Perawatan

Distress Napas
Pada Anak
Ns. Defi Efendi, M.Kep., Sp.Kep.An
 Definisi
UMUM
● Acute Respiratory Distress Sydrome
(ARDS) terjadi karena adanya akumulasi
cairan di alveoli yang menyebabkan
terjadinya gangguan pertukaran gas
sehingga distribusi oksigen ke
jaringan menjadi berkurang.
ANAK
● Pada anak terdapat penambahan pengukuran
oksigenasi dengan pulse oximetry jika
pengukuran oksigenasi darah arteri tidak
tersedia dibandingkan dengan
menggunakan PaO2/FiO2 (P/F) ratio →
Hypoxemia
● Oxygenation index (OI) = [(FiO2 · mean airway
pressure · 100)/PaO2]
● Oxygenation saturation index (OSI) = [(FiO2 ·
mean airway pressure · 100)/SpO2]
 POKOK BAHASAN

Definisi Pengkajian

Intervensi
Diagnosis
Kep
 Definisi

● OI = Oxygenation index
● OSI = Oxygen saturation index

● 1 = Use Pao2-based metric when

available. If Pao2 not available, wean
Fio2 to maintain Spo2 ≤ 97% to calculate
OSI or oxygen saturation/Fio2 ratio.
● 2 = For non-intubated patients treated
with supplemental oxygen or nasal
modes of noninvasive Ventilation
 Risiko PARDS

● 1 =Jika data tidak tersedia,

untuk pasien yang
menggunakan blender,
kalkulasi risiko Flow = FiO2 x
flow rate.
Contoh: Anak diberikan 6 lt/menit
dengan FiO2 35% → Flow = 6 X
0.35 = 2.1 lt/menit

● 2 = Jika PaO2 tidak tersedia,

weaning Fio2 hingga SpO2 ≤
97% untuk mengkalkulasi OSI

Pediatr Crit Care Med. 2015 June ; 16(5): 428–439.

doi:10.1097/PCC.0000000000000350
 PARDS

● OI = [(FiO2 · mean airway pressure · 100)/PaO2]

● OSI = [(FiO2 · mean airway pressure · 100)/SpO2]

Orlof, KE., et al. 2019. Pediatric Allergy, Immunology, And Pulmonology. V 32. No.2
 Invasive Ventilation

Conventional
Ventilator

FiO2 MAP MV
(Oxygenation) (Oxygenation) (CO2 Removal)

PEEP PIP IT & ET Delta Pressure Fr (RR/min)

(PIP – PEEP)

MAP = ( PIP X IT) + (PEEP X ET)

IT + ET
 Risiko PARDS

● PF ratio = [ PaO2/FiO2 ] <= 300

● SF ratio = [SpO2/FiO2] <= 264

Eg:
BiPAP use PEEP 7 cm, FiO2 50%, achieve SpO2 95%
SF ratio = 95/0,5 = 190 < 264 → at risk
 *Ineffective airway clearance
*ineffective breathing pattern

Respiratory care
defiefendi@ui.ac.id

FiO2: Fraction of Inspired Oxygen

H2O: Dihydrogen Monoxide
OI: Oxygenation Index (OI= mean airway pressure MAP × FiO2 × Bagan 1. Bantuan Napas pada Anak Suspected/Confirmed COVID-19 (Carlotti et al., 2020; Kache et al., 2020;
100÷PaO2) Kneyber et al., 2017; Meyers et al., 2019; Rose et al., 2020)
OSI: Oxygen Saturation Index (OSI=MAP × FiO2 × 100÷SpO2)
 NURSING CARE

Diagnosis
Pengkajian Kep

Dokumentasi Intervensi
 PENGKAJIAN
● Pengkajian awal → Setelah intubasi bagaimana perubahan kondisi anak
● Pengkajian umum → Warna kulit bayi, perfusi, tonus, aktivitas,
nyeri/kenyamanan, dan penampakan umum
 PENGKAJIAN (2)
Inspeksi Auskultasi
• Respiratory Assessment • Suara napas lobus kanan
dan kiri
• Gerakan dinding dada
sinkorn • Terdengar suara gas “bocor”
didekat ETT
• Kembang dada
• Frekuensi napas spontan
• Cek kedalaman ETT
 Pengkajian: Kenyamanan

● Kaji nyeri
○ Nyeri ringan = setiap 3 jam
defiefendi@ui.ac.id

○ Nyeri sedang = setiap 1 jam

setelah tatalaksana lakukan
pengkajian ulang

○ Nyeri Berat = 30 menit, setelah

tatalaksana lakukan pengkajian
ulang
● Bayi dengan nyeri dapat
VS
memperburuk indikator
pernapasan
 PENGKAJIAN NYERI
(SEDASI/INTUBASI)
defiefendi@ui.ac.i
d

International Journal of Pediatrics and Adolescent Medicine

(2015) 2, 123e127
 Modified Pediatric Early Warning Score
(MPEWS) (Vredebregt et al., 2019)
defiefendi@ui.ac.id

