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Evaluation and

Management of Patients
With Hypoxemic Failure
BUDHI ANTARIKSA
Department of Pulmonology and Respiratory Medicine
Faculty of Medicine University of Indonesia
Persahabatan Hospital Jakarta

Objektif
Definisi dan klasifikasi gagal napas
Patofisiologi gagal napas
Manifestasi klinik
Manajemen gagal napas

TRANSPORT O2

Sistem Respirasi
Fungsi respirasi suplai adekuat O2 ke kapiler
pulmoner dan membuang CO2 ke alveoli
2 prinsip tujuan :
- mempertahankan PaO2 adekuat, dan
- mengatur PaCO2
mempertahankan keseimbangan asambasa
Keduanya diperlukan untuk metabolisme
jaringan berlangsung normal.

OKSIGENASI
UDARA BEBAS:

PiO2

21% x 760 = 160 mmHg

PiCO2 : 0.04 % x 760 = 0.3 mmHg


PiN2

ALVEOLUS

: 78.6 % x 760 = 597mmHg

PiH2O : 0.46 % x 760 = 3.5 mmHg

N2
PAN2:
573 mmHg

PROSES DIFUSI

PAO2:
104 mmHg

Pulmonary Artery

O2
PvO2:
40 mmHg

O2
CO2

H2O

PAH2O:
47 mmHg
PACO2:
40 mmHg

CO2

KAPILER PARU

Pulmonary Vein
PaO2

O2
CO2

PcCO2: 45
PcCO2: 40
PcO2:
100
mmHg
mmHg
mmHg

PAO2 PcO2

OKSIGENASI
UDARA BEBAS:

PiO2

21% x 760 = 160 mmHg

PiCO2 : 0.04 % x 760 = 0.3 mmHg


PiN2

ALVEOLUS

: 78.6 % x 760 = 597mmHg

PiH2O : 0.46 % x 760 = 3.5 mmHg

N2
PAN2:
573 mmHg

PROSES DIFUSI

PAO2:
100 mmHg

Pulmonary Artery

O2
PvO2:
40 mmHg

O2
CO2
PcCO2: 45
mmHg

H2O

PAH2O:
47 mmHg
PACO2:
40 mmHg

CO2

KAPILER PARU

Pulmonary Vein
PaO2
PcO2: 100 O2
mmHg

CO2
PcCO2: 40
mmHg

PAO2 PcO2

Fungsi Paru
Metabolik
Pertukaran gas
Keseimbangan asam-basa via eliminasi CO2
Endokrin
Produksi angiotensin-converting enzyme
Sekresi peptida vasoaktiv
Prostaglandin, bradikinin, 5-HT, dan lain-lain
Sintesis
Surfaktan, mukopolisakarida, kolagen
Imun
Produksi IgA dan makofag alveolar
Lain-lain
Membuang bekuan darah mikro dan mirobubbles
Penampung darah (500900 ml)

Definisi Gagal Napas


Terjadi jika pertukaran O2 dan CO2 tidak
adekuat saat proses metabolisme
hipoksemia, dengan atau tanpa hiperkarbia.
Diagnosis membutuhkan penilaian gas darah
arteri PaO2 dan PaCO2.
PaO2 <8 kPa (60 mmHg), atau PaCO2 >6.7 kPa
(50 mmHg) saat pasien istirahat (permukaan
laut).

Definisi dan Klasifikasi Gagal Napas


Gagal napas ketidakmampuan sistem respirasi
mempertahankan pertukaran gas normal dari
atmosfer sampai sel yang dibutuhkan oleh tubuh.
Peran sistem respirasi mempertahankan pO2,
pCO2, dan pH tetap normal
Respirasi normal memerlukan fungsi integrasi
beberapa komponen sistem respirasi.

