Akutes Lungenversagen: neue Definitionen, neue Therapien

Kernaussagen

• Die Berlin-Definition zur Identifizierung des akuten Lungenversagens ist ein wichtiger Meilenstein der ARDS-Forschung. Sie beinhaltet vor allem eine vereinfachte Definition, die je nach Ausmaß der Oxygenierungsstörung unter Berücksichtigung von F_iO₂ und PEEP eine Unterteilung in 3 Schweregrade vorsieht.

• Diese neue klinische Einteilung ermöglicht eine bessere Risikobeurteilung und korreliert mit dem Grad bzw. der Schwere der Lungenschädigung [53].

• Fortschritte bei der Behandlung des akuten Lungenversagens haben seit Einführung der lungenprotektiven Beatmung zumindest zu einer leichten Verbesserung des Überlebens geführt. Trotzdem hält die Diskussion über die lungenprotektive Beatmung an, weil Untersuchungen zur weiteren Reduktion des Tidalvolumens [19] zeigen, dass gerade beim schweren ARDS eine „ultraprotektive“ Beatmung mit ca. 3 ml/kgKG sinnvoll sein kann

• Zur Rekrutierung der geschädigten Lunge muss man ein entsprechend hohes PEEP-Niveau („je kränker, desto höher“) einsetzen.

• Studien zu unterstützenden Therapiestrategien zeigen keine eindeutigen Ergebnisse und sind gegenwärtig noch Gegenstand der Diskussion.

• Eine pulmonale Vasodilatation mit NO und anderen Substanzen zur Behandlung des schwersten ARDS sollte Spezialzentren vorbehalten bleiben.

• Die technische Weiterentwicklung extrakorporaler Therapieverfahren bietet eine Möglichkeit der Lungenprotektion. Allerdings ist die ECMO nur bei schwersten Formen des ARDS mit akuter, vitaler Gefährdung des Patienten sinnvoll.

• Da extrakorporale Therapieformen nur bei wenigen Patienten eingesetzt werden, sollten nur spezialisierte Zentren diese schweren Verlaufsformen des ARDS (p_aO₂/F_iO₂ < 150 mmHg) behandeln.

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