ACUTE RESPIRATORY FAILURE

Ventilation CO2

Respiration
Oxygenation O2

Anatomy of respiratory system

Respiratory mechanic
ribs ribs vertebral column sternum sternum vertebral column

diafragma

diafragma

EXPIRATION

INSPIRATION

Kemoreseptor

Kemosensitif rostral & kaudal

Glomus karotikum & aortikum

air -4

Air flow

air

+2 Intra thoracal Intra pulmonal +4

- 10

-4

-7

INSPIRATION

EXPIRATION

Lung Volume
6.0

Inspiratory Reserve Volume

Tidal Volume Expiratory Reserve Volume

2.7 2.2

1.2
Residual Volume Dead Space

0.0 Volume (L)

ALVEOLI
Tipe-1

Tipe-1I

Gas transportation
ClHCO3- + H+ H2CO3 H2O + CO2 HHb H+ + HbHbO2 Hb + O2 O2 CO2

Lung

Plasma

ClCO2 CO2 + H2O H2CO3 H+ + HCO3-

Tissue
O2

HHb H+ + HbO2 + Hb HbO2

O2 158.0 CO2 0.3 H2O 5.7 N 596.0 inspirasi

ruang rugi 100.0 40.0 47.0 573.0 jantung kiri

alveoli O2 CO2 H2O N jantung kanan

O2 CO2 H2O N

116.0 32.0 47.0 565.0 expirasi

O2 CO2 H2O N

40.0 46.0 vena 47.0 573.0 O2 CO2 H2O N

kapiler 40.0 46.0 47.0 573.0 jaringan

O2 CO2 arteri H2O N

95.0 40.0 47.0 573.0

Faktor predisposisi
Struktur dan fungsi toraks belum sempurna Saluran nafas sempit Alveolus belum berkembang Defisiensi surfaktan Kelainan bawaan Rentan (mudah infeksi saluran nafas)

Anatomical & Physiological difference Neonate vs Adult

Lung weight, g of trachea, mm of bronchioles, mm of alveolus, Numbers of alveolus, 106 Number of airways, 106 Total alveolar surface area, M2 Total flow resistance, cm H2O/L/sec Respiratory rate/min Tidal Volume, ml/kg Neonate 50 8 0.1 50-100 24 1.5 4 68 40 6 Adult 800 18 0.2 200-300 296 14 80 5.5 20 7

Gangguan jalan nafas

Croup Sumbatan benda asing Bronkitis Asma Pnemonia Edema paru Deformitas toraks Hernia diafragmatika Fraktur iga Efusi plura Anemia berat/intoksikasi Renjatan Gagal jantung Trauma/infeksi batang otak Poliomielitis Trauma lahir (n.prenikus)

Etiologi

Gangguan mekanik Pernafasan

Gangguan transportasi gas Gangguan neurologik

Criteria for respiratory failure

Clinical
Decreased or absent inspiratory breath sounds Severe inspiratory retractions Cyanosis in 40 % O2 Depressed level of consciousness Poor skeletal muscle tone PaCO2 > 75 mmHg PaO2 < 100 mmHg in 100 % O2

Physiologic

Three clinical + One physiologic criterion = ARF

Management
Supportive Definitive

Supportive
Respiratory Circulatory/Hematologic Fluid/Electrolyte/Caloric

Negative pressure VENTILATOR Positive pressure

(Air shield isolatte) Pressure limited Volume limited I/E ratio limited

Time cycle

Time limited

High frequency

P-

P+

Negative pressure ventilator

Positive pressure ventilator

The steps in managing of mechanical ventilation

Choose appropriate goals for ventilation and oxygenation Select the modes of ventilation Determination of initial ventilatory parameters Set the selected parameters Initiate the ventilatory support Confirm the appropriateness of initial setting and make adjustments accordingly Anticipate complications Start weaning when ventilatory support no more required

Ventilation

Respiration

pH Minute Volume PaCO2 Rate ETCO2 Tidal Volume

FiO2 PaO2 Mean Airway Oxygenation SaO2 Pressure (MAP)