Zusammenfassung
Die akut dekompensierte chronische Herzinsuffizienz führt zu Vor- und Nachlastanstieg. Der Vorlastanstieg manifestiert sich in einem zunehmenden Grad von Lungenstauung bis hin zum Lungenödem. Die resultierenden Lungenfunktionsstörungen betreffen die Sauerstoffdiffusion, das Ventilations-Perfusions-Verhältnis, den Atemwegswiderstand und die Lungencompliance. In Abhängigkeit vom Grad der Störungen wird schließlich eine maschinelle Beatmung mit endexspiratorisch positivem Druck erforderlich sein, der als CPAP oder BiPAP via Maske bzw. als PEEP appliziert werden kann. Der endexspiratorisch positive Druck hat neben der Bedeutung für die Oxygenierung hämodynamische Konsequenzen, indem er die Vorlast beider Ventrikel herabsetzt. Dies stellt eine quasi kausale Therapie für den linken Ventrikel dar. Dadurch wird der Sauerstoffverbrauch des Myokards gesenkt und das Sauerstoffangebot an das Myokard erhöht. PEEP reduziert gleichzeitig die systolische linksventrikuläre Wandspannung. Die Nachlastsenkung bedeutet für den linken Ventrikel abermals Steigerung des Sauerstoffangebotes und Reduktion des Sauerstoffverbrauches. Damit wird Beatmung zu einer bedeutsamen Therapieoption im Endstadium der akut dekompensierten chronischen Herzinsuffizienz, bei akuter Herzinsuffizienz und im kardiogenen Schock.
Abstract
Acutely decompensated chronic heart failure causes increased left ventricular preload and afterload. Increasing preload manifests itself in conditions ranging from increasing degrees of pulmonary congestion to lung edema. The resulting disturbances of lung function affect oxygen diffusion, the ventilation/perfusion ratio, airway resistance, and lung compliance. Mechanical ventilation with positive endexpiratory pressure (PEEP), which can be applied using a CPAP or BiPAP mask, is then required depending on the severity of disturbed oxygenation. Beside the importance for oxygenation, PEEP has hemodynamic consequences. It reduces the preload of both ventricles and represents for the left ventricle a nearly causal treatment. Reduced preload reduces myocardial oxygen demand and increases myocardial oxygen supply. Simultaneously, PEEP reduces the systolic left ventricular wall tension. This reduction of afterload again implies increased oxygen supply and decreased myocardial oxygen demand. Artificial ventilation is an important treatment option of acutely decompensated chronic heart failure, acute left heart failure, and cardiogenic shock.
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Engelmann, L. Bedeutung und Einsatz der Beatmung bei akut dekompensierter Herzinsuffizienz. Intensivmed 46, 391–398 (2009). https://doi.org/10.1007/s00390-009-0082-8
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DOI: https://doi.org/10.1007/s00390-009-0082-8