Ventilator induzierter Zwerchfellschaden

 

 Buy Article Permissions and Reprints

Zusammenfassung

Maschinelle Beatmung bedeutet in vielen Fällen eine lebenserhaltende Maßnahme, nicht selten stellen sich aber auch beatmungsbedingte Schädigungen ein. Seit Jahren stehen beatmungsinduzierte Schäden der Lunge im klinischen und wissenschaftlichen Fokus. Kürzlich konnte im Tiermodell eine Beeinträchtigung der Atmungsmuskulatur, die als Ventilator-induced diaphragmatic dysfunction (VIDD) bezeichnet wird, nachgewiesen werden. Die Schädigung des Zwerchfells nimmt mit der Dauer der maschinellen Beatmung zu und ist unter kontrollierter Beatmung stärker ausgeprägt als unter assistierter Beatmung. Verschiedene Mechanismen wie Zwerchfellmuskelatrophie, oxidativer Stress, strukturelle Schäden und Transformation von Muskelfasern können, wie im Tiermodell gezeigt, zur VIDD führen. Obwohl die meisten über einen längeren Zeitraum mechanisch beatmeten Patienten eine Atmungsmuskelschwäche aufweisen, fehlt bisher die Evidenz für die Existenz einer VIDD bei kritisch kranken beatmeten Patienten. Begleitende Grunderkrankungen (z. B. critical illness polyneuropathy), Infektionen und Medikamente führen ebenfalls zur Zwerchfelldysfunktion, so dass die Differenzierung von VIDD als Ursache für eine vorliegende Zwerchfellmuskelschwäche bei fehlenden spezifischen Messmethoden schwierig ist. Bei der Reinform einer VIDD handelt es sich somit bisher um eine Ausschlussdiagnose. Aufgrund pathophysiologischer Überlegungen könnten assistierte Beatmungsmodi, Antioxidantien und Stimulation des N. phrenicus vorbeugende Maßnahmen bzw. therapeutische Optionen darstellen.

Abstract

Although life-saving, mechanical ventilation is associated with numerous complications. Recently, it was shown in animal models that controlled mechanical ventilation (CMV) can cause the so-called ventilator-induced diaphragmatic dysfunction (VIDD). The decrease in diaphragmatic strength proceeds along with prolonged mechanical ventilation. The decrease in diaphragmatic force occurs during CMV rather than during assisted modes of ventilation. Different mechanisms may cause VIDD: muscle atrophy, oxidative stress, structural injury and muscle fibre remodelling have been demonstrated in animal models. Although most critically ill patients receiving mechanical ventilation show profound diaphragmatic weakness, clear evidence supporting the existence of VIDD is still lacking. Since VIDD is particularly caused by comorbidity, a series of other factors may lead to diaphragmatic dysfunction. Whether or not VIDD causes weaning failure is difficult to decide since other reasons may also cause respiratory muscle weakness. However, based on pathophysiology, treatment options may be assisted mechanical ventilation, administration of antioxidative agents or stimulation of the phrenic nerve.

