Ventilator Mekanik

5/20/2018 Ventilator Mekanik

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Peran dan fungsi perawat pada pasiendengan respirator mekanik

By

MAS YOESZ


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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


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MEMBUKA JALAN NAPAS

MEMBERIKAN TAMBAHAN OKSIGEN

MENUNJANG VENTILASI

MENCEGAH ASPIRASI


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1.

INFANT ATERM, ID 3,5mm, PANJANG 12 cm

2.

ANAK, ID : 4 + , PANJANG 14 +

3. DEWASA :

ID WANITA 7 7.5, PANJANG 20 -24

ID LAKI-LAKI 7.5 -9, PANJANG 20 -24

Umur4

Umur4


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PROSES MEKANIK, KELUAR MASUKNYAUDARA DARI LUAR KE DALAM PARU DANSEBALIKNYA YAITU BERNAFAS

TERJADI ANTARA UDARA DALAM ALVEOLUSDENGAN DARAH DALAM KAPILER, PROSESNYADISEBUT DIFUSI

VENTILASI PARU

PERTUKARAN GAS

EKSTERNA

INTERNA

UTILISASI O2

PERTUKARAN GAS

PEMAKAIAN OKSIGENDALAM SEL PADA REAKSIPELEPASAN ENERGI

PERTUKARAN GASANTARA DARAHDENGAN SELJARINGAN/TISUE


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MEKANISME INSPIRASI

KONTRAKSI DIAFRAGMA & INTERKOSTALIS EKST

VOLUME INTRATORAKS >>

INTRAPLEURAL PRESSURE >> NEGATIF

PARU EKSPANSI (MENGEMBANG)

INTRAPULMONAL PRESSURE >> NEGATIF

UDARA MENGALIR KE DALAM PARU


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HUKUM BOYLEPRESSURE DARI GAS BERBANDINGTERBALIK DGN VOL CONTAINER

VOLUME

PRESSURE

VOLUME

PRESSURE

PERUBAHAN VOLUMEMENYEBABKAN

PERUBAHAN PRESSURE

TABRAKAN PARTIKEL2 GAS

KE DINDING KONTAINER

MENIMBULKAN PRESSURE


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INSPIRASI

KONTRAKSI OTOT INTERKOSTALIS EKSTERNA

IGA TERANGKAT

KONTRAKSI DIAFRAGMA DIAFRAGMA

BERGERAK INFERIOR

EKSPIRASI

RELAKSASI OTOT INTERKOSTALIS EKSTERNA

IGA KE POSISI SEMULA

RELAKSASI DIAFRAGMA DIAFRAGMA

BERGERAK KE POSISI SEMULA

INTRATORAK

VOLUME

PRESSURE

VOLUME

PRESSURE


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AIRWAY RESISTANCE

(RAW)

COMPLIANCE

(COMPL)

VENTILASI PARU

CL

RAW

LUNG

AIRWAY


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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 adalahmeningkatkan usaha nafas (WoB = RR >>, otot

bantu nafas >>)


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FLOW =

PRESSURE

RESISTANCE

BRONKUSNORMAL

AIRWAY RESISTANCE

(RAW)


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FLOW =PRESSURE

RESISTANCE

BRONKODILATASI:

EPINEFRIN

AMINOFILIN

BETA 2 AGONIS

AIRWAY RESISTANCE

(RAW)


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FLOW =

PRESSURE

RESISTANCE

BRONKOKONSTRIKSI:

HISTAMIN

OBSTRUKSI:

MUKUS/SEKRET

AIRWAY RESISTANCE

(RAW)


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FLOW =PRESSURE

RESISTANCE

BRONKOSPASME

TUMOR/SEKRET

ETT TERLALUKECIL

KOLAPS/ATELEKTASIS

AIRWAYRESISTANCE (RAW)


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Kaku Elastis

LOWCOMPLIANCE

HIGHCOMPLIANCE

BALON


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DefinisiRasio perubahan volume akibat terjadinya perubahan pressure V/PTerbagi 2;

Compl paru (edema paru, fibrosis, surfactan : u/memasukkan volume yang diinginkan dibutuhkan pressureyg lebih besar.