Gangguan setiap komponen gangguan


pertukaran gas normal gagal napas akut.
Yearbook of Intensive Care and Emergency Medicine 2008

Incidence and Outcome of Acute Respiratory Failure

Yearbook of Intensive Care and Emergency Medicine 2008

Short term & longterm consequences of


hypoxemia

N Eng J Med 1995; 333: 710-4

Klasifikasi Patofisiologik Gagal Napas Akut

Yearbook of Intensive Care and Emergency Medicine 2008

Gagal Napas
Dapat berasal dari kelainan jalan napas,
alveoli, pembuluh darah pulmoner, sistem
saraf pusat atau perifer, otot-otot pernapasan
dan dinding dada.
Perbedaan tipe gagal napas diketahui dari
interpretasi PaO2, PaCO2, dan HCO3-

Penyebab Gagal Napas


Obstruksi jalan napas
Jalan napas atas
O stru ti e sleep apnea
Trau a
Ste e sJohnson syndrome
Angio-edema
Inhalasi benda asing
Epiglotitis akut
Jalan napas bawah
Penyakit paru obstruktif kronik
Asma
Bronkiektasis
Fibrosis kistik
Bro hiolitis obliterans

Penyebab Gagal Napas


Gangguan parenkim paru
Akut
Adult respiratory distress syndrome (ARDS)
P eu o ia
Edema paru akut
Emboli paru akut
A ute fibrosing alveolitis (HammanRich syndrome)
Se ere a ute respiratory sy dro e SAS
Kronik
Chro i fibrosing alveolitis (usual interstitial pneumonia,
desquamative interstitial pneumonitis)
Pneumokoniosis
Sarkoidosis

Penyebab Gagal Napas


Gangguan respiratory muscle pump
Neurologik
Brai ste disease
Penyakit motor neuron (amyotropic lateral sclerosis)
O er-sedasi
Poliomielitis (post-polio syndrome)
A ute post-infectious polyneuritis (GuillainBarr syndrome)
Ce tral sleep apnea
Cer i al ord trau a
Muskuloskeletal
Kifoskoliosis
Myasthe ia gra is
Mus ular dystrophy
Co ge ital yopathy
Trauma dinding dada

Acute and Chronic Causes of Respiratory Failure

Gagal Napas
Tipe I
proses gangguan transfer O2 di paru
hipoksemia (akut atau gagal napas hipoksemik)
Tipe II ventilasi tidak adekuat
retensi CO2 dengan hiperkarbia dan hipoksemia
(kronik, gagal napas ventilasi atau hiperkapnik)
Campuran
kombinasi tipe I dan tipe II (acute-on-chronic).

Patofisiologi Gagal Napas


Gagal oksigenasi (hipoksemia, tipe I)
Tekanan parsial inspirasi O2 rendah
Hipoventilasi alveolar
Gangguan difusi
Ketidak imbangan Ventilasi/Perfusi (V/Q)
Pirau (Right-to-left shunt)
Gagal ventilasi (hiperkapnia, tipe II)
Gangguan pusat pernapasan
Gangguan neuromuskular
Kelainan dinding dada
Gangguan jalan napas
Gangguan paru

Tipe Gagal Napas


Gagal Napas

Lung failure

Pump failure

Tipe 1 Gagal Napas


Hipoksemik

Tipe 2 Gagal Napas


Hiperkapnik

Patofisiologi Hipoksemia

Ketidakimbangan Ventilasi/Perfusi
Shunt
Penurunan difusi O2
Hipoventilasi alveolar
Ketinggian (high altitude)

Ventilasi/Perfusi (V/Q)

