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Der Einfluß des kontinuierlichen axialen Lagewechsels bei der Behandlung des posttraumatischen Lungenversagens (ARDS)

Continuous axial rotation as a treatment option in posttraumatic ARDS

Eine klinische Studie

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Zusammenfassung

Das posttraumatische Lungenversagen stellt nach wie vor eine gefürchtete Komplikation dar. Aufgrund guter Erfahrungen mit einer kontinuierlichen axialen Lagerungstherapie in einem Spezialbett verglichen wir eine Gruppe von ARDS-Patienten, die nach Verschlechterung der Lungenfunktion mit Hilfe des Spezialbetts (Fa. KCI-Mediscus, Hoechstadt) gelagert wurde (Gruppe KIN), mit in herkömmlicher Rückenlage beatmeten Patienten mit ARDS (Gruppe KON). Folgende Parameter wurden täglich bestimmt: extravaskuläres Lungenwasser (EVLW, mittels Doppelindikatorverdünngsmethode), Oxygenierung (PaO2/FiO2) und berechnete Werte aus hämodynamischen Messungen mittels Pulmonalarterienkatheter. Bei Erreichen eines Oxygenierungsquotienten (PaO2/FiO2) von 150 wurde die kontinuierliche axiale Lagerung (beidseitige Rotation um die Körperlängsachse bis 62°) durchgeführt. Elf KIN-Patienten und elf KON-Patienten wurden in die Studie aufgenommen. Die Gesamtverletzungsschwere nach dem Injury Severity Score (ISS) betrug 29,6±6 Punkte in der KIN-Gruppe und 31,6±5 Punkte in der KON-Gruppe. Der Oxygenierungsquotient verbesserte sich signifikant innerhalb von fünf Tagen nur in der KIN-Gruppe (Tag 0: 140±45; Tag 5: 237±40) (p<0,05), bei KON-Patienten war keine Verbesserung feststellbar (Tag 0: 143±48, Tag 5: 133±44, p<0,05, im Gruppenvergleich). Die pulmonale Shuntfraktion field signifikant nur in der Gruppe KIN(Tag 0: 26,6±4%; Tag 5: 12,5±2%) und betrug bei KON-Patienten 36,6±6% am Tag 0 und 31,4±2% am Tag 5 (p<0,05 im Gruppenvergleich). Das extravaskuläre Lungenwasser stieg nur in der Gruppen KON im Vergleich zum Studienbeginn (Tag 0: 12,9±2 ml/kg KG; Tag 5: 17,4±3 ml/kg KG). Kontinuerliche axiale Lagerungswechsel bei Patienten mit posttraumatischem ARDS verbessert die Lungenfunktion und reduziert den intrapulmonalen Rechts-links-Shunt. Negative hämodynamische Nebeneffekte treten beim Lagerungswechsel nicht auf. Der kontinuierliche axiale Lagerungswechsel stellt eine erwägenswerte unterstützende Therapie für Patienten mit posttraumatischem ARDS dar.

Abstract

In the treatment of posttraumatic adult respiratory distress syndrome (ARDS) so far no breakthrough has been achieved. In several cases of severe ARDS we have seen improvements of lung function by means of continuous body positioning. We therefore compared the effect of kinetic positioning (KIN) on lung function and hemodynamics in ARDS patients to conventional (KON) supine positioning. 22 ARDS patiens with multiple trauma treated by supportive continuous body positioning (KIN) (KCI-Mediscus) and without continuous positioning (KON) were investigated daily. Pulmonary and systemic hemodynamics were determined on the basis of pulmonary artery catheter measurements. Oxygenation ratio (PaO2/FiO2) and pulmonary shunt (Qs/Qt, %) were calculated. Extravascular lung water (EVLW, ml/kg body weight) was determined by double indicator thermodilution technique. Total injury severity by injury severity score (ISS) was 29.6±6 points (KIN) and 31.6±5 points (KON). The oxygenation ratio (PaO2/FiO2) increased significantly from 140±45 (day 0) to 237±40 (p<0.05) [day 5] (KIN), in KON patients no improvement (143±48 [day 0], 133±44 [day 5]) was seen (p<0.05 between groups). There were no significant changes of systemic hemodynamics between the groups or compared to day 0. Pulmonary shunt decreased significantly from 26.6±4% (day0) to12.5±2% (day5) (p<0.05) in KIN patients and was 36.6±6% at day 0 and 31.4±2% at day 5 in KON patients (p<0.05 between groups). EVLW was 11.1±2 ml/kg body weight at day 0 and 9.4±1 ml/kg body weight at day 5 (KIN)-EVLW was 12.9±2 ml/kg body weight at day 0 and 17.4±3 ml/kg body weight at day 5 (KON) (not significant). We found no hemodynamic side effects from continuous body positioning. In ARDS-patients submitted to body positioning oxygenation and pulmonary shunt improved significantly and were significantly better compared to those with conventional supine positioning. Continuous body positioning appears to represent a promising supportive treatment regimen in posttraumatic ARDS.

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  1. H.-C Pape

    Present address: Unfallchirurgische Klinik der Medizinischen Hochschule, Konstanty-Gutschow-Straße 8, D-30625, Hannover

Authors and Affiliations

  1. Unfallchirurgische Klinik der Medizinischen Hochschule, Konstanty-Gutschow-Straße 8, D-30625, Hannover

    G. Regel, W. Borgmann, J. Sturm & H. Tscherne

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  1. H.-C Pape
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  2. G. Regel
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Pape, HC., Regel, G., Borgmann, W. et al. Der Einfluß des kontinuierlichen axialen Lagewechsels bei der Behandlung des posttraumatischen Lungenversagens (ARDS). Unfallchirurgie 19, 329–338 (1993). https://doi.org/10.1007/BF02592663

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