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Extrakorporale Lungenunterstützungssysteme

Extracorporeal lung support systems

  • Leitthema
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Der Pneumologe Aims and scope

Zusammenfassung

Bei schwerem akutem Lungenversagen (ARDS), das durch konventionelle Therapie nicht ausreichend beherrscht werden kann, können zur Unterstützung des Gasaustauschs extrakorporale Systeme eingesetzt werden.

Pumpengetriebene Systeme (venovenöse extrakorporale Membranoxygenierung; vv-ECMO) sind indiziert, wenn eine therapierefraktäre Hypoxämie oder eine respiratorische Azidose (pH <7,2) vorliegen. Überlebensraten >50% werden bei schwerem ARDS unter vv-ECMO berichtet. Diese Systeme können etwa 50–80% des benötigten Gastransfers leisten und ermöglichen dadurch eine protektivere Beatmung, was das Ausmaß eines ventilatorinduzierten Lungenschadens begrenzt.

Pumpenlose Systeme („interventional lung assist“; iLA) mit arteriovenöser Kanülierung eignen sich zur Kohlendioxidelimination; primäre Indikation ist eine therapierefraktäre Hyperkapnie mit respiratorischer Azidose. Der Blutfluss wird hier durch die arteriovenöse Druckdifferenz generiert; eine eingeschränkte Pumpfunktion des Herzens oder ein niedriger mittlerer arterieller Blutdruck sind daher Kontraindikationen. Grundsätzlich können durch extrakorporale Systeme vielfältige Komplikationen auftreten, die eine lückenlose Überwachung von Patient und System erfordern.

Abstract

In severe acute lung failure, which cannot be handled by conventional therapeutic options, pump-driven systems (veno-venous extracorporeal membrane oxygenation, ECMO) or pumpless systems (interventional lung assist, iLA) can be used for extracorporeal lung assist.

A veno-venous ECMO is indicated in refractory hypoxaemia and/or in severe respiratory acidosis with a pH <7.2. Survival rates of more than 50% have been reported with the use of vv-ECMO in severe ARDS. Veno-venous extracorporeal systems can supply about 50–80% of the necessary gas exchange. Thus, a more protective ventilation is possible and the extent of the ventilator-induced lung injury is limited.

Pumpless devices with an arteriovenous cannulation are well suited for carbon dioxide elimination. Therefore, their primary indication is for refractory hypercapnia with respiratory acidosis. As the blood flow is generated exclusively by the arteriovenous pressure difference, a reduced cardiac pump function or a low mean arterial pressure must be considered a contraindication. Because many complications can potentially occur with the use of extracorporeal systems, close surveillance of the patient and device is essential.

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Abbreviations

ALI:

Acute lung injury

aPTT:

Activated partial thromboplastin time

ARDS:

Acute respiratory distress syndrome

CESAR:

Conventional ventilation or ECMO for severe adult respiratory failure

COPD:

Chronic obstructive pulmonary disease

ECMO:

Extracorporeal membrane oxygenation

ELSO:

Extracorporeal Life Support Organization

FIO2 :

Fraction of inspired oxygen

HFOV:

Hochfrequenz-Oszillationsventilation

HIT II:

Heparininduzierte Thrombozytopenie Typ II

iLA:

Interventional Lung Assist

LIS:

Lung injury score

MAP:

Mean arterial pressure

NAVA:

Neurally adjusted ventilatory assist

PAVK:

Periphere arterielle Verschlusskrankheit

pECLA:

Pumpless extracorporeal lung assist

PEEP:

Positive end-expiratory pressure

PLS:

Permanent life support

va:

Venoarteriell

VILI:

Ventilator-induced lung injury

vv:

Venovenös

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Interessenkonflikt

Der korrespondierende Autor weist auf folgende Beziehungen hin: TM erhielt Vortragshonorare von der Firma Maquet Cardiopulmonary AG. ML gibt an, dass kein Interessenkonflikt besteht.

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  1. Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Deutschland

    T. Müller & M. Lubnow

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  1. T. Müller
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  2. M. Lubnow
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Correspondence to T. Müller.

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Müller, T., Lubnow, M. Extrakorporale Lungenunterstützungssysteme. Pneumologe 7, 441–447 (2010). https://doi.org/10.1007/s10405-010-0410-5

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