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Inhalative Vasodilatatoren beim akuten Lungenversagen

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Die Intensivtherapie bei akutem Lungenversagen

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Zusammenfassung

Die Therapie des akuten Lungenversagens (Acute Respiratory Distress Syndrome, ARDS) mit inhalativ verabreichten Vasodilatatoren ist seit etwa 10 Jahren Gegenstand intensiver Forschungsarbeit. Die Entdeckung der zentralen Bedeutung von Stickstoffmonoxid (NO) als physiologisch wirksamem Vasodilatator führte zu dem Versuch, inhaliertes NO und andere kurzwirksame Vasodilatatoren therapeutisch nutzbar zu machen, um beim ARDS eine Reduktion des pulmonalarteriellen Druckes und eine Verbesserung der Ventilations-Perfusionsverhältnisse zu erzielen. Zahlreiche tierexperimentelle und klinische Studien konnten nachweisen, dass die Inhalation von NO zu einer selektiven pulmonalarteriellen Vasodilatation und damit zu einer Reduktion des pulmonalarteriellen Druckes und einer Verbesserung des Gasaustausches durch Blutflussumverteilung zu Gunsten ventilierter Lungenareale führen kann. Die hohen Erwartungen, die mit diesen ersten Ergebnissen verknüpft waren, wurden jedoch bald gedämpft: Zunächst zeigte sich für die NO-Inhalation, dass nur bei einem Teil der ARDS-Patienten die erwünschten Effekte auftraten, während bei anderen ‚Non-Respondern ‘keine Verbesserung von Gasaustausch oder Hämodynamik nachzuweisen war. Weiterhin wurde nach Absetzten der Therapie ein Rebound-Phänomen beobachtet, in dessen Verlauf sich ein bedrohlicher Anstieg des pulmonalarteriellen Druckes entwickeln kann. Entscheidend für den heutigen Stellenwert der NO-Inhalation beim ARDS sind jedoch die Ergebnisse randomisierter Multicenterstudien, die ebenfalls nur für einen Teil der Patienten eine kurzfristige Verbesserung von Gasaustausch und Hämodynamik nachweisen konnten, während die Mortalität dieser Patienten im Vergleich zum Kontrollkollektiv nicht gesenkt werden konnte.

Inhalative Vasodilatatoren wie Prostacyclin oder andere Prostaglandine zeichnen sich durch eine vergleichbare Wirkung auf Hämodynamik und Gasaustausch bei günstigerem Nebenwirkungsprofil aus. Ergebnisse randomisierter Multicenterstudien, die langfristige positive Effekte der Prostaglandin-Inhalation beim ARDS nachweisen könnten, liegen allerdings bis heute nicht vor.

Die Inhalation von Vasodilatatoren beim ARDS muss deshalb sehr differenziert bewertet werden: So erscheint der Einsatz als Rescue- bzw. Bridging-Therapie im Einzelfall sinnvoll. Für die Kombination mit anderen Therapieverfahren wie der intravenösen Applikation von Almitrine, der Anwendung von PEEP oder der Gabe von Phosphodiesterase-Hemmern zur Verbesserung der Wirkung liegen hingegen bis heute zu wenig Daten vor. Zusammenfassend bleibt die Inhalation von Vasodilatatoren beim ARDS ein experimentelles Therapieverfahren, das einer strengen Indikationsstellung bedarf.

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  1. Klinik für Anästhesiologie, Universitätsklinikum der Rheinisch-Westfälisch-Technischen Hochschule Aachen, Pauwelsstraße 30, 52074, Aachen, Germany

    Dr. med. R. Dembinski, R. Kuhlen, M. Max & R. Rossaint

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Dembinski, R., Kuhlen, R., Max, M., Rossaint, R. (2003). Inhalative Vasodilatatoren beim akuten Lungenversagen. In: Die Intensivtherapie bei akutem Lungenversagen. Steinkopff, Heidelberg. https://doi.org/10.1007/978-3-642-57349-1_6

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  • DOI: https://doi.org/10.1007/978-3-642-57349-1_6

  • Publisher Name: Steinkopff, Heidelberg

  • Print ISBN: 978-3-7985-1395-2

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