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Neonatologie Scan 2016; 05(03): 197-217
DOI: 10.1055/s-0042-108267
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© Georg Thieme Verlag KG Stuttgart · New York

Noninvasive Surfactant-Applikation (LISA) – Erkenntnisstand 2016

Angela Kribs
,
Christian Wieg
,
Bernhard Roth
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Publication History

Publication Date:
18 August 2016 (online)

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Einleitung

Das Atemnotsyndrom (ANS) des Frühgeborenen stellt eine akut lebensbedrohliche Erkrankung dar und ist auch heute noch für einen großen Teil der neonatalen Morbidität und Mortalität sehr kleiner Frühgeborener verantwortlich [1]. Zusätzlich verursachen das ANS selbst sowie die notwendigen therapeutischen Maßnahmen Folgezustände, die mit einer Langzeitmorbidität einhergehen, insbesondere mit der sog. chronischen Lungenerkrankung des Frühgeborenen (CLD), die auch als bronchopulmonale Dysplasie (BPD) bezeichnet wird. Man unterscheidet eine überwiegend durch Beatmung induzierte alte Form (old BPD) und eine weitgehend beatmungsunabhängige neue Form (new BPD), die in erster Linie durch eine mangelnde strukturelle Ausreifung ausgelöst wird [2] [3]. Letztere tritt auf, wenn sich die Lunge außerhalb des Mutterleibs unter unphysiologischen Bedingungen weiterentwickeln muss.

In der Pathogenese der CLD spielen also sowohl die Unreife der Lunge selbst als auch die maschinelle Beatmung eine Rolle. Um die Möglichkeit der Schädigung durch maschinelle Beatmung zu minimieren, wurden in den letzten Jahrzehnten schonende Beatmungsformen sowie Strategien zur Beatmungsvermeidung entwickelt. Dazu gehört die Anwendung eines kontinuierlichen positiven Atemwegsdrucks (CPAP: Continuous Positive Airway Pressure) von Geburt an.

Neben der strukturellen Unreife der Lunge mit deutlich verminderter respiratorischer Oberfläche kommt der biochemischen Unreife mit einer stark eingeschränkten Fähigkeit zur Surfactant-Bildung bzw. Surfactant-Release eine erhebliche Bedeutung zu. Daher ist die Substitution von exogenem natürlichem Surfactant seit der Verfügbarkeit entsprechender Präparate ein maßgebliches Therapieprinzip. Die Substitution von Surfactant war bis vor Kurzem in der Regel an Intubation und maschinelle Beatmung gebunden, da Surfactant über den Endotrachealtubus appliziert wurde.

Neben einer pränatalen Lungenreifungsinduktion durch die Gabe von Steroiden an die Mutter, die heute als Standardtherapie bei drohender Frühgeburt gilt, stellen sowohl die Surfactant-Substitution als auch die Vermeidung maschineller Beatmung entscheidende Therapierichtlinien zur Vermeidung der CLD dar. Deshalb wird neuerdings neben den beiden klassischen therapeutischen Wegen zur Behandlung des ANS – reine CPAP-Anwendung oder maschinelle Beatmung über einen Endotrachealtubus, verbunden mit endotrachealer Gabe von Surfactant – die Kombination von CPAP mit einer wenig invasiven Gabe von Surfactant unter CPAP-unterstützter Spontanatmung diskutiert.

 

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