Keterbatasan Difusi

Tipe 1 Gagal Napas Hipoksemik


Ventilation-perfusion
mismatch

Anatomical
RL shunt
malformasi arteriovenous paru,
pneumonia

Low partial pressure


of inspired oxygen
ketinggian

Hypoxemia

PPOK, asma, emboli paru,


edema paru, fibrosis kistik,
bronkiektasis

Impaired
diffusion
diffuse parenchymal
lung disease

Alveolar
hypoventilation
overdosis opiat

Tipe 2 gagal napas hiperkapnik ketidak imbangan antara


pusat pernapasan, beban otot pernapasan dan kapasitas
otot pernapasan

HIGH LOAD
Resistive elastic
treshold

RESPIRATORY MUSCLE
PUMP FAILURE
Type 2 hypercapnic
respiratory failure

DRIVE FAILURE
Cortex brainstem

TRANSMISSION &
ACTION FAILURE
Spinal cord
Peripheral nerve
Neuromuscular junction
Respiratory muscles

Gagal Napas
Prosedur diagnostik

Riwayat penyakit dan pemeriksaan fisis


Analisis gas darah arteri
Foto toraks
CBC, kultur sputum/darah, elektrolit
EKG
Urinalisis
V/Q lung scan
Kateter arteri pulmoner (severe cases)

Manifestasi Gagal Napas


Perubahan status mental
Peningkatan work of breathing
Takipnea
Otot bantu napas, retraksi, napas paradoks
Pelepasan katekolamin
Takikardi, diaphoresis, hipertensi
Nilai gas darah arteri abnormal

Terapi
Melibatkan 2 tipe intervensi: suportive dan
spesifik
Suportive: stabilisasi situasi klinis melalui
perbaikan pertukaran gas (termasuk koreksi
abnormalitas gas darah dan asam basa)
Spesifik: penanggulangan abnormalitas
patofisiologi yang mendasari

Terapi suportive
Pada peningkatan Pa CO2: peningkatan eliminasi
CO2 (meningkatkan ventilasi alveolar) atau
menurunkan produksi metabolik CO2
(menurunkan demam, aktifitas otot skeletal
eksesif, diit rendah KH)

Terapi suportive
Gagal napas hiperkapnea hipoventilasi
penurunan Pa O2 terapi oksigen
Gagal napas nonhiperkapnea Pa O2 <, low
V/Q terapi oksigen
Shunting (ARDS) PEEP dengan/tanpa
ventilator

Terapi spesifik
Bergantung pada penyakit yang mendasari:
OD narkotik naloxone
Hipoventilasi alveolar primer stimulan pusat
pernapasan (progesterone)
Paralisis diafragma pacemaker diafragma
OSAS CPAP
Asma kortikosteroid + bronkodilator
ARDS atasi syok dan sepsis
PPOK/sistikfibrosis bronkodilator + AB

Tatalaksana
Pasien gagal napas akut harus sistematik
atau ABC Air ay, Breathi g, Cir ulatio )
Th/ high-flow O2 (15 liter/menit) via masker
dengan reservoir bag
Jika pasien tidak sadar dan responsif
perbaiki patensi jalan napas jaw thrust
manoevre atau gunakan jalan napas
orofaringeal.

Tatalaksana
Penting Th/ high-flow O2 harus selalu
diberikan kepada pasien dengan hipoksik.

Keadaan khusus high-flow O2 perburukan


pada pasien dengan retensi CO2 kronik yang
tergantung pada hipoksi untuk inisiasi pusat
pernapasan.

Algoritma Tatalaksana Gagal Napas

ABG, arterial blood gas


AC, anticoagulation
CXR, chest radiograph
H/P, history and physical examination
ICU, intensive care unit
NIPPV, noninvasive positive pressure
ventilation
PFT, pulmonary function test

Manajemen
Suplementasi Oxygen
Peningkatan FiO2
Match flow between delivery device
and inspiratory demand
High- vs. low-oxygen systems
High- vs. low-flow systems

Low-flow systems

Nasal cannulas
Provide 24-40% oxygen with flowrates up to 6 L/min in adults
(depending on ventilatory pattern)
Newborns and infants flows should be limited to a maximum of 2
L/min

