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Chapter 38

Nonivasive Mechanical
Ventilation
By:
Sugianto Parulian Simanjuntak
Anestesiologi dan Reanimasi
FK Unair/RSU dr. Sutomo

Ventilasi Mekanis Noninvasif


Pendahuluan
Teknologi

ventilasi mekanis non-invasif


Modus ventilasi mekanik non-invasif
Indikasi dan kontraindikasi
Melakukan ventilasi mekanis non-invasif
Butir-butir pemahaman
Penelitian pendukung

Diagram skematis Ventilator/Pasien:

Constant Pressure/Flow
Source.

Total Compliance & Resistance

Parameter: Tekanan, Volum, Aliran & Waktu

Beberapa singkatan lazim dalam


Airway Pres Release Vent (APRV)
Ventilasi Mekanik

Pressure Support Ventilation (PSV)


Proportional Assist Ventilation (PAV)
Pressure Augmented Ventilation (PAV)
Adaptive Support Ventilation (ASV)
Assisted Spontaneous Ventilation (ASV)
Volume Support Ventilation (VSV)
Volume Assured Pressure Supp (VAPS)
SIMV (VCV)+PSV
SIMV (PCV)+PSV
Continuous Airway Pressure (CAP)
Continuous Pos Airway Pres (CPAP)

Controlled Mechanical Ventilation (CMV)


Continuous Mandatory Ventilation (CMV)
Intermittent Pos Pres Ventilation (IPPV)
Volume Controlled Ventilation (VCV)
Assist Control Ventilation (ACV)
Pressure Control Ventilation (PCV)
Pres Regulated Volume Control (PRVC)
Intermittent Mandatory Ventilation (IMV)
Sync Interm Mandatory Ventilation (SIMV)
Auto Flow (AF)
Biphasic Pos Airway Pressure (BiPap)
Continuous Repetitive Airway Pressure (CRAP)

Definisi Modus Ventilator


Modus adalah metode bantuan ventilasi berkaitan dengan
hantaran nafas spontan atau diperintah. Bisa disebut sebagai
sekumpulan variabel kendali, fase dan kondisional tertentu.

Variabel Kendali
Biasanya Tekanan atau Volum (Flow)
Variabel Fase
Mengacu kpd Trigger, Limit & Cycle (TLC)
Variabel Kondisional
Biasanya Usaha pasien , Waktu atau Tidal/Minute Volume

Seluruh interaksi antara pasien dan ventilator bisa


dijabarkan
1. Continuous
Mandatory
Ventilation (CMV)
dalam
4 modus
dasar yaitu:
2. Sync Intermittent Mandatory Ventilation (SIMV)
3. Pressure Support Ventilation (PSV)
4. Continuous Positive Airway Pressure (CPAP)
Dalam modus CMV Variabel Kendali bisa berupa
Tekanan atau Volum sementara Trigger bisa berupa Mesin
(biasanya) atau Pasien (yang digabung dengan trigger)

TIPE PERNAFASAN
Ada empat tipe pernafasan dasar:
------------------------------------------------------------------------------Tipe Nafas
Variabel Fase
Trigger
Limit
Cycle
------------------------------------------------------------------------------1.MANDATORY
Mesin
Mesin
Mesin
2.ASSISTED

Pasien

Mesin

Mesin

3.SUPPORTED

Pasien

Mesin

Pasien

4.SPONTANEOUS
Pasien
Pasien
Pasien
-------------------------------------------------------------------------------

Continuous Mandatory Ventilation (CMV)


Kendali Volum

Kendali Tekanan

Cycle = Waktu

Limit = Aliran
Variabel
kendali

Limit = Tekanan
Variabel
Kendali

Trig =
Waktu

Trig =
Waktu
Cycle = Waktu

Sync Intermittent Mandatory Ventilation


(SIMV)

Limit = Pressure

Limit = Flow

Patient

Patient

Patient

Patient

(Mesin)

Patient

(Machine)

Patient

Trigger

Pressure Support Ventilation (PSV)

Continuous Positive Airway Pressure (CPAP)

SIMV/BIPAP with Auto Flow

INTRODUCTION
Noninvasive ventilation (NIV) the provision of ventilatory
assistance without an artificial airway effective in acute
respiratory failure

Acute
Cardiogenic
Pulmonary
Edema (ACPE)

Common medical emergency 1


million/year hospital admissions in USA
Mortality is high (10 20%)
>> suffer from severe respiratory distress
& hypoxemia

Some patient require ventilatory support for


respiratory distress & hypoxemia
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Introduction..

