Prävention der ventilatorassoziierten Pneumonie – Was ist evidenzbasiert?

Zusammenfassung

Die ventilatorassoziierte Pneumonie (VAP) ist eine häufige Infektion in der Intensivmedizin. Typischerweise werden Erreger aus dem oberen Respirationstrakt entlang des Beatmungstubus am Cuff vorbei aspiriert und verursachen eine Pneumonie. Die Kolonisation des oropharyngealen Raums mit Erregern und der Verlust der Autonomie des Patienten durch Krankheit und notwendige Analgosedierung sind Trigger für die ventilatorassoziierte Pneumonie. Moderne Behandlungsstrategien zur Vermeidung invasiver Beatmung (z.B. Übersedierung) und einer Besiedelung mit typischen nosokomialen Erregern (z.B. orale Dekontamination, Händedesinfektion) sowie moderne technische Möglichkeiten zur Vermeidung der Mikroaspiration (z.B. subglottische Absaugung) sind nur einige einer Vielzahl von Präventionsmaßnahmen. Eine erfolgreiche Prävention verkürzt die Beatmungsdauer, den Intensiv- und Krankenhausaufenthalt und reduziert Kosten. In Studien wird eine bessere Überlebensrate diskutiert und eine bis zu 10 % geringere Sterblichkeit angegeben. VAP kann jedoch nicht immer vermieden werden. Dieser Beitrag geht auf die Problematik der evidenzbasierten Beurteilung der Präventionsmaßnahmen ein und stellt ausgewählte Präventionsmaßnahmen bzgl. ihrer Wirkungsweise und Wirksamkeit dar.

Summary

Patients who suffer from a ventilator-associated pneumonia (VAP) are ventilated longer, stay longer in the ICU and in hospital and therefore lead to higher costs. Despite the therapeutic potential of the VAP nowadays there is about 10% additional mortality observed. Although the clinical VAP diagnosis is limited (sensitivity/specificity) rapid diagnosis promotes treatment (calculated antibiotic therapy) and improves the survival rate. And in the course the review of the VAP diagnosis of unnecessary antibiotics reduces the resistance development in that area and also the selection pressure.

Just because the development of VAP cannot be prevented to 100%, it is an important step to avoid unnecessary mechanical ventilation to reduce the risk of VAP.

Many of the actions have already shown positive effects on the incidence of VAP and are presented here. To promote the implementation of individual actions in clinical practice, the measures should be propagated as "bundle" and promoted in trainings. The individual "bundle" of a hospital depends on the documented evidence of a measure of outcome-based parameters and in the local circumstances in terms of risk profile of patients, local needs and the human and structural possibilities of an institution.

Kernaussagen

• Patienten mit einer ventilatorassoziierten Pneumonie (VAP) werden länger beatmet, verbleiben länger auf der Intensivstation und im Krankenhaus und verursachen höhere Kosten.

• Eine kürzere Beatmungsdauer verringert auch das Risiko einer VAP.

• Die frühzeitige Verdachtsdiagnose und die Einleitung einer zeitnahen Antibiotikatherapie sind wichtig für das Überleben der Patienten – trotz geringer Spezifität der Diagnose.

• Für die Beurteilung der Evidenz einer Präventionsmaßnahme sind zusätzliche Outcome-Parameter wie die Verkürzung der Beatmungsdauer und des Intensivstations- oder Krankenhausaufenthalts überzeugender als ”lediglich“ die Reduktion der VAP-Rate.

• Zu evidenzbasierten Präventionsmaßnahmen gehören v. a. Händedesinfektion, orale Mundpflege, subglottische Absaugung, Sedierungs- und Weaningprotokolle sowie Fortbildungen und ”bundles“.

• Nicht mit ausreichender Evidenz belegte Maßnahmen sind u. a. selektive Darmdekontamination und selektive orale Dekontamination, Ulkusprophylaxe und Ernährungsregime.

Schlüsselwörter:

ventilatorassoziierte Pneumonie - Prävention - Evidenz - Bundles

Key words:

ventilator-associated pneumonia - prevention - evidence - bundles

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