Kemenristek/BRIN

Jakarta - August 2020

Dasar-dasar ventilasi mekanik

Rudyanto Sedono

ICU Department of Anesthesiology

Faculty of Medicine Universitas Indonesia
Cipto Mangunkusumo Hospital
Jakarta
 SISTIM RESPIRASI

MEMENUHI KEBUTUHAN
METABOLISME SEL AKAN O2 DAN
MENGELUARKAN CO2 SEBAGAI SISA
METABOLISME SEL
Oxygen transport
 STRUKTUR ANATOMI
Trakea
CABANG BRONKUS
Bronkus
Dari lubang hidung sampai primer
bronkiolus terminalis disebut Bronkus
area konduksi (penghantar), sekunder
sedangkan dari bronkiolus sampai
alveoli disebut area respirasi Bronkus
(tempat pertukaran gas) tersier

Zona konduksi
Dari trakea sampai
bronkiolus banyak Bronkiolus
mengandung supporting
cartilage (tlg rawan) yg
berfungsi menjaga agar Bronkiolus
jalan nafas tetap terminalis
terbuka
Dari bronkiolus sampai br. Bronkiolus
Zona respirasi

Terminalis lebih banyak respiratori

mengandung otot polos u/
regulasi aliran udara
Saccus
alveolii
Guyton and Hall. Textbook of Medical Physiology. 13th ed. 2016
 Fick’s law for gas diffusion

C x A x ( P1 - P2 )
CO2 solubility 20x O2 O2
T
P2
Area
CO2 Solubility
C=
P1 MW

Thick
ness
 VENTILASI PARU
PROSES MEKANIK, KELUAR
MASUKNYA UDARA DARI LUAR KE
DALAM PARU DAN SEBALIKNYA à
YAITU BERNAFAS

EKSTERNA
PERTUKARAN GAS
TERJADI ANTARA UDARA DALAM ALVEOLUS
DENGAN DARAH DALAM KAPILER,
PROSESNYA DISEBUT DIFUSI
PROSES
RESPIRASI PERTUKARAN GAS
PERTUKARAN GAS ANTARA DARAH DENGAN
SEL JARINGAN/TISUE

INTERNA

UTILISASI O2
PEMAKAIAN OKSIGEN DALAM SEL PADA
REAKSI PELEPASAN ENERGI
Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016
 VENTILASI PARU

DEFINISI

• Ventilasi: proses keluar masuknya udara (gas)

dari dan ke dalam paru.
• Tidal Volume (VT): jumlah gas ekspirasi per
kali nafas – biasanya 500 ml (5-8 ml/kgBB)
• Minute Volume (VE):

RR X TIDAL VOLUME
 Terminologi dasar pada ventilasi mekanik

Satu siklus nafas terdiri dari inspirasi dan ekspirasi

I:E rasio adalah perbandingan waktu inspirasi dengan waktu ekspirasi
pada satu siklus nafas
FiO2 :
Tekanan parsial oksigen inspirasi yang diberikan (21% – 100%)
Volume tidal (VT):
Jumlah gas/ udara yang masuk pada saat indpirasi dalam satuan ml/kg BB

Frekuensi pernafasan (f) :

Jumlah siklus nafas yang diberikan atau dilakukan dalam satu menit

Flow rate :
Kecepatan aliran udara atau gas yang dihantarkan dalam satu menit

Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016

A pressure and time profile during volume-targeted
constant flow mechanical ventilation
chapter 1: physiology

I EIP

End-inspirator

Peak inspiratory pressure, Ppeak

Initial plateau pressure, Pplat-i

Pressure

Plateau pressure, Pplat

End-expiratory

Time Figure 1.8

during pos
Figure 1.7 A pressure and time profile during volume-targeted
Core Topics in Mechanical Ventilation, ed. Iain Mackenzie. hysteresis.
constant flow mechanical ventilation.
Cambridge University Press 2008;1-20
During insp
 Inspiratory and expiratory volume/pressure loop
er 1: physiology of ventilation and g as exchange

End-inspiratory lung volume

Inspiration
pressure, Ppeak Expiration

essure, Pplat-i
Volume (ml) Hysteresis
Pplat

End-expiratory lung volume

Pressure (cm water)

