Ventilator Mekanik

Ventilator Mekanik
Peran dan fungsi perawat pada pasien

dengan respirator mekanik
By
MAS YOESZ’
POKOK BAHASAN
 Review System Pernafasan
 Airway management
 Mengenal Terminologi ventilasi Mekanik
 Tatalaksana Ventilasi Mekanik
 Mode Ventilasi Mekanik
 Trobleshoting Ventilasi Mekanik
 Weaning
 Peran Dan Fungsi Perawat
 Modalitas Perawatpada Pasien Dengan Respirator Mekanik
TUJUAN PERLINDUNGAN AIRWAY
MEMBUKA JALAN NAPAS
MEMBERIKAN TAMBAHAN OKSIGEN
MENUNJANG VENTILASI
MENCEGAH ASPIRASI
EndotrachealTube
Ukuran ETT :
1. INFANT ATERM, ID 3,5mm, PANJANG 12 cm
Umur
2. ANAK, ID : 4 + Umur , PANJANG 14 + 4
4
3. DEWASA :
◦ ID WANITA 7 –7.5, PANJANG 20 -24
◦ ID LAKI-LAKI 7.5 -9, PANJANG 20 -24
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Ingatkah……
VENTILASI PARU
PROSES MEKANIK, KELUAR MASUKNYA
UDARA DARI LUAR KE DALAM PARU DAN
SEBALIKNYA  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
INTERNA DENGAN SEL
JARINGAN/TISUE
UTILISASI O2
PEMAKAIAN OKSIGEN
DALAM SEL PADA REAKSI
PELEPASAN ENERGI
VENTILASI PARU
MEKANISME INSPIRASI
KONTRAKSI DIAFRAGMA & INTERKOSTALIS EKST
VOLUME INTRATORAKS >>
INTRAPLEURAL PRESSURE >> NEGATIF
PARU EKSPANSI (MENGEMBANG)
INTRAPULMONAL PRESSURE >> NEGATIF
UDARA MENGALIR KE DALAM PARU

VENTILASI PARU
HUKUM BOYLE PRESSURE DARI GAS BERBANDING

TERBALIK DGN VOL CONTAINER
TABRAKAN PARTIKEL2 GAS

KE DINDING KONTAINER
MENIMBULKAN PRESSURE
PERUBAHAN VOLUME VOLUME VOLUME

MENYEBABKAN
PERUBAHAN PRESSURE PRESSURE PRESSURE
VENTILASI PARU
INSPIRASI EKSPIRASI
KONTRAKSI OTOT INTERKOSTALIS EKSTERNA  RELAKSASI OTOT INTERKOSTALIS EKSTERNA

IGA TERANGKAT  IGA KE POSISI SEMULA
KONTRAKSI DIAFRAGMA DIAFRAGMA RELAKSASI DIAFRAGMA  DIAFRAGMA

BERGERAK INFERIOR BERGERAK KE POSISI SEMULA
VOLUME VOLUME
PRESSURE PRESSURE
INTRATORAK
Terminologi Ventilator Mechanic
VENTILASI PARU
AIRWAY RESISTANCE COMPLIANCE

(RAW) (COMPL)
RAW
AIRWAY
CL
LUNG
AIRWAY RESISTANCE (RAW)
– Membatasi jumlah gas yg mengalir melewati jalan

