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Peran dan fungsi perawat pada pasien

dengan respirator mekanik


By
MAS YOESZ
Review System Pernafasan
Airway management
Mengenal Terminologi ventilasi Mekanik
Tatalaksana Ventilasi Mekanik
Mode Ventilasi Mekanik
Trobleshoting Ventilasi Mekanik
Weaning
Peran Dan Fungsi Perawat
Modalitas Perawatpada Pasien Dengan Respirator Mekanik
MEMBUKA JALAN NAPAS
MEMBERIKAN TAMBAHAN OKSIGEN
MENUNJANG VENTILASI
MENCEGAH ASPIRASI



















1. INFANT ATERM, ID 3,5mm, PANJANG 12 cm

2. ANAK, ID : 4 + , PANJANG 14 +

3. DEWASA :
ID WANITA 7 7.5, PANJANG 20 -24
ID LAKI-LAKI 7.5 -9, PANJANG 20 -24
Umur
4
Umur
4










PROSES MEKANIK, KELUAR MASUKNYA
UDARA DARI LUAR KE DALAM PARU DAN
SEBALIKNYA YAITU BERNAFAS
TERJADI ANTARA UDARA DALAM ALVEOLUS
DENGAN DARAH DALAM KAPILER, PROSESNYA
DISEBUT DIFUSI
VENTILASI PARU
PERTUKARAN GAS
EKSTERNA
INTERNA
UTILISASI O2
PERTUKARAN GAS
PEMAKAIAN OKSIGEN
DALAM SEL PADA REAKSI
PELEPASAN ENERGI
PERTUKARAN GAS
ANTARA DARAH
DENGAN SEL
JARINGAN/TISUE
MEKANISME INSPIRASI
KONTRAKSI DIAFRAGMA & INTERKOSTALIS EKST
VOLUME INTRATORAKS >>
INTRAPLEURAL PRESSURE >> NEGATIF
PARU EKSPANSI (MENGEMBANG)
INTRAPULMONAL PRESSURE >> NEGATIF
UDARA MENGALIR KE DALAM PARU
HUKUM BOYLE
PRESSURE DARI GAS BERBANDING
TERBALIK DGN VOL CONTAINER
VOLUME
PRESSURE
VOLUME
PRESSURE
PERUBAHAN VOLUME
MENYEBABKAN
PERUBAHAN PRESSURE
TABRAKAN PARTIKEL2 GAS
KE DINDING KONTAINER
MENIMBULKAN PRESSURE
INSPIRASI
KONTRAKSI OTOT INTERKOSTALIS EKSTERNA
IGA TERANGKAT
KONTRAKSI DIAFRAGMA DIAFRAGMA
BERGERAK INFERIOR
EKSPIRASI
RELAKSASI OTOT INTERKOSTALIS EKSTERNA
IGA KE POSISI SEMULA
RELAKSASI DIAFRAGMA DIAFRAGMA
BERGERAK KE POSISI SEMULA
INTRATORAK
VOLUME
PRESSURE
VOLUME
PRESSURE

