, Volume 63, Issue 1, pp 47-53

Ventilatorinduzierte diaphragmale Dysfunktion

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Zusammenfassung

Die mechanische Beatmung ist für Patienten mit respiratorischem Versagen oder im Rahmen der tiefen Sedierung lebensrettend. Während kontinuierlicher mandatorischer Beatmung ist das Diaphragma inaktiviert und unterliegt einer pathophysiologischen Kaskade, die zum Kraftverlust und zur Verringerung der Muskelfasermasse führt. Diese Prozesse sind im Gegensatz zur peripheren Skelettmuskulatur bereits nach 12 h nachweisbar und haben Einfluss auf die Beatmungsentwöhnung von Intensivpatienten – und damit auf Letalität sowie Morbidität. Studien der letzten Jahre haben tierexperimentell die pathophysiologischen Zusammenhänge untersucht und sind durch klinische Untersuchungen bestätigt worden. Diese Übersicht beschreibt die biochemischen Zusammenhänge, Einflüsse von Pharmaka und Interventionen zur Prophylaxe.

Abstract

Mechanical ventilation is a life-saving intervention for patients with respiratory failure or during deep sedation. During continuous mandatory ventilation the diaphragm remains inactive, which activates pathophysiological cascades leading to a loss of contractile force and muscle mass (collectively referred to as ventilator-induced diaphragm dysfunction, VIDD). In contrast to peripheral skeletal muscles this process is rapid and develops after as little as 12 h and has a profound influence on weaning patients from mechanical ventilation as well as increased incidences of morbidity and mortality. In recent years, animal experiments have revealed pathophysiological mechanisms which have been confirmed in humans. One major mechanism is the mitochondrial generation of reactive oxygen species that have been shown to damage contractile proteins and facilitate protease activation. Besides atrophy due to inactivity, drug interactions can induce further muscle atrophy. Data from animal research concerning the influence of corticosteroids emphasize a dose-dependent influence on diaphragm atrophy and function although the clinical interpretation in intensive care patients (ICU) patients might be difficult. Levosimendan has also been proven to increase diaphragm contractile forces in humans which may prove to be helpful for patients experiencing difficult weaning. Additionally, antioxidant drugs that scavenge reactive oxygen species have been demonstrated to protect the diaphragm from VIDD in several animal studies. The translation of these drugs into the IUC setting might protect patients from VIDD and facilitate the weaning process.