High compliance Muscle relaxant, COPD, open chestdgn pressure yg

kecil dapat tidal volume yg masuk besar


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Work Of Breathing

ComplianceNormal 35-100ml/cm H2O

ResistanceNormal 6cmH2O/l/sec

Minute Ventilation

Normal 12High VD/VTHigh CO2 Production


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15 30

250

500

0

P

Vol

500 500

250 250

15 30 15 30

LOWCOMPLIANCE

HIGHCOMPLIANCENORMAL

PEEP 5INSPIRASI

EKSPIRASI

NAFASSPONTAN


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ANATOMICAL

DEAD SPACE

ALVEOLAR

DEAD SPACE

PHYSIOLOGICAL

DEAD SPACE

VENOUS ADMIXTURE

(SHUNT)

V/Q =

V/Q > 1

V/Q = 1

V/Q < 1

V/Q = 0

TRAKEA

KAPILER

PARU MECHANICAL

DEAD SPACE:

TUBE

CONNECTOR

ET CO2

BREATHING

CIRCUIT

NORMAL


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FiO2 :

FRAKSI KONSENTRASIOKSIGEN INSPIRASI YG

DIBERIKAN (21 100%)

TIDAL VOLUME (VT):

JUMLAH GAS/UDARA YGDIBERIKAN VENTILATOR

SELAMA INSPIRASI DALAM

SATUAN ml/cc ATAU liter. (5-

10 cc/kgBB)

FREKUENSI / RATE (f) :

JUMLAH BERAPA KALI

INSPIRASI DIBERIKANVENTILATOR DALAM 1

MENIT (10-12 bpm)

FLOW RATE :

KECEPATAN ALIRAN GAS

ATAU VOLUME GAS YGDIHANTARKAN PERMENIT

(liter/menit)


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- 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

T I M E = WAKTU frekuensi


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Setelan sensitifitas akan menentukan variabel trigger

Variabel trigger menentukan kapan ventilator mengenali adanya

upaya nafas pasien

Ketika upaya nafas pasien dikenali, ventilator akan memberikannafas

Variabel trigger dapat berupa pressure atau flow


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Upaya nafas pasien dimulai saat terjadi kontraksi otot diafragma

Upaya nafas ini akan menurunkan tekanan (pressure) di dalam

sirkuit ventilator (tubing)

X X


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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.

BaselineTrigger

Patient effort

Pressure


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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


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Flow Triggering

Ventilator secara kontinyu memberikan flow rendahke dalam sirkuit pasien (open system)

Delivered flowReturned flow

No patient effort


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Flow Triggering

1. Upaya nafas dimulai saat kontraksi diafragma2. Saat pasien bernafas beberapa bagian flow didiversi ke

pasien

Delivered flowLess flow returned


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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

Time

Pressure


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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


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PEEP 5

REDISTRIBUSI CAIRAN

EKSTRAVASKULAR PARU

MENINGKATKAN VOLUMEALVEOLUS

MENGEMBANGKAN ALVEOLI YGKOLAPS (ALVEOLI RECRUITMENT)


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REDISTRIBUSI CAIRANEKSTRAVASKULAR PARU

+100

A B


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MENINGKATKAN VOLUME

ALVEOLUS

+20+100

A B C


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Work of Breathing

AirwayProtectionOxygenation


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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


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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)


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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


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Non invasive

Negative pressure

Producing Neg. pressure

intermittently in the

pleural space/ around the

thoracic cage

Positive pressure

Delivering air/gas with

positive pressure to the

airway

e.g.: Iron

Lung

BiPAP & CPAP


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non-invasive mechanicalventilation


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Head gear

Interface (mask)

ventilator

Invasive


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Positive Pressure

Pressure cycle Volume cycle

Time cycle


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Mode Description of a breath type and the timing

of breath delivery

Basically there are three breath delivery techniquesused with invasive positive pressure ventilation

