutes Lungenversagen - adjunktive Therapie - supportive Therapie - Lungenödem - Management

acute respiratory distress syndrome - nonventilatory interventions - pulmonary edema - management

Kernaussagen

• Innerhalb der letzten 20 Jahre konnten wesentliche Fortschritte im Verständnis der pathophysiologischen Vorgänge des akuten Lungenversagens und der Auswirkungen einer mechanischen Beatmung erzielt werden.

• Innerhalb der letzten Dekade wurden unterschiedliche Strategien zur Behandlung des akuten Lungenversagens in multizentrischen, randomisierten, kontrollierten Untersuchungen evaluiert.

• Für die untersuchten Patientengruppen mit akutem Lungenversagen zeigte keine dieser Strategien hinsichtlich des finalen Outcomeparameters „Mortalität” einen Vorteil.

• Keine der dargestellten Strategien wird derzeit als Routineverfahren für die Behandlung des akuten Lungenversagens empfohlen.

• Einzelne Strategien konnten bei Patienten mit akutem Lungenversagen die Anzahl beatmungsfreier Tage erhöhen und die Anzahl der Intensivtage verringern. Dies könnte die Behandlungskosten von ARDS–Patienten reduzieren.

• Die Therapiestrategien konnten zwar in den untersuchten Patientengruppen keinen Vorteil erzielen; die negativen Ergebnisse der Studien bedeuten aber nicht notwendigerweise, dass diese Strategien komplett ineffektiv sind.

• Die Gründe für die negativen Ergebnisse der klinischen Untersuchungen sind multifaktoriell: z.B. Translation experimenteller Bedingungen in eine klinische Situation, Heterogenität der untersuchten Patientengruppen.

• Neue pharmakologische Strategien werden derzeit experimentell und klinisch evaluiert und das Studiendesign zukünftiger Untersuchungen wird kritisch überdacht hinsichtlich modifizierte Endpunkte und differenziertere Patientenauswahl (z.B. extrapulmonales vs. pulmonales Lungenversagen).

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