Sunteți pe pagina 1din 40

DASAR DASAR

VENTILATOR

ARIE ZAINUL FATONI


 A 30-year-old male patient presented with acute
onset of breathlessness, drycough, fever, myalgia,
and malaise for 4 days. On examination, he was
found tobe febrile and restless, with respiratory rate
of 46/min and pulse rate of 124/min.His oxygen
saturation was 80% on room air, and chest skiagram
showed bilateralparenchymal infiltrate

 What type respiratory support should be initiated?


 What setting should be selected for respiratory
support?
 What are the goal of respiratory support?
THE VENTILATOR AS A “BLACK BOX”

 A mechanical ventilator is an automatic


machine designed to provide all or part of the
work the body must do to move gas into and
out of the lungs (Ventilation)
 To understand how a machine can be
controlled to replace or supplement the
natural function of breathing, we need to first
understand something about the mechanics
of breathing itself

Tobil et al, 2013


MECHANISMS OF BREATHING
 The periodic exchange of alveolar gas with
the fresh gas from the upper airway
reoxygenates desaturated blood and
eliminates CO2
 BRAIN  control of breathing in brain stem,
espescially medulla and pons
 NERVES
 RESPIRATORY MUSCLE  thoracic cavity,
diaphrgama and intercostal muscle
 LUNG  alveoli

Morgan et al, 2013


Purpella, 2018
Nunn’s Applied Physiology
Lung Volumes and capacities
 Tidal Volume = each normal breadth (Vt) VT = 5 – 8 cc / kg
 Minute Volume = The total amount of air moved in and out of
the lungs each minute (VT x RR) 5 Lpm
 Minute Volume  hipoventilasi / hiperventilation
 Respiratory rate 12 – 20 x/m
 PaCO2 35 – 45 mmHg PaO2 80 – 100 mmHg
 PH 7.35 – 7.45
MECHANICAL VENTILATOR

 Concept of GAS LAW


 Boyle’s (PxV=k), Charles (P/T=k) and
Avogadro’s law (V/n=k)
 Ideal GAS  P.V = n R.T
Indications

 Hypoxia
 Hipoventilation/hipercarbia
 Increased work of breathing
 Others (ex. Cerebral rescusitation, shock,
post ROSC)
Types

 Iron Lung (Negative pressure Ventilation)


 Postive pressure Ventilation
1. Non Invasive (NPPV)
2. Invasive Mechanical Ventilation
a. Anesthesia Machine (OT)
b. Mechanical Ventilator / MV (ICU)
c. Hybrid
Compliance (V/ P)
 "Static" Compliance is a measure of the "stiffness"
of lung and chest wall, typically 50 ml/cmH2O in
adults
 Surfactant improves lung compliance, especially at
low lung volumes
 V / (P-plat - PEEP).

 "Dynamic" compliance includes the extra pressure


needed to overcome resistance to airflow, inertia of
chest wall, and viscoelasticity of tissues.
V / (P-peak - PEEP).
How it works ?
How it works ? TTCE

 Trigger : initiating inspiration / breath initition


 Target/Limit : The value of the limit variable
cannot be exceeded at any time during
inspiration
 Cycling to expiration : The changeover from
inspiration to expiration
 Expiration (Baseline) : variable that is
controlled at end exhalation
Definisi Siklus Bernapas
(cycling)
 Siklus respirasi dibagi menjadi 2 fase:
 Inspirasi  aktif
 Ekspirasi  pasif
 Lama inspirasi: inspiratory time (Ti, in
seconds).
 Lama ekspirasi: expiratory time (Te, in
seconds).
 The cycle time (Tc, in seconds):
Tc = Ti + Te
KURVA NAFAS VENTILASI MEKANIK;

INITIATION / TRIGER:
• Control (waktu)
• Assisted (trigger) TARGET / LIMITED:
• Volume
• Pressure
PRESSURE
CYCLED:
• Volume
• Time
• Flow

TIME
0

Inspirasi Ekspirasi
KURVA NAFAS SPONTAN
INITIATION = TRIGGER

 TIME TRIGGER
 Berdasarkan setting waktu atau sesuai setting RR
ventilator  (tidak ada tambahan nafas dari
pasien)
 Control

 PATIENT TRIGGER
 Berdasarkan penurunan tekanan di jalan nafas
(ada upaya nafas pasien)  jumlah RR yang ada
lebih banyak dari jumlah setting)
 Assisted
TARGET = LIMITATION = ORIENTED

 VOLUME TARGET/ORIENTED/LIMITED
Berdasarkan setting tidal volume
sebelumnya

 PRESSURE TARGET/ORIENTED/LIMITED
Berdasarkan setting pressure sebelumnya
MODEs of MV
MODE VENTILATOR

