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Intensivmedizin up2date 2016; 12(02): 159-174
DOI: 10.1055/s-0041-110072
Allgemeine Prinzipien der Intensivmedizin
© Georg Thieme Verlag KG Stuttgart · New York

Intensivpflichtige Virusinfektionen der unteren Atemwege

Nora Drick
,
Tobias Welte
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Publication Date:
30 March 2016 (online)

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Kernaussagen

  • Virusinfektionen der unteren Atemwege sind auf der Intensivstation häufig und können zu schweren Krankheitsverläufen führen. Vor allem in der kalten Jahreszeit sowie bei Risikopatienten, insbesondere unter Immunsuppression, sollte man an eine Virusinfektion denken.

  • Bei der Diagnostik schwerer Atemwegsinfektionen untersucht man vorzugsweise Proben aus den unteren Atemwegen (BAL, Trachealsekret). Goldstandard ist im intensivmedizinischen Bereich der direkte Virusnachweis mit PCR.

  • Bei schweren Influenza-Pneumonien eine antivirale Therapie mit Neuraminidasehemmern (Oseltamivir, Zanamivir) erwägen. Therapiebeginn möglichst innerhalb von 48 Stunden nach Auftreten der Symptome. Mit der Influenza-Impfung steht eine wirksame Prophylaxe zur Verfügung. Der Einsatz von Kortikosteroiden bei der Influenza-Pneumonie wird nicht empfohlen.

  • Eine RSV-Infektion gilt als möglicher Risikofaktor für eine Abstoßungsreaktion bei lungentransplantierten Patienten. Kleine Studien legen den Verdacht nahe, dass eine Therapie mit Ribavirin das Risiko für eine Abstoßungsreaktion reduzieren kann.

  • Das Middle East Respiratory Syndrome wird vom MERS-Coronavirus ausgelöst. Neben einer Pneumonie kommt es häufig zu einem akuten Nierenversagen. Dromedare scheinen die Quelle für die zoonotischen Infektionen zu sein. Bei Reisenden aus den arabischen Risikogebieten muss an eine solche Infektion gedacht werden.

  • Bei den Viren der Herpesgruppe unterscheidet man zwischen einer Infektion und einer klinisch relevanten Erkrankung. Der mechanische Reiz durch eine Intubation und mechanische Beatmung scheint eine Herpes-simplex-Reaktivierung zu begünstigen.

  • Für die CMV-Diagnostik steht mit dem pp65-Antigen-Test eine weitere Methode zum direkten Virusnachweis zur Verfügung. Bei der Therapie der CMV-Erkrankung muss man auf toxische Nebenwirkungen der Medikamente achten.

  • Essenziell bei der Therapie des akuten Lungenversagens (ARDS) ist die lungenprotektive Beatmung. Diese umfasst niedrige Tidalvolumina (≤ 6 ml/kgKG) und einen niedrigen Spitzendruck (< 30 cmH2O). Die Mortalität des ARDS senken kann zudem eine frühzeitige und ausreichend lange Bauchlagerung des Patienten.

  • Das Verfahren der Wahl für eine extrakorporale Membranoxygenierung beim ARDS ist die venovenöse ECMO. Indikationen sind eine schwere Hypoxämie, eine Hyperkapnie mit dekompensierter respiratorischer Azidose oder eine nichtprotektive Beatmung.

 

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