AIRWAY RESISTANCE
(RAW)
COMPLIANCE
(COMPL)
VENTILASI PARU
C
L
R
AW
LUNG

AIRWAY
Membatasi jumlah gas yg mengalir melewati jalan
nafas (obstruksi jalan nafas)
Flow = pressure/resistance
Jika R Flow
Ditentukan oleh besarnya diameter jalan nafas
Pada nafas spontan, jika resistance me ,
secara normal respon tubuh adalah
meningkatkan usaha nafas (WoB = RR >>, otot
bantu nafas >>)
FLOW =
PRESSURE
RESISTANCE
BRONKUS
NORMAL
AIRWAY RESISTANCE
(RAW)
FLOW =
PRESSURE
RESISTANCE
BRONKODILATASI:
EPINEFRIN
AMINOFILIN
BETA 2 AGONIS
AIRWAY RESISTANCE
(RAW)
FLOW =
PRESSURE
RESISTANCE
BRONKOKONSTRIKSI:
HISTAMIN
OBSTRUKSI:
MUKUS/SEKRET
AIRWAY RESISTANCE
(RAW)
FLOW =
PRESSURE
RESISTANCE
BRONKOSPASME
TUMOR/SEKRET
ETT TERLALU
KECIL
KOLAPS/ATELEKTASIS
AIRWAY
RESISTANCE (RAW)
Kaku Elastis
LOW
COMPLIANCE
HIGH
COMPLIANCE
BALON
Definisi
Rasio perubahan volume akibat terjadinya perubahan pressure
V/P
Terbagi 2;
Compl paru (edema paru, fibrosis, surfactan <<)
Compl dinding dada (obesitas, distensi abdomen)
Low compliance
Edema paru, pneumonia berat, ARDS, efusi pleura,
hematopneumotoraks, abdominal pressure >>: u/
memasukkan volume yang diinginkan dibutuhkan pressure
yg lebih besar.
High compliance
Muscle relaxant, COPD, open chest dgn pressure yg
kecil dapat tidal volume yg masuk besar
Work Of Breathing
Compliance
Normal 35-100ml/cm H2O
Resistance
Normal 6cmH2O/l/sec
Minute Ventilation
Normal <10L
<25
Alveolar filling
Pleural
Extrathoracic
>15
Airway narrowing
Small ETT
Mucus Plugging
>12
High VD/VT
High CO2 Production
15 30
250
500
0
P
Vol
500 500
250 250
15 30 15
30
LOW
COMPLIANCE
HIGH
COMPLIANCE
NORMAL
PEEP 5
INSPIRASI
EKSPIRASI
NAFAS
SPONTAN
ANATOMICAL
DEAD SPACE
ALVEOLAR
DEAD SPACE
PHYSIOLOGICAL
DEAD SPACE
VENOUS ADMIXTURE
(SHUNT)
V/Q =
V/Q > 1
V/Q = 1
V/Q < 1
V/Q = 0
TRAKEA
KAPILER
PARU
MECHANICAL
DEAD SPACE:
TUBE
CONNECTOR
ET CO2
BREATHING
CIRCUIT
NORMAL
FiO2 :
FRAKSI KONSENTRASI
OKSIGEN INSPIRASI YG
DIBERIKAN (21 100%)
TIDAL VOLUME (V
T
):
JUMLAH GAS/UDARA YG
DIBERIKAN VENTILATOR
SELAMA INSPIRASI DALAM
SATUAN ml/cc ATAU liter. (5-
10 cc/kgBB)
FREKUENSI / RATE (f) :
JUMLAH BERAPA KALI
INSPIRASI DIBERIKAN
VENTILATOR DALAM 1
MENIT (10-12 bpm)
FLOW RATE :
KECEPATAN ALIRAN GAS
ATAU VOLUME GAS YG
DIHANTARKAN PERMENIT
(liter/menit)

