Nichtinvasive Beatmung und körperliche Belastung bei Patienten mit COPD

Zusammenfassung

Der Einsatz einer nichtinvasiven Beatmung (noninvasive ventilation = NIV) zur Verbesserung der körperlichen Belastung bei Patienten mit COPD wurde in der Vergangenheit in einer Vielzahl von Studien untersucht. Grundsätzlich muss unterschieden werden, ob die NIV während der körperlichen Belastung appliziert wird und somit direkt die Belastbarkeit beeinflusst oder ob eine intermittierende, meist nächtliche NIV indirekt zu einem Anstieg der körperlichen Leistungsfähigkeit führt. Mehrere Arbeiten zeigten, dass der direkte Einsatz einer NIV während körperlicher Belastung zu einer Steigerung der Belastbarkeit bei gleichzeitiger Reduktion der belastungsinduzierten Dyspnoe führt. Des Weiteren konnten gute Trainingsergebnisse erzielt werden, wenn das körperliche Training mit NIV unterstützt wurde. Allerdings gibt es interindividuelle Unterschiede, was die Toleranz und die positive Beeinflussung der Belastbarkeit und der Dyspnoe betrifft. In den meisten Studien der direkten Anwendung wurden COPD-Patienten ohne Indikation zur Langzeitanwendung der NIV mit meist niedrigen Beatmungsdrücken ventiliert, was zu unterschiedlichen Ergebnissen führte. Dagegen war bei hyperkapnischen COPD-Patienten der Einsatz einer NIV mit hohen Inspirationsdrücken im Hinblick auf eine Belastungssteigerung meist effektiver. Die intermittierende NIV führte nach Studienergebnissen ebenfalls zu einer positiven Beeinflussung der Belastbarkeit bei COPD-Patienten, wenngleich auch hier unterschiedliche Ergebnisse bei sehr verschiedenen Beatmungsstrategien mit einer großen Varianz der angewandten Beatmungsdrücke erzielt wurden. Sowohl bei der direkten als auch bei der intermittierenden Applikation der NIV kamen mehrere Formen zum Einsatz: CPAP, pressure support ventilation, proportional assist ventilation und zuletzt eine kontrollierte NIV. Dies erschwert eine konklusive Aussage darüber, ob und wie eine NIV die Belastbarkeit bei COPD-Patienten beeinflusst. Somit gilt es in der Zukunft genau zu definieren, welche Untergruppen von COPD-Patienten von einer NIV in welchem Modus und mit welcher Einstellung profitieren.

Abstract

The use of non-invasive ventilation (NIV) to improve physical activity in COPD patients has been addressed in several clinical investigations in the past. In general, NIV can be applied directly during exercise, but also intermittently when used for long-term treatment thereby aiming at improving physical activity during spontaneous breathing. There is increasing evidence that NIV enhances exercise capacity in COPD patients with a reduction of exercise-induced dyspnea when applied during exertion. Furthermore, physical training has been shown to produce positive results when training was performed under NIV-aided conditions. However, the results regarding tolerance of NIV, exercise ability and dyspnea are individually different. In most studies where NIV was applied during exercise, patients had no indication for long-term NIV, and patients were ventilated with low inspiratory pressures, which produced varying results. In contrast, the use of higher inspiratory pressures in hypercapnic COPD patients was more effective in enhancing exercise capacity. The intermittent application of NIV also positively affects exercise capacity in COPD patients, although different results were achieved with different ventilator strategies, mainly with a variety of inspiratory pressure levels. Different ventilation modes were used for NIV to aid exercise and for the intermittent approach in addition to different settings: CPAP, pressure support ventilation, proportional assist ventilation and controlled NIV. Therefore, it is still unclear how to define the best technique for NIV to be used in order to enhance exercise capability in COPD patients. Future studies are needed to define which subgroup of patients benefit from NIV in view of its effects on exercise. Further studies should also be aimed at clarifying which mode and which ventilator settings are most beneficial in improving exercise capability in COPD patients.

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