nafas (obstruksi jalan nafas)
– Flow = pressure/resistance
– Jika R  Flow
– Ditentukan oleh besarnya diameter jalan nafas
– Pada nafas spontan, jika resistance me , secara
normal respon tubuh adalah meningkatkan usaha
nafas (WoB = RR >>, otot bantu nafas >>)
AIRWAY RESISTANCE
(RAW)
BRONKUS
NORMAL
PRESSURE
FLOW =
RESISTANCE
AIRWAY RESISTANCE
(RAW)
BRONKODILATASI:
PRESSURE EPINEFRIN
FLOW = AMINOFILIN
RESISTANCE BETA 2 AGONIS
AIRWAY RESISTANCE
(RAW) BRONKOKONSTRIKSI:
 HISTAMIN
PRESSURE
FLOW =
RESISTANCE
OBSTRUKSI:
 MUKUS/SEKRET
PRESSURE
AIRWAY
RESISTANCE (RAW) FLOW =
RESISTANCE
ETT TERLALU
KECIL
BRONKOSPASME
TUMOR/SEKRET
KOLAPS/ATELEKTASIS
COMPLIANCE (COMPL)
BALON
Kaku Elastis
LOW HIGH
COMPLIANCE COMPLIANCE
COMPLIANCE (COMPL)
Definisi
Rasio perubahan volume akibat terjadinya perubahan pressure
 V/P
Terbagi 2;
 Compl paru (edema paru, fibrosis, surfactan <<)
 Compl dinding dada (obesitas, distensi abdomen)
Low compliance
◦ Edema paru, pneumonia berat, ARDS, efusi pleura,
hematopneumotoraks, abdominal pressure >>:  u/
memasukkan volume yang diinginkan dibutuhkan pressure
yg lebih besar.
High compliance
◦ Muscle relaxant, COPD, open chest  dgn pressure yg
kecil dapat tidal volume yg masuk besar
P-V LOOP
EKSPIRASI
Vol
LOW HIGH
NORMAL COMPLIANCE COMPLIANCE
500 500 500
250 250 250
0 15 30 15 30 15 30
PEEP 5
INSPIRASI
NAFAS
SPONTAN
SHUNT DAN DEAD SPACE
Hubungan Ventilasi (V) dan Perfusi (Q)
TRAKEA ANATOMICAL
DEAD SPACE
PHYSIOLOGICAL
DEAD SPACE
V/Q = 
KAPILER ALVEOLAR
PARU DEAD SPACE MECHANICAL
V/Q > 1 DEAD SPACE:
TUBE
NORMAL CONNECTOR
V/Q = 1
ET CO2
BREATHING
CIRCUIT
V/Q < 1
VENOUS ADMIXTURE
(SHUNT)
V/Q = 0
FiO2 : TIDAL VOLUME (VT):
FRAKSI KONSENTRASI JUMLAH GAS/UDARA YG
OKSIGEN INSPIRASI YG DIBERIKAN VENTILATOR
DIBERIKAN (21 – 100%) SELAMA INSPIRASI DALAM
SATUAN ml/cc ATAU liter. (5-
10 cc/kgBB)
FREKUENSI / RATE (f) : FLOW RATE :

JUMLAH BERAPA KALI KECEPATAN ALIRAN GAS
INSPIRASI DIBERIKAN ATAU VOLUME GAS YG
VENTILATOR DALAM 1 DIHANTARKAN PERMENIT
MENIT (10-12 bpm) (liter/menit)
T I M E = WAKTU frekuensi
- Menentukan siklus respirasi
- Jika setting RR pd ventilator 10 x/menit  maka
60/10 = 6 dtk
- Jadi T (Total) = T (Inspirasi) + T (Ekspirasi) = 6 dtk
- Berarti inspirasi + ekspirasi harus selesai dalam
waktu 6 dtk.
6 dtk 6 dtk
Ins + Eksp Ins + Eksp

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 Triggering
 Upaya nafas pasien dimulai saat terjadi kontraksi otot
diafragma
 Upaya nafas ini akan menurunkan tekanan (pressure) di dalam
sirkuit ventilator (tubing)
X X
Pressure Triggering
 Ketika pressure turun mencapai batas yang diset oleh dokter,
ventilator akan mentrigger nafas dari ventilator
 Namun tetap ada keterlambatan waktu antara upaya nafas
pasien dengan saat ventilator mengenali kemudian
memberikan nafas.
Patient effort
Pressure
Baseline
Trigger
Pressure Triggering
1. Setelan sensitivity pada -2 cm H2O
2. Gambar dibawah menunjukkan pada 2 nafas pertama upaya
nafas pasien mencapai sensitivitas yang diset; sedangkan
gbr ketiga terlihat bahwa upaya nafas pasien tidak mencapai
sensitivitas yg diset sehingga ventilator tidak mengenalinya
-2 cm H2O
Flow Triggering
Ventilator secara kontinyu memberikan flow rendah
ke dalam sirkuit pasien (open system)
Returned flow Delivered flow
No patient effort
Flow Triggering
1. Upaya nafas dimulai saat kontraksi diafragma
2. Saat pasien bernafas beberapa bagian flow didiversi ke
pasien
Less flow returned Delivered flow

Flow Triggering
1. Level flow yg rendah akan lebih nyaman untuk pasien (lebih

sensitif)
2. Keterlambatan waktu lebih kecil dibanding pressure trigger
3. Meningkatan respon waktu dari ventilator
All inspiratory efforts recognized
Pressure
Time
PEEP
 DEFINISI
◦ POSITIVE END EXPIRATORY PRESSURE
◦ SEWAKTU AKHIR EXPIRATORY, AIRWAY
PRESSURE TIDAK KEMBALI KETITIK NOL
 DIGUNAKAN BERSAMA DENGAN MODE LAIN
SEPERTI; SIMV, ACV ATAU PS
 DISEBUT CPAP JIKA DIGUNAKAN PADA MODE
NAFAS SPONTAN
PEEP
(Positive End Expiratory Pressure)
PEEP 5
REDISTRIBUSI CAIRAN
EKSTRAVASKULAR PARU
MENINGKATKAN VOLUME MENGEMBANGKAN ALVEOLI YG

ALVEOLUS KOLAPS (ALVEOLI RECRUITMENT)
PEEP
REDISTRIBUSI CAIRAN
EKSTRAVASKULAR PARU
0
+10
A
B
PEEP
MENINGKATKAN VOLUME
ALVEOLUS
0 +10 +20
A B C
Indications for Mechanical ventilation
Goals
 Patient comfort and rest

