Publikationsserver der Universitätsbibliothek Marburg

Titel:Pilotstudie zur nicht-invasiven Messung des intrinsischen PEEP bei Patienten mit stabiler chronisch obstruktiver Lungenerkrankung (COPD) unter nicht-invasiver Beatmung
Autor:Alt, Yvonne
Weitere Beteiligte: Köhler, Ulrich (Prof. Dr. )
Veröffentlicht:2012
URI:https://archiv.ub.uni-marburg.de/diss/z2012/0555
DOI: https://doi.org/10.17192/z2012.0555
URN: urn:nbn:de:hebis:04-z2012-05551
DDC: Medizin, Gesundheit
Titel(trans.):pilot study measuring intrinsic PEEP in patients with chronic obstructive pulmonary disease under non-invasive ventilation
Publikationsdatum:2012-10-05
Lizenz:https://rightsstatements.org/vocab/InC-NC/1.0/

Dokument

Schlagwörter:
Nicht-invasive Beatmung, Intrinsischer PEEP, COPD, COPD, Intrinsic PEEP, Non-invasive Ventilation

Zusammenfassung:
Die nicht-invasive Beatmung wird in der Therapie des COPD-bedingten chronischen oder akuten respiratorischen Versagens eingesetzt. Durch Applikation von CPAP kann der intrinsische PEEP kompensiert und dadurch die respiratorische Muskelanstrengung reduziert werden. Eine exakte Messung des individuellen intrinsischen PEEP ist nötig, um eine optimale Beatmungseinstellung zu finden, bei der die Atemarbeit reduziert und eine zusätzliche Lungenüberblähung verhindert wird. Derzeit stellt die Ösophagusdrucksonde die standardisierte und vielfach verwendete Technik für die Messung des intrinsischen PEEP dar, sie ist jedoch invasiv und häufig klinisch schwierig durchführbar. In der vorliegenden Studie wurden zwei nicht-invasive Messmethoden zur Ermittlung des intrinsischen PEEP untersucht. Durch Messung der Atembewegungen mittels respiratorischer Induktionsplethysmographie bei gleichzeitiger Aufzeichnung des Atemflusses an der Beatmungsmaske sollte überprüft werden, ob aus der zeitlichen Verschiebung beider Signale auf den intrinsischen PEEP rückgeschlossen werden kann. Desweiteren wurde untersucht, ob durch Bildung des Verhältnisses zwischen Inspiration und Exspiration der intrinsische PEEP bestimmt werden kann. Außerdem sollte geklärt werden, ob die Ermittlung des intrinsischen PEEP in allen Schlafstadien problemlos möglich ist, ob Schlafbezogene Atmungsstörungen oder andere Faktoren einen Einfluss auf die Messungen haben und ob die Messungen Weckreaktionen verursachen. In der Studie wurden beide zu untersuchenden Ansätze mit der Standardmethode verglichen. Dafür wurden 12 Patienten mit stabiler COPD und lungenfunktionsanalytisch nachgewiesener Lungenüberblähung untersucht. Die Messungen enthielten eine vollständige Polysomnographie inklusive respiratorischer Induktionsplethysmographie (Thorax- und Abdomen-Atemgurt), mit zusätzlicher Ösophagusdruckmessung mittels einer piezoelektrischen Doppeldrucksonde. Während der Studiennacht wurden mehrere Drucktreppen mit Applikation eines nasalen CPAP-Drucks (nCPAP) mit den Druckstufen von 4mbar - 12mbar mit der Dauer von 20 Sekunden und 60 Sekunden pro Druckstufe appliziert. Die Drucktreppen wurden im Wachzustand sowie bei stabilem Schlaf durchgeführt. Die Daten wurden mit der Software EDF-Trace (Schlaflabor Marburg) automatisch analysiert sowie visuell nachkontrolliert. Die Ergebnisse wurden beatmungsdruckbezogen dargestellt und die Unterschiede in den ermittelten intrinsischen PEEP der verschiedenen Methoden mittels des Rangkorrelationskoeffizienten nach Spearman-Rho auf Signifikanz geprüft. Es konnten nur geringe Korrelationen zwischen den einzelnen Verfahren festgestellt werden, so zeigte sich ein Korrelationskoeffizient von r=0,524 zwischen Thorax-Atemgurt und Standardmethode, r=0,383 zwischen Abdomen-Atemgurt und Standardmethode, sowie r=0,272 beim Vergleich des Inspirations- zu Exspirationsverhältnis und Standardmethode. Es konnte gezeigt werden, dass die untersuchten nicht-invasiven Methoden derzeit die Standardmethode bei der Ermittlung des intrinsischen PEEP nicht ersetzen können. Im Hinblick auf die respiratorische Induktionsplethysmographie mittels Thorax-Atemgurt konnten vielversprechende Tendenzen festgestellt werden, die jedoch in größeren Studienpopulationen weiter untersucht werden müssen. Die Ergebnisse zeigten, dass die Ermittlung des intrinsischen PEEP schlafbeeinträchtigend ist. In der kleinen Studienpopulation wurden Faktoren beobachtet, die die Ergebnisse möglicherweise beeinflussen können: der Grad einer Adipositas und die Höhe des Residualvolumens. Der Einfluss dieser Faktoren muss jedoch in einer größer angelegten Studie überprüft werden. Schlafbezogene Atmungsstörungen konnten als Störfaktoren in dieser Studie nicht bestätigt werden. Die Messungen zeigten desweiteren, dass der intrinsische PEEP durch einen extern applizierten Druck nicht vollständig kompensiert werden kann und bei zu hohem Druck der intrinsische PEEP noch weiter zunimmt. Umso wichtiger ist es, eine zuverlässige, nicht-invasive Methode zu finden, die den intrinsischen PEEP individuell exakt misst.