- Menentukan siklus respirasi
- Jika setting RR pd ventilator 10 x/menit maka
60/10 = 6 dtk
- Jadi T
(Total)
= T
(Inspirasi)
+ T
(Ekspirasi)
= 6 dtk
- Berarti inspirasi + ekspirasi harus selesai dalam
waktu 6 dtk.
6 dtk 6 dtk
Ins + Eksp Ins + Eksp
T I M E = WAKTU frekuensi
Setelan sensitifitas akan menentukan variabel trigger
Variabel trigger menentukan kapan ventilator mengenali adanya
upaya nafas pasien
Ketika upaya nafas pasien dikenali, ventilator akan memberikan
nafas
Variabel trigger dapat berupa pressure atau flow
Upaya nafas pasien dimulai saat terjadi kontraksi otot diafragma
Upaya nafas ini akan menurunkan tekanan (pressure) di dalam
sirkuit ventilator (tubing)
X X
Ketika pressure turun mencapai batas yang diset oleh dokter,
ventilator akan mentrigger nafas dari ventilator
Namun tetap ada keterlambatan waktu antara upaya nafas
pasien dengan saat ventilator mengenali kemudian
memberikan nafas.
Baseline
Trigger
Patient effort
Pressure
Pressure Triggering
1. Setelan sensitivity pada -2 cm H
2
O
2. Gambar dibawah menunjukkan pada 2 nafas pertama upaya
nafas pasien mencapai sensitivitas yang diset; sedangkan
gbr ketiga terlihat bahwa upaya nafas pasien tidak mencapai
sensitivitas yg diset sehingga ventilator tidak mengenalinya
-2 cm H
2
O
Flow Triggering
Ventilator secara kontinyu memberikan flow rendah
ke dalam sirkuit pasien (open system)
Delivered flow Returned flow
No patient effort
Flow Triggering
1. Upaya nafas dimulai saat kontraksi diafragma
2. Saat pasien bernafas beberapa bagian flow didiversi ke
pasien
Delivered flow Less flow returned
Flow Triggering
1. Level flow yg rendah akan lebih nyaman untuk pasien (lebih
sensitif)
2. Keterlambatan waktu lebih kecil dibanding pressure trigger
3. Meningkatan respon waktu dari ventilator
All inspiratory efforts recognized
Time
Pressure
DEFINISI
POSITIVE END EXPIRATORY PRESSURE
SEWAKTU AKHIR EXPIRATORY, AIRWAY
PRESSURE TIDAK KEMBALI KETITIK NOL
DIGUNAKAN BERSAMA DENGAN MODE LAIN
SEPERTI; SIMV, ACV ATAU PS
DISEBUT CPAP JIKA DIGUNAKAN PADA MODE
NAFAS SPONTAN
PEEP 5
REDISTRIBUSI CAIRAN
EKSTRAVASKULAR PARU
MENINGKATKAN VOLUME
ALVEOLUS
MENGEMBANGKAN ALVEOLI YG
KOLAPS (ALVEOLI RECRUITMENT)
REDISTRIBUSI CAIRAN
EKSTRAVASKULAR PARU
+10
0
A
B
MENINGKATKAN VOLUME
ALVEOLUS
+20 +10 0
A
B
C
Work of Breathing
Airway Protection Oxygenation
Patient comfort and rest
Reversal of Hypoxemia
Reversal of acute respiratory acidosis
Reversal of respiratory muscle fatigue
Prevention/Reversal of atelectasis
Decrease myocardial ischemic
Allowance of neuromuscular blockade
Improve lung compliance
Fraction of Inspired O2 - FIO2
Tidal Volume - TV
Respiratory Rate - RR(f)
Flow Rate - Vi(L/m)
PSV
Mode (A/C, SIMV, PS)
PEEP (cm of H2O)
Non Invasive Invasive
Non Invasive: Ventilatory support that is given
without establishing endo- tracheal intubation or
tracheostomy is called Non invasive mechanical
ventilation
Invasive: Ventilatory support that is given through
endo-tracheal intubation or tracheostomy is called
as Invasive mechanical ventilation
Non invasive
Negative pressure
Producing Neg. pressure
intermittently in the
pleural space/ around the
thoracic cage
Positive pressure
Delivering air/gas with
positive pressure to the
airway
e.g.: Iron
Lung
BiPAP & CPAP

non-invasive mechanical
ventilation



Head gear
Interface (mask)
ventilator
Positive Pressure
Pressure cycle Volume cycle Time cycle
Invasive

Mode
Description of a breath type and the timing
of breath delivery
Basically there are three breath delivery techniques
used with invasive positive pressure ventilation
CMV controlled mode ventilation
SIMV synchronized
Spontaneous modes
CMV
Continuous Mandatory Ventilation
All breaths are mandatory and can be volume or
pressure targeted

Controlled Ventilation when mandatory breaths
are time triggered

Assist/Control Ventilation when mandatory
breaths are either time triggered or patient
triggered
CMV
Continuous Mandatory Ventilation
Controlled Ventilation when mandatory breaths
are time triggered
Mandatory breath ventilator determines the start
time (time triggered) and/or the volume or pressure
target
CMV
Controlled Ventilation
Appropriate when a patient can make no effort to
breathe or when ventilation must be completely
controlled
Drugs
Cerebral malfunctions
Spinal cord injury
Phrenic nerve injury
Motor nerve paralysis
CMV
Controlled Ventilation
In other types of patients, controlled ventilation is
difficult to use unless the patient is sedated or
paralyzed with medications
Seizure activity
Tetanic contractions
Inverses I:E ratio ventilation
Patient is fighting (bucking) the ventilator
Crushed chest injury stabilizes the chest
Complete rest for the patient
CMV
Controlled Ventilation
Adequate alarms must be set to safeguard the
patient
Ex. disconnection

Sensitivity should be set so that when the patient
begins to respond, they can receive gas flow from
the patient

Do not lock the patient out of the ventilator!
CMV
Assist/Control Ventilation
A time or patient triggered CMV mode in which
the operator sets a minimum rate, sensitivity
level, type of breath (volume or pressure)
The patient can trigger breaths at a faster rate
than the set minimum, but only the set volume or
pressure is delivered with each breath