CMV controlled mode ventilation

SIMV synchronized

Spontaneous modes


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CMV Continuous Mandatory Ventilation

All breaths are mandatory and can be volume or

pressure targeted

Controlled Ventilation when mandatory breathsare time triggered

Assist/Control Ventilationwhen mandatory

breaths are either time triggered or patienttriggered


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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 pressuretarget


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CMV Controlled Ventilation

Appropriate when a patient can make no effort to

breathe or when ventilation must be completelycontrolled

Drugs

Cerebral malfunctions

Spinal cord injury

Phrenic nerve injury Motor nerve paralysis


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In other types of patients, controlled ventilation is

difficult to use unless the patient is sedated orparalyzed 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


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Adequate alarms must be set to safeguard the

patient Ex. disconnection

Sensitivity should be set so that when the patientbegins to respond, they can receive gas flow from

the patient

Do not lock the patient out of the ventilator!


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CMV Assist/Control Ventilation

A time or patient triggered CMV mode in which

the operator sets a minimum rate, sensitivitylevel, type of breath (volume or pressure)

The patient can trigger breaths at a faster ratethan the set minimum, but only the set volume orpressure is delivered with each breath


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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


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CMV Volume Controlled

CMV Time or patient

triggered, volumetargeted, volume cycledventilation

Graphic (VC-CMV) Time-triggered,

constant flow, volume-targeted ventilation


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CMV Volume Controlled

CMV Time or patient

triggered, volumetargeted, volume cycledventilation

Graphic (VC-CMV) Time-triggered,

descending-flow,volume-targetedventilation


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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), thepressure level, and the backup rate of ventilation

VT is based on the compliance and resistance ofthe patients lungs, patient effort, and the setpressure


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Note inspiratory pause


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Note shorter Ti


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Airway pressure is limited, which may help guardagainst barotrauma or volume-associated lunginjury 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 severeoxygenation problems

Usually reserved for patient who have poorresults with a conventional ventilation strategyof volume ventilation


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Occasionally, Ti is set longer than TE during PC-

CMV; known asPressure Control Inverse Ratio

Ventilation

Longer Ti provides better oxygenation to somepatients by increasing mean airway pressure

Requires sedation, and in some cases paralysis


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IMV and SIMV Intermittent Mandatory Ventilation IMV

Periodic volume or pressure targeted breaths

occur at set interval (time triggering)

Between mandatory breaths, the patientbreathes spontaneously at any desired baselinepressure without receiving a mandatory breath

Patient can breathe either from a continuous flow

or gas or from a demand valve


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Indications

Facilitate transition from full ventilatory support topartial support

Advantages

Maintains respiratory muscle strength by avoiding

muscle atrophy Decreases mean airway pressure

Facilitates ventilator discontinuation weaning


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Complications

When used for weaning, may be done too quicklyand cause muscle fatigue

Mechanical rate and spontaneous rate mayasynchronous causing stacking

May cause barotrauma or volutrauma


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IMV and SIMV Synchronized IMV

Operates in the same way as IMV except thatmandatory breaths are normally patienttriggered rather than time triggered (operatorset the volume or pressure target)

As in IMV, the patient can breathe spontaneously

through the ventilator circuit between mandatorybreaths


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At a predetermined interval (respiratory rate),which is set by the operator, the ventilator waitsfor the patients next inspiratory effort

When the ventilator senses the effort, theventilator assists the patient by synchronously

delivering a mandatory breath


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If the patient fails to initiate ventilation within apredetermined interval, the ventilator provides amandatory breath at the end of the time period


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Indications

Facilitate transition from full ventilatory support topartial support

Advantages

Maintains respiratory muscle strength by avoidingmuscle atrophy

Decreases mean airway pressure

Facilitates ventilator discontinuation weaning


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Complications

When used for weaning, may be done too quicklyand cause muscle fatigue


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Spontaneous Modes Three basic means of providing support for

continuous spontaneous breathing during

mechanical ventilation

Spontaneous breathing

CPAP

PSV Pressure Support Ventilation


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Spontaneous Modes Spontaneous breathing

