Moderne Beatmungskonzepte in der Therapie des akuten Atemnotsyndroms (ARDS)

Zusammenfassung

In der modernen Intensivmedizin hat die maschinelle Beatmung einen wichtigen Stellenwert. Im Laufe der Jahre haben sich hierbei aufgrund neuerer Erkenntnisse moderne Beatmungskonzepte etabliert, die dem auf der Intensivstation tätigen Personal vertraut sein sollten. Dazu gehört u. a. die sogenannte „protektive Beatmung” bei ARDS-Patienten, für die im Gegensatz zu anderen Beatmungskonzepten ein signifikanter Überlebensvorteil gezeigt werden konnte. Neben der konservativen Beatmungstherapie etablieren sich aktuell zunehmend alternative Beatmungsverfahren wie die Hochfrequenz-Oszillations-Ventilation (HFOV) und die extrakorporale CO₂-Elimination (Extracorporeal Lung Assist, ECLA), welche allein oder in Kombination mit konventioneller Beatmung eine „ultraprotektive” Ventilation mit sehr kleinen Tidalvolumina ermöglichen. Diese Verfahren wurden bislang nicht in großen randomisierten Studien validiert, so dass daher deren Anwendung zur Zeit noch eine Einzelfallentscheidung bleibt.

Summary

In current intensive care medicine mechanical ventilation is of particular importance. In recent years new ventilation concepts have been established. Most notably, the idea of protective ventilation of patients suffering from ARDS had lasting effects in the ventilation management on these patients. In contrast to other ventilation concepts, a significant survival benefit was shown. Alternative treatment options are high-frequency-oscillatory ventilation, extracorporeal assist devices or a combination of both in order to apply an extrem small tidal volume. These alternative treatment options have never been evaluated in randomised controlled trials, so a definite statement for practical application cannot be made.

Schlüsselwörter

akutes Lungenversagen - ARDS - Beatmung - Hochfrequenz-Oszillations-Ventilation - extrakorporale CO₂-Elimination

Keywords

acute respiratory distress syndrome - ARDS - ventilation - high-frequency oscillatory ventilation - extracorporeal lung assist