Ventilator Support
for ACPE

Recent years :
Noninvasive positive
pressure ventilation (NPPV)

Traditionally :
Endotracheal Intubation
& Mechanical
Ventilation

Advantages :
Patient comfort
Maintenance of airway defense mechanisms
Ability to eat & speak
Avoid complications associated with endoteacheal intubation
Beneficial Effects in ACPE Improve oxygenation, Increase CO,
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& reduce the work of breathing

NONINVASIVE VENTILATION
(NIV)
The recent increase in use of NIV in the
acute care setting reduce
complications of Invasive Ventilation

Patients must be selected carefully because


the risk of complications could be increased if
NIV is used inappropriately.

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Modalities of NIV
Negative Pressure Ventilation
Support ventilation by lowering the pressure surrounding
the chest wall during inspiration & reversing the pressure to
atmospheric level during expiration
Not readily accepted by patients because of their awkward
size & their propensity to cause upper airway obstructions in
some patients

Noninvasive Positive-Pressure Ventilation (NPPV)


Delivered by a nasal or face mask eliminating intubation
or tracheostomy
NPPV may be used as an intermittent mode of assistance
depending on patients clinical situation
The total duration of ventilator use varies with the
underlying disease
>> advantage compare to invasive ventilator

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Noninvasive Positive-Pressure Ventilation..

Hillberg,1997

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Noninvasive Positive-Pressure Ventilation..


Table 2. Evidence To Support Use of NPPV for Different Types of Acute
Respiratory Failure

Liesching et al.
2003

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Noninvasive Positive-Pressure Ventilation..


Guidelines for the Use of NPPV in Patients with Acute Respiratory
Failure

Blood Gas Findings

Clinical Inclusion
Criteria

PaCO2 > 45 mmHg


pH < 7,35 but more than 7,10
PaO2 & FiO2 < 200

Signs or symptoms of
acute respiratory distress
Moderate to severe
dyspnea, increase over
usual
RR > 24x/minute
Accessory muscle use
Abdominal paradox
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Noninvasive Positive-Pressure Ventilation..


Guidelines for the Use of NPPV in Patients with Acute Respiratory
Failure

Contraindications

Factors
Predictive of
Success

Respiratory arrest
Inability to use mask because of trauma or
surgery
Excessive secretions
Hemodynamic instability or life-threatening
arrtytmia
High risk of aspiration
Impaired mental status
Uncooperative or agitated patient
Life-threatening refractory hypoxemia
Younger age
Lower acuity of illness (lower APACHE score)
Patient able to cooperate
Ability to coordinate breathing with ventilator
Moderate hypercapnia (PaCO2 > 45 but < 92
mmHg)
Moderate acidemia (pH > 7,10 but < 7,35)
Improvement in gas exchange & heart & RR
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within first 2 hours

ACUTE CARDIOGENIC PULMONARY


EDEMA
Cardiogenic Pulmonary Edema
Due to increased capillary hydrostatic
pressure secondary to elevated pulmonary
venous pressure
Accumulation of fluid with a low-protein
content in lung interstitium & alveoli
Symptoms :

Sudden onset of extreme shortness of


breath,
takipneu, takikardi, severe hypoxemia
respiratory distress

Acute Cardiogenic
Pulmonary Edema

Initial management ABCs resuscitation


Oxygen SaO2 > 90%

Patient remain hypoxic despite


supplemental
oxygenation ventilatory support
O2 delivery depend on hypoxemia,

acidosis &
level of consciousness
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NIV types BiPAP or CPAP

Acute Cardiogenic Pulmonary


Edema..
Medical therapy focuses on 3 main goals :
Reduction of
pulmonary venous
return (preload
reduction)

