DASAR VENTILASI MEKANIK

Zulkimaulub Ritonga, SpAn

RSUD M Yunus
BENGKULU

Objectives
Describe types of breaths and modes
of mechanical ventilation
Describe interactions between
ventilatory parameters and
modifications needed to avoid harmful
effects

Early ventilators

Ventilator ~ ventilasi
Ventilasi = keluar masuknya udara dari atmosfer ke alveolus
Ventilator = menghantarkan (delivery) udara
udara/gas
/gas TEKANAN
POSITIF ke dalam paru
Ventilasi semenit = TV x RR (frekuensi
(frekuensi nafas)
nafas )
TV

= 5-7 cc/kgBB
cc/ kgBB

RR = 10 12 kali/menit
kali/ menit

Compliance = Pengukuran dari elastisitas paru dan dinding

dada
Nilai compliance mengekspresikan adanya perubahan volume
akibat perubahan dari tekanan (pressure)
Compliance rendah = Stiff lung - edema paru
paru,, efusi pleura,
obstruksi,, distensi abdomen dan pneumotoraks
obstruksi
Compliance tinggi = penurunan elastisitas resistensi pada inspirasi
dan penurunan kemampuan mengeluarkan udara waktu ekspirasi
(COPD)

Kriteria tradisional untuk bantuan ventilasi mekanik

PARAMETER

INDIKASI VENTILASI

Mekanik (RR)

> 35x/m

TV (cc/kg)

<5

Oksigenasi (PaO2mmHg)

<60 dg FiO2 0,6

P(A-aDO2) mmHg

> 350

Ventilasi (PaCO2mmHg)

> 60

NORMAL RANGE
10-20x/m
5-7
75-100 (air)
25-65(FiO2 1.0)
35-45

TUJUAN KLINIS / INDIKASI PEMAKAIAN

VENTILASI MEKANIK
GAGAL NAFAS HIPOKSEMIK:
Reverse hypoxemia dgn pemberian PEEP dan konsentrasi O2
tinggi (ARDS,edema paru atau pneumonia akut)
GAGAL NAFAS VENTILASI:
Reverse acute respiratory acidosis
- Koma : trauma kepala, encefalitis, overdosis, CPR
- Trauma med spinalis, polio, motor neuron disease
- Polineuropati, miastenia gravis
- Anesthesia (relaksan u/operasi, tetanus, epilepsi)
STABILISASI DINDING DADA:
Flail chest
MENCEGAH ATAU MENGOBATI ATELEKTASIS

TUJUAN FISIOLOGIS
MEMPERBAIKI VENTILASI ALVEOLAR
MEMPERBAIKI OKSIGENASI ALVEOLAR
(FiO2, FRC,V'A)
MEMBERIKAN PUMP SUPPORT ( ME
WOB)
Consensus conference on mechanical ventilation, Int Care Med 1994,
20:64-79

Indications for
Mechanical Ventilation
Ventilation abnormalities
Respiratory muscle dysfunction
Respiratory muscle fatigue
Chest wall abnormalities
Neuromuscular disease

Decreased ventilatory drive

Increased airway resistance and/or
obstruction

Indications for
Mechanical Ventilation
Oxygenation abnormalities
Refractory hypoxemia
Need for positive endexpiratory pressure (PEEP)
Excessive work of breathing

Types of Ventilator Breaths

Volume-cycled breath
Volume breath
Preset tidal volume

Time-cycled breath
Pressure control breath
Constant pressure for preset time

Flow-cycled breath
Pressure support breath
Constant pressure during inspiration

Modes of Mechanical Ventilation

Consider trial of NPPV
Determine patient needs
Goals of mechanical ventilation
Adequate ventilation and oxygenation
Decreased work of breathing
Patient comfort and synchrony

Modes of Mechanical Ventilation

Point of Reference:
Spontaneous Ventilation

Continuous Positive Airway

Pressure (CPAP)
No machine breaths delivered
Allows spontaneous breathing at
elevated baseline pressure
Patient controls rate and tidal volume