Literatur

• 1 Esteban A, Anzueto A, Alia I. et al . How is mechanical ventilation employed in the intensive care unit? An international utilization review.  Am J Respir Crit Care Med. 2000;  161 (5) 1450-1458
  Google Scholar
• 2 International consensus conferences in intensive care medicine . Ventilator-associated lung injury in ARDS.  Am J Respir Crit Care Med. 1999;  160 2118-2124
  Google Scholar
• 3 Körber W, Laier-Groeneveld G, Criée C P. Endotracheal complications after long-term ventilation. Noninvasive ventilation in chronic thoracic diseases as an alternative to tracheostomy.  Med Klin (Munich) 1999. Apr ;  94 (1 Spec No) 45-50
  Google Scholar
• 4 Schönhofer B, Köhler D. Hyperkapnie.  Intensivmed. 1997;  34 501-512
  Google Scholar
• 5 Tobin M J. Advances in mechanical ventilation.  N Engl J Med. 2001;  344 (26) 1986-1996
  Google Scholar
• 6 Schönhofer B, Windisch W. Die Atempumpe. Med Wissenschaftliche Verlagsgesellschaft 2007
  Google Scholar
• 7 Jalinous R. Technical and practical aspects of magnetic nerve stimulation.  J Clin Neurophysiol. 1991;  8 10-25
  Google Scholar
• 8 Vassilakopoulos T, Petrof B J. Ventilator-induced diaphragmatic dysfunction.  Am J Respir Crit Care Med. 2004;  169 (3) 336-341
  Google Scholar
• 9 Le Bourdelles G, Viires N, Boczkowski J. et al . Effects of mechanical ventilation on diaphragmatic contractile properties in rats.  Am J Respir Crit Care Med. 1994;  149 1539-1544
  Google Scholar
• 10 Powers S K, Shanely R A, Coombes J S. et al . Mechanical ventilation results in progressive contractile dysfunction in the diaphragm.  J Appl Physiol. 2002;  92 (5) 1851-1858
  Google Scholar
• 11 Sassoon C S, Caiozzo V J, Manka A. et al . Altered diaphragm contractile properties with controlled mechanical ventilation.  J Appl Physiol. 2002;  92 (6) 2585-2595
  Google Scholar
• 12 Radell P J, Remahl S, Nichols D G. et al . Effects of prolonged mechanical ventilation and inactivity on piglet diaphragm function.  Intensive Care Med. 2002;  28 (3) 358-364
  Google Scholar
• 13 Anzueto A, Peters J I, Tobin M J. et al . Effects of prolonged controlled mechanical ventilation on diaphragmatic function in healthy adult baboons.  Crit Care Med. 1997;  25 (7) 1187-1190
  Google Scholar
• 14 Sassoon C S, Zhu E, Caiozzo V J. Assist-control mechanical ventilation attenuates ventilator-induced diaphragmatic dysfunction.  Am J Respir Crit Care Med. 2004;  170 (6) 626-632
  Google Scholar
• 15 Yang L, Luo J, Bourdon J. et al . Controlled mechanical ventilation leads to remodeling of the rat diaphragm.  Am J Respir Crit Care Med. 2002;  166 (8) 1135-1140
  Google Scholar
• 16 Shanely R A, Zergeroglu M A, Lennon S L. et al . Mechanical ventilation-induced diaphragmatic atrophy is associated with oxidative injury and increased proteolytic activity.  Am J Respir Crit Care Med. 2002;  166 (10) 1369-1374
  Google Scholar
• 17 Shanely R A, Coombes J S, Zergeroglu A M. et al . Short-duration mechanical ventilation enhances diaphragmatic fatigue resistance but impairs force production.  Chest. 2003;  123 (1) 195-201
  Google Scholar
• 18 Bernard N, Matecki S, Py G. et al . Effects of prolonged mechanical ventilation on respiratory muscle ultrastructure and mitochondrial respiration in rabbits.  Intensive Care Med. 2003;  29 (1) 111-118
  Google Scholar
• 19 Capdevila X, Lopez S, Bernard N. et al . Effects of controlled mechanical ventilation on respiratory muscle contractile properties in rabbits.  Intensive Care Med. 2003;  29 (1) 103-110
  Google Scholar
• 20 Racz G Z, Gayan-Ramirez G, Testelmans D. et al . Early changes in rat diaphragm biology with mechanical ventilation.  Am J Respir Crit Care Med. 2003;  168 (3) 297-304
  Google Scholar
• 21 Gayan-Ramirez G, de Paepe K, Cadot P. et al . Detrimental effects of short-term mechanical ventilation on diaphragm function and IGF-I mRNA in rats.  Intensive Care Med. 2003;  29 (5) 825-833
  Google Scholar
