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Pneumologie 2010; 64(4): 207-240
DOI: 10.1055/s-0029-1243978
Leitlinie

© Georg Thieme Verlag KG Stuttgart · New York

Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz

S2-Leitlinie herausgegeben von der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin e. V.Non-Invasive and Invasive Mechanical Ventilation for Treatment of Chronic Respiratory FailureS2-Guidelines Published by The German Medical Association of Pneumology and Ventilatory SupportW.  Windisch1 , J.  Brambring2 , S.  Budweiser3 , D.  Dellweg4 , J.  Geiseler5 , F.  Gerhard6 , T.  Köhnlein7 , U.  Mellies8 , B.  Schönhofer9 , B.  Schucher10 , K.  Siemon4 , S.  Walterspacher1 , M.  Winterholler11 , H.  Sitter12 für die Projektgruppe „Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz”
  • 1Universitätsklinik Freiburg, Abteilung Pneumologie, Freiburg
  • 2Heimbeatmungsservice Brambring Jaschke GmbH, Unterhaching
  • 3Klinik Donaustauf, Donaustauf
  • 4Fachkrankenhaus Kloster Grafschaft, Schmallenberg – Grafschaft
  • 5Asklepios Fachkliniken München-Gauting, Gauting
  • 6isb Ambulante Dienste gGmbH, Wuppertal
  • 7Medizinische Hochschule Hannover, Abteilung Pneumologie, Hannover
  • 8Universitätsklinikum Essen, Abteilung Pädiatrische Pulmologie, Essen
  • 9Klinikum Hannover Oststadt, Abteilung Pneumologie, Hannover
  • 10Krankenhaus Großhansdorf, Großhansdorf
  • 11Krankenhaus Rummelsberg, Neurologische Klinik, Schwarzenbruck bei Nürnberg
  • 12Philipps-Universität Marburg, Institut für Theoretische Chirurgie, Marburg
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Publication History

Publication Date:
07 April 2010 (online)

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Zusammenfassung

Die fundamentale berufspolitische Bedeutung der Beatmungsmedizin für die deutsche Pneumologie ist unbestritten. Vor diesem Hintergrund formuliert die Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP) diese S2-Leitlinie zur außerklinischen Beatmung. Die außerklinische Beatmung kann nichtinvasiv über Gesichtsmasken oder invasiv nach Anlage eines Tracheostomas erfolgen und wird zunehmend zur Therapie der chronischen ventilatorischen Insuffizienz eingesetzt, wobei die chronisch obstruktive Lungenerkrankung, thorakal restriktive Erkrankungen, das Obesitas-Hypoventilations-Syndrom sowie neuromuskuläre Erkrankungen die Hauptindikationen darstellen. Wesentlich für die Indikationsstellung sind das Vorliegen von Symptomen der ventilatorischen Insuffizienz sowie der Nachweis der Hypoventilation, in der Regel die Hyperkapnie. Diesbezüglich werden in der Leitlinie die krankheitsspezifischen Indikationsparameter aufgeführt und in Form von Therapie-Algorithmen zusammengefasst, wobei auch auf die Besonderheiten des Sekretmanagements und der pädiatrischen Patienten eingegangen wird. Die außerklinische Beatmung muss um ein Beatmungszentrum mit Expertise in der Indikationsstellung, dem Beginn und der Überwachung einer außerklinischen Beatmung organisiert sein. Entsprechend informiert die Leitlinie detailliert über die notwendige technische Ausstattung sowie Einstellung, Umstellung, Kontrolle und Organisation der außerklinischen Beatmung. Eine entscheidende Vorraussetzung für die außerklinische Beatmung ist zudem die suffiziente, in der Leitlinie weiter spezifizierte, Qualifikation des außerklinischen Pflegeteams. Die Beatmungstherapie stellt eine in die Integrität des Patienten stark eingreifende und oft lebenserhaltende Therapie dar. Das selbstbestimmte Leben hat neben der Qualitätssicherung der Beatmungstherapie oberste Priorität. Eine außerklinische Beatmung verbessert nachweislich die gesundheitsbezogene Lebensqualität von Patienten mit chronischer ventilatorischer Insuffizienz. Sie kann zudem das Langzeitüberleben bei den meisten Patientengruppen verlängern. Dennoch ist die Langzeitprognose trotz Beatmungstherapie zum Teil schwer limitiert. Vor diesem Hintergrund berücksichtigt die Leitlinie auch ethische Aspekte. Sie bezieht sich dabei auf die Aufklärung des Patienten, die Kommunikation am Lebensende beatmeter Patienten, die Möglichkeiten einer Patientenverfügung sowie über die Behandlungsschritte während des Sterbeprozesses.

Abstract

The field of mechanical ventilation is highly important in pulmonary medicine. The German Medical Association of Pneumology and Ventilatory Support [„Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. (DGP)”] therefore has formulated these guidelines for home mechanical non-invasive and invasive ventilation. Non-invasive home mechanical ventilation can be administered using various facial masks; invasive home mechanical ventilation is performed via a tracheostomy. Home mechanical ventilation is widely and increasingly accepted as a treatment option for chronic ventilatory failure which most often occurs in COPD, restrictive lung diseases, obesity-hypoventilation syndrome and neuromuscular disorders. Essential for the initiation of home mechanical ventilation are the presence of symptoms of ventilatory failure and the detection of hypoventilation, most importantly hypercapnia. These guidelines comprise general indication criteria along with disease-specific criteria summarised by treatment algorithms. In addition, the management of bronchial secretions and care of paediatric patients are addressed. Home mechanical ventilation must be organised around a specialised respiratory care centre with expertise in patient selection, the initiation and the control of home mechanical ventilation. In this regard, the guidelines provide detailed information about technical requirements (equipment), control and settings of mechanical ventilation as well as organisation of patient care. A key requirement for home mechanical ventilation is the qualification of specialised home-care services, which is addressed in detail. Independent living and the quality of respiratory care are of highest priority in patients receiving home mechanical ventilation, since home mechanical ventilation can interfere with the integrity of a patient and often marks a life-sustaining therapy. Home mechanical ventilation has been shown to improve health-related quality of life of patients with chronic ventilatory failure. Long-term survival is improved in most patient groups, even though the long-term prognosis is often severely limited. For this reason, ethical issues regarding patient education, communication with ventilated patients at the end of life, living will, testament and medical care during the dying process are discussed.

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Prof. Dr. med. Wolfram Windisch

Universitätsklinik Freiburg
Abteilung Pneumologie

Killianstraße 5
79106 Freiburg i. Br.

Email: wolfram.windisch@uniklinik-freiburg.de

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