"Ein Dogma gerät ins Wanken" überschreibt die Ärzte-Wochenzeitung
Medical Tribune (Ausgabe 14.Mai 2004) einen Artikel bei
dem es um die Frage geht, ob Kranke bei starkem Husten aufgefordert
werden sollen viel zu trinken oder lieber nicht.
Dabei bezieht sich der Autor auf eine Untersuchung die im renommierten
British Medical Journal publiziert wurde. In diesem Artikel
hatten australische Forscher darauf hingewiesen, dass es bisher
keine überzeugenden wissenschaftlichen Belage dafür gibt, dass
eine erhöhte Flüssigkeitszufuhr tatsächlich bei jeder Art von
Husten die Beschwerden lindert.
Tatsächlich gibt es sogar Hinweise darauf, dass eine erhöhte
Flüssigkeitszufuhr - insbesondere bei Entzündungen der unteren
Luftwege (Lungenentzündung)- schädlich sein kann und in seltenen
Ausnahmefällen sogar in Verdacht geraten ist, zu tödlichen Komplikationen
beigetragen zu haben.
Welche Konsequenzen sollten aus diesem neuen Gesichtspunkt gezogen
werden?
Es erscheint bei der unsicheren Datenlage derzeit sinnvoll zu
sein, dass Betroffene diese Problematik mit den behandelnden
Ärzten zumindest diskutieren und sich selbst so lange auf eine
"normale" Flüssigkeitszufuhr beschränken bis eine
Lungenentzündung durch den Arzt ausgeschlossen wurde.
BMJ
2004;328:499-500 (28 February),
"Drink plenty of fluids": a systematic review of evidence
for this recommendation in acute respiratory infections
Michelle P B Guppy, academic general practice registrar1, Sharon
M Mickan, senior research fellow1, Chris B Del Mar, professor
of general practice1
1 Centre for General Practice, Medical School, University of
Queensland, Herston, 4006, Queensland, Australia
Correspondence to: C B Del Mar c.delmar@cgp.uq.edu.au
Doctors often recommend drinking extra fluids to patients with
respiratory infections. Theoretical benefits for this advice
are replacing insensible fluid losses from fever and respiratory
tract evaporation, correcting dehydration from reduced intake,
and reducing the viscosity of mucus.1 2 To many this advice
is self evident and justified on the basis that even if the
benefit is uncertain, or at best small, at least it is harmless.
However, there are theoretical reasons for increased fluid intake
to cause harm. Antidiuretic hormone conserves fluid by stimulating
water reabsorption from the renal collecting ducts. Increased
antidiuretic hormone secretion has been reported in adults and
children with lower respiratory tract infections of bronchitis,
bronchiolitis, and pneumonia of viral and bacterial aetiology.3
4 It is uncertain if this also occurs in upper respiratory tract
infections.
Several mechanisms have been proposed for this increased hormone
secretion, acting through fever, hypoxia, hypercarbia, pain,
emotion, or nausea. Secretion may be stimulated by a resetting
of osmostat receptors to lower levels.3 Also, lung hyperinflation
and pulmonary infiltrates may stimulate hormone secretion by
causing a false perception of hypovolaemia by intrathoracic
receptors.4 This would be in keeping with findings that antidiuretic
hormone secretion in pneumonia increases proportionally with
the extent of lung parenchymal involvement.3
Giving extra fluids while antidiuretic hormone secretion is
increased may theoretically lead to hyponatraemia and fluid
overload. Clinical symptoms of hyponatraemia are irritability,
confusion, lethargy, coma, and convulsions. Fluid restriction
may be appropriate management to prevent this.
Methods and results
To determine whether recommending increased fluids was beneficial
or harmful, we undertook a systematic review and posed three
questions:
Does recommending increased fluid intake for acute respiratory
infections improve duration and severity of symptoms?
Are there adverse effects from this recommendation? Are any
benefits or harm related to site (upper or lower respiratory
tract) or severity of illness?
Using the Cochrane Acute Respiratory Infections Group search
strategy, together with additional terms (see bmj.com for details),
we did a conventional search of the Cochrane Central Register
of Controlled Trials, Medline (1966-2003), Embase (1974-2003),
and Current Contents (1966-2003). We examined references of
relevant papers and contacted experts in the subject.
We found no randomised controlled trials comparing increased
and restricted fluid regimens in patients with respiratory infections.
Two prospective prevalence studies reported hyponatraemia at
rates of 31% and 45% for children with moderate to severe pneumonia
(see table).1 2 None of these children showed clinical signs
of dehydration. Symptoms associated with hyponatraemia were
not reported, but four children with a serum sodium below 125
mmol/l died during one study.
We also found several case series in which patients with respiratory
infections developed hyponatraemia, of which some were symptomatic
(table).5 These patients were all successfully treated with
fluid restriction.
Comment
We found data to suggest that giving increased
fluids to patients with respiratory infections may cause harm.
To date there are no randomised controlled trials to provide
definitive evidence, and these need to be done. Until we have
this evidence, we should be cautious about universally recommending
increased fluids to patients, especially those with infections
of the lower respiratory tract.
References
1. Shann F, Germer S. Hyponatraemia associated with pneumonia
or bacterial meningitis. Arch Dis Child 1985;60: 963-6.[Abstract]
2. Dhawan A, Narang A, Singhi S. Hyponatraemia and the inappropriate
ADH syndrome in pneumonia. Ann Trop Paediatr 1992;12: 455-62.[ISI][Medline]
3. Dreyfuss D, Leviel F, Paillard M, Rahmani J, Coste F. Acute
infectious pneumonia is accompanied by latent vasopressin-dependent
impairment of renal water excretion. Am Rev Respir Dis 1988;138:
583-9.[ISI][Medline]
4. Gozal D, Colin AA, Jaffe M, Hochberg Z. Water, electrolyte,
and endocrine homeostasis in infants with bronchiolitis. Pediatr
Res 1990;27: 204-9.[Abstract]
5. Rivers RP, Forsling ML, Olver RP. Inappropriate secretion
of antidiuretic hormone in infants with respiratory infections.
Arch Dis Child 1981;56: 358-63.[Abstract]
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