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Medikamentöse Therapie der refraktären Atemnot

Eine systematische Literaturübersicht

Pharmacological therapy of refractory dyspnoea

A systematic literature review

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Zusammenfassung

Hintergrund

Die symptomatische Therapie der Atemnot bei Patienten mit einer lebenslimitierenden Erkrankung ist schwierig und komplex. Ziel dieser systematischen Literaturübersicht ist die Zusammenstellung und Analyse relevanter klinischer Studien zu vier Therapieverfahren (Opioide, Benzodiazepine, Kortikosteroide, Sauerstoff) zur Linderung von Atemnot.

Material und Methoden

Die Arbeit stützt sich auf eine im Juli 2011 in Medline, Embase und der Cochrane Library durchgeführte Datenbankrecherche sowie auf Kontakt zu Experten im Feld. Eingeschlossen wurden systematische Literaturübersichten, kontrollierte und randomisiert kontrollierte Studien bei Patienten mit Atemnot aufgrund einer fortgeschrittenen Erkrankung. Die Studien wurden von zwei unabhängigen Reviewern selektiert, Daten extrahiert und bewertet. Es wurde eine narrative Synthese durchgeführt.

Ergebnisse

Aus 2559 Treffern in der Datenbanksuche wurden 5 relevante systematische Literaturübersichten und 10 randomisiert-kontrollierte Studien in die Analyse eingeschlossen. Die einzige Gruppe mit einem Wirksamkeitsnachweis sind orale und parenterale Opioide. Für Benzodiazepine zeigt sich aufgrund der aktuellen Studienlage kein signifikanter Wirksamkeitsnachweis zur Linderung der Atemnotintensität, allerdings eine Tendenz zu einem Benefit. Für Steroide konnten keine Studien identifiziert werden. Bei nichthypoxischen Tumorpatienten hat Sauerstoff keinen Benefit im Vergleich zu Raumluft, bei nichthypoxischen COPD-Patienten mit Atemnot konnte ein statistisch signifikanter Wirksamkeitsnachweis für Sauerstoff gezeigt werden.

Schlussfolgerung

Orale und parenterale Opioide zeigen einen signifikanten Wirksamkeitsnachweis und sind Mittel der 1. Wahl zur symptomatischen Therapie der Atemnot. Benzodiazepine sollten zurückhaltend eingesetzt werden. Außer bei COPD-Patienten gibt es für den Einsatz von Steroiden derzeit keine Evidenz. Nichthypoxische Tumorpatienten haben keinen Benefit von Sauerstoff gegenüber Raumluft.

Abstract

Background

The management of breathlessness in patients with life-limiting diseases is still difficult and complex. This systematic review aims to summarize and analyze clinical trials of four different treatment options (opioids, benzodiazepines, corticosteroids and oxygen) for the relief of breathlessness.

Materials and methods

A systematic review based on database searching of Medline, Embase and Cochrane Library was carried out and experts in the field were contacted. The search was conducted in July 2011. Included were systematic reviews, controlled and randomized controlled clinical trials in patients suffering from breathlessness due to advanced disease. Studies were selected, extracted and the data analyzed by two independent reviewers using narrative synthesis.

Results

The search retrieved 2,559 hits. Five systematic reviews and 10 randomized controlled trials were included. Opioids (oral and parenteral) were the only drug group with evidence for relief of breathlessness. Benzodiazepines failed to show a significant effect for the relief of breathlessness intensity but demonstrated a tendency towards benefit. No studies were identified assessing steroids. There is no additional benefit from oxygen compared to room air in non-hypoxemic cancer patients but there is a statistically significant benefit of oxygen in non-hypoxemic COPD patients.

Conclusion

Oral and parenteral opioids seem to be effective for the relief of breathlessness and should be the first choice for pharmacological treatment. Benzodiazepines should be used with reservation. There is not enough evidence for the use of steroids except for COPD patients. Non-hypoxemic cancer patients do not benefit from oxygen. The English full text version of this article will be available in SpringerLink as of November 2012 (under “Supplemental”).

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Interessenkonflikt

Der korrespondierende Autor weist für sich und seine Koautoren auf folgende Beziehungen hin: Der Erstautor ist verantwortlich für die Durchführung einer klinischen Studie (IIT) zur Wirksamkeit von Fentanyl bei Atemnot, die von TEVA GmbH finanziell unterstützt wird. Die weiteren Autoren geben keine Interessenkonflikte an.

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Correspondence to S.T. Simon M.D., MSc.

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Simon, S., Köskeroglu, P. & Bausewein, C. Medikamentöse Therapie der refraktären Atemnot. Schmerz 26, 515–522 (2012). https://doi.org/10.1007/s00482-012-1228-3

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  • DOI: https://doi.org/10.1007/s00482-012-1228-3

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