CMV
Assist/Control Ventilation
Indications
Patients requiring full ventilatory support
Patients with stable respiratory drive

Advantages
Decreases the work of breathing (WOB)
Allows patients to regulate respiratory rate
Helps maintain a normal PaCO2

Complications
Alveolar hyperventilation
CMV
Volume Controlled
CMV
Time or patient
triggered, volume
targeted, volume cycled
ventilation


Graphic (VC-CMV)
Time-triggered,
constant flow, volume-
targeted ventilation
CMV
Volume Controlled
CMV
Time or patient
triggered, volume
targeted, volume cycled
ventilation


Graphic (VC-CMV)
Time-triggered,
descending-flow,
volume-targeted
ventilation


CMV
Pressure Controlled CMV
PC CMV (AKA Pressure control ventilation -
PCV)

Time or patient triggered, pressure targeted
(limited), time cycled ventilation

The operator sets the length of inspiration (Ti), the
pressure level, and the backup rate of ventilation

VT is based on the compliance and resistance of
the patients lungs, patient effort, and the set
pressure
CMV
Pressure Controlled CMV
Note inspiratory pause
CMV
Pressure Controlled CMV
Note shorter Ti
CMV
Pressure Controlled CMV
Airway pressure is limited, which may help guard
against barotrauma or volume-associated lung
injury
Maximum inspiratory pressure set at 30 35 cm
H2O
Especially helpful in patients with ALI and ARDS

Allows application of extended inspiratory time,
which may benefit patients with severe
oxygenation problems

Usually reserved for patient who have poor
results with a conventional ventilation strategy
of volume ventilation
CMV
Pressure Controlled CMV
Occasionally, Ti is set longer than TE during PC-
CMV; known as Pressure Control Inverse Ratio
Ventilation
Longer Ti provides better oxygenation to some
patients by increasing mean airway pressure
Requires sedation, and in some cases paralysis
IMV and SIMV
Intermittent Mandatory Ventilation IMV
Periodic volume or pressure targeted breaths
occur at set interval (time triggering)

Between mandatory breaths, the patient
breathes spontaneously at any desired baseline
pressure without receiving a mandatory breath
Patient can breathe either from a continuous flow
or gas or from a demand valve
IMV and SIMV
Intermittent Mandatory Ventilation IMV
Indications
Facilitate transition from full ventilatory support to
partial support

Advantages
Maintains respiratory muscle strength by avoiding
muscle atrophy
Decreases mean airway pressure
Facilitates ventilator discontinuation weaning
IMV and SIMV
Intermittent Mandatory Ventilation IMV
Complications
When used for weaning, may be done too quickly
and cause muscle fatigue
Mechanical rate and spontaneous rate may
asynchronous causing stacking
May cause barotrauma or volutrauma
IMV and SIMV
Synchronized IMV
Operates in the same way as IMV except that
mandatory breaths are normally patient
triggered rather than time triggered (operator
set the volume or pressure target)

As in IMV, the patient can breathe spontaneously
through the ventilator circuit between mandatory
breaths
IMV and SIMV
Synchronized IMV
At a predetermined interval (respiratory rate),
which is set by the operator, the ventilator waits
for the patients next inspiratory effort

When the ventilator senses the effort, the
ventilator assists the patient by synchronously
delivering a mandatory breath

IMV and SIMV
Synchronized IMV
If the patient fails to initiate ventilation within a
predetermined interval, the ventilator provides a
mandatory breath at the end of the time period

IMV and SIMV
Synchronized IMV
Indications
Facilitate transition from full ventilatory support to
partial support

Advantages
Maintains respiratory muscle strength by avoiding
muscle atrophy
Decreases mean airway pressure
Facilitates ventilator discontinuation weaning
IMV and SIMV
Synchronized IMV
Complications
When used for weaning, may be done too quickly
and cause muscle fatigue
Spontaneous Modes
Three basic means of providing support for
continuous spontaneous breathing during
mechanical ventilation

Spontaneous breathing

CPAP

PSV Pressure Support Ventilation
Spontaneous Modes
Spontaneous breathing
Patients can breathe spontaneously through a
ventilator circuit; sometimes called T-Piece
Method because it mimics having the patient ET
tube connected to a Briggs adapter (T-piece)

