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Nichtinvasive Beatmung bei akuter respiratorischer Insuffizienz

Indikationen und Grenzen

Non-invasive ventilation in acute respiratory failure

Indications and limitations

  • Leitthema
  • Published:
Der Pneumologe Aims and scope

Zusammenfassung

Nichtinvasive (NIV) und invasive Beatmung sind einander ergänzende Verfahren bei akuter respiratorischer Insuffizienz (ARI). Während NIV erfolgreich bei hyperkapnischer ARI eingesetzt werden kann, ist die Intubation bei der hypoxämischen ARI oft unumgänglich. Zur effektiven Rekrutierung von Gasaustauschfläche und zur Verbesserung der Compliance sind bei hypoxämischer ARI im Rahmen akut-inflammatorischer Lungenerkrankungen hohe Atemwegsdrücke erforderlich, die mit NIV wegen Maskenleckage oder Diskonnektion oft nicht aufrecht erhalten werden können. Die Verzögerung einer notwendigen Intubation durch eine probatorische NIV kann die Prognose erheblich verschlechtern, sodass NIV bei Patienten mit Pneumonie und ARDS nur in erfahrenen Zentren erfolgen sollte.

Die hyperkapnische ARI bei akut exazerbierter COPD ist die Domäne der NIV, da hier eine kausale Therapie durch Atemmuskelentlastung erfolgt. Bei thorakorestriktiven oder neuromuskulären Erkrankungen sowie beim Asthma bronchiale ist NIV in der Akutsituation möglich, bedarf aber der strengen Indikationsstellung und Überwachung. Hypoxämische oder hyperkapnische ARI kardialer Genese sind sehr gut mit CPAP oder NIV zu beherrschen, auch in der präklinischen Anwendung.

Abstract

Non-invasive (NIV) and invasive ventilation are complementary therapies for acute respiratory insufficiency (ARI). As NIV and invasive ventilation relieve the burden on the respiratory muscles with equal efficacy and NIV prevents ventilator-associated pneumonia, NIV should be favored for use in hypercapnic ARI. NIV is recommended as first line therapy in hypercapnic ARI induced by acute exacerbated chronic obstructive pulmonary disease (AECOPD) and it is also reasonably effective in acute ventilatory failure associated with thoracic restriction, neuromuscular disease and severe asthma.

Hypoxemic ARI caused by pulmonary or systemic inflammation mostly requires intubation and invasive ventilation for adequate lung recruitment and improvement in pulmonary compliance. Maintaining sufficiently high airway pressures during NIV is a challenge due to mask leakage or disconnection of the interface. When intubation is necessary a delay by NIV may worsen the prognosis suggesting that for non-cardiogenic hypoxemic ARI NIV should only be carried out in centers with experienced teams. In contrast, hypoxemic ARI in cardiogenic lung edema is effectively treated with continuous positive airway pressure (CPAP) or NIV even in out-of-hospital situations.

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  1. Klinik für Pneumologie, Lungenklinik Hemer, Theo-Funccius-Str. 1, 58675, Hemer, Deutschland

    M. Westhoff

  2. Medizinische Klinik m.S. Infektiologie und Pneumologie, CC12, Charité-Universitätsmedizin Berlin, Berlin, Deutschland

    S. Rosseau

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Westhoff, M., Rosseau, S. Nichtinvasive Beatmung bei akuter respiratorischer Insuffizienz. Pneumologe 7, 89–99 (2010). https://doi.org/10.1007/s10405-009-0368-3

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