Früh- und Neugeborene mit einem Acute Respiratory Distress Syndrome (ARDS): welche Rolle spielt die Surfactantsubstitution?

Zusammenfassung

Hintergrund: Die exogene Zufuhr von Surfactantpräparationen zur Behandlung des neonatalen Atemnotsyndroms (engl.: Respiratory Distress Syndrome (RDS)) insbesondere extrem Frühgeborener ist während der letzten beiden Jahrzehnten zur etablierten Standardtherapie geworden.

Diskussion: Eine Surfactantsubstitution bei Frühgeborenen und reifen Neugeborenen mit ARDS wird weltweit von vielen Neonatologen im Sinne einer individualisierten Behandlung eingesetzt. Die so behandelte Patientengruppe differiert erheblich bezüglich Gestationsalter, Lungenreife und sekundärer Lungenerkrankung. Pathophysiologisch ist das ARDS des Früh- und Neugeborenen weniger Folge eines primären Surfactantmangels. Vielmehr setzen verschiedene prä- und auch postnatale Ereignisse wie Chorioamnionitis und Funisitis, Pneumonie und Sepsis, Fruchtwasser-, Blut- oder Mekoniumaspiration eine Inflammationskaskade in Gang. In deren Endstrecke kommt es als Resultat eines komplexen Prozesses aus Surfactant-Fehlfunktion und Surfactant-Inaktivierung durch eine Schädigung der alveolo-kapillären Einheit und den Einstrom von Plasmaproteinen in die Atemwege zu einer alveolären Instabilität und damit zu der lebensbedrohlichen Lungenerkrankung.

Schlussfolgerung: Für den Einsatz von Surfactant beim Mekonium-Aspirationssyndrom konnte gezeigt werden, dass der Einsatz der extrakorporalen Membranoxygenierung (ECMO) gesenkt werden konnte. Für die Mehrzahl der weiteren, denkbaren Indikationen − insbesondere auch das ARDS bei Flüssigkeitslunge − fehlen Daten aus randomisierten, kontrollierten Studien. Die klinischen Erfahrungen lassen aber annehmen, das mit dem Einsatz von Surfactant auch bei weiteren Indikationen die Lungenfunktion und damit auch die Oxygenierung verbessert werden kann. Diese Heilversuche scheinen auch deshalb gerechtfertigt, da unerwünschte Nebenwirkungen nicht beobachtet werden.

Abstract

Background: Surfactant treatment in preterm infants and term newborns with ARDS-like severe respiratory failure has become part of an individualised treatment strategy in many intensive care units around the world.

Discussion: These babies constitute heterogeneous groups with regards to gestational age, lung maturity, underlying disease processes and postnatal interventions. The pathophysiology of respiratory failure in preterm infants is characterised by a combination of primary surfactant deficiency and surfactant inactivation as a result of plasma proteins leaking into the airways from areas of epithelial disruption and injury. Various pre- and postnatal factors, − such as exposure to chorioamnionitis, pneumonia, fluid lung, sepsis and asphyxia − can induce an injurious inflammatory response in the lung which may subsequently affect surfactant function, synthesis and alveolar stability.

Conclusion: Surfactant inactivation and dysfunction is also a hallmark in newborns with meconium aspiration syndrome (MAS), for which a beneficial effect of exogenous surfactant replacement. i.e., reduction of need for ECMO, could be shown. Although for the majority of the above-mentioned diseases process data from randomised, controlled trials are lacking, it is evident from clinical experience that surfactant replacement which counterbalances surfactant inactivation seems to improve oxygenation and lung function in many babies with ARDS without apparent negative side effects. Thus surfactant treatment seems to be justified in many neonates with ARDS.

Schlüsselwörter

Frühgeborene - reife Neugeborene - Surfactant - ARDS

Key words

preterm infants - term newborns - surfactant - ARDS

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