Advantage
Ventilator can monitor the patients breathing and
activate an alarm if something undesirable occurs

Disadvantage
May increase patients WOB with older ventilators
Spontaneous Modes
CPAP
Ventilators can provide
CPAP for spontaneously
breathing patients
Helpful for improving
oxygenation in patients
with refractory hypoxemia
and a low FRC
CPAP setting is adjusted
to provide the best
oxygenation with the
lowest positive pressure
and the lowest FiO2

Positive airway pressure maintained
throughout respiratory cycle: during
inspiratory and expiratory phases
Can be administered via ETT or nasal prongs
Spontaneous
Modes
CPAP
Advantages
Ventilator can
monitor the
patients
breathing and
activate an alarm
if something
undesirable
occurs
Spontaneous Modes
PEEP (Positive End Expiratory Pressure)
According to its purest definition, the term PEEP
is defined as positive pressure at the end of
exhalation during either spontaneous breathing
or mechanical ventilation. However, use of the
term commonly implies that the patient is also
receiving mandatory breaths from a ventilator.
(Pilbeam)

PEEP becomes the baseline variable during
mechanical ventilation
Spontaneous Modes
PEEP
Helps prevent early airway closure and alveolar
collapse and the end of expiration by increasing
(and normalizing) the functional residual capacity
(FRC) of the lungs

Facilitates better oxygenation

NOTE: PEEP is intended to improve oxygenation, not to
provide ventilation, which is the movement of air into
the lungs followed by exhalation
Spontaneous Modes
Pressure Support Ventilation PSV
Patient triggered, pressure targeted, flow cycled
mode of ventilation

Requires a patient with a consistent spontaneous
respiratory pattern

The ventilator provides a constant pressure
during inspiration once it senses that the patient
has made an inspiratory effort
Spontaneous Modes
PSV
Spontaneous Modes
PSV
Indications
Spontaneously breathing patients who require
additional ventilatory support to help overcome
WOB, CL, Raw
Respiratory muscle weakness

Weaning (either by itself or in combination with
SIMV)
Spontaneous Modes
PSV
Advantages
Full to partial ventilatory support
Augments the patients spontaneous VT
Decreases the patients spontaneous respiratory
rate
Decreases patient WOB by overcoming the
resistance of the artificial airway, vent circuit and
demand valves
Allows patient control of TI, I, f and VT

Spontaneous Modes
PSV
Advantages
Set peak pressure
Prevents respiratory muscle atrophy
Facilitates weaning
Improves patient comfort and reduces need for
sedation
May be applied in any mode that allows
spontaneous breathing, e.g., VC-SIMV, PC-SIMV
Spontaneous Modes
PSV
Disadvantages
Requires consistent spontaneous ventilation
Patients in stand-alone mode should have back-
up ventilation
VT variable and dependant on lung characteristics
and synchrony
Low exhaled E
Fatigue and tachypnea if PS level is set too low
Spontaneous Modes
Flow Cycling During PSV
Flow cycling occurs when the
ventilator detects a decreasing flow,
which represents the end of
inspiration

This point is a percentage of peak
flow measured during inspiration
PB 7200 5 L/min
Bear 1000 25% of peak flow
Servo 300 5% of peak flow

No single flow-cycle percent is right
for all patients
Spontaneous Modes
Flow Cycling During PSV
Effect of changes in
termination flow

A: Low percentage (17%)

B: High percentage (57%)

Newer ventilators have an
adjustable flow cycle
criterion, which can range
from 1% - 80%, depending
on the ventilator
Spontaneous Modes
PSV during SIMV
Spontaneous breaths during SIMV can be
supported with PSV (reduces the WOB)
PCV SIMV with
PSV
Spontaneous Modes
PSV during SIMV
Spontaneous breaths during SIMV can be
supported with PSV
VC SIMV with PSV
Spontaneous Modes
PSV
NOTE: During pressure support ventilation (PSV),
inspiration ends if the inspiratory time (TI)
exceeds a certain value. This most often occurs
with a leak in the circuit. For example, a
deflated cuff causes a large leak. The flow
through the circuit might never drop to the flow
cycle criterion required by the ventilator.
Therefore, inspiratory flow, if not stopped would
continue indefinitely. For this reason, all
ventilators that provide pressure support also
have a maximum inspiratory time.
Spontaneous Modes
PSV
Setting the Level of Pressure Support
Goal: To provide ventilatory support
Spontaneous tidal volume is 10 12 mL/Kg of
ideal body weight
Maintain spontaneous respiratory rate
<25/min