Patients can breathe spontaneously through aventilator circuit; sometimes called T-Piece

Method because it mimics having the patient ETtube connected to a Briggs adapter (T-piece)

Advantage Ventilator can monitor the patients breathing and

activate an alarm if something undesirable occurs

Disadvantage May increase patients WOB with older ventilators


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Spontaneous Modes CPAP

Ventilators can provideCPAP for spontaneouslybreathing patients Helpful for improving

oxygenation in patientswith refractory hypoxemiaand a low FRC

CPAP setting is adjustedto provide the bestoxygenation with thelowest positive pressureand the lowest FiO2


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Positive airway pressure maintainedthroughout respiratory cycle: duringinspiratory and expiratory phases

Can be administered via ETT or nasal prongs


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SpontaneousModes CPAP

Advantages Ventilator can

monitor thepatientsbreathing andactivate an alarm

if somethingundesirableoccurs


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Spontaneous Modes PEEP (Positive End Expiratory Pressure)

According to its purest definition, the term PEEPis defined as positive pressure at the end ofexhalation during either spontaneous breathingor mechanical ventilation. However, use of theterm commonly implies that the patient is alsoreceiving mandatory breaths from a ventilator.(Pilbeam)

PEEP becomes the baseline variable duringmechanical ventilation


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Spontaneous Modes PEEP

Helps prevent early airway closure and alveolarcollapse 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 intothe lungs followed by exhalation


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Spontaneous Modes Pressure Support Ventilation PSV

Patient triggered, pressure targeted, flow cycledmode of ventilation

Requires a patient with a consistent spontaneousrespiratory pattern

The ventilator provides a constant pressureduring inspiration once it senses that the patienthas made an inspiratory effort


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Spontaneous Modes PSV


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Indications

Spontaneously breathing patients who requireadditional ventilatory support to help overcome

WOB, CL, Raw

Respiratory muscle weakness

Weaning (either by itself or in combination withSIMV)


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Advantages

Full to partial ventilatory support

Augments the patients spontaneous VT

Decreases the patients spontaneous respiratoryrate

Decreases patient WOB by overcoming theresistance of the artificial airway, vent circuit and

demand valves Allows patient control of TI, I, f and VT


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Advantages

Set peak pressure

Prevents respiratory muscle atrophy

Facilitates weaning

Improves patient comfort and reduces need forsedation

May be applied in any mode that allowsspontaneous breathing, e.g., VC-SIMV, PC-SIMV


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Disadvantages

Requires consistent spontaneous ventilation

Patients in stand-alone mode should have back-up ventilation

VT variable and dependant on lung characteristicsand synchrony

Low exhaled E

Fatigue and tachypnea if PS level is set too low


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Spontaneous Modes Flow Cycling During PSV

Flow cycling occurs when theventilator detects a decreasing flow,

which represents the end ofinspiration

This point is a percentage of peakflow 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 rightfor all patients


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Spontaneous Modes Flow Cycling During PSV

Effect of changes intermination flow

A: Low percentage (17%)

B: High percentage (57%)

Newer ventilators have anadjustable flow cyclecriterion, which can rangefrom 1% - 80%, dependingon the ventilator


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Spontaneous Modes PSV during SIMV

Spontaneous breaths during SIMV can besupported with PSV (reduces the WOB)

PCV SIMV withPSV


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Spontaneous Modes PSV during SIMV

Spontaneous breaths during SIMV can besupported with PSV

VC SIMV with PSV


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NOTE:During pressure support ventilation (PSV),inspiration ends if the inspiratory time (TI)exceeds a certain value. This most often occurswith a leak in the circuit. For example, adeflated cuff causes a large leak. The flowthrough the circuit might never drop to the flowcycle criterion required by the ventilator.

Therefore, inspiratory flow, if not stopped wouldcontinue indefinitely. For this reason, allventilators that provide pressure support alsohave a maximum inspiratory time.