Assist-Control Ventilation
Volume or time-cycled breaths + minimal ventilator
rate
Additional breaths delivered with inspiratory effort
Advantages: reduced work of breathing; allows
patient to modify minute ventilation
Disadvantages: potential adverse hemodynamic
effects or inappropriate hyperventilation

Pressure-Support Ventilation
Pressure assist during spontaneous
inspiration with flow-cycled breath
Pressure assist continues until inspiratory
effort decreases
Delivered tidal volume dependent on
inspiratory effort and
resistance/compliance of lung/thorax

Pressure-Support Ventilation
Potential advantages
Patient comfort
Decreased work of breathing
May enhance patient-ventilator synchrony
Used with SIMV to support spontaneous breaths

Pressure-Support Ventilation
Potential disadvantages
Variable tidal volume if pulmonary
resistance/compliance changes rapidly
If sole mode of ventilation, apnea alarm
mode may be only backup
Gas leak from circuit may interfere with
cycling

Synchronized Intermittent
Mandatory Ventilation (SIMV)
Volume or time-cycled breaths at a preset
rate
Additional spontaneous breaths at tidal
volume and rate determined by patient
Used with pressure support

Synchronized Intermittent
Mandatory Ventilation (SIMV)
Potential advantages
More comfortable for some patients
Less hemodynamic effects

Potential disadvantages
Increased work of breathing

Controlled Mechanical Ventilation

Preset rate with volume or time-cycled breaths

No patient interaction with ventilator
Advantages: rests muscles of respiration
Disadvantages: requires sedation/neuromuscular blockade, potential adverse
hemodynamic effects

Inspiratory Plateau Pressure (IPP)

Airway pressure measured at end of inspiration with
no gas flow present
Estimates alveolar pressure at end-inspiration
Indirect indicator of alveolar distension
PIP
Plateau pressure

Inspiration

Expiration

Peak pressure

Plateau pressure

Inspiratory Plateau Pressure (IPP)

High inspiratory plateau
pressure
Barotrauma
Volutrauma
Decreased cardiac output

Methods to decrease IPP

Decrease PEEP
Decrease tidal volume

Inspiratory Time: Expiratory Time

Relationship (I:E ratio)
Spontaneous breathing I:E = 1:2
Inspiratory time determinants with volume
breaths
Tidal volume
Gas flow rate
Respiratory rate
Inspiratory pause

Expiratory time passively determined

I:E Ratio during Mechanical Ventilation

Expiratory time too short for
exhalation
Breath stacking
Auto-PEEP

Reduce auto-PEEP by shortening

inspiratory time
Decrease respiratory rate
Decrease tidal volume
Increase gas flow rate

Permissive Hypercapnia
Acceptance of an elevated PaCO22, e.g.,
lower tidal volume to reduce peak airway
pressure
Contraindicated with increased
intracranial pressure
Consider in severe asthma and ARDS
Critical care consultation advised

Auto-PEEP

Can be measured on some ventilators

Increases peak, plateau, and mean
airway pressures
Potential harmful physiologic effects

Auto-PEEP
Can be measured on some ventilators
Increases peak, plateau, and mean
airway pressures
Potential harmful physiologic effects

Pediatric Considerations
Infants (< 5 kg)
Time-cycled, pressure-limited ventilation
Peak inspiratory pressure initiated
at 1820 cm H22O
Adjust to adequate chest movement or
exhaled tidal volume ~8 mL/kg
Low level of PEEP (24 cm H22O) to prevent
alveolar collapse

Pediatric Considerations
Children
SIMV mode
Tidal volume 8-10 mL/kg
Flow rate adjusted to yield desired
inspiratory time

Infants 0.50.6 secs

Toddlers 0.6-0.8 secs
Older 0.81.0 secs

Rate <1820 breaths/min

PEEP 24 cm H22O