 Reversal of Hypoxemia
 Reversal of acute respiratory acidosis
 Reversal of respiratory muscle fatigue
 Prevention/Reversal of atelectasis
 Decrease myocardial ischemic
 Allowance of neuromuscular blockade
 Improve lung compliance
Variables for Initial
Settings
 Fraction of Inspired O2 - FIO2
 Tidal Volume - TV
 Respiratory Rate - RR(f)
 Flow Rate - Vi(L/m)
 PSV
 Mode (A/C, SIMV, PS)
 PEEP (cm of H2O)
Mechanical Ventilation
Non Invasive Invasive

Non Invasive: Ventilatory support that is given
without establishing endo- tracheal intubation or
tracheostomy is called Non invasive mechanical
ventilation
Invasive: Ventilatory support that is given through
endo-tracheal intubation or tracheostomy is called
as Invasive mechanical ventilation
Non invasive
Negative pressure Positive pressure

Producing Neg. pressure Delivering air/gas with
intermittently in the pleural positive pressure to the
space/ around the thoracic airway
cage
e.g.: Iron BiPAP & CPAP

Lung

Non Invasive Mechanical ventilation
 การใช ้ non-invasive mechanical

ventilation ในผูป้ ่ วยทีเ่ หมาะสม จะลด
โอกาสการใสท ่ อ
่ ชว ่ ยหายใจได้
Non invasive mechanical ventilation
Head gear
ventilator
Interface (mask)
Invasive
Positive Pressure
Pressure cycle Volume cycle Time cycle

Modes of Ventilation
 Mode
◦ Description of a breath type and the timing
of breath delivery
 Basically there are three breath delivery techniques
used with invasive positive pressure ventilation
 CMV – controlled mode ventilation
 SIMV – synchronized
 Spontaneous modes
 CMV
◦ Continuous Mandatory Ventilation
 All breaths are mandatory and can be volume or
pressure targeted
 Controlled Ventilation – when mandatory breaths

are time triggered
 Assist/Control Ventilation – when mandatory

breaths are either time triggered or patient
triggered
 CMV
◦ Continuous Mandatory Ventilation
 Controlled Ventilation – when mandatory breaths
are time triggered
 Mandatory breath – ventilator determines the start
time (time triggered) and/or the volume or pressure
target
 CMV
◦ Controlled Ventilation
 Appropriate when a patient can make no effort to
breathe or when ventilation must be completely
controlled
 Drugs
 Cerebral malfunctions
 Spinal cord injury
 Phrenic nerve injury
 Motor nerve paralysis
 CMV
 In other types of patients, controlled ventilation is
difficult to use unless the patient is sedated or
paralyzed with medications
 Seizure activity
 Tetanic contractions
 Inverses I:E ratio ventilation
 Patient is fighting (bucking) the ventilator
 Crushed chest injury – stabilizes the chest
 Complete rest for the patient
 CMV
 Adequate alarms must be set to safeguard the
patient
 Ex. disconnection
 Sensitivity should be set so that when the patient

begins to respond, they can receive gas flow from
the patient
Do not lock the patient out of the ventilator!

 CMV
◦ Assist/Control Ventilation
 A time or patient triggered CMV mode in which
the operator sets a minimum rate, sensitivity
level, type of breath (volume or pressure)
 The patient can trigger breaths at a faster rate
than the set minimum, but only the set volume
or pressure is delivered with each breath
 CMV
◦ Assist/Control Ventilation
 Indications
 Patients requiring full ventilatory support
 Patients with stable respiratory drive
 Advantages
 Decreases the work of breathing (WOB)
 Allows patients to regulate respiratory rate
 Helps maintain a normal PaCO2
 Complications
 Alveolar hyperventilation
 CMV
◦ Volume Controlled – CMV
 Time or patient triggered,
volume targeted, volume
cycled ventilation
 Graphic (VC-CMV)
 Time-triggered, constant
flow, volume-targeted
ventilation
 CMV
◦ Volume Controlled – CMV
 Time or patient triggered,
volume targeted, volume
cycled ventilation
 Graphic (VC-CMV)
 Time-triggered,
descending-flow, volume-
targeted ventilation
 CMV
◦ Pressure Controlled – CMV
 PC – CMV (AKA – Pressure control ventilation - PCV)
 Time or patient triggered, pressure targeted

