Verwendung differenzierter Beatmungsstrategien in der präklinischen Notfallmedizin in der Bundesrepublik Deutschland

Zusammenfassung

Ziel der Studie Die vorliegende Arbeit untersucht den präklinischen Einsatz differenzierter Beatmungsstrategien in Deutschland.

Methodik Onlinebefragung deutscher Notärzte nach Verfügbarkeit moderner Respiratoren, regelhaft verwendeten Beatmungseinstellungen, Monitoring und Zielparametern der Ventilation.

Ergebnisse Die Verfügbarkeit moderner Notfallrespiratoren betrug 95%. Regelhafte Abweichungen von den Leitlinien zur Beatmung wurden von 68% angegeben und betrafen positiven endexspiratorischer Druck (19%), Tidalvolumen (13%), Spitzendruck (3%) Atemfrequenz (2%). 90% verwendeten regelmäßig die Kapnografie. 82% steuerten den inspiratorischen Sauerstoffgehalt anhand der Sauerstoffsättigung. Eine Inverse-Ratio-Ventilation wurde regelmäßig von 9% verwendet.

Schlussfolgerung Abweichungen von leitliniengerechten Beatmungseinstellungen und -Monitoring sind häufig. Die aus der Intensivmedizin stammenden Empfehlungen sollten präklinisch auf Anwendbarkeit evaluiert und ggf. adaptiert werden.

Abstract

Objectives To determine the use of differentiated invasive ventilation strategies in the prehospital setting by German emergency physicians.

Methods Online survey of German emergency physicians on availability of modern respirators, regularly used ventilator settings, monitoring and target parameters of ventilation.

Results 95% had pre-hospital access to differentiated respirators. 68% regularly use non-guideline compliant ventilation settings. Deviations mainly affected positive endexpiratory pressure (19%), tidal volume (13%), peak pressure (3%) and respiratory rate (2%). 90% regularly used capnography, 82% stated to adjust fraction of inspiratory oxygen by peripheral capillary oxygen saturation. Interestingly, inversed ratio ventilation was used by 9% of German emergency physicians.

Conclusion Deviations from guideline recommendations for ventilation strategies are frequent. The recommendations from intensive care medicine should be evaluated preclinically for applicability.