Literatur

• 1 Bein T, Weber F, Philipp A, Prasser C, Pfeifer M, Schmid F X, Butz B, Birnbaum D, Taeger K, Schlitt H J. A new pumpless extracorporeal interventional lung assist in critical hypoxemia/hypercapnia.  Crit Care Med. 2006;  34 (5) 1372-7
• 2 Bollen C W, van Well G T, Sherry T, Beale R J, Shah S, Findlay G, Monchi M, Chiche J D, Weiler N, Uiterwaal C S, van Vught A J. High frequency oscillatory ventilation compared with conventional mechanical ventilation in adult respiratory distress syndrome: a randomized controlled trial [ISRCTN24242669].  Crit Care. 2005;  9 (4) R430-9 , Epub 2005 Jun 21
• 3 Borges J B, Okamoto V N, Matos G F, Caramez M P, Arantes P R, Barros F, Souza C E, Victorino J A, Kacmarek R M, Barbas C S, Carvalho C R, Amato M B. Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome.  Am J Respir Crit Care Med. 2006;  174 (3) 268-78 , Epub 2006 May 11
• 4 Brederlau J, Anetseder M, Schoefinius A, Wurmb T, Muellenbach R, Kredel M, Schwemmer U, Zahn P, Thiel A, Roewer N. Arteriovenous extracorporeal lung assist and high frequency oscillatory ventilation in post-traumatic acute respiratory distress syndrome.  J Trauma. 2008;  64 (4) E65-8
• 5 Cartotto R. High-frequency oscillatory ventilation (HFOV) in trauma patients.  J Trauma. 2007;  62 1315-6
• 6 David M, Heinrichs W. High-frequency oscillatory ventilation and an interventional lung assist device to treat hypoxaemia and hypercapnia.  Br J Anaesth. 2004;  93 (4) 582-6 , Epub 2004 Jul 26
• 7 Derdak S, Mehta S, Stewart T E, Smith T, Rogers M, Buchman T G, Carlin B, Lowson S, Granton J. Multicenter Oscillatory Ventilation For Acute Respiratory Distress Syndrome Trial (MOAT) Study Investigators . High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: a randomized, controlled trial.  Am J Respir Crit Care Med. 2002;  166 (6) 801-8
• 8 Dreyfus D, Saumon G. Ventilator-induced Lung Injury. Lessons from Experimental Studies.  Am J Respir Crit Care Med. 1998;  157 294-323
• 9 Fessler H E, Hager D N, Brower R G. Feasibility of very high-frequency ventilation in adults with acute respiratory distress syndrome.  Crit Care Med. 2008;  36 (4) 1043-8
• 10 Finkielman J D, Gajic O, Farmer J C, Afessa B, Hubmayr R D. The initial Mayo Clinic experience using high-frequency oscillatory ventilation for adult patients: a retrospective study.  BMC Emerg Med. 2006;  6 2
• 11 Fischer S, Hoeper M M, Tomaszek S, Simon A, Gottlieb J, Welte T, Haverich A, Strueber M. Bridge to lung transplantation with the extracorporeal membrane ventilator Novalung in the veno-venous mode: the initial Hannover experience.  ASAIO J. 2007;  53 (2) 168-70
• 12 Fischer S, Simon A R, Welte T, Hoeper M M, Meyer A, Tessmann R, Gohrbandt B, Gottlieb J, Haverich A, Strueber M. Bridge to lung transplantation with the novel pumpless interventional lung assist device NovaLung.  J Thorac Cardiovasc Surg. 2006;  131 (3) 719-23
• 13 Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri V M, Quintel M, Russo S, Patroniti N, Cornejo R, Bugedo G. Lung recruitment in patients with the acute respiratory distress syndrome.  N Engl J Med. 2006;  354 (17) 1775-86
• 14 Gerbode F. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung.  N Engl J Med. 1972;  286 (12) 629-34
• 15 Hager D N, Fessler H E, Kaczka D W, Shanholtz C B, Fuld M K, Simon B A, Brower R G. Tidal volume delivery during high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.  Crit Care Med. 2007;  35 (6) 1522-9
• 16 Mehta S, Granton J, MacDonald R J, Bowman D, Matte-Martyn A, Bachman T, Smith T, Stewart T E. High-frequency oscillatory ventilation in adults: the Toronto experience.  Chest. 2004;  126 (2) 518-27
• 17 Mehta S, MacDonald R, Hallett D C, Lapinsky S E, Aubin M, Stewart T E. Acute oxygenation response to inhaled nitric oxide when combined with high-frequency oscillatory ventilation in adults with acute respiratory distress syndrome.  Crit Care Med. 2003;  31 383-9
• 18 Mercat A, Richard J C, Vielle B, Jaber S, Osman D, Diehl J L, Lefrant J Y, Prat G, Richecoeur J, Nieszkowska A, Gervais C, Baudot J, Bouadma L, Brochard L. Expiratory Pressure (Express) Study Group . Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial.  JAMA. 2008;  299 (6) 646-55
• 19 Muellenbach R M, Kredel M, Said H M, Klosterhalfen B, Zollhoefer B, Wunder C, Redel A, Schmidt M, Roewer N, Brederlau J. High-frequency oscillatory ventilation reduces lung inflammation: a large-animal 24-h model of respiratory distress.  Intensive Care Med. 2007;  33 (8) 1423-33 , Epub 2007 Jun 12
• 20 Muellenbach R M, Wunder C, Nuechter D C, Smul T, Trautner H, Kredel M, Roewer N, Brederlau J. Early treatment with arteriovenous extracorporeal lung assist and high frequency oscillatory ventilation in a case of severe acute respiratory distress syndrome.  Acta Anaesthesiol Scand. 2007;  51 766-9
• 21 Terragni P P, Rosboch G, Tealdi A, Corno E, Menaldo E, Davini O, Gandini G, Herrmann P, Mascia L, Quintel M, Slutsky A S, Gattinoni L, Ranieri V M. Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome.  Am J Respir Crit Care Med. 2007;  175 (2) 160-6 , Epub 2006 Oct 12
• 22 The Acute Respiratory Distress Syndrome Network . 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 (18) 1301-8
• 23 The National Heart, Lung, and Blood Institute ARDS Clinical Trials Network . Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.  N Engl J Med. 2004;  351 327-36
• 24 Zapol W M, Snider M T, Hill J D, Fallat R J, Bartlett R H, Edmunds L H, Morris A H, Peirce E C 2nd, Thomas A N, Proctor H J, Drinker P A, Pratt P C, Bagniewski A, Miller Jr R G. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study.  JAMA. 1979;  242 (20) 2193-6