Therapie des akuten Lungenversagens

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• 作者：M. Kredel ; D. Bierbaum ; C. Lotz ; J. Küstermann ; N. Roewer…
• 关键词：Beatmungstherapie ; Tidalvolumen ; Positiver endexspiratorischer Druck ; Extrakorporale Membranoxygenierung ; Intensivstationen ; Respiratory therapy ; Tidal volume ; Positive end expiratory pressureExtracorporeal membrane oxygenation ; Intensive care units
• 刊名：Der Anaesthesist
• 出版年：2015
• 出版时间：April 2015
• 年：2015
• 卷：64
• 期：4
• 页码：277-285
• 全文大小：664 KB
• 参考文献：1.Afshari A, Brok J, Moller AM et al (2011) Inhaled nitric oxide for acute respiratory distress syndrome and acute lung injury in adults and children: a systematic review with meta-analysis and trial sequential analysis. Anesth Analg 112:1411-421View Article PubMed
  2.Amato MB, Barbas CS, Medeiros DM et al (1998) Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 338:347-54View Article PubMed
  3.Anonymous (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 342:1301-308View Article
  4.Barkhausen J, Stoblen F, Dominguez-Fernandez E et al (1999) Impact of CT in patients with sepsis of unknown origin. Acta Radiol 40:552-55View Article PubMed
  5.Bein T, Sabel K, Scherer A et al (2004) Comparison of incomplete (135 degrees) and complete prone position (180 degrees) in patients with acute respiratory distress syndrome. Results of a prospective, randomised trial. Anaesthesist 53:1054-060View Article PubMed
  6.Bein T, Weber-Carstens S, Goldmann A et al (2013) Lower tidal volume strategy (approximately 3?ml/kg) combined with extracorporeal CO2 removal versus ?conventional-protective ventilation (6?ml/kg) in severe ARDS: the prospective randomized Xtravent-study. Intensive Care Med 39:847-56View Article PubMed Central PubMed
  7.Briel M, Meade M, Mercat A et al (2010) Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 303:865-73View Article PubMed
  8.Corradi F, Brusasco C, Pelosi P (2014) Chest ultrasound in acute respiratory distress syndrome. Curr Opin Crit Care 20:98-03View Article PubMed
  9.Eichacker PQ, Gerstenberger EP, Banks SM et al (2002) Meta-analysis of acute lung injury and acute respiratory distress syndrome trials testing low tidal volumes. Am J Respir Crit Care Med 166:1510-514View Article PubMed
  10.Ely EW, Truman B, Shintani A et al (2003) Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 289:2983-991View Article PubMed
  11.Esteban A, Alia I, Gordo F et al (2000) Prospective randomized trial comparing pressure-controlled ventilation and volume-controlled ventilation in ARDS. For the Spanish Lung Failure Collaborative Group. Chest 117:1690-696View Article PubMed
  12.Fuehner T, Kuehn C, Hadem J et al (2012) Extracorporeal membrane oxygenation in awake patients as bridge to lung transplantation. Am J Respir Crit Care Med 185:763-68View Article PubMed
  13.Guerin C, Reignier J, Richard JC et al (2013) Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 368:2159-168View Article PubMed
  14.Kredel M, Bierbaum D, Lotz C et al (2014) Ventilation during extracorporeal membrane oxygenation for adult respiratory distress syndrome. Crit Care 18:442View Article PubMed Central PubMed
  15.Kredel M, Bischof L, Wurmb T et al (2014) Combination of positioning therapy and venovenous extracorporeal membrane oxygenation in ARDS patients. Perfusion 29:171-77View Article PubMed
  16.Kress JP, Pohlman AS, O’Connor MF et al (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471-477View Article PubMed
  17.Mohnle P, Briegel J (2012) Corticosteroid administration for acute respiratory distress syndrome: therapeutic option? Anaesthesist 61:344-53View Article PubMed
  18.Papazian L, Forel JM, Gacouin A et al (2010) Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med 363:1107-116View Article PubMed
  19.Peek GJ, Mugford M, Tiruvoipati R et al (2009) Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 374:1351-363View Article PubMed
  20.Pontes-Arruda A, Demichele S, Seth A et al (2008) The use of an inflammation-modulating diet in patients with acute lung injury or acute respiratory distress syndrome: a meta-analysis of outcome data. JPEN J Parenter Enteral Nutr 32:596-05View Article PubMed
  21.Putensen C, Zech S, Wrigge H et al (2001) Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 164:43-9View Article PubMed
  22.Ranieri VM, Rubenfeld GD, Thompson BT et al (2012) Acute respiratory distress syndrome: the Berlin Definition. JAMA 307:2526-533PubMed
  23.Roch A, Hraiech S, Masson E et al (2014) Outcome of acute respiratory distress syndrome patients treated with extracorporeal membrane oxygenation and brought to a referral center. Intensive Care Med 40:74-3View Article Pu
• 作者单位：M. Kredel (1)
  D. Bierbaum (1)
  C. Lotz (1)
  J. Küstermann (1)
  N. Roewer (1)
  PD Dr. R.M. Muellenbach MHBA (1)
  
