Beatmungsformen und Beatmungsparameter

Zusammenfassung

Die künstliche Überdruckbeatmung geht mit einem erheblichen Schädigungspotential für die Lunge einher. Bei der Wahl der Beatmungsform und der Beatmungsparameter ist daher auf eine möglichst lungenprotektive Einstellung zu achten. Die Beatmung sollte mit niedrigem Atemzugvolumen (6 ml/kg IKG), limitiertem Plateaudruck (30 bis 35 cm H₂O) und positivem endexspiratorischen Druck (PEEP) erfolgen. Es ist derzeit unklar, ob eine fluss– oder druckkonstante Beatmung günstiger ist. Die Anpassung von In– und Exspirationszeit sollte die Atmungsmechanik berücksichtigen und die Generierung eines intrinsischen PEEP verhindern. Beatmungsformen, die die Spontanatmung unterstützen, sollten so früh wie möglich zur Anwendung kommen.

Summary

Mechanical ventilation has a considerable potential for injuring the lung tissue. Therefore, attention has to be paid to the proper choice of ventilatory mode and settings to secure lung–protective ventilation whenever possible. Such ventilator strategy should account for low tidal volume ventilation (6 ml/kg PBW), limited plateau pressure (30 to 35 cm H₂O) and positive end–expiratory pressure (PEEP). It is unclear whether pressure controlled or volume controlled ventilation with square flow profile is beneficial. The adjustment of inspiration and expiration time should consider the actual breathing mechanics and anticipate the generation of intrinsic PEEP. Ventilatory modes with the possibility of supporting spontaneous breathing should be used as soon as possible.

Schlüsselwörter

lungenprotektive Beatmung - Beatmungsform - mechanische Beatmung - assistierte Spontanatmung - akutes Lungenversagen

Keywords

lung protective ventilation - ventilatory mode - mechanical ventilation - assisted spontaneous breathing - acute lung injury

Kernaussagen

• Aufgrund von fehlenden multizentrischen, randomisierten, kontrollierten Studien ist derzeit unklar, ob eine fluss– oder eine druckkonstante Beatmung zu bevorzugen ist.

• Die Beatmung sollte mit einem maximalen Plateaudruck von 30–35cmH₂O und einem maximalen Atemzugvolumen von 6ml/kg IKG durchgeführt werden.

• Bei kontrolliert beatmeten Patienten sollten die In– und Exspirationszeiten so gewählt werden, dass es zu einer (nahezu) vollständigen In– und Exspiration kommt.

• ARDS–Patienten sollten mit PEEP beatmet werden. Die Höhe des PEEP kann mit Hilfe einer PEEP/FIO₂–Tabelle, eines PEEP–Trials oder einer quasi statischen Druckvolumenschleife bestimmt werden.

• SIMV kann zur Entwöhnung von der Beatmung nicht mehr empfohlen werden. PSV oder intermittierende T–Stück–Versuche erzielen bei der Entwöhnung vergleichbare Ergebnisse. Bei schwieriger Entwöhnung kann PSV die Beatmungsdauer reduzieren.

• Die Entwöhnung von der Beatmung sollte mit Hilfe von Entwöhnungs– und Analgosedierungsprotokollen durchgeführt werden.

• Die PAV zur Entwöhnung von der Beatmung ist derzeit aufgrund von notwendigen technischen Weiterentwicklungen und fehlenden positiven randomisierten, kontrollierten Studien nicht zu empfehlen.

• Der Erhalt der Spontanatmung mit BIPAP zeigt sowohl bei Patienten mit und ohne Lungenschädigung viele vorteilhafte Effekte. Andere Organsysteme werden durch BIPAP mit Spontanatmung weniger negativ beeinflusst als bei konventioneller Beatmung.

• APRV gewährleistet eine sichere Oxygenierung und alveoläre Ventilation und lässt eine Spontanatmung zu. Große RKS, die APRV mit anderen Beatmungsformen vergleichen, wurden bisher nicht durchgeführt.

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