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Setting the Level of Pressure Support

Goal: To provide ventilatory support

Spontaneous tidal volume is 10 12 mL/Kg ofideal body weight

Maintain spontaneous respiratory rate


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Exercise: Using the PIP and thePPlateaufrom the pressurewaveform below, recommend a pressure support settingfor this patient (patient is in VC-SIMV mode)

35

25

Answer: 1 cm H2O


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Spontaneous Modes PSV - The results of your work

35 cm H2O

10 cm H2O


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Spontaneous Modes 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


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Commonly patient triggered but can be timetriggered, 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


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The operator sets two pressure levels

IPAP

EPAP

NOTE:The pressure difference between IPAP and EPAP is pressure support


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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.


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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 remaindry and clean.


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Properly trained personnel should only use.

Familiarising staff with operators manuel before

using on a patient.

One manufacturers manual may not exactly

match with other brands).

Appropriate monitoring the functioning state of

the ventilator while in use.


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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.


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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.


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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.


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All ventilators are equipped with visual

and audible alarms which notify the user

problems.


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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.


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Depending upon the patients status and

nature of the alarm, act appropriately.

This includes disconnecting the ventilator

and connecting another means of ventilation

to patient Bains/ Ambu.


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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


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But hear the alarm and respond

See the problem and

Ask if you do not know what to do

Ensure Alarm knobs / switches are turned


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on and functional.

Alarm Cause Shooting

Apnoea No breath wasdelivered for the

operator set apnoeatime in spont, SIMV,AC, CMV & NIV modes

Because spontaneous

Ventilation is too highor patient effort is toominimal

Trigger level setimproperly.

Check the patient-Arouse if needed

Activate back upfacility if it was notdone already.

Consider switching

over to any mandatormode

Or go up on rate

Set trigger level

appropriately

Low SpO2 Delivery of O2 :

FiO2, PEEPDisconnect patient

from ventilator


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Air / O2Blendercontinuous

alarm

2

High resistancedue to various

clinical reasons

Supply pressures

are inadequate.

from ventilator

Manually bag with

Bains and Ambu.

Insert the gas hose

fittings (air & O2)

correctly into the wall

outlets.Ensure wall outlets

has adequate

pressure

HighPressureAlarm

The measured peakinspiratory pressureis great than setl l b f


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level because of

Secretions inairway

Partial block(ETt)

Kinking of tubeBiting the tube

Water in the tube

Cuff herniation

Deep Rt. sidedintubation

Fighting the

ventilator

Suctioning, Irrigation

Release tubings

Bite block insertion

Empty the tubings and

water traps

Deflate & reinflate cuff

3-4 times

Reposition the ET tube

Reposition the patientRe assurance

Sedation &

medication (pain)

Low pressureor

Low min.Vent

The measuredPIP is lesser thanthe set minimuml l b f

Evaluate cuff pressureat regular intervals.

Reinflate if leak /


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Or

Low exhaledvolume or

Disconnection

level because of

cuff leak.Leak in the

circuit

Connections

may be looseET tube

displacement

Disconnection

Inadequate

flow

/

ruptured is noticed

change ET tube.

Check circuits,junctions-

tighten or replace.

Check water traps

Check ET tube

placement. Position it

properly.Reconnect ventilator.

Patient may require

higher flow.

Highpressure

Cough

Increased airway

Medication

Bronchodilators


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alarmy

resistance or

decreased

compliance

because of

Bronchospasm

Atelectasis

Fluid overload

Pneumothorax

Adjust the settings

VT& Rate

Adjust the settings

VT Rate, PEEP

(Peak pressure to bemonitored)

Immediate intervention

Auto Cycling Leak & Improperi i

Secure all


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High Tidal

Volume

trigger setting

Patient trying to

take more volume ofair

tubings tight

Set propertrigger level

Increase flow

rate or

Increase tidal

volume


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The transition process fromtotal ventilatory support

to spontaneous breathing.

