Zusammenfassung
Hintergrund
Das akute hyperkapnische Atemversagen betrifft im klinischen Alltag im Wesentlichen Patienten mit chronisch-obstruktiver Lungenerkrankung (COPD) und Obesitas-Hypoventilationssyndrom (OHS). Es kann je nach Auslöser auch mit einem hypoxämischen Atemversagen assoziiert sein und stellt besondere Anforderungen an die Beatmungstherapie.
Ziel
Vermittlung des aktuellen Kenntnisstands zur Beatmungsindikation und -durchführung bei hyperkapnischem Atemversagen.
Material und Methoden
Review der Literatur.
Ergebnisse
Die führende Komponente des Atemversagens ist wichtig bei der Wahl des Beatmungsverfahrens. Bei hyperkapnischem Atemversagen mit einem pH < 7,35 hat sich bewährt, primär die nichtinvasive Beatmung (NIV) einzusetzen, wobei Kontraindikationen zu beachten sind. Ihr Einsatz bedarf insbesondere bei schwerer respiratorischer Azidose eines geschulten und erfahrenen Beatmungsteams und eines engmaschigen Monitorings, um frühzeitig ein NIV-Versagen zu erkennen. Die Beatmungseinstellung bei COPD-Exazerbation muss darauf abzielen, eine weitere Überblähung und Zunahme des intrinsischen PEEP zu vermeiden. Deshalb sind lange Exspirations- und kurze Inspirationszeiten zu wählen. Bei Patienten mit OHS oder Overlap-Syndrom ist eine Anpassung der Beatmung an die jeweilige Pathophysiologie erforderlich. Bei schwersten und beatmungstechnisch nicht beherrschbaren Hyperkapnien und respiratorischen Azidosen sind extrakorporale Verfahren eine Option, auch Berichte über den Einsatz bei wachen Patienten liegen vor.
Schlussfolgerung
Die NIV ist das führende Beatmungsverfahren bei hyperkapnischem Atemversagen, bedarf aber engmaschiger Kontrollen, damit der Zeitpunkt für eine invasive Beatmung nicht verpasst wird. Der Stellenwert extrakorporaler Verfahren zur CO2-Elimination ist noch unklar.
Abstract
Background
Acute hypercapnic respiratory failure is mostly seen in patients with chronic obstructive pulmonary disease (COPD) and obesity hypoventilation syndrome (OHS). Depending on the underlying cause it may be associated with hypoxemic respiratory failure and places high demands on mechanical ventilation.
Objective
Presentation of the current knowledge on indications and management of mechanical ventilation in patients with hypercapnic respiratory failure.
Material and methods
Review of the literature.
Results
Important by the selection of mechanical ventilation procedures is recognition of the predominant pathophysiological component. In hypercapnic respiratory failure with a pH < 7.35 non-invasive ventilation (NIV) is primarily indicated unless there are contraindications. In patients with severe respiratory acidosis NIV requires a skilled and experienced team and close monitoring in order to perceive a failure of NIV. In acute exacerbation of COPD ventilator settings need a long expiration and short inspiration time to avoid further hyperinflation and an increase in intrinsic positive end-expiratory pressure (PEEP). Ventilation must be adapted to the pathophysiological situation in patients with OHS or overlap syndrome. If severe respiratory acidosis and hypercapnia cannot be managed by mechanical ventilation therapy alone extracorporeal venous CO2 removal may be necessary. Reports on this approach in awake patients are available.
Conclusion
The use of NIV is the predominant treatment in patients with hypercapnic respiratory failure but close monitoring is necessary in order not to miss the indications for intubation and invasive ventilation. Methods of extracorporeal CO2 removal especially in awake patients need further evaluation.
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U. Kreppein und P. Litterst geben an, dass kein Interessenkonflikt besteht. M. Westhoff hat Vortragshonorare von den Firmen VitalAire und Heinen + Löwenstein erhalten.
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Kreppein, U., Litterst, P. & Westhoff, M. Hyperkapnisches Atemversagen. Med Klin Intensivmed Notfmed 111, 196–201 (2016). https://doi.org/10.1007/s00063-016-0143-2
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DOI: https://doi.org/10.1007/s00063-016-0143-2
Schlüsselwörter
- Nichtinvasive Beatmung
- Mechanische Beatmung
- Chronisch-obstruktive Lungenerkrankung
- Obesitas-Hypoventilationssyndrom
- Respiratorische Azidose