• 22 Zergeroglu M A, McKenzie M J, Shanely R A. et al . Mechanical ventilation-induced oxidative stress in the diaphragm.  J Appl Physiol. 2003;  95 (3) 1116-1124
  Google Scholar
• 23 Hussain S N, Vassilakopoulos T. Ventilator-induced cachexia.  Am J Respir Crit Care Med. 2002;  166 (10) 1307-1308
  Google Scholar
• 24 Glickman M H, Ciechanover A. The ubiquitin-proteasome proteolytic pathway: destruction for the sake of construction.  Physiol Rev. 2002;  82 (2) 373-428
  Google Scholar
• 25 Goldberg A L, Elledge S J, Harper J W. The cellular chamber of doom.  Sci Am. 2001;  284 68-73
  Google Scholar
• 26 Bodine S C, Latres E, Baumhueter S. et al . Identification of ubiquitin ligases required for skeletal muscle atrophy.  Science. 2001;  294 (5547) 1704-1708
  Google Scholar
• 27 Ku Z, Yang J, Menon V. et al . Decreased polysomal HSP-70 may slow polypeptide elongation during skeletal muscle atrophy.  Am J Physiol. 1995;  268 (6 Pt 1) C1369-1374
  Google Scholar
• 28 Shanely R A, Gammeren D van, Deruisseau K C. et al . Mechanical ventilation depresses protein synthesis in the rat diaphragm.  Am J Respir Crit Care Med. 2004;  170 (9) 994-999
  Google Scholar
• 29 Knisely A S, Leal S M, Singer D B. Abnormalities of diaphragmatic muscle in neonates with ventilated lungs.  J Pediatr. 1988;  113 (6) 1074-1077
  Google Scholar
• 30 Kondo H, Nakagaki I, Sasaki S. et al . Mechanism of oxidative stress in skeletal muscle atrophied by immobilization.  Am J Physiol. 1993;  265 (6 Pt 1) E839-844
  Google Scholar
• 31 Geiger P C, Cody M J, Macken R L. et al . Maximum specific force depends on myosin heavy chain content in rat diaphragm muscle fibers.  J Appl Physiol. 2000;  89 (2) 695-703
  Google Scholar
• 32 Esteban A, Alia I, Ibanez J. et al . Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. The Spanish Lung Failure Collaborative Group.  Chest. 1994;  106 (4) 1188-1193
  Google Scholar
• 33 Watson A C, Hughes P D, Louise Harris M. et al . Measurement of twitch transdiaphragmatic, esophageal, and endotracheal tube pressure with bilateral anterolateral magnetic phrenic nerve stimulation in patients in the intensive care unit.  Crit Care Med. 2001;  29 (7) 1325-1331
  Google Scholar
• 34 Laghi F, Cattapan S E, Jubran A. et al . Is weaning failure caused by low-frequency fatigue of the diaphragm?.  Am J Respir Crit Care Med. 2003;  167 (2) 120-127
  Google Scholar
• 35 De Jonghe B, Sharshar T, Lefaucheur J P. et al . Paresis acquired in the intensive care unit: a prospective multicenter study.  JAMA. 2002;  288 2859-2867
  Google Scholar
• 36 Ebihara S, Hussain S N, Danialou G. et al . Mechanical ventilation protects against diaphragm injury in sepsis: interaction of oxidative and mechanical stresses.  Am J Respir Crit Care Med. 2002;  165 (2) 221-228
  Google Scholar
• 37 Schönhofer B. Schwieriges Weaning nach Langzeitbeatmung.  Anästhesiologie und Intensivmedizin. 2005;  46 529-542
  Google Scholar
• 38 Betters J L, Criswell D S, Shanely R A. et al . Trolox attenuates mechanical ventilation-induced diaphragmatic dysfunction and proteolysis.  Am J Respir Crit Care Med. 2004;  170 (11) 1179-1184
  Google Scholar
• 39 Nathens A B, Neff M J, Jurkovich G J. et al . Randomized, prospective trial of antioxidant supplementation in critically ill surgical patients.  Ann Surg. 2002;  236 (6) 814-822
  Google Scholar
• 40 Ayas N T, McCool F D, Gore R. et al . Prevention of human diaphragm atrophy with short periods of electrical stimulation.  Am J Respir Crit Care Med. 1999;  159 2018-2020
  Google Scholar
• 41 Pavlovic D, Wendt M. Diaphragm pacing during prolonged mechanical ventilation of the lungs could prevent from respiratory muscle fatigue.  Med Hypotheses. 2003;  60 (3) 398-403
  Google Scholar

Dr. med. Klaus Schild

Abteilung für Pneumologie und Beatmungsmedizin, Ev. Krankenhaus Göttingen-Weende, Standort Lenglern

Pappelweg 5

37120 Bovenden-Lenglern

Email: klaus.schild@t-online.de