Intraoperative Strategien für die Ein-Lungen-Ventilation

Zusammenfassung

Das Management der Ein-Lungen-Ventilation (ELV) beinhaltet mehrere Herausforderungen. Diese umfassen die adäquate Oxygenierung und Ventilation und den Schutz der Lunge vor pathophysiologischen Noxen zur Vermeidung postoperativer pulmonaler Komplikationen. Während der ELV wird die Belüftung des zu operierenden Lungenflügels durch verschiedene Techniken unterbrochen, während die Perfusion in vermindertem Umfang erhalten bleibt. Das entsprechende Tidalvolumen (V_T) wird somit lediglich einer Lunge zugeführt.

Die derzeitigen Empfehlungen zur Aufrechterhaltung des Gasaustausches und die lungenprotektiven Maßnahmen können sich diametral widersprechen, wie z. B. die Applikation einer hohen vs. niedrigen inspiratorischen Sauerstofffraktion (FiO₂) oder die eines hohen vs. niedrigen Atemzugvolumens. Angesichts der limitierten Evidenz beleuchtet diese Arbeit aktuelle intraoperative Strategien für die ELV, welche die Reduktion der FiO₂, ein niedriges V_T, die Applikation eines positiven endexspiratorischen Druckes (PEEP) in der ventilierten Lunge und eines kontinuierlichen positiven Atemwegsdruckes (CPAP) in der nicht ventilierten Lunge sowie alveoläre Rekrutierungsmanöver umfassen. Weitere Ansätze, wie die Wahl des Anästhesieverfahrens, die ischämische Präkonditionierung, das hämodynamische Management und die Volumentherapie sowie die postoperative Schmerztherapie können die lungenprotektiven Strategien unterstützen und das klinische Ergebnis verbessern.

Das Management der Ein-Lungen-Ventilation (ELV) beinhaltet mehrere Herausforderungen: adäquate Oxygenierung und Ventilation sowie Schutz der Lunge vor pathophysiologischen Noxen, um postoperative Komplikationen zu vermeiden. Die derzeitigen Empfehlungen zur Aufrechterhaltung des Gasaustausches und die lungenprotektiven Maßnahmen können sich dabei diametral widersprechen. Dieser Beitrag beleuchtet aktuelle intraoperative Strategien für die ELV.

Abstract

The management of thoracic surgery patients is challenging to the anesthetist, since one-lung ventilation (OLV) includes at least two major conditions: sufficient oxygenation and lung protection. The first is mainly because the ventilation of one lung is stopped while perfusion to that lung continues; the latter is related to the fact that the whole ventilation is applied to only a single lung. Recommendations for maintaining the oxygenation and methods of lung protection may contradict each other (e. g. high vs. low inspiratory oxygen fraction (FiO₂), high vs. low tidal volume, etc.). Therefore, a high degree of pathophysiological understanding and manual skills are required in the management of these patients.

In light of recent clinical studies, this review focuses on a current protective strategy for OLV, which includes a possible decrease in FiO₂, lowered V_T, the application of positive end-expiratory pressure (PEEP) to the dependent and continuous positive airway pressure (CPAP) to the non-dependent lung and alveolar recruitment manoeuvres as well. Other approaches such as the choice of anaesthetics, remote ischemic preconditioning, fluid management and pain therapy can support the success of ventilatory strategy. The present work describes new developments that may change the classical approach in this respect.

Kernaussagen

• Die optimale Durchführung der ELV im Rahmen thoraxchirurgischer Eingriffe beinhaltet folgende Herausforderungen:

  • Die zentrale Aufgabe ist die Sicherstellung des Gasaustauschs.

  • Die Applikation des gesamten V_T in eine Lunge kann durch die vermehrte Beimischung von venösem Blut in einer Hypoxämie resultieren.

  • Die ELV induziert ein alveoläres Trauma infolge der erhöhten mechanischen Belastung der ventilierten Lunge, erkennbar an erhöhten Atemwegsdrücken („driving pressure“).

  • Die ventilationsinduzierte pulmonale Schädigung ist eine wesentliche Determinante einer erhöhten pulmonalen Morbidität und Mortalität selbst bei zuvor lungengesunden Patienten.

• Lungenprotektive Ansätze zur Vermeidung des akuten Lungenschadens und einer Verbesserung der Oxygenierung wurden an die Empfehlungen der ARDS-Therapie angelehnt.

• Die sinnvolle Kombination verschiedener Maßnahmen – wie die Ventilation mit einem niedrigen V_T, die Anwendung alveolärer Rekrutierungsmanöver und die Applikation eines suffizienten PEEP in der ventilierten Lunge – sichert einen adäquaten Gasaustausch und reduziert den mechanischen Stress der Lunge. In der Folge vermindert sich die alveoläre Immunreaktion nach der ELV.

• Der Modus der Ventilation ist wahrscheinlich von geringerer Bedeutung als die Sicherstellung eines möglichst niedrigen effektiven Atemwegsdrucks.

• Die Applikation eines CPAP in der nicht ventilierten Lunge ist eine effektive Methode zur Reduktion der sicheren inspiratorischen Sauerstoffkonzentration und Verminderung der mechanischen Belastung der Lunge. Sie kann aber nur in enger Kooperation mit dem chirurgischen Vorgehen erfolgen.

• Inhalationsanästhetika wie Desfluran oder Sevofluran besitzen möglicherweise klinische Vorteile gegenüber i. v. Anästhetika während und nach der ELV.

• Inwieweit einzelne oder Kombinationen dieser Maßnahmen postoperative Komplikationen verringern und das individuelle Ergebnis verbessern, muss in weiteren prospektiven Studien überprüft werden.

Schlüsselwörter

Ein-Lungen-Ventilation - FiO₂ - Atemzugvolumen - mechanische Ventilation - pulmonaler Gasaustausch

Key words

one-lung ventilation - pulmonary gas exchange - mechanical ventilation - anesthetic management

Publication History

Article published online:
26 May 2021

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