Sauerstofftherapie in der Intensivmedizin

Was ist neu?

Pulsoxymetrie und Blutgasanalysen Die Pulsoxymetrie hat eine hohe Sensitivität, aber nur eine geringe Spezifität zur Erfassung von Hypoxämien. Arterielle Blutgasanalysen sind der Goldstandard zur Überwachung einer O₂-Therapie. Venöse Blutgasanalysen sollten zur O₂-Steuerung nicht zum Einsatz kommen.

Zielwerte der O₂-Therapie Der Zielbereich der akuten O₂-Therapie für beatmete Patienten und nicht beatmete Patienten ohne Hyperkapnie-Risiko soll bei einer pulsoxymetrisch gemessenen Sauerstoffsättigung (SpO₂) zwischen 92% und 96% liegen. Indikationen einer hochdosierten O₂-Therapie ohne Zielbereich sind in der Intensivmedizin die Kohlenmonoxidvergiftung und Patienten mit schwerer Atemnot, wenn keine SpO₂ ableitbar ist. Eine Hyperoxämie, d.h. SpO₂-Werte über 96%, hat in randomisierten Studien an überwiegend beatmeten Intensivpatienten das Überleben nicht verbessert. Unter einer Hyperoxämie bei nicht beatmeten Patienten mit Hyperkapnie-Risiko (z.B. Patienten mit chronisch-obstruktiver Lungenerkrankung) besteht bei jedem dritten Patienten das Risiko eines zunehmenden Kohlendioxidanstiegs. Deswegen soll bei diesen Patienten eine Ziel-SpO₂ von 88–92% angestrebt werden.

O₂-Zielbereiche an extrakorporalen Verfahren Es gibt keine randomisierten Studien, die andere SpO₂-Zielbereiche für Patienten an extrakorporalen Verfahren empfehlen. Diese Patienten sollen immer mit arteriellen Blutgasen – bei peripherer VA-ECMO am rechten Arm und hinter dem Oxygenator – überwacht werden.

High-Flow-Sauerstoff-Therapie beim akuten hyperkapnischen Atemversagen Die High-Flow-Sauerstoff-Therapie (HFNC) war in einer Metaanalyse überwiegend bei Patienten mit akuter Hypoxämie (Typ-I-Atemversagen) gegenüber konventionellem O₂ nicht mit einer reduzierten Krankenhaussterblichkeit assoziiert, allerdings wurde die Intubationsrate reduziert. Auch beim moderaten hyperkapnischen Atemversagen (Typ II) ist die HFNC mit hohen Flussraten der nicht invasiven Beatmung (NIV) nicht unterlegen.

Abstract

Pulse oximetry and blood gas analyses Pulse oximetry has high sensitivity but low specificity for detecting hypoxemia. Arterial blood gas analyses are the gold standard for monitoring O2 therapy. Venous blood gas analyses should not be used in this setting.

Target values of O2 therapy The target range of acute O2 therapy for ventilated patients and nonventilated patients not at risk of hypercapnia should be between 92% and 96% for oxygen saturation (SpO2) measured by pulse oximetry. Indications for high-dose O2 therapy without a target range in critical care include carbon monoxide poisoning and patients with severe respiratory distress when SpO2 cannot be derived. Hyperoxemia, i.e., SpO2 values above 96%, has not improved survival in randomized trials of predominantly ventilated ICU patients. Under hyperoxemia in nonventilated patients at risk of hypercapnia (e.g., patients with chronic obstructive pulmonary disease), one in three patients is at risk of increasing carbon dioxide. Therefore, a target SpO2 of 88–92% should be aimed for in these patients.

O2 target ranges on extracorporeal procedures There are no randomized studies recommending other SpO2 target ranges for patients on extracorporeal procedures. These patients should always be monitored with arterial blood gases-in the case of peripheral VA-ECMO on the right arm and downstream of the oxygenator.

High-flow oxygen therapy for acute hypercapnic respiratory failure High-flow oxygen therapy (HFNC) was not associated with reduced in-hospital mortality compared with conventional O2 in a meta-analysis of predominantly patients with acute hypoxemia (type I respiratory failure), although intubation rates were reduced. Also, in acute hypercapnic respiratory failure (type II), HFNC with high flow rates is not inferior to noninvasive ventilation (NIV).

Schlüsselwörter

Sauerstofftherapie - High-Flow-Sauerstoff - Pulsoxymetrie - Hypoxämie - Hyperoxämie

Keywords

oxygen inhalation therapy - hypoxia - respiratory rate - pulse oximetry - positive-pressure respiration - high-flow oxygen

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