Skor 0- : Kaji ulang skor PEWS minimal 1x24 jam

2 : Ulangi pengkajian skor PEWS setiap 4 jam
Skor 3 : Ulangi pengkajian skor PEWS setiap 1 jam
Skor 4 : Seger a hubungi dokter penanggungjawab untuk
Skor ≥ konsultasi tindakan lebih lanjut
5

Gambar. Modified Pediatric Early Warning Score (MPEWS) (Ditampilkan dengan izin: Vredebregt et al., (2019)
Cicconi et.al. (2020) Early Predictors of Clinical Deterioration in a Cohort of
239 Patients Hospitalized for Covid-19 Infection in Lombardy, Italy
 ROX INDEX

Sumber: http://www.emdocs.net/covid-19-oxygen-escalation-therapy-and-noninvasive-ventilation/rox-index/
 Diagnosis KEPERAWATAN
defiefendi@ui.ac.i

(D.005) (D.0001)
Pola Napas Tidak Efektif Bersihan Jalan Napas Tidak Efektif
d

(D.0004) (D.0003)
Gangguan Ventilasi Spontan Gangguan Pertukaran Gas
(D.0006) (D.0002)
Risiko Aspirasi Gangguan Penyapihan Ventilator
Nursing Care Guidelines…

Efendi, D., et al (2022). PLOS One. Vol. 17. No. 2. https://doi.org/10.1371/journal.pone.0263267

 Manajemen Ventilasi Mekanik

● High PEEP (7-10 cmH2O)

● Vte/kg = 5-7 ml/KgBB (ideal)
defiefendi@ui.ac.i

● Pplat <28-32 cmH2O

defiefendi@ui.ac.id
● Pressure ≤ 15 cmH2O
d

● Titrasi FiO2 untuk target SpO2 92-

96. Pada pasien dengan derajat
kritis minimal SpO2 88% dapat
diterima
● Permisif Hypercapnia (pH >
7.20)
 Intervensi: Suction - Indikasi

● Agitation and restlessness

● Apnea • Changes in blood gas values •
defiefendi@ui.ac.i

Decreased breath sounds • Color changes

(pale, dusky, or cyanotic) • Decreased
d

chest wiggle for neonates on high-frequency

ventilators • Increasing oxygen requirements •
Loss of or poor chest wall excursion with
ventilator breaths • Pattern change in
ventilator graphics • Tachycardia
 Perubahan Grafik Ventilator:

Indikasi Suction
defiefendi@ui.ac.i
d
 Perubahan Grafik Ventilator:

Indikasi Suction
defiefendi@ui.ac.i
d

Perhatikan grafik Flow

 Intervensi:
Prosedur Suction
• BW NaCl 0,9% tidak direkomendasikan, dan berpotensi untuk menimbulkan kolonisasi bakteri
• Tekanan negative 60 -100 mmHg
• Tidak ada bukti: rotasi kateter, memutar kepala bayi. Bayi hendaknya dijaga dengan posisi mideline
defiefendi@ui.ac.i

symmetric untuk memberikan rasa nyaman dan mencegah peningkatan tekanan intracranial
(Gardner, S.L et al, 2016)
d

• Suction < 10 detik untuk mencegah hipoksemia. Durasi yang lebih lama berkaitan dengan kejadian
hypoksia dan bradikardia
• Ukuran kateter tidak lebih dari separuh ukuran diameter internal ETT (Bailey, 2015).
• Pre oksigen : 10 – 30%
• Sction tidak melibihi ETT
• Fase istirahat antara 2 suction
• Suction hanya saat ada indikasi
 Nursing Care for Ped. With Mechanical Ventilation

● Monitoring : 3,85<Rox index>4,88 → intubation (Roca et al., 2019), PEWS as

monitoring tools (Venturini et al., 2020)
● Early and prolonged prone positioning in moderate-to-severe PARDS (i.e. PaO2/FiO2 <
150; OI ≥ 12; OSI ≥ 10). Practices vary between 12 – 18 hrs per day with the patient in
prone position (avoid disconnection) (Battaglini et al., 2020; Carlotti et al., 2020; Deitrick
et al., 2020; ESPNIC, 2020; Kache et al., 2020; Shang et al., 2020)
●
defiefendi@ui.ac.i

Use DOPE pneumonic for sudden hypoxia, identification and treatment of shockable
rhythm (Matos & Chung, 2020)
● Daily assessment of spontaneous breathing ability (Lazzeri et al., 2020)
● Stop flow with ETT clamping when circuit disconnection can’t be avoided (Carlotti et al.,
d

2020)
● No routine ventilator circuit changes unless contaminated (Lazzeri et al., 2020) (ESPNIC,
2020)
● Avoid inhalation. If it’s can be avoided, use Aeroneb solo(Miller & Epstein, 2020)
● Always use closed (in-line) suction (Cook et al., 2020; Lamb et al., 2020; Şentürk et al.,
2020)
● Routine chest physiotherapy is not recommended (P. Thomas et al., 2020). Individual
consideration may be needed (Abdullahi, 2020)(Battaglini et al., 2020)
 Nursing Care for Ped. With Mechanical Ventilation
(Efendi., Hasan., Natalia…, Sari, 2021)