This period may take many forms ranging fromabrupt withdrawal to gradual withdrawal from

ventilatory support.


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Discontinuation of IPPV is achieved inmost 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


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Inadequate respiratory drive

Inability of the lungs to carryout gas exchange effectively

Psychological dependency

Inspiratory fatigue


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Patients who fail attempts at weaningconstitute a unique problem in critical

care

It is necessary to understand the

mechanisms of ventilatory failure in

order to address weaning in this

population


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Concept of Load exceeding

Capacity to breathe

Load on respiratory system

Capacity of respiratory system


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Most patients fail the transition fromventilator support to sustain spont.breathing because of failure of the

respiratory muscle pumpThey typically have a resp muscle

load the exceeds the resp

neuromuscular capacity


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Need for increase ventilation

increased carbon dioxide

productionincreased dead space ventilation

increased respiratory drive Increased work of breathing


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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


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Central drive to breathe

Transmission of CNS signal via Phrenic

nerve

Impairment of resp muscles to generate

effective pressure gradients

Impairment of normal muscle forcegeneration


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DefinitionsToleratedobservations to monitor

Look at patient, do they look unsettled/tired/stressed?

Is respiratory rate below 35bpm & above 8bpm?


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p y p p

Are O2saturations above 90%? (or as appropriate for patient)

Are ABGs acceptable for the patient?

Is PaO2/ FiO2ratio >27.5kpc?

Is TV 5ml/kg?

Is patient cardiovasculary stable?

Is patient settled and showing no signs of fatigue?

Is respiratory rate/TV ratio


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Peran Dan Fungsi Perawat

Peran Dan Fungsi Perawat


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SETTINGS


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O

2

Air Power

Ventilator

Patient


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circuit


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Stabilize the ETT


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Nebulisation


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NURSE


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NURSE


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Tracheobronchial Hygiene:

Placement of tube: Chest movementAuscultationPost 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 :


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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


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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,


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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


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It is advisable to put all thepatients on bronchodilators on

regular basis.

Nebulise as per the doctors order


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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)


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Try and maintain a SpO2

of > 90% and PaO

2

of

60 90 mmHg with minimum possible FiO

2

to prevent O

2

toxicity.

Especially for COPD patients :

Maintain SpO

2

of 85 90% and PaO

2

of 55 70 mmHg.


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Enteral nutrition to support the patients

metabolic needs and defend against

infection.

Avoid high carbohydrate diet during weaning.

NG tube if necessary relieves gastric

distension and prevents aspiration.


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Very common in critically ill patients

Send stools for occult blood and gastric juice

for pH estimation

Auscultate bowel movements

Sedation and antacids adequately.


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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 Fowlers

position to improve comfort and facilitate

respiration.

If conscious, explain the environment,


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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 patients emotional response and

any signs of psychosis

Include family in the care

Co-operation with medical and nursing

interventions


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Certain breathing techniques The patient to recognize the importance of

breathing techniques.

Frequent assessment of consciousness level,

adequate rest etc. are necessary.


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Multiply the tracheal tubes inner diameter by 2


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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: 6 x 2 = 16; next

smallest catheter is 14 French


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Hypoxemia - #1 complication


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give oxygen before and aftercatheter 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 touchvacuum adjustment


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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

The nurse should explain the procedure to


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p p

the patient and prepare suction. Thepatient should be sitting up at least 45degrees.

Prior to extubating, the patient should be

suctioned both via the ETT and orally. All fasteners holding the ETT should be

loosened.


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A sterile suction catheter should beinserted into the ETT and withdrawn asthe tube is removed.

The ETT should be removed in a steady,

quick motion as the patient will likelycough and gag.


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The patient should be asked to cough andspeak. Quite often, the patients firstrequest is for water because of a dry, sorethroat. Generally, you can immediately

swab the patients mouth with an oralswab dipped in water.


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Humidified oxygen

Respiratory exercises

Assessment and monitoring

Prepare for intubation

Documents

Ventilator Mekanik