Akute Exazerbation der COPD – Besonderheiten der Therapie und Prävention

Die akute Exazerbation der chronisch obstruktiven Lungenerkrankung (COPD) ist definiert als Zunahme der Symptomatik, die eine Änderung der Behandlung erforderlich macht. Ihre Bedeutung liegt vor allem im beschleunigten Verlust an Lungenfunktion. Meist liegen virale Infektionen zugrunde, bakterielle Erreger werden in bis zu 50 % der Fälle gefunden. Bei leicht- bis mittelschwerer COPD überwiegen H. influenzae, S. pneumoniae und M. catarrhalis, bei einer FEV₁ < 50 % des Solls kommen Enterobakterien und P. aeruginosa hinzu. Die Therapie der akuten Exazerbation unterscheidet sich wesentlich von der der ambulant erworbenen Pneumonie. Bei schweren Exazerbationen hat die Sicherstellung der Ventilation Vorrang. Die medikamentöse Therapie besteht in der Gabe antiinflammatorischer und bronchodilatatorischer Substanzen. Eine Indikation zur antimikrobiellen Therapie ist gegeben bei Patienten mit eitrigem Auswurf sowie bei schwerer Exazerbation; für andere Indikationen besteht keine hinreichende Evidenz. Bei akuter respiratorischer Insuffizienz ist Sauerstoff indiziert, bei ventilatorischer Insuffizienz die nichtinvasive Beatmung (NIV). Die Prävention umfasst neben der Sicherstellung der Mobilität und Vermeidung von Untergewicht Impfungen gegen Influenza und Pneumokokken sowie die Standardinhalativa der COPD. Bei Patienten mit rezidivierenden Exazerbationen und P. aeruginosa ist Azithromycin eine Option.

Acute exacerbations of COPD are defined by an increase in symptoms requiring a change of treatment. Exacerbations are associated with an acceleration of lung function decline (FEV₁). Viral infections are usually present, whereas bacterial pathogens are found in around 50 % of cases. In mild-to moderate COPD, H. influenzae, S. pneumoniae and M. catarrhalis are the leading pathogens, in patients with FEV₁ < 50 % predicted enterobacteria and P. aeruginosa are additionally prevalent. Treatment of acute exacerbations differs fundamentally from that of community-acquired pneumonia. Ventilatory support is most important in severe exacerbations. Medical treatment includes antiinflammatory agents and bronchodilatators. Antimicrobial treatment is indicated in patients with purulent sputum as well as severe exacerbations; in all other circumstances, there is currently no sufficient evidence for such treatment. In patients with acute respiratory failure, oxygen is indicated, whereas noninvasive ventilatory support is required in those with ventilator failure. Preventive measures include mobilization, avoidance of underweight, influenza and pneumococcal vaccination and standard inhalative treatment. In patients with recurrent exacerbations in the presence of P.aeruginosa, azithromycin may be administered.

Key words

COPD - exacerbations - infection - ventilator failure - prevention

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