Simple oxygen masks


Provide 35-50% oxygen at flowrates from 5-10 L/min
Flowrates should be maintained at 5 L/min or more in order to avoid
rebreathing exhaled CO2 that can be retained in the mask

Masks with reservoir bags (partial rebreathers and non-rebreathers)


Provide FIO2 of about 0.6 (depending on mask fit and ventilatory
variables) provided the flowrate is sufficient to keep the reservoir bag
inflated during inspiration.
Higher FIO2 is possible depending on mask fit and ventilatory variables

High-flow systems
Jet-mixing masks / Ventury masks
Can accurately deliver predetermined oxygen
concentration to the trachea up to 40%.
Jet-mixing masks rated at 50% or higher usually do not
deliver flowrates adequate to meet the inspiratory
flowrates of adults in respiratory distress

Aerosol masks, tracheostomy collars, T-tube adapters, and


face tents
Can be used with high-flow supplemental oxygen systems

Nasal Kanul
Nasal kanul inspiratory oxygen fraction
(FiO2) 24-40% aliran 1 5 L/min.
Rumus FiO2 = 20% + (4 oxygen litre flow).
FiO2 dipengaruhi frekuensi napas, volume
tidal dan patofisiologi.
The slower the inspiratory flow the higher the
FiO2

Nasal Kanul
100% oxygen delivered
Low flow
< 0,5 5,0 L/min
Low oxygen
FIO2 < 0,4 0,5

High Concentration Reservoir Mask

Simple Face Mask


Volume face mask 100 300 mL.
FiO2 40 60% pada 5 10 L/min.
FiO2 dipengaruhi frekuensi napas, volume tidal
dan patologi.
Indikasi pasien dengan iritasi hidung atau
epistaksis, bernapas dengan mulut
Face mask tidak nyaman, ganggu
komunikasi, batuk dan makan

Simple Face Mask

Aerosol Face Mask


100% O2 + large-bore tubing
Nebulizer/O2 blender
Flow matching
If mist disappears in inspiration,

air is entrained
Moderate-flow, variable FiO2 device

Reservoir Face Mask


Reservoir bag filled with
100% O2
High oxygen
High flow

Nonrebreathing face mask with reservoir


and one-way valve
Indikasi kebutuhan FiO2 >40%
FiO2 > 90% pada high flow settings.
Aliran O2 ke dalam reservoir 8 10 L/min
konsentrasi O2 tinggi
Its major drawback is that the mask must be tightly
sealed on the face, which is uncomfortable.
There is also a risk of CO2 retention

Nonrebreathing face mask with reservoir


and one-way valve

Reservoir cannulas
Reservoir cannulas improve the efficiency of
oxygen delivery.
Hence, patients may be well oxygenated at
lower flows.
Litre flows of =8 Lmin-1 have been reported to
adequately oxygenate patients with a high
flow requirement

Air Entrainment Masks (Venturi Mask)


A Venturi mask mixes oxygen with room air,
creating high-flow enriched oxygen of a
settable concentration.
It provides an accurate and constant FI,O2.
Typical FI,O2 delivery settings are 24, 28, 31,
35 and 40% oxygen.
The Venturi mask is often employed when the
clinician has a concern about CO2 retention

Air-Entrainment Face Mask


100% O2 + entrainment device
High flow
Variable oxygen
FIO2 0.240.5

Air Entrainment Masks (Venturi Mask)

Air Entrainment Masks (Venturi Mask)

Noninvasive ventilation (NIV) refers to the delivery of


mechanical ventilation to the lungs using techniques that
do not require an endotracheal airway.

Kesimpulan
Berbagai macam penyakit dapat menyebabkan gagal
napas.
Gagal napas dibagi menjadi gagal napas akut
(hipoksik) dan kronik (hiperkapnik)
Gambaran klinik dan patologik gagal napas
bervariasi.
Manajemen gagal napas tergantung penyakit dasar.
Terapi oksigen merupakan tatalaksana dasar gagal
napas.