Mechanical
Respiratory Ventilation
Management Management: • ETT
Invasive

● Gunakan ETT Cuff

● Monitor tekanan setiap 6-12 jam
● Batas tekanan < 20 cm H2O
 Nursing Care for Ped. With Mechanical Ventilation
(Efendi., Hasan., Natalia…, Sari, 2021)

Mechanical
Respiratory Ventilation • BC
Management Management: • HEPA
Invasive • HME

● BC sekali pakai
● Gunakan HEPA* filter pada saluran ekspirasi
● HME** diganti setiap 48 jam atau Ketika
kotor

*high efficiency particulate air

**Heat and moisture exchanger (
 Nursing Care for Ped. With Mechanical Ventilation

Setting Ventilator: • Pastikan jumlah air sesuai

dengan rentang yang ada
Kelembapan pada humidifier
• Pilih mode intubasi
V • Suhu rentang 37-39C

S • Cek adanya uap air pada

breathing circuit
 Nursing Care for Ped. With Mechanical Ventilation
(Efendi., Hasan., Natalia…, Sari, 2021)

Respiratory Airway
Management • Close
Suctioning suction

● Gunakan kateter suction dengan sistem

tertutup
 Nursing Care for Ped. With Mechanical Ventilation
(Efendi., Hasan., Natalia…, Sari, 2022)

Respiratory Oxygen
Management • Prevent
Therapy Arosolization

● Intubasi dini lebih direkomendasikan

dibandingkan dengan mengguakan NIV
● Jaga SpO2 > 94%
● Berikan kelembapan pada pemberian terapi
oksigen > 4 lt/mnt
● Hindari penggunaan HVN/NIV
 Nursing Care for Ped. With Mechanical Ventilation

Immobility
Positioning management
defiefendi@ui.ac.id

● Early prone position or prolonged moderate to

severe PARDS (i.e. PaO2 / FiO2 <150; OI ≥ 12; OSI ≥
10 for 12-18 hours per day (avoid disconnection)
and discontinue if PaO2 / FiO2 ≥ 150; OI <12; OSI <10
● Rubah posisi kembali jika terjadi serangan jantung
● Jika prone panjang tidak mampu laksana, lakukan
1-4 jam perhari
 Nursing Care for Ped. With Mechanical Ventilation

Immobility
defiefendi@ui.ac.id

Positioning management

RJP dapat dilakukan dalam posisi

prone pada pasien yang terintubasi
 Inhalasi
defiefendi@ui.ac.id

Continous inhalation (Aeroneb Solo) Modifikasi RSUI

Courtesy: Gracia, 2020
 D.O.P.E.S
D • ETT: posisi, koneksi
(Dislocation) • Sirkuit: Leak, kondensasi
O • ETT: kinking, mucus
defiefendi@ui.ac.id

(Obstruction) • Pengembangan thorax

• Deviasi kontralateral trakea
P • Perburukan progresif: desat, retraksi berat, takikardia,
(Pneumothorax) mottling
•• Ventilator
Tidak berspons terhadap perubahan pengaturan Vent
E • Listik
(Environment) • Tekanan Gas
• Suhu ruang sangat dingin
S • Gagguan pada diafragma, distensi abd, belly syndrome
(Stomatch)
 Pendokumentasian
• MODE ❑ Dokumentasikan
setiap jam
• FiO2
❑ Perhatikan akurasi
• TI & Triger data:
defiefendi@ui.ac.id

• RR • Berapa Leak
yang dapat
• PIP dikompensasi
oleh mesin
• PEEP • Bagiamana
kondisi flow
• MAP sensor
• Cek kesusuaian
• MV dengan klinis
• VT bayi
 ND: Risk for impaired attatchment
Implementation of FCC in pediatric isolation with COV-19
● Prinsip pencegahan infeksi
● Pada kondisi khusus anak tidak bisa
defiefendi@ui.ac.id

terpisah dengan orang tua

● Lakukan pertemuan keluarga, jelasakan
berbagai alternatif skenerionya dan
dampaknya
● Sediakan informasi perkembangan anak
untuk keluarga
● Untuk anak yang harus di rawat bersama
orang tua, raber → Gunakan masker,
pengukuran suhu sekala, hand hygiene, PPE
● Kurangi stress anak dengan menyediakan
penjelasan, distrasksi misal melalui game
tertentu.
(ESPNIC, 2020; Hart, Turnbull, Oppenheim, & Courtright, 2020)
 Kesimpulan
● Distress napas pada anak memiliki definisi khas pada anak
● Asuhan keperawatan pada anak dengan ventilasi mekanik dimulai
defiefendi@ui.ac.id

dari pengkajian, penegakan diagnosis keperawatan, intervensi

keperawatan, dan Evaluasi/Dokumentasi
● Pada kasus distress anak dengan COVID-19, intervensi keperawatan
diberikan dengan membertimbangkan dampak penyebaran infeksi
 Caring With Love….
“You can love anyone. Love is just
defiefendi@ui.ac.id

caring about someone very deeply.

Feeling like that person matters to
you, like your whole world would be
sadder without them in it. . . ”

Anna Carrey
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