Mechanical

Ven+la+on
FISIOLOGI PERNAFASAN
 VENTILASI PARU

PRESSURE DARI GAS BERBANDING

HUKUM BOYLE TERBALIK DGN VOL CONTAINER

TABRAKAN PARTIKEL2 GAS

KE DINDING KONTAINER
MENIMBULKAN PRESSURE

PERUBAHAN VOLUME
VOLUME VOLUME
MENYEBABKAN
PERUBAHAN PRESSURE PRESSURE PRESSURE
 MEKANISME BERNAFAS
INSPIRASI EKSPIRASI

KONTRAKSI OTOT INTERKOSTALIS EKSTERNA RELAKSASI OTOT INTERKOSTALIS

IGA TERANGKAT EKSTERNA IGA KE POSISI SEMULA

KONTRAKSI DIAFRAGMA DIAFRAGMA RELAKSASI DIAFRAGMA DIAFRAGMA

BERGERAK INFERIOR BERGERAK KE POSISI SEMULA

INSERT

VOLUME VOLUME
INTRATORAK PRESSURE
PRESSURE
 VENTILASI PARU
INSPIRASI PERUBAHAN TEKANAN DALAM
PLEURA (INTRAPLEURAL PRESSURE) INTRAPULMONARY
PRESSURE

VOLUME PARU INTRAPLEURAL

MENJADI LEBIH PRESSURE 762
BESAR
1 761

0 760
-1 759
-2 758
-3 757
-4 INSPIRASI 756
-5 755
Iga -6 754
terangkat
-7 753

PARU TIDAL
VOLUME
0.5
TEKANAN 0
KONTRAKSI INSPIRASI EKSPIRASI
PLEURA TURUN
LEBIH NEGATIF DINDING
5 DETIK
DADA
 VENTILASI PARU

AIRWAY COMPLIANCE
RESISTANCE (RAW) (COMPL)

RAW
AIRWAY

CL
LUNG
AIRWAY RESISTANCE (RAW)

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 >>) sesak
AIRWAY RESISTANCE
(RAW)
BRONKUS
NORMAL

PRESSURE
FLOW =
RESISTANCE
AIRWAY RESISTANCE
(RAW) BRONKOKONSTRIKSI:
HISTAMIN

PRESSURE
FLOW =

RESISTANCE

OBSTRUKSI:
MUKUS/SEKRET
AIRWAY RESISTANCE
(RAW)

PRESSURE BRONKODILATASI:
EPINEFRIN
FLOW = AMINOFILIN
RESISTANCE BETA 2 AGONIS
COMPLIANCE (COMPL)

BALON

Kaku Elastis

LOW HIGH
COMPLIANCE COMPLIANCE
COMPLIANCE (COMPL)

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 hanya dgn pressure yg
kecil tidal volume yg masuk besar
SHUNT DAN DEAD SPACE
 Hubungan Ventilasi (V) dan Perfusi (Q)

TRAKEA ANATOMICAL
DEAD SPACE

PHYSIOLOGICAL
DEAD SPACE
V/Q =
KAPILER ALVEOLAR
PARU DEAD SPACE MECHANICAL
V/Q > 1 DEAD SPACE:
TUBE
NORMAL CONNECTOR
V/Q = 1
ET CO2
BREATHING
CIRCUIT
V/Q < 1
VENOUS ADMIXTURE
(SHUNT)
V/Q = 0
KOMPONEN VENTILATOR
 NEGATIVE PRESSURE VENTILATOR

1. MEMASUKKAN UDARA KE DALAM PARU DENGAN CARA

MEMBUAT TEKANAN SEKELILING DADA NEGATIF
2. DAHULU DIGUNAKAN PADA PASIEN2 POLIO, SAAT INI
DIGUNAKAN PADA PASIEN2 YG MENDERITA PENYAKIT
NEUROMUSKULAR DGN FUNGSI PARU NORMAL
3. IRON LUNG MENARIK RONGGA TORAKS SEHINGGA
UDARA MASUK KE PARU.
4. AKSES KE PASIEN TERBATAS
5. HARUS CUKUP MENGATASI RESISTENSI DAN COMPLIANCE
PASIEN
EARLY VENTILATOR
 POSITIVE PRESSURE VENTILATOR
(PPV)

1. MEMBERIKAN TEKANAN POSITIF KE DALAM PARU PASIEN

2. BANYAK DIGUNAKAN SAAT INI
3. UDARA MENGALIR BERDASARKAN PERBEDAAN TEKANAN
DARI TEKANAN TINGGI KE TEKANAN RENDAH
4. HARUS DAPAT MENGATASI RESISTENSI DAN COMPLIANCE
PARU DAN DINDING DADA
5. TEKANAN DALAM RONGGA TORAK POSITIF SAAT INSPIRASI
YG BERIMPLIKASI MENGGANGGU VENOUS RETURN KE
JANTUNG, MENINGKATKAN RESITENSI PEMBULUH DARAH
PARU, DAN MENURUNKAN CARDIAC OUTPUT (HEART-LUNG
INTERACTION)
6. SANGAT TIDAK FISIOLOGIS
 PERBEDAAN ANTARA NAFAS SPONTAN DAN NAFAS
VENTILASI MEKANIK