Goal: To overcome system resistance (ET Tube,
circuit, etc.) in the spontaneous or IMV/SIMV mode
Set pressure at (PIP Pplateau) achieved in a
volume breath or at 5 10 cm H2O

Spontaneous Modes
PSV
Exercise: Using the PIP and the PPlateau from the pressure
waveform below, recommend a pressure support setting
for this patient (patient is in VC-SIMV mode)

35
25
Answer: 10 cm H2O
Spontaneous Modes
PSV - The results of your work
35 cm H2O
10 cm H2O
Spontaneous Modes
Bilevel Positive Airway Pressure (BiPAP)
An offshoot of PEEP/CPAP therapy
Most often used in NPPV
AKA
Bilevel CPAP
Bilevel PEEP
Bilevel Pressure Support
Bilevel Pressure Assist
Bilevel Positive Pressure
Bilevel Airway Pressure

Spontaneous Modes
Bilevel Positive Airway Pressure (BiPAP)
Commonly patient triggered but can be time
triggered, pressure targeted, flow or time cycled

The operator sets two pressure levels
IPAP (Inspiratory Positive Airway Pressure)
IPAP is always set higher than EPAP
Augments VT and improves ventilation

EPAP (Expiratory Positive Airway Pressure)
Prevents early airway closure and alveolar collapse at
the end of expiration by increasing (and normalizing)
the functional residual capacity (FRC) of the lungs
Facilitates better oxygenation
Spontaneous Modes
Bilevel Positive Airway Pressure (BiPAP)
The operator sets two pressure levels
IPAP
EPAP

NOTE: The pressure difference between IPAP and EPAP is pressure support









I. Power:
Plug into a grounded AC power with
correct voltage receptacle.
Secure the power cord properly.

Battery Back up:

Check the battery level before connecting.
Charging should be carried out regularly.
Remember it is for short term use.



Preferable to have centralised supply.
If cylinders used, should be full
Spare cylinders should be available.
Gas hoses should be in good condition.
Hoses not contaminated with grease or oil
(combustible)
Availability of compressors should be ensured.
Gases should remain dry and clean.

Properly trained personnel should only use.
Familiarising staff with operators manuel before
using on a patient.
(One manufacturers manual may not exactly
match with other brands).
Appropriate monitoring the functioning state of
the ventilator while in use.

Familiarizing staff with alarm system.
Do not place ventilators in a combustible or
explosive environment.
Do not use with flammable anaesthetic agents such
as nitrous oxide and ether.
Qualified personnel should undertake servicing.
Ventilator housing should not be opened while it is
still connected with power.
Follow the specifications mentioned in the service
manual.
Use replacement parts supplied by the
manufacturer only.
General servicing at regular intervals
should be done.
Run the prescribed tests and calibrations
before using the ventilator on a patient.
Ensure that the ventilators pass all the
tests before putting them in to clinical
use.
All ventilators are equipped with visual
and audible alarms which notify the user
problems.
Never ignore an alarm.
Never mute the alarm on regular basis.
Find out for yourself what alarm is on.
Check the patient.
Silence the alarm.
Depending upon the patients status and
nature of the alarm, act appropriately.
This includes disconnecting the ventilator
and connecting another means of ventilation
to patient Bains/ Ambu.




The use of an alarm monitoring system
does not give absolute assurance of
warning for every form of trouble that
may occur with the ventilator.
But hear the alarm and respond
See the problem and
Ask if you do not know what to do
Ensure Alarm knobs / switches are turned
on and functional.


Alarm Cause Shooting
Apnoea No breath was
delivered for the
operator set apnoea
time in spont, SIMV,
AC, CMV & NIV modes
Because spontaneous
Ventilation is too high
or patient effort is too
minimal
Trigger level set
improperly.
Check the patient-
Arouse if needed
Activate back up
facility if it was not
done already.
Consider switching
over to any mandatory
mode
Or go up on rate
Set trigger level
appropriately

Low SpO
2






Air / O
2

Blender
continuous
alarm

Delivery of O
2
:
FiO
2
, PEEP

High resistance
due to various
clinical reasons

Supply pressures
are inadequate.

Disconnect patient
from ventilator
Manually bag with
Bains and Ambu.



