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Akute und chronische respiratorische Insuffizienz

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Therapie innerer Krankheiten

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Zusammenfassung

Mit dem Wechsel in das neue Jahrtausend ist es 35 Jahre nach der Erstbeschreibung des ARDS („adult respiratory distress syndrome“), das die Extremform einer akuten respiratorischen Insuffizienz darstellt, erstmals gelungen die Sterblichkeit in einer multizentrischen, kontrollierten Studie an 861 Patienten um 22% zu senken (ARDS-Network Study 2000). Die herausragende Bedeutung dieser Untersuchung muss vor dem Hintergrund gesehen werden, dass über 35 Jahre eine Vielzahl von Therapieanstrengungen unternommen worden waren, die bislang alle keinen Vorteil für das Überleben der Patienten mit ARDS erbracht hatten. Dieser Erfolg wurde jedoch nicht durch Einsatz neuer komplizierter oder raffinierter Pharmaka erzielt, sondern lediglich durch die Begrenzung des Atemzugvolumens auf 6 ml/kgKG gegenüber 12 ml/kgKG.

Im Rückschluss müssen wir aus dieser Studie aber auch lernen, dass die Beatmung schädigen und die Prognose der von uns beatmeten Patienten negativ beeinflussen kann. Der Stellenwert der invasiven Beatmung zur Überbrückung akuter lebensbedrohlicher hypoxämischer Zustände gilt nach wie vor als unumstritten, unterschiedliche Beatmungsstrategien können aber mit einer signifikanten Reduktion der Letalität einher gehen. Mit dem Wissen um die „iatrogene“ Schädigung der Lunge unter der Beatmung ist es naheliegend, den Stellenwert der nichtinvasiven Beatmung, neben seiner Bedeutung für die chronisch obstruktiven Lungenerkrankungen, auch für das hypoxämische Lungenversagen nicht als Alternative sondern als ergänzende Therapieoption zur konventionellen Beatmung zu diskutieren. Für die nichtinvasive Beatmung bei COPD-Patienten belegte eine Metaanalyse (Keenan et al. 1997) eindeutig einen Überlebensvorteil. Eine neue multizentrische, kontrollierte Studie (Plant et al. 2000) bei 236 COPD-Patienten erzielte sogar eine Senkung der Letalität durch die Ergänzung der Standardtherapie mit nichtinvasiver Beatmung um 50%.

Zusammenfassend zeigen diese Untersuchungen, dass der Beatmung als Therapie eine entscheidende Bedeutung zufällt und „Indikationen, Dosis, Nebenwirkungen etc.“ wie bei allen übrigen Therapieformen ebenfalls beherrscht werden müssen.

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  1. D. Walmrath
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  2. F. Grimminger
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  3. W. Seeger
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  1. Medizinische Klinik und Poliklinik I und II, Klinikum der Universität München-Großhadern, Ludwig-Maximilians-Universität, Marchioninistr. 15, 81377, München

    Gerhard Steinbeck  & Gustav Paumgartner  & 

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Walmrath, D., Grimminger, F., Seeger, W. (2005). Akute und chronische respiratorische Insuffizienz. In: Steinbeck, G., et al. Therapie innerer Krankheiten. Springer, Berlin, Heidelberg. https://doi.org/10.1007/3-540-26504-X_26

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  • DOI: https://doi.org/10.1007/3-540-26504-X_26

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