Schlüsselwörter

Beatmung - Atemwegsmanagement - Intubation - Notfallmedizin - Intensivmedizin

Keywords

emergency care - intubation - ventilation - airway management

• Literatur

• 1 Timmermann A, Böttiger BW, Byhahn C, Dörges V, Eich C, Gräsner JT, Hoffmann F, Hossfeld B, Landsleitner B, Piepho T, Noppens R, Russo SG, Wenzel V, Zwißler B, Bernhard M. S1-Leitlinie Prähospitales Atemwegsmanagement. Accessed September 20, 2020 at: https://www.awmf.org/uploads/tx_szleitlinien/001-040l_S1_Praehospitales-Atemwegsmanagement_2019-03_1.pdf
• 2 Bollinger M, Roessler M, Russo SG. Incidence of invasive medical procedures in emergency medical services. Considerations regarding emergency paramedic. Notfall Rettungsmed 2015; 18: 215-221
• 3 Piepho T, Cavus E, Noppens R. et al. S1 guidelines on airway management: Guideline of the German Society of Anesthesiology and Intensive Care Medicine. Anaesthesist 2015; 64: 27-40
• 4 Fuller BM, Mohr NM, Dettmer M. et al. Mechanical ventilation and acute lung injury in emergency department patients with severe sepsis and septic shock: an observational study. Acad Emerg Med 2013; 20: 659-669
• 5 Stoltze AJ, Wong TS, Harland KK. et al. Prehospital tidal volume influences hospital tidal volume: A cohort study. J Crit Care 2015; 30: 495-501
• 6 Helm M, Hauke J, Lampl L. A prospective study of the quality of pre-hospital emergency ventilation in patients with severe head injury. Br J Anaesth 2002; 88: 345-349
• 7 Epstein SK, Nevins ML, Chung J. Effect of unplanned extubation on outcome of mechanical ventilation. Am J Respir Crit Care Med 2000; 161: 1912-1916
• 8 Karsten J, Heinze H. Ventilation as a trigger for organ dysfunction and sepsis. Med Klin Intensivmed Notfmed 2016; 111: 96-106
• 9 Fichtner F, Moerer O, Laudi S. et al. Mechanical Ventilation and Extracorporeal Membrane Oxygena tion in Acute Respiratory Insufficiency. Dtsch Arztebl Int 2018; 115: 840-847
• 10 Girardis M, Busani S, Damiani E. et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA 2016; 316: 1583-1589
• 11 Dräger. Oxylog VE300. Accessed September 20, 2020 at: https://www.draeger.com/Products/Content/oxylog-ve300-pi-9103865-de-master.pdf
• 12 Dräger. Oxylog 1000. Accessed September 20, 2020 at: https://www.hissin.de/fileadmin/Mediapool/Prospekte_Draeger/Prospekte_Oxylog_1000/Oxylog_1000.pdf
• 13 Dräger. Oxylog® 2000 plus. Accessed September 20, 2020 at: http://donar.messe.de/exhibitor/interschutz/2015/Q771140/produktinformation-oxylog-R-2000-plus-ger-393620.pdf
• 14 Dräger. Oxylog® 3000 plus. Accessed September 20, 2020 at: http://donar.messe.de/exhibitor/interschutz/2015/Q771140/produktinformation-oxylog-R-3000-plus-ger-393630.pdf
• 15 WEINMANN Emergency Medical Technology. Medumat Transport. Accessed September 20, 2020 at: https://www.weinmann-emergency.com/download/?tx_downloadcenter_downloadcenter[action]=show&tx_downloadcenter_downloadcenter[category]=1&tx_downloadcenter_downloadcenter[controller]=Product&tx_downloadcenter_downloadcenter[product]=1&cHash=63d70699e9b0bbd8e1b3fb2319855693
• 16 WEINMANN Emergency Medical Technology. Medumat Standard. Accessed September 20, 2020 at: https://www.weinmann-emergency.com/download/?tx_downloadcenter_downloadcenter[action]=show&tx_downloadcenter_downloadcenter[category]=1&tx_downloadcenter_downloadcenter[controller]=Product&tx_downloadcenter_downloadcenter[product]=4&cHash=5bfea3412eb4f729de2aa17ae2406345
• 17 Hamilton Medical. HAMILTON-T1 – Intelligente Transportbeatmung. Accessed September 20, 2020 at: https://www.hamilton-medical.com/de_DE/Products/Mechanical-ventilators/HAMILTON-T1.html
• 18 Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. (AWMF). S3 – Leitlinie Polytrauma/Schwerverletzten-Behandlung. Accessed September 20, 2020 at: https://www.awmf.org/uploads/tx_szleitlinien/012-019l_S3_Polytrauma_Schwerverletzten-Behandlung_2017-08.pdf
• 19 Gesundheitsberichterstattung des Bundes. Accessed September 20, 2020 at: http://www.gbe-bund.de/oowa921-install/servlet/oowa/aw92/dboowasys921.xwdevkit/xwd_init?gbe.isgbetol/xs_start_neu/
• 20 [Anonym]. Rettungsdienstfahrzeuge und deren Ausrüstung – Krankenkraftwagen; Deutsche Fassung EN 1789: 2007+A2: 2014. Berlin: Beuth; 2014
• 21 Amato MB, Barbas CS, Medeiros DM. et al. Beneficial effects of the “open lung approach” with low distending pressures in acute respiratory distress syndrome. A prospective randomized study on mechanical ventilation. Am J Respir Crit Care Med 1995; 152: 1835-1846
• 22 Writing Group for the PReVENT Investigators. Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS. The PReVENT Trial. JAMA 2018; 320: 1872-1880
• 23 Bristle TJ, Collins S, Hewer I. et al. Anesthesia and critical care ventilator modes: past, present, and future. AANA J 2014; 82: 387-400
• 24 Helmerhorst HJ, Schultz MJ, van der Voort PH. et al. Bench-to-bedside review: the effects of hyperoxia during critical illness. Crit Care 2015; 19: 15-996
• 25 Brower RG, Matthay MA, Morris A. Acute Respiratory Distress Syndrome Network. et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1301-1308
• 26 Grensemann J, Fuhrmann V, Kluge S. Oxygen treatment in intensive care and emergency medicine. Dtsch Arztebl Int 2018; 115: 455-462
• 27 Helm M, Hauke J, Sauermuller G. et al. Quality of emergency ventilation. A prospective study of trauma patients. Unfallchirurg 1999; 102: 347-353
• 28 Warner KJ, Cuschieri J, Copass MK. et al. The impact of prehospital ventilation on outcome after severe traumatic brain injury. J Trauma 2007; 62: 1330-1338
• 29 Wilharm A, Kulla M, Baacke M. et al. Prähospitale Kapnometrie als Qualitätsindikator der Schwerverletztenversorgung. Eine erste Auswertung aus dem TraumaRegister DGU®. Anästh Intensivmed 2019; 60: 419-432
• 30 Mercat A, Richard JC, Vielle B. et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA 2008; 299: 646-655
• 31 Mercat A, Graini L, Teboul JL. et al. Cardiorespiratory Effects of Pressure-controlled Ventilation With and Without Inverse Ratio in the Adult Respiratory Distress Syndrome. Chest 1993; 104: 871-875