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Diaphragmale Dysfunktion

Fakten für den Kliniker

Diaphragm dysfunction

Facts for clinicians

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Zusammenfassung

Die diaphragmale Funktion des kritisch kranken Patienten kann entscheidend für das Outcome im Rahmen einer Intensivbehandlung sein. Das Versagen der Atemmuskelpumpe insbesondere bei vorerkrankten Patienten beispielsweise im Rahmen einer akuten Exazerbation einer chronisch-obstruktiven Lungenerkrankung resultiert in einer Hyperkapnie und führt zur Intubationspflicht, wenn nichtinvasive Beatmungsverfahren versagen. Die Veränderungen der biomechanischen Eigenschaften durch eine Überblähung und Veränderungen der Faserstruktur des Diaphragmas können das Entstehen eines hyperkapnischen Atemversagens erleichtern und in eine maschinelle Beatmung münden. Nach Intubation und folgender Inaktivierung unterliegt das Diaphragma einer pathophysiologischen Kaskade, die zur Atrophie und Dysfunktion führt. Zusätzlich zu den Einflüssen durch die Inaktivierung (ventilatorinduzierte diaphragmale Dysfunktion) verändern Komorbiditäten, Pharmaka, und Erkrankungen die diaphragmale Homöostase. Insbesondere das Auftreten einer Sepsis kann während des Intensivaufenthalts das Diaphragma grundlegend verändern und so zum Weaningversagen führen. Die Erfassung der diaphragmalen Kraft in der Beatmungsentwöhnung gelingt aktuell nur mit invasiven Verfahren – sonographische Methoden werden zunehmend etabliert, benötigen aber noch weitere und größere Studien, um einen verlässlichen klinischen Nutzen zu ermöglichen.

Abstract

Diaphragm function is crucial for patient outcome in the ICU setting and during the treatment period. The occurrence of an insufficiency of the respiratory pump, which is predominantly formed by the diaphragm, may result in intubation after failure of noninvasive ventilation. Especially patients suffering from chronic obstructive pulmonary disease are in danger of hypercapnic respiratory failure. Changes in biomechanical properties and fiber texture of the diaphragm are further cofactors directly leading to a need for intubation and mechanical ventilation. After intubation and the following inactivity the diaphragm is subject to profound pathophysiologic changes resulting in atrophy and dysfunction. Besides this inactivity-triggered mechanism (termed as ventilator-induced diaphragmatic dysfunction) multiple factors, comorbidities, pharmaceutical agents and additional hits during the ICU treatment, especially the occurrence of sepsis, influence diaphragm homeostasis and can lead to weaning failure. During the weaning process monitoring of diaphragm function can be done with invasive methods – ultrasound is increasingly established to monitor diaphragm contraction, but further and better powered studies are in need to prove its value as a diagnostic tool.

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  1. Klinik für Operative Intensivmedizin und Intermediate Care, Universitätsklinik der RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland

    C. S. Bruells & G. Marx

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  1. C. S. Bruells
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  2. G. Marx
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Correspondence to C. S. Bruells.

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Bruells, C.S., Marx, G. Diaphragmale Dysfunktion. Med Klin Intensivmed Notfmed 113, 526–532 (2018). https://doi.org/10.1007/s00063-016-0226-0

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