(limited), time cycled ventilation
 The operator sets the length of inspiration (Ti), the

pressure level, and the backup rate of ventilation
 VT is based on the compliance and resistance of the

patient’s lungs, patient effort, and the set pressure
 CMV
 Note inspiratory pause
 CMV
 Note shorter Ti
 CMV
 Airway pressure is limited, which may help guard
against barotrauma or volume-associated lung injury
 Maximum inspiratory pressure set at 30 – 35 cm H2O
 Especially helpful in patients with ALI and ARDS
 Allows application of extended inspiratory time,

which may benefit patients with severe oxygenation
problems
 Usually reserved for patient who have poor results

with a conventional ventilation strategy of volume
ventilation
 CMV
 Occasionally, Ti is set longer than TE during PC-
CMV; known as Pressure Control Inverse Ratio
Ventilation
 Longer Ti provides better oxygenation to some
patients by increasing mean airway pressure
 Requires sedation, and in some cases paralysis
 IMV and SIMV

◦ Intermittent Mandatory Ventilation – IMV
 Periodic volume or pressure targeted breaths
occur at set interval (time triggering)
 Between mandatory breaths, the patient

breathes spontaneously at any desired baseline
pressure without receiving a mandatory breath
 Patient can breathe either from a continuous flow
or gas or from a demand valve
 IMV and SIMV

 Indications
 Facilitate transition from full ventilatory support to
partial support
 Advantages
 Maintains respiratory muscle strength by avoiding
muscle atrophy
 Decreases mean airway pressure
 Facilitates ventilator discontinuation – “weaning”
 IMV and SIMV

 Complications
 When used for weaning, may be done too quickly
and cause muscle fatigue
 Mechanical rate and spontaneous rate may
asynchronous causing “stacking”
 May cause barotrauma or volutrauma
 IMV and SIMV

◦ Synchronized IMV
 Operates in the same way as IMV except that
mandatory breaths are normally patient
triggered rather than time triggered (operator
set the volume or pressure target)
 As in IMV, the patient can breathe spontaneously

through the ventilator circuit between
mandatory breaths
 IMV and SIMV

 At a predetermined interval (respiratory rate),
which is set by the operator, the ventilator waits
for the patient’s next inspiratory effort
 When the ventilator senses the effort, the

ventilator assists the patient by synchronously
delivering a mandatory breath
 IMV and SIMV

 If the patient fails to initiate ventilation within a
predetermined interval, the ventilator provides a
mandatory breath at the end of the time period
 IMV and SIMV

 Indications
 Facilitate transition from full ventilatory support to
partial support
 Advantages
 Maintains respiratory muscle strength by avoiding
muscle atrophy
 Decreases mean airway pressure
 Facilitates ventilator discontinuation – “weaning”
 IMV and SIMV

 Complications
 When used for weaning, may be done too quickly
and cause muscle fatigue
 Spontaneous Modes
◦ Three basic means of providing support for
continuous spontaneous breathing during
mechanical ventilation
 Spontaneous breathing
 CPAP
 PSV – Pressure Support Ventilation

◦ Spontaneous breathing
 Patients can breathe spontaneously through a
ventilator circuit; sometimes called T-Piece
Method because it mimics having the patient ET
tube connected to a Briggs adapter (T-piece)
 Advantage
 Ventilator can monitor the patient’s breathing and
activate an alarm if something undesirable occurs
 Disadvantage
 May increase patient’s WOB with older ventilators
◦ CPAP
 Ventilators can provide
CPAP for spontaneously
breathing patients
 Helpful for improving
oxygenation in patients
with refractory hypoxemia
and a low FRC
 CPAP setting is adjusted
to provide the best
oxygenation with the
lowest positive pressure
and the lowest FiO2
Continuous Positive Airway Pressure
(CPAP)
 Positive airway pressure maintained
throughout respiratory cycle: during
inspiratory and expiratory phases
 Can be administered via ETT or nasal prongs
 Spontaneous
Modes
◦ CPAP
 Advantages
 Ventilator can
monitor the
patient’s
breathing and
activate an alarm
if something
undesirable
occurs
◦ PEEP (Positive End Expiratory Pressure)
“According to its purest definition, the term PEEP
is defined as positive pressure at the end of
exhalation during either spontaneous breathing
or mechanical ventilation. However, use of the
term commonly implies that the patient is also
receiving mandatory breaths from a ventilator.”
(Pilbeam)
 PEEP becomes the baseline variable during

◦ PEEP
 Helps prevent early airway closure and alveolar
collapse and the end of expiration by increasing
(and normalizing) the functional residual capacity
(FRC) of the lungs
 Facilitates better oxygenation
NOTE: PEEP is intended to improve oxygenation, not to

provide ventilation, which is the movement of air into
the lungs followed by exhalation
◦ Pressure Support Ventilation – PSV
 Patient triggered, pressure targeted, flow cycled
mode of ventilation
 Requires a patient with a consistent

spontaneous respiratory pattern
 The ventilator provides a constant pressure

during inspiration once it senses that the patient
has made an inspiratory effort
◦ PSV
◦ PSV
 Indications
 Spontaneously breathing patients who require
additional ventilatory support to help overcome
 WOB, CL, Raw
 Respiratory muscle weakness
 Weaning (either by itself or in combination with