  1. Klinik und Poliklinik für An?sthesiologie, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland
  
• 刊物类别：Medicine
• 刊物主题：Medicine & Public Health
  Anesthesiology
  Emergency Medicine
  Intensive and Critical Care Medicine
  Pain Medicine
  
• 出版者：Springer Berlin / Heidelberg
• ISSN：1432-055X

文摘

Background In addition to specific treatment of the underlying cause, the therapy of acute respiratory distress syndrome (ARDS) consists of lung protective ventilation and a range of adjuvant and supportive measures. Aim A survey was conducted to determine the current treatment strategies for ARDS in German ARDS centers. Material and methods The 39 centers listed in the German ARDS network in 2011 were asked to complete a questionnaire collecting data on the clinic, epidemiology as well as diagnostic and therapeutic measures regarding ARDS treatment. Results Of the centers 25 completed the questionnaire. In 2010 each of these centers treated an median of 31 (25-5 percentile range 20-9) patients. Diagnostic measures at admission were computed tomography of the thorax (60- of the centers), whole body computed tomography (56-), chest x-ray (52-), abdominal computed tomography (32-) and?cranial computed tomography (24-). Transesophageal echocardiography was performed in 64-, pulmonary artery pressure was measured in 56- and cerebral oximetry in 12-. Sedation wasregularly interrupted in 92- of the centers and in 68- this was attempted at least once a day. A median minimum tidal volume of 4?ml/kg (range 2-) and a maximum tidal volume of 6?ml/kg (4-) were used. Methods to determine the optimal positive end-expiratory pressure (PEEP) were the best PEEP method (60-), ARDS network table (48-), empirical (28-), pressure volume curve (16-), computed tomography (8-), electrical impedance tomography (8-) and others (8-). Median minimum and maximum PEEPs were 10?cmH₂O (range 5-5) and 21?cmH₂O (15-5), respectively. Median plateau pressure was limited to 30?cmH₂O (range 26-5). The respiratory rate was set below 20/min in 20- and below 30/min in 44-. Controlled ventilator modes were generally preferred with 80- using biphasic positive airway pressure (BIPAP/BiLevel), 20- pressure controlled ventilation (PCV) and 4- airway pressure release ventilation (APRV). Assisted modes were only utilized by 8- of the centers. Recruitment maneuvers were used by 28-, particularly during the early phase of the ARDS. Muscle relaxants were administered by 32- during the early phase of the ARDS. Complete prone positioning was used by 60- of the centers, whereas 88- utilized incomplete (135°) prone positioning. Continuous axial rotation was utilized by 16-. Spontaneous breathing tests were used in 88- of the centers with 60- performing these at least once a day. Supportive therapies were frequently applied and mainly consisted of nitrous oxide (44-), prostacycline (48-) and corticosteroids (52-). A restrictive fluid therapy was used in 48- and a special nutrition regimen in 28- of the centers. Of the participating centers 22 were able to offer extracorporeal membrane oxygenation (ECMO). In this case, respiratory therapy was modified by further reducing tidal volumes (91-), inspiratory pressures (96-) as well as using lower respiratory rates (≤-/min in 31-). Only 9- reduced PEEP during ECMO. Regular recruitment maneuvers were used by 14-. Positioning maneuvers during ECMO were used by 82-. Conclusions Lung protective ventilation with reduced tidal volumes as well as inspiratory pressures represents the current standard of care and was utilized in all network centers. Prone positioning was widely used. Promising adjuvant therapies such as the muscle relaxation during the early phase of the ARDS, fluid restriction and corticosteroids were used less frequently. During ECMO respirator therapy was generally continued with ultraprotective ventilator settings.