PRESSURE Inspirasi = Tekanan positif

INSPIRASI EKSPIRASI
Ekspirasi = Tekanan > negatif

TIME
0
-2 Intrapleural pressure

Ekspirasi = Tekanan Positif

Inspirasi = Tekanan negatif

Principles of
Mechanical Ventilation
The Basics
Goals of Mechanical Ventilation

Ventilation Oxygenation

Elimination Enhance
of CO2 O2
diffusion
 Principles (1): Ventilation
The goal of ventilation is to facilitate CO2 release and maintain normal PaCO2

Minute ventilation (VE)

Total amount of gas exhaled/min.
VE = (RR) x (TV)
VE comprised of 2 factors
VA = alveolar ventilation
VD = dead space ventilation
VD/VT = 0.33
V E regulated by brain stem,
responding to pH and PaCO2
Ventilation in context of ICU
Increased CO2 production V/Q Matching. Zone 1 demonstrates dead-space ventilation
(ventilation without perfusion). Zone 2 demonstrates normal perfusion.
Zone 3 demonstrates shunting (perfusion without ventilation).
fever, sepsis, injury, overfeeding
Increased VD
atelectasis, lung injury, ARDS,
pulmonary embolism
Adjustments: RR and TV
 Vent settings to improve <ventilation>
RR and TV are adjusted to maintain VE and PaCO2
Respiratory rate I:E ratio (IRV)
Max RR at 35 breaths/min Increasing inspiration time will
Efficiency of ventilation decreases increase TV, but may lead to
with increasing RR auto-PEEP
Decreased time for alveolar emptying PIP
TV Elevated PIP suggests need for
switch from volume-cycled to
Goal of 6-8 ml/kg
pressure-cycled mode
Risk of volutrauma
Maintained at <40cm H2O to
Other means to decrease PaCO2 minimize barotrauma
Reduce muscular activity/seizures Plateau pressures
Minimizing exogenous carb load Pressure measured at the end
Controlling hypermetabolic states of inspiratory phase
Permissive hypercapnea Maintained at <30-35cm H2O to
minimize barotrauma
Preferable to dangerously high RR
and TV, as long as pH > 7.15
 Principles (2): Oxygenation
The primary goal of oxygenation is to maximize O2 delivery to blood (PaO2)

Alveolar-arterial O2 gradient
(PAO2 PaO2)
Equilibrium between oxygen in
blood and oxygen in alveoli
A-a gradient measures efficiency
of oxygenation
PaO2 partially depends on
ventilation but more on V/Q
matching
Oxygenation in context of ICU
V/Q mismatching V/Q Matching. Zone 1 demonstrates dead-space ventilation
(ventilation without perfusion). Zone 2 demonstrates normal perfusion.
Patient position (supine) Zone 3 demonstrates shunting (perfusion without ventilation).

Airway pressure, pulmonary

parenchymal disease, small-airway
disease
Adjustments: FiO2 and PEEP
 Vent settings to improve <oxygenation>
PEEP and FiO2 are adjusted in tandem

FIO2
Simplest maneuver to quickly increase PaO2
Long-term toxicity at >60%
Free radical damage
Inadequate oxygenation despite 100% FiO2
usually due to pulmonary shunting
Collapse Atelectasis
Pus-filled alveoli Pneumonia
Water/Protein ARDS
Water CHF
Blood - Hemorrhage
 Vent settings to improve <oxygenation>
PEEP and FiO2 are adjusted in tandem

PEEP
Increases FRC
Prevents progressive atelectasis and
intrapulmonary shunting
Prevents repetitive opening/closing (injury)
Recruits collapsed alveoli and improves
V/Q matching
Resolves intrapulmonary shunting
Improves compliance
Enables maintenance of adequate PaO2
at a safe FiO2 level
Disadvantages
Increases intrathoracic pressure (may
require pulmonary a. catheter)
May lead to ARDS
Rupture: PTX, pulmonary edema Oxygen delivery (DO2), not PaO2, should be
used to assess optimal PEEP.
1. The Trigger: sinyal untuk membuka katup inspirasi,
sehingga udara dapat mengalir ke paru
PRINSIP KERJA VENTILASI
pasien;
2. The Limit: MEKANIK
faktor yang membatasi banyaknya
Kapadia,
udara yang [Postgrad
mengalir keMed J 1998
paru 74 330-5].
pasien;
3. T h e C y c l i=Three
n g : s i n ybasic
a l u n tterm
u k m e=nghentikan
proses inspirasi bersamaan dengan pembukaan
katup ekspirasi.
 KLASIFIKASI VENTILASI MEKANIK
INITIATION / TRIGER:
Berdasarkan waktu (Control )
Berdasarkan trigger/upaya
nafas (Assisted)
TARGET / LIMITED:
Berdasarkan volume
Berdasarkan pressure