SIMV)
◦ PSV
 Advantages
 Full to partial ventilatory support
 Augments the patients spontaneous VT
 Decreases the patient’s spontaneous respiratory
rate
 Decreases patient WOB by overcoming the
resistance of the artificial airway, vent circuit and
demand valves
 Allows patient control of TI, I, f and VT
◦ PSV
 Advantages
 Set peak pressure
 Prevents respiratory muscle atrophy
 Facilitates weaning
 Improves patient comfort and reduces need for
sedation
 May be applied in any mode that allows
spontaneous breathing, e.g., VC-SIMV, PC-SIMV
◦ PSV
 Disadvantages
 Requires consistent spontaneous ventilation
 Patients in stand-alone mode should have back-
up ventilation
 VT variable and dependant on lung characteristics
and synchrony
 Low exhaled E
 Fatigue and tachypnea if PS level is set too low
◦ Flow Cycling During PSV
 Flow cycling occurs when the ventilator
detects a decreasing flow, which
represents the end of inspiration
 This point is a percentage of peak flow

measured during inspiration
 PB 7200 – 5 L/min
 Bear 1000 – 25% of peak flow
 Servo 300 – 5% of peak flow
 No single flow-cycle percent is right

for all patients
◦ Flow Cycling During PSV
 Effect of changes in
termination flow
 A: Low percentage (17%)
 B: High percentage (57%)
 Newer ventilators have an

adjustable flow cycle
criterion, which can range
from 1% - 80%, depending
on the ventilator
◦ PSV during SIMV
 Spontaneous breaths during SIMV can be
supported with PSV (reduces the WOB)
PCV – SIMV with

PSV
◦ PSV during SIMV
 Spontaneous breaths during SIMV can be
supported with PSV
VC – SIMV with PSV

◦ PSV
NOTE: During pressure support ventilation (PSV),
inspiration ends if the inspiratory time (TI)
exceeds a certain value. This most often occurs
with a leak in the circuit. For example, a
deflated cuff causes a large leak. The flow
through the circuit might never drop to the flow
cycle criterion required by the ventilator.
Therefore, inspiratory flow, if not stopped would
continue indefinitely. For this reason, all
ventilators that provide pressure support also
have a maximum inspiratory time.
◦ PSV
 Setting the Level of Pressure Support
 Goal: To provide ventilatory support
 Spontaneous tidal volume is 10 – 12 mL/Kg of
ideal body weight
 Maintain spontaneous respiratory rate
<25/min
 Goal: To overcome system resistance (ET Tube,

circuit, etc.) in the spontaneous or IMV/SIMV mode
 Set pressure at (PIP – Pplateau) achieved in a
volume breath or at 5 – 10 cm H2O
◦ PSV
Exercise: Using the PIP and the PPlateau from the pressure
waveform below, recommend a pressure support setting
for this patient (patient is in VC-SIMV mode)
35
25
Answer: 10 cm H2O
◦ PSV - The results of your work
35 cm H2O
10 cm H2O
◦ Bilevel Positive Airway Pressure (BiPAP)
 An offshoot of PEEP/CPAP therapy
 Most often used in NPPV
 AKA
 Bilevel CPAP
 Bilevel PEEP
 Bilevel Pressure Support
 Bilevel Pressure Assist
 Bilevel Positive Pressure
 Bilevel Airway Pressure
 Commonly patient triggered but can be time
triggered, pressure targeted, flow or time cycled
 The operator sets two pressure levels

 IPAP (Inspiratory Positive Airway Pressure)
 IPAP is always set higher than EPAP
 Augments VT and improves ventilation
 EPAP (Expiratory Positive Airway Pressure)

 Prevents early airway closure and alveolar collapse at
the end of expiration by increasing (and normalizing)
the functional residual capacity (FRC) of the lungs
 Facilitates better oxygenation
 The operator sets two pressure levels
 IPAP
 EPAP
NOTE: The pressure difference between IPAP and EPAP is pressure support
Trouble Shooting
(Mechanical Ventilation)
Precautions that would reduce
troubles
I. Power:
 Plug into a grounded AC power with
correct voltage receptacle.
 Secure the power cord properly.
Battery Back up:
 Check the battery level before connecting.

 Charging should be carried out regularly.
 Remember it is for short term use.
II. Gas Source
 Preferable to have centralised supply.
 If cylinders used, should be full
 Spare cylinders should be available.
 Gas hoses should be in good condition.
 Hoses – not contaminated with grease or oil
(combustible)
 Availability of compressors should be ensured.
 Gases should remain dry and clean.
III. Personnel
 Properly trained personnel should only use.
 Familiarising staff with operator’s manuel before
using on a patient.
(One manufacturer’s manual may not exactly
match with other brands).
 Appropriate monitoring the functioning state of
the ventilator while in use.

Contd…
 Familiarizing staff with alarm system.