Insert the gas hose
fittings (air & O
2
)
correctly into the wall
outlets.
Ensure wall outlets
has adequate
pressure
High
Pressure
Alarm
The measured peak
inspiratory pressure
is great than set
level because of
Secretions in
airway
Partial block
(ETt)
Kinking of tube
Biting the tube
Water in the tube
Cuff herniation
Deep Rt. sided
intubation
Fighting the
ventilator



Suctioning, Irrigation
Release tubings
Bite block insertion
Empty the tubings and
water traps
Deflate & reinflate cuff
3-4 times
Reposition the ET tube
Reposition the patient
Re assurance
Sedation &
medication (pain)

Low pressure
or
Low min.Vent
Or
Low exhaled
volume or
Disconnection
The measured
PIP is lesser than
the set minimum
level because of
cuff leak.
Leak in the
circuit
Connections
may be loose
ET tube
displacement
Disconnection
Inadequate
flow

Evaluate cuff pressure
at regular intervals.
Reinflate if leak /
ruptured is noticed
change ET tube.
Check circuits,
junctions-
tighten or replace.
Check water traps
Check ET tube
placement. Position it
properly.
Reconnect ventilator.
Patient may require
higher flow.

High
pressure
alarm

Cough
Increased airway
resistance or
decreased
compliance
because of
Bronchospasm
Atelectasis
Fluid overload

Pneumothorax

Medication
Bronchodilators
Adjust the settings
V
T
& Rate
Adjust the settings
V
T
Rate, PEEP
(Peak pressure to be
monitored)


Immediate intervention
Auto Cycling




High Tidal
Volume
Leak & Improper
trigger setting



Patient trying to
take more volume of
air



Secure all
tubings tight
Set proper
trigger level

Increase flow
rate or
Increase tidal
volume
The transition process from
total ventilatory support
to spontaneous breathing.

This period may take many forms ranging from
abrupt withdrawal to gradual withdrawal from
ventilatory support.
Discontinuation of IPPV is achieved in
most patients without difficulty
up to 20% of patients experience difficulty
requires more gradual process so that they
can progressively assume spont. respiration
the cost of care, discontinue IPPV should
proceed as soon as possible
Inadequate respiratory drive
Inability of the lungs to carry
out gas exchange effectively
Psychological dependency
Inspiratory fatigue
Patients who fail attempts at weaning
constitute a unique problem in critical
care
It is necessary to understand the
mechanisms of ventilatory failure in
order to address weaning in this
population
Concept of Load exceeding
Capacity to breathe
Load on respiratory system
Capacity of respiratory system
Most patients fail the transition from
ventilator support to sustain spont.
breathing because of failure of the
respiratory muscle pump
They typically have a resp muscle
load the exceeds the resp
neuromuscular capacity
Need for increase ventilation
increased carbon dioxide
production
increased dead space ventilation
increased respiratory drive
Increased work of breathing
Nutrition and metabolic deficiencies: K, Mg, Ca,
Phosphate and thyroid hormone
Corticosteroids
Chronic renal failure
Systemic disceases; protein synthesis,
degradation, glycogen stores
Hypoxemia and hypercapnia
Central drive to breathe
Transmission of CNS signal via Phrenic
nerve
Impairment of resp muscles to generate
effective pressure gradients
Impairment of normal muscle force
generation








Definitions
Tolerated observations to monitor
Look at patient, do they look unsettled/tired/stressed?
Is respiratory rate below 35bpm & above 8bpm?
Are O
2
saturations above 90%? (or as appropriate for patient)
Are ABGs acceptable for the patient?
Is PaO
2
/ FiO
2
ratio >27.5kpc?
Is TV 5ml/kg?
Is patient cardiovasculary stable?
Is patient settled and showing no signs of fatigue?
Is respiratory rate/TV ratio <105 breaths/min (spontaneous rate for 1
min divided by the TV in Litres)

Signs of fatigue are:
Decreasing TV
Increasing respiratory rate
Changes in blood gases
Decreases in O
2
saturations
Tachycardic
ECG changes
Hypertension
Breathlessness
Use of accessory muscles
Changes in conscious levels
Sweating
Inform Anaesthetist and
discontinue weaning if
any changes noted.

Document: All changes on
ventilator and check
ventilator changes with
another nurse.



