DASAR VENTILASI MEKANIK

ANANG ACHMADI, SpAn

ICU Bedah
RS Jantung Pusat Nasional
Harapan Kita - Jakarta

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 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
udara/gas
/gas TEKANAN
POSITIF ke dalam paru
Ventilasi semenit = TV x RR (frekuensi
(frekuensi nafas)
nafas )
TV = 5-7 cc/kgBB
cc/ kgBB
RR = 10 12 kali/menit
kali/ menit

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

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Kriteria tradisional untuk bantuan ventilasi mekanik

PARAMETER INDIKASI VENTILASI NORMAL RANGE

Mekanik (RR) > 35x/m 10-20x/m

TV (cc/kg) <5 5-7

Oksigenasi (PaO2- <60 dg FiO2 0,6 75-100 (air)

mmHg)
P(A-aDO2) mmHg > 350 25-65(FiO2 1.0)
Ventilasi (PaCO2- > 60 35-45
mmHg)

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TUJUAN KLINIS / INDIKASI PEMAKAIAN
VENTILASI MEKANIK
GAGAL NAFAS HIPOKSEMIK:
Reverse hypoxemia dgn pemberian PEEP dan konsentrasi O2
tinggi (ARDS,edema paru atau pneumonia akut)
GAGAL NAFAS VENTILASI:
Reverse acute respiratory acidosis
- Koma : trauma kepala, encefalitis, overdosis, CPR
- Trauma med spinalis, polio, motor neuron disease
- Polineuropati, miastenia gravis
- Anesthesia (relaksan u/operasi, tetanus, epilepsi)
STABILISASI DINDING DADA:
Flail chest
MENCEGAH ATAU MENGOBATI ATELEKTASIS

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TUJUAN FISIOLOGIS

MEMPERBAIKI VENTILASI ALVEOLAR

MEMPERBAIKI OKSIGENASI ALVEOLAR
(FiO2, FRC,V'A)
MEMBERIKAN PUMP SUPPORT ( ME
WOB)

Consensus conference on mechanical ventilation, Int Care Med 1994,

20:64-79

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 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 end-
expiratory 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/neuro-
muscular 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 Peak pressure Plateau 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 PaCO22, e.g.,

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 H22O
Adjust to adequate chest movement or
exhaled tidal volume ~8 mL/kg
Low level of PEEP (24 cm H22O) to prevent
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 H22O