Figure 1.8 Inspiratory and expiratory volume/pressure loop

during positive pressure inflation showing the phenomenon of
e-targeted
hysteresis. Core Topics in Mechanical Ventilation, ed. Iain Mackenzie.
Cambridge University Press 2008;1-20
During inspiration (blue) of the lung, both pressure (x-axis)
iance is
Bila seorang pola ventilasi atau bernafas 10 kali per
menit dengan volume tidal 500 ml dan I:E = 1:2, maka

Satu siklus nafas adalah 6o detik : 10 = 6 detik

Waktu inspirasi adalah (1: 3) x 6 detik = 2 detik
Waktu ekspirasi adalah (2 : 3) x 6 detik = 4 detik
Volume tidal (500 ml) masuk pada saat inspirasi yaitu 2 detik
Flow rate pernafasan orang tersebut adalah (60 detik : 2 detik) x
500 ml = 15.000 ml atau 15 liter
Peak Inspiratory Pressure terjadi karena volume tidal (500 ml)
masuk dalam waktu 2 detik

Sedono, 2020
Bila seorang tersebut pola ventilasi atau nafas berubah
menjadi 20 kali per menit dengan volume tidal tetap
500 ml dan I:E = 1:2, maka

Satu siklus nafas adalah 6o detik : 20 = 3 detik

Waktu inspirasi adalah (1: 3) x 3 detik = 1 detik
Waktu ekspirasi adalah (2 : 3) x 3 detik = 2 detik
Volume tidal (500 ml) masuk pada saat inspirasi yaitu 1 detik
Flow rate pernafasan orang tersebut menjadi (60 detik : 1 detik)
x 500 ml = 30.000 ml atau 30 liter
Peak Inspiratory Pressure terjadi karena volume tidal (500 ml)
masuk dalam waktu 1 detik, sehingga lebih tinggi dari kasus
pertama

Sedono, 2020
 Cycling Between the I and E Phase
Time Cycling
In time cycling, the change from I to E occurs after a fixed time and is not
influenced by the state of the patient’s lungs. This is the most common method
of cycling used in modern ventilators, both portable and hospital devices. Time
cycling is associated with preset volume in the case of many portable gas –
powered ventilators.

Volume Cycling
In volume cycling, the ventilator cycles between I and E when a predetermined
Vt has been delivered. The duration of the I phase is determined by the flow
rate of gas during the I phase.

Pressure Cycling
In pressure cycling, the change from the I to E phases occurs when a preset
pressure is reached. The time taken to reach this pressure is determined by the
lung mechanics. Therefore the time taken to reach a preset pressure and
therefore the duration of the I phase is much shorter when the airway
resistance is high.

Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016

A. Inspiration is pressure-targeted and time-cycled.
B. Flow is targeted, but volume is not, and inspiration is volume-cycled.
C. Both volume and flow are targeted, and inspiration is time-cycled

Tobin. Principles and practice of mechanical ventilation, 3rd ed, 2015

Early ventilators
 Jenis ventilator

Non invasif Invasif

CPAP non invasif

HFNC
Endotracheal tube
 with the higher PEEP. This
Table 4. Monitoring that adjusting settings may r
failure: Noninvasive ven- of NIV
Monitoring of noninvasive ventilation
ancing of beneficial and adve
respiratory failurea for acute respiratory failure
come up with the best comb
Subjective given patient.
Mask comfort Monitoring of NIV. To as
Tolerance of ventilator settings
Respiratory distress cess of NIV, close monitori
Physical findings sary, especially during the i
e "11b Respiratory rate riod (Table 4). Favorable
” or “tolerance” Other vital signs responses—including toler
Accessory muscle use
5 breaths/minb Abdominal paradox
mask and air pressure and
failure Ventilator parameters respiratory distress and eff
Air leaking portant to establish early.
Adequacy of pressure support should be sought and minim
Adequacy of PEEP exchange should be stabili
"175 for ARDS) after 1 Tidal volume (5–7 mL/kg)
Patient-ventilator synchrony proved.
Gas exchange The location of NIV del
Continuous oximetry (until stable) important to assure adequ
ABGs, baseline and 1–2 hrs, then as indicated ing. Most studies have m
Location
Usually ICU or respiratory care unit to start
tients in ICUs or respirator
structive pulmonary dis-
General ward may be OK if patient stable units, but some have report
e Physiology and Chronic
ALI, acute lung injury; Depends on monitoring needs of patients and application of NIV on gen
y distress syndrome; SAPS monitoring capabilities of unit wards (59, 60). Monitoring s
ysiology Score II. lored to the acuity of illness.
PEEP, positive end-expiratory pressure;
te from Ambrosino Thorax Hill. Crit Care Med becomes unstable within
2007; 35:2402–2407
ABGs, arterial blood gases; ICU, intensive care
Antonelli ICM 2001, An- mask removal, then close m
Bag mask ventilation
A low cost mechanical ventilation for covid patient
Basic Principles of Ventilator Design Pneumatic Based