 Do not place ventilators in a combustible or
explosive environment.
 Do not use with flammable anaesthetic agents such
as nitrous oxide and ether.

IV Servicing and Testing
 Qualified personnel should undertake servicing.
 Ventilator housing should not be opened while it is
still connected with power.

 Follow the specifications mentioned in the service
manual.
 Use replacement parts supplied by the
manufacturer only.
Contd….
 General servicing at regular intervals

should be done.
 Run the prescribed tests and calibrations
before using the ventilator on a patient.

 Ensure that the ventilators pass all the
tests before putting them in to clinical

use.
ALARMS
 All ventilators are equipped with visual

and audible alarms which notify the user
problems.
Points to remember
 Never ignore an alarm.

 Never mute the alarm on regular basis.
 Find out for yourself what alarm is on.
 Check the patient.
 Silence the alarm.
Act Swiftly
 Depending upon the patient’s status and
nature of the alarm, act appropriately.
 This includes disconnecting the ventilator and
connecting another means of ventilation to

patient – Bain’s/ Ambu.
Do not forget
 The use of an alarm monitoring system

does not give absolute assurance of
warning for every form of trouble that
may occur with the ventilator.
Do not be like this !
But hear the alarm and respond

See the problem and
Ask if you do not know what to do
Common Troubles and Shooting
Ensure Alarm knobs / switches are turned
on and functional.
Alarm Cause Shooting
Apnoea •No breath was •Check the patient-
delivered for the Arouse if needed
operator set apnoea •Activate back up
time in spont, SIMV, facility if it was not
AC, CMV & NIV modes done already.
•Because spontaneous •Consider switching
Ventilation is too high over to any mandatory
or patient effort is too mode
minimal •Or go up on rate
•Trigger level set
•Set trigger level
improperly. appropriately
Low SpO2 Delivery of O2 : • Disconnect patient
FiO2, PEEP from ventilator
• Manually bag with
• High resistance Bain’s and Ambu.

due to various
clinical reasons
Air / O2 Supply pressures • Insert the gas hose

Blender are inadequate. fittings (air & O2)
continuous correctly into the wall
alarm outlets.
• Ensure wall outlets
has adequate
pressure
High The measured peak
Pressure inspiratory pressure
Alarm is great than set
level because of •Suctioning, Irrigation
•Secretions in
• Release tubings
airway
• Bite block insertion
• Partial block –
• Empty the tubings and
(ETt)
• Kinking of tube water traps
• Deflate & reinflate cuff
• Biting the tube
• Water in the tube 3-4 times

• Reposition the ET tube
• Cuff herniation
• Reposition the patient
• Deep Rt. sided
• Re assurance
intubation
• Sedation &
• Fighting the
ventilator medication (pain)

Low pressure The measured •Evaluate cuff pressure
or PIP is lesser than at regular intervals.
Low min.Vent the set minimum • Reinflate if leak /
Or level because of
ruptured is noticed –
• cuff leak.
Low exhaled change ET tube.
• Leak in the
volume or • Check circuits,
Disconnection circuit junctions-
• Connections
tighten or replace.
may be loose • Check water traps
• ET tube
• Check ET tube
displacement placement. Position it
• Disconnection
properly.
• Inadequate
• Reconnect ventilator.
flow • Patient may require
higher flow.
High • Cough • Medication
pressure • Increased airway • Bronchodilators
alarm resistance or • Adjust the settings
decreased ¯VT &  Rate
compliance • Adjust the settings

because of VT  Rate,  PEEP
• Bronchospasm
(Peak pressure to be
• Atelectasis monitored)
• Fluid overload
• Pneumothorax • Immediate intervention

Auto Cycling Leak & Improper • Secure all
trigger setting tubings tight
• Set proper
trigger level
High Tidal Patient trying to • Increase flow

Volume take more volume of rate or
air
Increase tidal
volume
Weaning from Mechanical Ventilation
Definition of Weaning
The transition process from
total ventilatory support
to spontaneous breathing.
This period may take many forms ranging from
abrupt withdrawal to gradual withdrawal from
ventilatory support.
Weaning
* Discontinuation of IPPV is achieved in most
patients without difficulty
* up to 20% of patients experience difficulty
* requires more gradual process so that they
can progressively assume spont. respiration
* the cost of care, discontinue IPPV should
proceed as soon as possible
Reversible reasons for prolonged
 Inadequate respiratory drive

 Inability of the lungs to carry
out gas exchange effectively

 Psychological dependency
 Inspiratory fatigue
Weaning
 Patients who fail attempts at weaning
constitute a unique problem in critical
care
 It is necessary to understand the
mechanisms of ventilatory failure in

order to address weaning in this
population
Why patients are unable to sustain
spontaneous breathing
 Concept of Load exceeding

