Zusammenfassung
Das akute Lungenversagen stellt eines der wesentlichen Krankheitsbilder der modernen
Intensivmedizin dar. Es ist durch einen akute, teilweise lebensbedrohliche Hypoxämie
auf dem Boden einer Ventilations-Perfusions-Verteilungsstörung der Lunge gekennzeichnet.
Diese wiederum ist Ausdruck der Abnahme der pulmonalen Gasaustauschfläche durch einen
entweder primären oder sekundären pulmonalen Inflammationsprozess, von dem wir heute
wissen, dass er nicht auf das Kompartiment Lunge beschränkt bleibt, sondern systemische
Wirkung auf Hämodynamik und Funktion nicht pulmonaler Organsysteme entfaltet. Die
maschinelle Beatmung ist von entscheidender Bedeutung bei der Therapie des Lungenversagens,
mit dem Ziel die Hypoxämie durch Rekrutierung der Lunge zu beheben, ohne aber weitere
Schäden durch Überblähung oder zyklischen Kollaps der Lunge in Exspiration zu verursachen.
Hierzu wird auf dem Boden evidenter klinischer Daten heute das Konzept der protektiven
Beatmung mit reduzierten Atemzugvolumina verfolgt, für das eine Reduktion der Letalität
belegt ist. Darüber hinaus existieren verschiedene, pathophysiologisch teilweise faszinierende
Ansätze zur erweiterten Therapie des beatmeten Patienten mit Lungenversagen, die in
diesem Artikel dargestellt und im Hinblick auf ihren klinischen Stellenwert kritisch
eingeordnet werden. In Anbetracht der Einfachheit des Konzeptes der protektiven Beatmung
und des nach wie vor geringen Durchdringungsgrades dieser Therapie in der klinischen
Praxis erscheint eine Fokussierung hierauf nach wie vor gerechtfertigt.
Abstract
Acute lung injury (ALI) is of paramount importance for modern intensive care since
it is one of the most frequent conditions necessitating admission to an ICU. ALI is
characterised by severe life threatening hypoxemia which is based on ventilation perfusion
mismatching within the lung. This is mostly resulting from atelectasis formation due
to primary or secondary inflammation of lung tissue. Many studies showed that this
inflammatory process is not restricted to the respiratory system but might result
in non pulmonary organ failure and hemodynamic compromise as well. Mechanical ventilation
is considered the hallmark treatment for ALI patients aimed to recruit lung tissue
and thereby reverse hypoxemia without causing additional lung injury potentially resulting
from overdistention or cycling collapse during expiration. Scientific evidence shows
us that prevention of ventilator induced lung injury by protective ventilation with
reduced tidal volumes is resulting in better clinical outcomes. Moreover, different
technologies and adjunctive therapies have been suggested based on their pathophysiology.
All these treatment options will be summarized in this article. Given the clear evidence
for protective ventilation and bearing in mind that clinical application of this easy
concept is still not widespread we will focus on this aspect.
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Bereits erschienene Beiträge dieser Serie
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Prof. Dr. med. R. Kuhlen
Klinik für Intensivmedizin Helios Klinikum Berlin Buch
Hobrechtsfelder Chaussee 100
13125 Berlin
Email: rkuhlen@berlin.helios-kliniken.de
