Mechanical Ventilation

PENDAHULUAN
Tindakan setelah intubasi dan memerlukan ventilasi
mekanik, merupakan intervensi penyelamat jiwa yang
sering di departemen emergensi

Manajemen ventilator yang buruk dapat menyebabkan

kerusakan pulmoner serta ekstrapulmoner berat yang
tidak selalu muncul di awal

Mode ventilasi adalah pengaturan siklus ventilasi saat

ekspirasi dan inspirasi agar pasien dapat bernafas
spontan.
Indication for mechanical ventilation
 Mechanical ventilation
• Physiology:
– Positive pressure ventilation versus natural negative
pressure ventilation
• Effects:
– Heterogeneous ventilation
• Preferential ventilation of the non-dependent regions
– Increased physiologic dead space
– Improvement of physiologic shunt causes by
atelectasis and/or alveolar filling
– Rapid disuse atrophy of the diaphragm
– Impairment of mucociliary clearance
• Cardiovascular effects:
– Decreased venous return
• Exacerbated by:
– Auto-PEEP
– Applied PEEP
– Intravascular volume depletion
– Cardiac tamponnade
– Increased right ventricular afterload:
• Compression of the pulmonary vascular bed  Increased
PVR
– May decrease left ventricular afterload
• Lung exansion decreased extramural pressure
 Mechanical ventilation:
Complications
• Barotrauma
– Incidence ~3%
– To Avoid: Keep plateau pressure < 35 cm
• Vili
– Over stretch
– Atelectotrauma
• Auto-PEEP
• Asyncrhony
 Mechanical ventilation: Modes
• There are two basic modus of mechanical
ventilation, based on the method used to
inflate the lung:
– Volume control ventilation
the lung inflated at a constant flow rate until
the desired volume is delivered
– Pressure control ventilation
high flow rates are used at the onset of lung
inflation to achieve the desire inflation pressure
quickly
 Volume limited vs pressure limited
• Volume limited • Pressure limited
– Physician sets: – Physician sets:
• Tidal volume • Peak airway pressure
• Rate • Inspiratory time
– Guaranteed constant tidal – Tidal volume and minute
volume ventilation depends entirely
– Guaranteed minute on patient factors:
ventilation compliance and airway
– High peak pressures resistance
– Associated with lower peak
airway pressure
– Associated with more
homogenous gas
distribution

No difference in mortality, oxygenation, or work of breathing

WHICH METHOD IS PREFERRED
• Advantage of VCV is the ability to maintain a constant level of
alveolar ventilation, despite change in the mechanical properties of
the lung. With PVC, alveolar ventilation will decrease if there is an
increase in arways resistance
• Another advantage of VCVis the ability to use the llung protective
ventilation protocol
• Major advantage of PVC is patient comfort, which promotes
syncronous breathing with the ventilator and reduce wob.
• Another advantage of PVC is the lower peak airway pressure
 Mechanical ventilation: Modes
• Choices:
– Mandatory vs non-mandatory
• Mandatory
– Volume vs pressure limited ventilation
– Mandatory rate
– Modes:
» SIMV
» Assist Control
» PCV
» Hybrid Modes: PRVC, SIMV/PRVC
• Non-mandatory or assisted breaths
– PSV
 Variables: some default values
• Trigger sensitivity: -1 to -3 cm
• Tidal volume: 6-8mg/kg/IBW
• Rate: 10 to 14
• PEEP: 5 cm H2O
• Flow rate: 60 L/min
• I to E ratio
• Peak pressure
• Plateau pressure
– Surrogate for peak alveolar distending
pressure
• Peak – Plateau
– Resistive pressure
• Mean airway pressure
– Pressure applied acorss the lung and chest
wall averaged throughout the ventilary cycle
 Assist-Control
• Allows the patient the initiate a ventilator breath, but possible,
ventilator breath are delivered at a preselected rate.
• Set variables
– Volume controlled or pressure controlled
– Flow rate or Ti
– PEEP FiO2
– Mandatory rate
• Spontaneous breaths
– Additional cycles can be triggered; patient triggered & time
triggered
 SIMV
• Allows patients to breath spontaneously between ventilator breaths.
Ventilator breaths are delivered in synchrony with the patients
spontaneous breath, this is called SIMV
• Set variables
– Targeted volume or pressure
– Flow rate
– Manatory frequency
– PEEP
– FiO2
– PS augmentation for spontaneous breaths
• Spontaneous breaths
– Increased wob, wich can be reduced by pressure-support
ventilation duing spontaneous breathing period
 PSV
• Pressure-augmented spontaneous breathing
• Patient terminates the lung inflation, the breath
terminated when the flow rate falls to 25% of the peak
level
• Allows the patient to determine the duration of lung
inflation, and the resulting tidal volume
LUNG PROTECTIVE