Summary:
Non-invasive positive pressure ventilation is known to improve the outcome in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). By applying an external Continuous Positive Airway Pressure (CPAP) the intrinsic PEEP can be compensated and therefore respiratory muscle effort can be minimized. The exact measurement of intrinsic PEEP seems essential concerning an optimal ventilator setting in order to reduce work of breathing and avoid hyperinflation. The gold standard for measuring intrinsic PEEP is an esophageal catheter. However, esophageal pressure measurement is invasive and difficult to obtain in clinical routine for example in patients with acute COPD exacerbation. The purpose of this study was to evaluate two methods of non-invasively determining the intrinsic PEEP. Respiratory movements were recorded by inductive plethysmography simultaneously with respiratory flow to determine whether the time delay between both signals is in accordance with the intrinsic PEEP. Furthermore we generated the inspiration to expiration ratio to determine the intrinsic PEEP. In addition the study was to clarify if the detection of the intrinsic PEEP is possible in all sleep stages, whether sleep associated breathing disorders or other factors have an influence on the measurements and if the examination itself causes arousals. Both methods were compared with the gold standard for measuring intrinsic PEEP. Therefore 12 patients were included with a history of COPD, all stable in GOLD stage II to IV and marked hyperinflation. Patients were measured in a sleep lab with standard polysomnography including thoracic and abdominal inductive plethysmography. In addition esophageal and gastric pressures were recorded via catheter. Several times during the night, nasal pressure was increased from 4 to 12 mbar in steps of one mbar, each step lasting 20 seconds or 60 seconds. These pressure ramps were passed both awake and in stable sleep. The software EDF-Trace (Sleep lab Marburg) automatically analyzed the data, which were also visually controlled. The results were illustrated in relation to the CPAP pressure and the differences in detected intrinsic PEEP by the different methods were verified on statistical significance using the correlation coefficient by Spearman-Rho. Low statistical correlations between the different methods were found. Concerning thoracic inductive plethysmography the correlation coefficient was r=0,524, r=0,383 regarding abdominal inductive plethysmography and r=0,272 in comparison of the inspiration to expiration ratio to the esophageal catheter. In conclusion, both non-invasively methods are unable to replace the gold standard for measuring intrinsic PEEP. The thoracic inductive plethysmography has shown promising tendency, but it has to be examined furthermore in larger studies. The results also show that determining intrinsic PEEP affects sleep. In this small study it was discovered, that factors like the level of adipositas and the level of residual volume can affect the results potentially. Larger studies will be needed to verify their influence. Sleep associated breathing disorders were not a disturbing factor. In all patients applying an external pressure did not completely eliminate intrinsic PEEP and a further increase in external pressure did lead to a steady rise of the intrinsic PEEP. Therefore it is really important to find a safe non-invasively method which determinates the intrinsic PEEP exactly.

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