DASAR VENTILASI MEKANIK

ANANG ACHMADI, SpAn ICU Bedah RS Jantung Pusat Nasional Harapan Kita - Jakarta

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/gas TEKANAN udara/gas POSITIF ke dalam paru Ventilasi semenit = TV x RR (frekuensi nafas) (frekuensi nafas)
TV = 55cc/ kgBB RR = 5555 menit kali/

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, efusi pleura, paru, obstruksi, obstruksi, distensi abdomen dan pneumotoraks Compliance tinggi = penurunan elastisitas resistensi pada inspirasi dan penurunan kemampuan mengeluarkan udara waktu ekspirasi (COPD)

Kriteria tradisional untuk bantuan ventilasi mekanik

PARAMETER Mekanik (RR) TV (cc/kg) Oksigenasi (PaO5 mmHg) P(A-aDO5 mmHg ) Ventilasi (PaCO5 mmHg) INDIKASI VENTILASI > 55 x/m <5 < 55 FiO555 dg , > 555 > 55 NORMAL RANGE 55 x/m -55 55 55 - 555 (air) 55 (FiO555 - 55 . ) 55 -55

T U J U A N K L IN IS / IN D IK A S I P E M A K A IA N V E N T IL A S I M E K A N IK
G A G A L N A F A S H I P O K S E: M IK R e v e rs e h y p o x e mdia n p e m b e riaPE E P d a n ko n s e n t ra O5 g n si t in g g i(A R D S , e d e mp a r u a t a u n e u m o n ia k u t a p a ) G A G A L N A F A S V E N T I L A S I: R e v e rs e a c u te re s p ira to ry a c id o s is - K o m a: t ra u m a e p a la e n ce fa litiso v e rd o s isC PR k , , , - T r a u m a m es p in a lis p o lio , m o t o r n e u ro n d is e a se d , - P o lin e u ro p a ti ia s te n ia ra v is ,m g - A n e s th e s ia e(la k s a n /o p e ra s, i te ta n u se p ile p s) i r u , S T A B IL IS A S I D IN D IN G D A D A : F la i l c h e s t M E N C E G A H AT A U M EN G O B A T I A T E L EK T A S IS

T U J U A N F IS IO L O G IS
M E M P E R B A IK I V E N T ILA S I A LV E O LA R M E M P E R B A IK I O K S IG E N A S I A LV E O L A (F iO5 FR C ,V 'A ) , M E M B E R IK A N P U M P S U P P O R T ( M E W OB )

C on s e ns u s c o n fe ren c e o n m ec h a nic a l v en tilat io n , M e d 5 5 ,5 I nt C are 5 5: 55 55 - 5

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

Peak pressure

Plateau pressure

Inspiration

Expiration

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 PaCO2, e.g., 2 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 H2O 2 Adjust to adequate chest movement or exhaled tidal volume ~8 mL/kg Low level of PEEP (24 cm H2O) to prevent 2 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 H2O 2