Tobin. Principles and practice of mechanical ventilation, 3rd ed, 2015

 Use of mechanical ventilation
Patient “mode of ventilation”
Ventilator “mode of ventilation”

Patient-ventilator asynchrony

Dangerous, Harmful, Unsafe, Hazardous etc

Sedono, 2020
 Trigger sensitivity

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
 Pressure trigger
Upaya nafas pasien dimulai saat terjadi kontraksi otot diafragma
Upaya nafas ini akan menurunkan tekanan (pressure) di dalam
sirkuit ventilator (tubing)
Ketika pressure turun mencapai batas yang diset oleh dokter,
ventilator akan mengenali usaha nafas dari pasien dan akan
membuka katup inspirasi serta memberikan dukungan ventilasi
sesuai yang diset oleh dokter
Pressure trigger
 Flow trigger

Ventilator secara kontinyu memberikan flow rendah ke dalam

sirkuit pasien (open system)
Saat pasien bernafas beberapa bagian flow didiversi ke pasien
 PEEP

Positive End Expiratory Pressure

 Ventilator Portable

1. Resucitation ventilators

These devices are designed to be very simple to operate.

They are powered by compressed oxygen or air and have only a
single control for both tidal volume and frequency of ventilation.
Resuscitation ventilators can operate automatically or using a
manual override to deliver individual breaths as part of CPR (a
cycle of two breaths followed by 30 chest compressions,
according to the ILCOR guidelines).
This type of ventilator usually has no monitoring but may be
fitted with an audible high pressure alarm to indicate a high
pressure in the patient circuit

Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016

 Ventilator Portable

1. Resucitation ventilators

Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016

 Ventilator Portable

2. Emergency Ventilators

These are portable ventilators with more controls and

monitoring devices than a resuscitation ventilator.
They consist of a control unit, powered by compressed gas,
connected to the patient by a patient circuit and a patient valve.
Emergency ventilators are designed to be used for longer term
ventilation although they can also be used for resuscitation.
They have independent controls for frequency and tidal volume.
Monitoring shows the inflation pressure during the inspiratory
phase.

Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016

 Ventilator Portable

2. Emergency Ventilators

Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016

 Ventilator Portable
3. Transport Ventilators
Transport ventilators are portable ventilators that are designed for the
transport of patients who require artificial ventilation (but are not in an
emergency situation) from one location to another.
In hospital transportation or inter hospital transportation (which may be
anything from a few to many thousands of miles away)
Transport ventilators are usually more complex than emergency
ventilators
They range from pneumatic ventilators with more variable controls than
the emergency ventilators described above to computer – controlled
devices that are in effect miniature versions of ventilators found the ICU
and which are capable of delivering a wide range of ventilation modes.
The simplest transport ventilators are designed for use essentially by non
specialists whereas the most sophisticated are used by transport teams
that include a specialist anaesthetist or emergency physician

Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016

 Ventilator Portable

3. Transport Ventilators

Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016

 Komplikasi ventilasi mekanik

Barotrauma
Volutrauma
Oxygen toxicity

Baker. Artificial Ventilation A Basic Clinical Guide. Springer 2016

 Ventilator Putra Bangsa

Pengembang BPFK Uji praklinis Ijin edar

Kemenkes

Proses ini untuk menjamin mutu, kualitas dan keamanan dari

ventilator yang dikembangkan oleh putra bangsa
Masing-masing mempunyai standar prosedur sendiri yang
independen tetapi tetap membangun komunikasi dan diskusi untuk
membuat relaksasi dengan tetap menjamin kualitas dan keamanan
ventilator yang dikembangkan oleh putra bangsa
Quality control untuk mampu bersaing dengan ventilator dari
negara lain
 Rekap Jenis Alkes Uji Prototipe BPFK Jakarta

