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Patienten mit interstitiellen Lungenerkrankungen auf der Intensivstation

Patients with interstitial lung disease in the intensive care unit

  • Leitthema
  • Published:
Der Pneumologe Aims and scope

Zusammenfassung

Trotz relevanter Fortschritte in der Behandlung der interstitiellen Lungenerkrankungen („interstitial lung diseases“, ILD) sind Morbidität und Mortalität bei Patienten mit ILD hoch. Patienten unter intensivmedizinischer Behandlung wegen akuter Exazerbation einer idiopathischen Lungenfibrose („acute exacerbation of idiopathic pulmonary fibrosis“, AE-IPF) zeigen eine erhöhte Mortalität. Therapieentscheidend ist die Ursachenabklärung, es sollten eine akute Exazerbation, Rechtsherzdekompensation bei pulmonaler Hypertonie, Infektion, Lungenembolie, Medikamentenassoziation und Verschlechterung von Komorbiditäten in Betracht gezogen werden. Bei Patienten mit dem Verdacht auf AE-IPF sollte neben Anamnese und körperlicher Untersuchung unter Berücksichtigung der Differenzialdiagnosen rasch eine hochauflösende Computertomographie („high-resolution computed tomography“, HRCT; obligat ohne Kontrastmittel) erfolgen. Das derzeitige Therapieregime besteht aus hochdosierten Kortikosteroiden mit Tapering, ggf. Antibiotika und Immunsuppressiva. Die Mortalitätsrate bei Patienten, die im Rahmen einer AE-IPF maschinell beatmet werden müssen, liegt bei 87 %. In der deutschen Leitlinie wird von einer mechanischen invasiven Beatmung abgeraten, wenn die Ursache in einer Progression der IPF liegt. Nur bei potenziell reversiblen Erkrankungen sollte die invasive Beatmung überbrückend erfolgen. Die Anwendung einer nichtinvasiven Beatmung kann diskutiert werden. Überbrückende Maßnahmen wie eine extrakorporale Membranoxygenierung (ECMO) können eine lebensrettende Option für Patienten mit ILD und akuter respiratorischer Insuffizienz sein, sofern sie Kandidaten für die Lungentransplantation sind. Falls nicht, wird die schlechte Prognose jedoch durch diese Maßnahmen nicht verändert.

Abstract

Despite relevant advances in the treatment of interstitial lung diseases (ILD), morbidity and mortality in patients with ILD are high. Patients receiving intensive care treatment for acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) exhibit increased mortality. Determination of the possible causes of the respiratory failure is crucial for further treatment and reasons include acute exacerbations, right heart failure in pulmonary hypertension, infection, pulmonary embolism, drug-associated complications, and aggravation of comorbidities. In patients with suspected AE-IPF, a HRCT (high-resolution computed tomography; obligate without contrast agent) should be performed immediately in addition to a medical history and physical examination, which should in particular take into account the differential diagnoses. The current therapeutic regimen for AE-IPF consists of high-dose corticosteroids with tapering, and possibly antibiotics and immunosuppressants. The mortality rate for patients who require mechanical ventilation in acute exacerbation is 87 %. Therefore, mechanical ventilation is discouraged in the German IPF guideline if the underlying cause of respiratory failure is due to IPF progression. Only in potentially reversible disease should invasive ventilation be considered. The use of noninvasive ventilation may be discussed. The use of extracorporeal membrane oxygenation (ECMO) as a bridging therapy can be a lifesaving option for patients with ILD and acute respiratory failure, if they are candidates for lung transplantation. The poor prognosis, however, can not be altered by this action if they are not suitable for a lung transplant.

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Authors and Affiliations

  1. Zentrum für interstitielle und seltene Lungenerkrankungen, Pneumologie und Beatmungsmedizin, Thoraxklinik, Universitätsklinikum Heidelberg, Röntgenstr. 1, 69126, Heidelberg, Deutschland

    J. Wälscher &  M. Kreuter

  2. Diagnostische und Interventionelle Radiologie, Thoraxklinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    C. P. Heußel

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  1. J. Wälscher
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  2. C. P. Heußel
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  3. M. Kreuter
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Correspondence to M. Kreuter.

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J. Wälscher, C. P. Heußel und M. Kreuter geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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J. Lorenz, Lüdenscheid

J. F. Meyer, München

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Wälscher, J., Heußel, C.P. & Kreuter, M. Patienten mit interstitiellen Lungenerkrankungen auf der Intensivstation. Pneumologe 13, 294–307 (2016). https://doi.org/10.1007/s10405-016-0053-2

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