VOLUME CYCLED
Berdasarkan setting volume sebelumnya

TIME CYCLED
Berdasarkan setting waktu sebelumnya

FLOW CYCLED
Berdasarkan penurunan peak flow 25%
(manufactured)
Control Volume Cycled
(VC,IPPV,CMV)
Control mode
Control Time Cycled
(PC,P-CMV)
P

T
0
6 DETIK 6 DETIK 6 DETIK

RR pasien sesuai dengan yg disetting


Setting trigger > -2 (sensitivity = tidak sensitif)
Setiap ada trigger tidak akan dibantu ventilator
Tidak nyaman u/ pasien sadar, harus sedasi atau relaksasi
Biasa digunakan untuk resusitasi otak, dimana nilai PCO2
sudah ditetapkan
Assisted Volume Cycled

Assisted mode
Assisted Time Cycled

T
0
4 DETIK 3 DETIK 5 DETIK

1. RR pasien lebih dari setting


2. Trigger insp berdasar upaya nafas pasien (negative pressure)
3. Sensitivity dibuat < 0 (sensitif terhadap upaya nafas pasien)
4. Setiap trigger akan dibantu ventilator
5. Jika RR pasien lebih dari yg di setting disebut assisted mode, jika
sama dgn setting RR disebut control mode.
6. Komplikasi hiperventilasi (PCO2 <<)
SIMV mode
P

T
0

Periode SIMV Periode spontan

Siklus SIMV
1. Contoh, Jika setting SIMV rate = 6. Berarti siklus SIMV = 60/6 =
10 detik
2. Jika RR pasien 20; maka periode SIMV dibuat sama dgn RR pasien
yaitu = 60/20 = 3 detik, bisa dengan menaikkan RR,flow rate antara
60-80 L/menit atau setting T inspirasi
3. Sisanya adalah periode spontan 10 – 3 = 7 detik untuk memberi
kesempatan pasien bernafas spontan tanpa dibantu.
4. Contoh, jika SIMV diberi PS 10 cmH2O, maka setiap nafas spontan
akan diberi support sebesar 10 cm H2O
CPAP mode

5
PEEP 5
0

1. PEEP pada nafas spontan


2. Untuk proses weaning
3. Tidak mengganggu cardiac output, karena tekanan negatif
pada inspirasi
Flow Cycled mode = PS, ASB, Spont.

Paw 4 KOMPONEN
1.Trigger
2 4
2. Presurisasi
Pinsp
3. Akhir inspirasi
4. ekspirasi
PEEP
•Jika flow mencapai 25% dari peak flow  flow stop
•RR, peak flow dan tidal volume ditentukan oleh pasien
Peak
sendiri.
60 L/mnt
flow •Trigger berdasarkan usaha nafas pasien (neg pressure),
25% of peak
jika pasien tidak bernafas (apneu) maka
15 L/mnt flow ventilator juga tidak memberikan ventilasi
support
•Karena sangat tergantung trigger pasien, maka
biasanya di back dgn SIMV
•Jika Pressure > 20 = Pressure control
1 3 •Untuk mengurangi WOB akibat resistensi tubing dan
tube,  proses weaning
MODEs of MV
Stepwise to MV
(PBW = 50/45.5 + 0.91 (cm – 152.4))
1. Set the ventilator setting
2. Set alarms
 Peak pressure high/low  10–15 cm above or
below the peak inspiratory pressure generated
on constant basis
 Minute ventilation  high/low (50% above or
below the set volume)
 Low exhaled tidal volume  (50% of the
delivered tidal volume)
 High respiratory rate
 Set apnea ventilation parameters

3. Connect the ventilator to the patient


4. Monitoring and adjustments during MV
 Patients should be closely monitored
 Clinically and graphic/Monitor (Pressure,
Volume, Leak, etc)
5. Monitor and manage complications
6. Weaning

7. Monitoring during postextubation period


Weaning
 Weaning adalah suatu proses berkesinambungan yang
dimulai dari intubasi sampai pasien KRS

1 Treatment 3 Assessing 5 Extubation 6 Re-intubation


of ARF readiness to wean

2 Suspicion 4 SATSBT

Admit Discharge
Tanda-tanda kegagalan
 Agitasi, anxietas, diaphoresis atau perubahan status mental
 RR > 30 - 35/men
 SpO2 < 90%
 > 20% ↑ atau ↓ HR atau HR > 120 - 140/men
 TD sistolik > 180 atau < 90 mmHg
 Abdominal paradox, use of accessory muscle, dyspnea

Pasien harus dikembalikan ke tunjangan napas penuh selama


24 jam agar otot-otot pernapasan pulih fungsinya
Lung protective strategy for
ARDS
Terima kasih

S-ar putea să vă placă și