Tahapan Jumlah Alkes

Bimtek 1 25
Aerosol 1
CPAP 3
HFNC 1
Respirator(PAPR) 2
Resuscitator Emergensi ( Automatic) 8
UV Strelizir 2
Ventilator 1
Ventilator Emergency 5
Bimtek 2 7
CPAP 1
Resuscitator Emergensi ( Automatic) 4
Ventilator Emergency 2
Lulus Uji Produk 15
CPAP 3
HFNC 1
Respirator(PAPR) 1
Resuscitator Emergensi ( Automatic) 7
Ventilator Emergency 3
Tahap Uji Produk 8
Aerosol 1
HFNC 2
Resuscitator Emergensi ( Automatic) 2
UV Strelizir 1
Ventilator Emergency 2
Uji Produk 1
CPAP 1
Grand Total 56
 Rekapitulasi Pengembang BPFK Jakarta
No Instansi/Pengembang Jenis Alkes
1  BPPT Serpong Resuscitator Emergensi
2 Polyjaya Resuscitator Emergensi
    Ventilator Emergency
3 PT. Dharma Cikarang  Ventilator Emergency
4 Univ Indonesia Ventilator Emergency
5 Univ. Al Azhar Respirator(PAPR)
6 Robovent Resuscitator Emergensi
    CPAP
    Oxygen Concentrator
7 LIPI dan Gerlik HFNC
8 ITB Bandung (Salman) CPAP
    HFNC
9 PUDAK Scientific Bandung Resuscitator Emergensi
10 Litbang ESDM Resuscitator Emergensi
11 Sampoerna Kayoe Resuscitator Emergensi
12 PT. Pindad Bandung Resuscitator Emergensi
13 ITB Vent 76 CPAP
14 ITB Dirgantara  Resuscitator Emergensi
15 PT. Agusta Resuscitator Emergensi
16 POLMAN ASTRA Respirator(PAPR)
17 PT. Unggul Cipta Teknologi Resuscitator Emergensi
18 GPS Infrared / Heat source
19 Surya Sarana Dinamika Resuscitator Emergensi
20 PRSG- BATAN Ventilator Emergency
21 Poltekes Jakarta II HFNC
22 LABS 247 Resuscitator Emergensi
23 PT. Fyrom International CPAP
24 PT. Parametrik Resuscitator Emergensi
25 PT. AHM Resuscitator Emergensi
    CPAP
 Rekapitulasi Pengembang BPFK Jakarta

26 PT. ENNESERS Ventilator Emergency

27 SGU Resuscitator Emergensi ( Automatic)
28 PT. ASKI Aerosol
29 PT. Medytra Ventilator Emergency
30 PT. Xirka CPAP
31 Deteksi Jasa Kelistrikan CPAP
32 HAEI Resuscitator Emergensi ( Automatic)
33 Sanggar Sarana Baja Resuscitator Emergensi ( Automatic)
34 PT. Latitce Teknologi Mandiri Ventilator Emergency
35 PT. Triputra Ventilator Emergency
36 Poltekes Tasikmalaya Resuscitator Emergensi ( Automatic)
37 Persatuan Insinyur Indonesia Resuscitator Emergensi ( Automatic)
38 PT. Medcalindo Ventilator Emergency
39 PT. Tatagata Meditech Indonesia HFNC
40 PT. Global Utama Alkesindo Aerosol
41 Univ Indonesia (Riset & Inovasi) Respirator(PAPR)
42 PT. Kencana Indah Putra UV Strelizir
43 PT. Simpul Reka Sarana Ventilator Emergency
44 PT. LEN Industri CPAP
45 Pindad Engineering Indonesia Resuscitator Emergensi ( Automatic)
46 PT. Inti Karya Sukses Bersama Ventilator Emergency
47 Eluma Consultant Ventilator
48 PT.Ebconnect Ventilator Emergency
49 Institut Teknologi Calvin Indonesia Resuscitator Emergensi ( Automatic)
50 Trimega Abadi UV Strelizir
51 LPIK ITB UV Strelizir
 Rekapitulasi Pengembang BPFK Surabaya

1 UGM Ventilator Emergency

2 ITS
3 Universitas Telkom Surabaya
4 Politeknik Malang
5 PT Indo Prima Surabaya
Ventilator ICU
Ventilator Emergency
Ventilator Emergency
Ventilator Emergency
Ventilator Emergency