Zusammenfassung
Der Beginn einer maschinellen Beatmung und die Rückkehr zur Spontanatmung (Weaning)
induzieren erhebliche Änderungen des intrathorakalen Drucks mit Konsequenzen für die
Herz-Kreislauf-Funktion. Trotz dieser bekannten pathophysiologischen Zusammenhänge
wird die kardiovaskuläre Situation der Patienten häufig vor und beim Weaning nicht
ausreichend beachtet. Die publizierten und in Leitlinien empfohlenen Kriterien für
Beginn des Weanings, Extubation und Reintubation sind notgedrungen allgemein gehalten.
Die Erkenntnis, dass eine kardiale Dysfunktion ein erfolgreiches Weaning verhindern
kann, basiert auf Studien bei Patienten mit bekannter kardiovaskulärer Erkrankung.
Tatsächlich haben viele Intensivpatienten eine latente oder noch nicht diagnostizierte
kardiale Dysfunktion. Zudem limitiert die intensivmedizinische Grunderkrankung häufig
die kardiovaskulären Kompensationsoptionen. Daher scheitert das Weaning bei nicht
wenigen Intensivpatienten an einer ungenügenden hämodynamischen Reserve. Diese Arbeit
stellt die klinisch relevanten Grundlagen für das erfolgreiche Weaning mit besonderer
Berücksichtigung der kardiovaskulären Situation des Patienten dar.
Abstract
The initiation of and weaning from mechanical ventilation with extubation cause significant
changes in intrathoracic pressures and have profound consequences for the cardiovascular
function. However, in spite of the known pathophysiological relationships, frequently
little attention is paid to the cardiovascular situation during the weaning period.
The currently available guidelines concerning weaning and extubation/reintubation
are based on only limited evidence and are thus rather general. Moreover, recommendations
for the cardiovascular management during weaning reflect mainly the pathophysiological
rationale. In patients with known cardiac disease, studies have demonstrated the necessity
for a prolonged weaning process. On the contrary, many intensive care patients have
subclinical or undiagnosed cardiac disease, and cardiovascular compensation mechanisms
are frequently hampered by the underlying critical illness. Therefore, in a significant
proportion of patients, weaning and extubation attempts fail due to the patient’s
limited cardiovascular reserves. This review summarises the relevant information for
a successful weaning and extubation with special respect to the cardiovascular function.
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Priv.-Doz. Dr. med. F. Joachim Meyer
Abt. Innere Medizin III
Universitätsklinikum
Im Neuenheimer Feld 410
69120 Heidelberg
eMail: Joachim.Meyer@med.uni-heidelberg.de