Capacity to breathe
 Load on respiratory system
 Capacity of respiratory system
Balance Load vs Capacity
 Most patients fail the transition from
ventilator support to sustain spont.
breathing because of failure of the
respiratory muscle pump
 They typically have a resp muscle load the
exceeds the resp neuromuscular capacity

Load on Respiratory System
 Need for increase ventilation
increased carbon dioxide production
increased dead space ventilation
increased respiratory drive
 Increased work of breathing
Causes of Inspiratory respiratory muscle fatigue
 Nutrition and metabolic deficiencies: K, Mg, Ca,

Phosphate and thyroid hormone
 Corticosteroids
 Chronic renal failure
 Systemic disceases; protein synthesis,
degradation, glycogen stores

 Hypoxemia and hypercapnia
Capacity of respiratory system
 Central drive to breathe
 Transmission of CNS signal via Phrenic
nerve
 Impairment of resp muscles to generate
effective pressure gradients

 Impairment of normal muscle force
generation
Definitions
Tolerated – observations to monitor
Look at patient, do they look unsettled/tired/stressed?
Is respiratory rate below 35bpm & above 8bpm?
Are O2 saturations above 90%? (or as appropriate for patient)
Are ABGs acceptable for the patient?
Is PaO2 / FiO2 ratio >27.5kpc?
Inform Anaesthetist and Is TV 5ml/kg?
discontinue weaning if Is patient cardiovasculary stable?
any changes noted. Is patient settled and showing no signs of fatigue?
Document: All changes on Is respiratory rate/TV ratio <105 breaths/min (spontaneous rate for 1
ventilator and check
min divided by the TV in Litres)
ventilator changes with
another nurse. Signs of fatigue are:
 Decreasing TV
 Increasing respiratory rate
 Changes in blood gases
 Decreases in O2 saturations
 Tachycardic
 ECG changes
 Hypertension
 Breathlessness
 Use of accessory muscles
 Changes in conscious levels
 Sweating
Peran Dan Fungsi Perawat
Peran Dan Fungsi Perawat
SETTINGS
O2 Air Power
Ventilator
Patient
 มีน้ำใน circuit มากจนต้องเททิ้งบ่อยๆ
suction ETT
Stabilize the ETT
VAP: Preventive strategies
 Nebulisation
NURSE
NURSE
Precaution & Care
 Tracheobronchial Hygiene:
 Placement of tube: Chest movement

Auscultation
Post intubation X-ray
 Cuff pressure: If insufficient

 Leak - Displacement of the tube, Aspiration
 high pressure - Tracheal stenosis
Desired Pressure - 20-30cm water

Humidification Filling water & adjusting temperature
appropriately :
If inadequate: secretions would become thicker and lead

to tube block
Medication:
 Besides specific therapautic drugs the
following basic drugs are to be given.

 Sedatives & paralysing agents if needed.
 Analgesics
 Diuretics to reduce circulating fluid and volume
overload
 Reduce Gastric Acid: H2 blockers
Suction
 Should be done on PRN basis
 Ascultate and assess
 View the chest X-ray
 Determine the need and for effective
suctioning
 Hyperoxygenation & ventilation –
ambu/normal
 Keep strict vigil on the cardiac monitor pulse
oximeter during and soon after
suctioning
 If necessary carry out effective chest physio
 Monitoring:
Continuous and Periodic monitoring of

 Vital parameters such as temperature,SpO2, Pulse,
BP,ECG pattern, breath rate etc.
 Ventilator settings: All settings should be

recorded as per the doctors order
 Sensorium
 Intake and output
 Level of comfort
 Arterial blood gases twice daily
Nebulisation
 It
is advisable to put all the
patients on bronchodilators on
regular basis.
 Nebulise as per the doctor’s order

Monitoring for infection
 Colour, consistency, and amount of the

sputum / secretions with each suctioning
should be observed.
 Fever and other parameters have to closely

observed for any other infection. (central line,
etc)
Oxygen toxicity
 Try and maintain a SpO2 of > 90% and PaO2 of

60 – 90 mmHg with minimum possible FiO2
to prevent O2 toxicity.
 Especially for COPD patients :

Maintain SpO2 of 85 – 90% and PaO2
of 55 – 70 mmHg.
Nutrition:
 Enteral nutrition to support the patient’s
metabolic needs and defend against
infection.
 Avoid high carbohydrate diet during weaning.
NG tube if necessary – relieves gastric

distension and prevents aspiration.
Stress gastric ulcer
 Very common in critically ill patients
 Send stools for occult blood and gastric juice
for pH estimation
 Auscultate bowel movements
 Sedation and antacids adequately.
Alarms & Positioning:
 Never keep alarm system muted
 Never ignore even when you know the cause
for the alarm and may not be fatal
 Place the patient in low or semi Fowler’s

position to improve comfort and facilitate
respiration.
Communication:
 If conscious, explain the environment,
procedures, co-operation expected etc.
 Use verbal & non verbal methods
 Use paper & pen if necessary
 Provide calling bell if necessary
 Reassurance and support the patient during
the period of anxiety, frustration and
hopelessness
 Document patient’s emotional response and
any signs of psychosis
 Include family in the care
Teach……
 Co-operation with medical and nursing
interventions
 Certain breathing techniques
 The patient to recognize the importance of
breathing techniques.
 Frequent assessment of consciousness level,
adequate rest etc. are necessary.
Choosing the right catheter
• Multiply the tracheal tubes inner diameter by 2.

