Nicht-invasive Beatmung auf der Intensivstation — Geht es noch ohne?
Tóm tắt
Nicht-invasive Beatmung mit positiven Drücken (NIPPV) ist in den vergangenen Jahren zu einem vieldiskutierten Beatmungsverfahren geworden, ohne dass es eine dementsprechende Verbreitung auf Intensivstationen gefunden hat. Grund dafür sind Unsicherheiten in der Indikationsstellung und Schwierigkeiten bei der Anwendung der Methode. In den letzten Jahren wurde durch die Einführung der Ganzgesichtsmaske und des Beatmungshelms eine Beatmungsmöglichkeit auch bei Patienten mit ungewöhnlicher Gesichtsform und Problemen mit Drucknekrosen gefunden. Für klassische Intensivbeatmungsgeräte sind speziell auf NIPPV ausgerichtete Software-Komponenten erhältlich. Klassische Indikationen für NIPPV (neuromuskuläre Erkrankungen. Wirbelsäulenfehlbildungen, Thoraxwanderkrankungen, COPD, kardiogenes Lungenödem) konnten in großen Studien gesichert werden. Für den Einsatz in der Beatmungsentwöhnung und beim respiratorischen Versagen nach Extubation fehlen ausreichende Daten. Es zeichnet sich jedoch eine Indikation für NIPPV ab, wenn die Therapie frühzeitig eingesetzt wird und ausreichend hohe Beatmungsdrücke gewählt werden. Beim hypoxisch hypokapnischen Lungenversagen zeigte sich mit Ausnahme des Einsatzes von NIPPV bei Patienten mit malignen Grunderkrankungen kein sicherer Vorteil gegenüber einer Standardtherapie. Lediglich an einen prophylaktischen Einsatz bei Hochriskopatienten ohne ausgeprägte respiratorische Insuffizienz ist zu denken. Strenge Abbruchkriterien für NIPPV sind jedoch gerade bei diesen Patienten notwendig, um nicht den Zeitpunkt zur Intubation zu verpassen. Gasaustauschstörungen bei fortgeschrittener Fibrose, Pneumonie und ARDS lassen sich mit NIPPV nicht ausreichend korrigieren. Kontraindikationen für NIPPV sind der nicht mitarbeitsfähige Patient, fehlende Husten- und Schluckreflexe, ausgeprägter Sekretverhalt und maligne Herzrhythmusstörungen. Relative Kontraindikationen sind das katecholaminpflichtigen Kreislaufversagen und der akute Myokardinfarkt, weil hier keine ausreichenden Daten zur Sicherheit unter NIPPV vorliegen.
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