Decreased
pulmonary capillary
hydrostatic
pressure
Reduces fluid
transudation into
the
pulmonary
interstitium &

Reduction of
systemic vascular
resistance
(afterload
reduction)

Increased CO &
improves renal
perfusion, which
allows for diuresis
in patient with
fluid overload

Inotropic
Support

Maintain adequate
blood pressure
Patient with severe
LV dysfunction or
acute valvular
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disorders

APPLICATION NIV FOR ACUTE CARDIOGENIC PULMONARY


EDEMA

Acute Cardiogenic Pulmonary


Edema
Shunt intrapulmonal
Ventilation - perfusion mismatch

HYPOXEMIA

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Application NIV for ACPE..


Noninvasive pressure support ventilation (NPSV) :
Maintains the patency of the fluid-filled alveoli &
prevents them from collapsing during exhalation
patient saves the energy spent trying to reopen
collapsed alveoli
Improves pulmonary air exchange
Increase intrathoracic pressure with reduction in
preload & afterload
Several Studies :
Decreased length of stay ICU, mechanical ventilation &
hospital costs
Faster improvement of oxygen saturation in patients
with CPE
More superior than standard therapy
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Application NIV for ACPE..

Two types of NPPV

Continuous positive
airway pressure (CPAP)

Bilevel positive airway


pressure (BiPAP)

single airway pressure

is maintained
throughout all phases
of the respiratory cycle

high pressure applied


during inspiration &
low pressure during
expiration

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Application NIV for ACPE..

Nava et al (2003)
& Gray et al
(2008)

CPAP
Vs.
BiPAP

Both CPAP & BiPAP rapid improvement


dyspnea & RR; reduced endotracheal
intubation rate compared to standard therapy
NIV as adjunctive therapy in patient ACPE
with respiratory distress & no clinical
improvement with pharmacologic therapy
One small study BiPAP associated with
more rapid improvement in vital sign but an
increased rate of myocard infarctions
Another study NOT show any increased
rate of myocard infarction in patients with
CPAP or BiPAP

CPAP is the preferred methods when NPPV is used


unless the patients has obstructive airway disease
CPAP resulted in easier & less expensive application
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Application of CPAP
ACPE

LV dysfunction Acute increased in


extravascular lung water reduces lung
volume & lung compliance & increase airway
pressure

Both work & oxygen cost of breathing rise

CPAP
Improve oxygenation & cardiac
function
Decrease respiratory work
Main physiological benefit :
Decreased LV pre-load & afterload owing to increased intrathoracic
pressure
Increase in functional residual capacity reopens collapsed alveoli27

Application of CPAP..
Table 3. Summary of Trials Using CPAP in Acute Pulmonary Edema

Mehta et al. 2001


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MONITORING
Patients must be carefully monitored & attention :
Patients comfort, mental state, chest wall
movement, accessory muscle recruitment,
coordination of respiratory effort with the
ventilator, heart rate, respiratory rate & oxygen
saturation
Blood gas analysis after 1-2 hours of NIV & after 46 hours if the earlier sample showed little
improvement

If no improvement NIV should be discontinued


& invasive ventilation considered
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COMPLICATIONS OF NPPV
Most common problems :
Local damage to facial tissue
Mild gastric distention
Eye irritation & sinus pain
Barotrauma is uncommon

Unsuccessful NIV :
Hemodynamic instability
Deteriorating mental status
Increasing respiratory rate
Increasing respiratory acidosis
Inability to maintain adequate oxygen saturation
Problem with respiratory secretions

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CONCLUSIONS
Recent studies shows that NIV is an
effective treatment for selected patients
with acute respiratory failure, including
acute
edema
NIV cardiogenic
Lower ratespulmonary
of endotracheal
intubation or tracheostomy, fewer
complications, & improved survival
Two types of NIV for ACPE CPAP &
BiPAP
CPAP is the preferred methods when
NIV is used for respiratory distress in
acute cardiogenic pulmonary edema
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Ware et al,2005

Ware et al,2005

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