PRESSURE
CYCLED
perubahan dari inspirasi ekspirasi:
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
Perbedaan Volume vs. Pressure target

Volume Ventilation Pressure Ventilation:

Tidal volume yang Tidal volume berubah-ubah
dihantarkan konstan tergantung kondisi paru
Inspiratory pressure Inspiratory pressure konstan
berubah-ubah tergantung
kondisi paru Inspiratory flow berubah-ubah
Inspiratory flow konstan Inspiratory time ditentukan
Inspiratory time dengan setting oleh dokter/
ditentukan dengan perawat
setting flow dan tidal
volume
CYCLED = END OF EXPIRATION

VOLUME CYCLED
Berdasarkan setting volume sebelumnya

TIME CYCLED
Berdasarkan setting waktu sebelumnya

FLOW CYCLED
Berdasarkan penurunan peak flow 25%
(manufactured)
Principles of Mechanical Ventilation

PEEP

ET tube Alveoli
Ventilator Tubing
Major Airways
 Principles of Mechanical Ventilation

Positive pressure ventilation involves delivering a

mechanically generated breath to get O2 in and CO2 out.

Gas is pumped in during inspiration (Ti) and the patient

passively expires during expiration (Te).

The sum of Ti and Te is the respiratory cycle or breath.

 Principles of Mechanical Ventilation

In the fully ventilated patient, positive pressure breaths

are delivered either as preset volume or pressure
continuous mandatory breaths (CMV) breaths.

The mechanical ventilator triggers the breath and

switches from inspiration to expiration when the preset
volume, pressure (or time) is achieved/delivered.

During CMV the patient takes no spontaneous breaths.

CMV is usually used in theatre and in very unwell ICU

patients.
 Principles of Mechanical Ventilation

Mandatory breaths are delivered during inspiration, to

generate a tidal volume (Vt), at a set rate (f), the quotient
of which is the minute volume (MV).

Minute Volume = Tidal Volume x frequency

In volume control ventilation, an inspiratory flow rate is

also set.

The ratio of the time spent in inspiration:expiration (I:E

ratio) is usually 1:2.
 Principles of Mechanical Ventilation

Volume Control Breath Pressure Control Breath

Pressure
Flow

Ti Te Ti Te
 Principles of Mechanical Ventilation

Mechanically ventilated patients usually receive positive

end-expiratory pressure (PEEP), to overcome the loss of
physiological PEEP provided by the larynx and vocal
cords.

PEEP is delivered throughout the respiratory cycle and

is synonymous to CPAP, but in the intubated patient.

Standard PEEP setting is 5 cm H20.

Sedation is often required to prevent ventilator-patient

asynchrony.
Interpretation of curve
patterns
 P-V LOOP
EKSPIRASI

Vol
LOW HIGH
NORMAL COMPLIANCE COMPLIANCE
500 500 500

250 250 250

0 15 30 15 30 15 30
PEEP 5
INSPIRASI

NAFAS
SPONTAN
 Peak
pressure

PRESSURE Paw PRESSURE Paw

Ppeak Ppeak

Plateau
pressure Pplateau

0 0
TIME TIME

Perubahan resistensi Perubahan compliance

Resistensi meningkat: Compliance menurun :
peak pressure meningkat plateau dan peak pressure naik
Resistensi menurun: Compliance meningkat :
peak pressure turun peak dan plateau pressure turun
 Ventilator management algorithim
Modified from Sena et al, ACS Surgery:
Principles and Practice (2005). Initial intubation
FiO2 = 50% RR = 12 15
PEEP = 5 VT = 6-8 ml/kg

SaO2 < 90% SaO2 > 90%

SaO2 < 90% SaO2 > 90%

Increase FiO2 (keep SaO2>90%) No injury Adjust RR to maintain PaCO2 = 40 Pass SBT
Increase PEEP to max 20 Reduce FiO2 < 50% as tolerated Extubate
Identify possible acute lung injury Reduce PEEP < 8 as tolerated Airway stable
Identify respiratory failure causes Assess criteria for SBT daily

Acute lung injury Fail SBT

Airway stable

Acute lung injury Persistently fail SBT

Low TV (lung-protective) settings Consider tracheostomy Pass SBT
Reduce TV to 6 ml/kg Resume daily SBTs with CPAP or
Increase RR up to 35 to keep tracheostomy collar
pH > 7.2, PaCO2 < 50
Adjust PEEP to keep FiO2 < 60% Intubated > 2 wks

SaO2 < 90% SaO2 > 90%

Prolonged ventilator
SaO2 < 90% SaO2 > 90% dependence
Pass SBT
Dx/Tx associated conditions Continue lung-protective Consider PSV wean (gradual
(PTX, hemothorax, hydrothorax) ventilation until: reduction of pressure support)
Consider adjunct measures PaO2/FiO2 > 300 Consider gradual increases in SBT
(prone positioning, HFOV, IRV) Criteria met for SBT duration until endurance improves