Then use the next smallest size catheter.
Example: 6mm ETT: 6 x 2 = 12; next

smallest catheter is 10 French
Example: 8mm ETT: 8 x 2 = 16; next

smallest catheter is 14 French
Complications and Hazards of Suctioning
Hypoxemia - #1 complication
– give oxygen before and after
– catheter size
• if the catheter is too big, there will be little or no air
entrained
– Time – suction no more that 15 secs.
Tissue trauma
– May be able to prevent it . . .
– catheter selection?
– intermittent vs. continuous
– a “delicate touch”
– vacuum adjustment
Complications and Hazards of Suctioning
Cardiac arrhythmias
– Vagal stimulation will cause
• bradycardia
– Hypoxemia can cause
• PVCs
• tachycardia
– If these occur…
STOP procedure and give oxygen
Extubation
 The nurse should explain the procedure to

the patient and prepare suction. The
patient should be sitting up at least 45
degrees.
 Prior to extubating, the patient should be
suctioned both via the ETT and orally.
 All fasteners holding the ETT should be
loosened.
Extubation
 A sterile suction catheter should be

inserted into the ETT and withdrawn as
the tube is removed.
 The ETT should be removed in a steady,
quick motion as the patient will likely

cough and gag.
Extubation
 The patient should be asked to cough and

speak. Quite often, the patient’s first
request is for water because of a dry, sore
throat. Generally, you can immediately
swab the patient’s mouth with an oral
swab dipped in water.
Post-Extubation Care
 Humidified oxygen
 Respiratory exercises
 Assessment and monitoring
 Prepare for intubation

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Peran dan fungsi perawat pada pasien

VOLUME INTRATORAKS >>

INTRAPLEURAL PRESSURE >> NEGATIF

PARU EKSPANSI (MENGEMBANG)

INTRAPULMONAL PRESSURE >> NEGATIF

UDARA MENGALIR KE DALAM PARU

HUKUM BOYLE PRESSURE DARI GAS BERBANDING

TABRAKAN PARTIKEL2 GAS

PERUBAHAN VOLUME VOLUME VOLUME

KONTRAKSI OTOT INTERKOSTALIS EKSTERNA  RELAKSASI OTOT INTERKOSTALIS EKSTERNA

KONTRAKSI DIAFRAGMA DIAFRAGMA RELAKSASI DIAFRAGMA  DIAFRAGMA

AIRWAY RESISTANCE COMPLIANCE

– Membatasi jumlah gas yg mengalir melewati jalan

250 250 250

FREKUENSI / RATE (f) : FLOW RATE :

Ins + Eksp Ins + Eksp

Returned flow Delivered flow

Less flow returned Delivered flow

1. Level flow yg rendah akan lebih nyaman untuk pasien (lebih

All inspiratory efforts recognized

MENINGKATKAN VOLUME MENGEMBANGKAN ALVEOLI YG

 Patient comfort and rest

Non Invasive Invasive

Negative pressure Positive pressure

e.g.: Iron BiPAP & CPAP

 การใช ้ non-invasive mechanical

Pressure cycle Volume cycle Time cycle

 Controlled Ventilation – when mandatory breaths

 Assist/Control Ventilation – when mandatory

 Sensitivity should be set so that when the patient

Do not lock the patient out of the ventilator!

 Time or patient triggered, pressure targeted

 The operator sets the length of inspiration (Ti), the

 VT is based on the compliance and resistance of the

 Allows application of extended inspiratory time,

 Usually reserved for patient who have poor results

 IMV and SIMV

 Between mandatory breaths, the patient

 IMV and SIMV

 IMV and SIMV

 IMV and SIMV

 As in IMV, the patient can breathe spontaneously

 IMV and SIMV

 When the ventilator senses the effort, the

 IMV and SIMV

 IMV and SIMV

 IMV and SIMV

 PSV – Pressure Support Ventilation

 PEEP becomes the baseline variable during

 Facilitates better oxygenation

NOTE: PEEP is intended to improve oxygenation, not to

 Requires a patient with a consistent

 The ventilator provides a constant pressure

 Weaning (either by itself or in combination with

 This point is a percentage of peak flow

 No single flow-cycle percent is right

 A: Low percentage (17%)

 B: High percentage (57%)

 Newer ventilators have an

PCV – SIMV with

VC – SIMV with PSV

 Goal: To overcome system resistance (ET Tube,

 The operator sets two pressure levels