Peran Dan Fungsi Perawat
Peran Dan Fungsi Perawat

SETTINGS
O
2
Air

Power

Ventilator
Patient






circuit




Stabilize the ETT


Nebulisation
Tracheobronchial Hygiene:

Placement of tube: Chest movement
Auscultation
Post intubation X-ray

Cuff pressure: If insufficient
- Leak - Displacement of the tube, Aspiration
- high pressure - Tracheal stenosis

Desired Pressure - 20-30cm water
Humidification Filling water & adjusting temperature
appropriately :

If inadequate: secretions would become thicker and
lead to tube block

Medication:
Besides specific therapautic drugs the
following basic drugs are to be given.
Sedatives & paralysing agents if needed.
Analgesics
Diuretics to reduce circulating fluid and volume
overload
Reduce Gastric Acid: H2 blockers

Should be done on PRN basis
Ascultate and assess
View the chest X-ray
Determine the need and for effective
suctioning
Hyperoxygenation & ventilation
ambu/normal
Keep strict vigil on the cardiac monitor
pulse oximeter during and soon
after suctioning
If necessary carry out effective chest physio


Monitoring:

Continuous and Periodic monitoring of
Vital parameters such as temperature,SpO
2
, Pulse,
BP,ECG pattern, breath rate etc.

Ventilator settings: All settings should be
recorded as per the doctors order

Sensorium
Intake and output
Level of comfort
Arterial blood gases twice daily




It is advisable to put all the
patients on bronchodilators on
regular basis.

Nebulise as per the doctors order
Colour, consistency, and amount of the
sputum / secretions with each suctioning
should be observed.

Fever and other parameters have to closely
observed for any other infection. (central line,
etc)
Try and maintain a SpO
2
of > 90% and PaO
2
of
60 90 mmHg with minimum possible FiO
2

to prevent O
2
toxicity.

Especially for COPD patients :
Maintain SpO
2
of 85 90% and PaO
2

of 55 70 mmHg.

Enteral nutrition to support the patients
metabolic needs and defend against
infection.
Avoid high carbohydrate diet during weaning.

NG tube if necessary relieves gastric
distension and prevents aspiration.



Very common in critically ill patients
Send stools for occult blood and gastric juice
for pH estimation
Auscultate bowel movements
Sedation and antacids adequately.
Never keep alarm system muted
Never ignore even when you know the cause
for the alarm and may not be fatal

Place the patient in low or semi Fowlers
position to improve comfort and facilitate
respiration.

If conscious, explain the environment,
procedures, co-operation expected etc.
Use verbal & non verbal methods
Use paper & pen if necessary
Provide calling bell if necessary
Reassurance and support the patient during
the period of anxiety, frustration and
hopelessness
Document patients emotional response and
any signs of psychosis
Include family in the care


Co-operation with medical and nursing
interventions
Certain breathing techniques
The patient to recognize the importance of
breathing techniques.
Frequent assessment of consciousness level,
adequate rest etc. are necessary.






Multiply the tracheal tubes inner diameter by 2.
Then use the next smallest size catheter.

Example: 6mm ETT: 6 x 2 = 12; next
smallest catheter is 10 French

Example: 8mm ETT: 6 x 2 = 16; next
smallest catheter is 14 French



Hypoxemia - #1 complication
give oxygen before and after
catheter size
if the catheter is too big, there will be little or no air
entrained
Time suction no more that 15 secs.
Tissue trauma
May be able to prevent it . . .
catheter selection?
intermittent vs. continuous
a delicate touch
vacuum adjustment
Complications and Hazards of Suctioning
Cardiac arrhythmias
Vagal stimulation will cause
bradycardia
Hypoxemia can cause
PVCs
tachycardia
If these occur
STOP procedure and give oxygen
The nurse should explain the procedure to
the patient and prepare suction. The
patient should be sitting up at least 45
degrees.
Prior to extubating, the patient should be
suctioned both via the ETT and orally.
All fasteners holding the ETT should be
loosened.
A sterile suction catheter should be
inserted into the ETT and withdrawn as
the tube is removed.
The ETT should be removed in a steady,
quick motion as the patient will likely
cough and gag.
The patient should be asked to cough and
speak. Quite often, the patients first
request is for water because of a dry, sore
throat. Generally, you can immediately
swab the patients mouth with an oral
swab dipped in water.

Humidified oxygen
Respiratory exercises
Assessment and monitoring
Prepare for intubation