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Ventilator mekanik
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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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CMV Controlled Ventilation
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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CMV Controlled Ventilation
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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CMV Pressure Controlled CMV
Note inspiratory pause
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CMV Pressure Controlled CMV
Note shorter Ti
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CMV Pressure Controlled CMV
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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CMV Pressure Controlled CMV
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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IMV and SIMV Intermittent Mandatory Ventilation IMV
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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IMV and SIMV Intermittent Mandatory Ventilation IMV
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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IMV and SIMV Synchronized IMV
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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IMV and SIMV Synchronized IMV
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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IMV and SIMV Synchronized IMV
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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IMV and SIMV Synchronized IMV
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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Spontaneous Modes PSV
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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Spontaneous Modes PSV
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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Spontaneous Modes PSV
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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Spontaneous Modes PSV
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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Spontaneous Modes PSV
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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Spontaneous Modes PSV
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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Spontaneous Modes PSV
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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Spontaneous Modes Bilevel Positive Airway Pressure (BiPAP)
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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Spontaneous Modes Bilevel Positive Airway Pressure (BiPAP)
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