Unit Kerja Koordinasi

Emergensi Dan Rawat Intensif Anak

Ikatan Dokter Anak Indonesia

MODES OF VENTILATION

Ririe Fachrina Malisie

 Objective

Memahami prinsip kerja modus dasar ventilator

Mampu memilih parameter inisial
Mampu melakukan pengaturan awal
Mampu melakukan penyesuaian sesuai kondisi
pasien
TIPE NAPAS BERDASARKAN PEMICU, PENGATURAN GAS SAAT INSPIRASI & EKSPIRASI
 Classification of Ventilatory Variables

Control variable: Flow (volume) & Pressure

Phase variable: Trigger, Limit, Cycle & Baseline

Conditional variable: Patient effort & Time

BAGAN BERBAGAI MACAM MODE DASAR MV
 Which one ?

PSV
V
VC
R VC V
P PC

AP
RV

Which one ?

V
VC

V
PC

PSV
 Control Mode (CMV)
Pasien pasif (tidak ada usaha bernapas):

- Akibat penyakit/kondisinya

- Akibat dibuat:

Pengaruh obat penekan pusat napas

Penggunaan obat pelumpuh otot (muscle

relaxant)

Semua parameter pernapasan ditentukan oleh mesin

- Frekuensi napas

- Volume Tidal / Minute Volume

- Waktu Inspirasi : Ekspirasi (Rasio I : E)

 Control Mode (CMV)

PRESSURE CONTROL
Banyaknya udara yang ditiup ( TV ) bervariasi.
Tekanan di jalan nafas sesuai dengan setting mesin.
Inspirasi berakhir setelah pressure tercapai.

VOLUME CONTROL
Banyaknya udara yang ditiup ( TV ) sesuai dengan setting
mesin.
Tekanan di jalan nafas bervariasi.
Inspirasi berakhir setelah TV tercapai.
 Pressure Control Ventilation (PCV)
Ventilator determines inspiratory time no patient participation

Parameters
Triggered by time
Limited by pressure
Affects inspiration only
Disadvantages
Requires frequent adjustments
to maintain adequate VE
Pt with noncompliant lungs
may require alterations in
inspiratory times to achieve
adequate TV
 Assist Control Mode (ACMV)
Bila pasien tidak merangsang mesin untuk bernapas

CMV

Pasien sudah mampu/mempunyai inisiatif memicu napas

sehingga akan merangsang mesin memberi bantuan:
sensitivitas (Trigger sensitivity)

Triggering / Pemicu:

Pressure (tekanan)

Flow (volume)

Time (waktu)
 Assist/Control Mode
Ventilator delivers a fixed volume

Control Mode
Pt receives a set number of
breaths and cannot breathe
between ventilator breaths
Similar to Pressure Control
Assist Mode
Pt initiates all breaths, but
ventilator cycles in at initiation
to give a preset tidal volume
Pt controls rate but always
receives a full machine breath
Assist/Control Mode
A s s i s t m o d e u n l e s s p t s R a p i d l y b r e a t h i n g p t s c a n
respiratory rate falls below overventilate and induce severe
preset value respiratory alkalosis and
Ventilator then switches to hyperinflation (auto-PEEP)
control mode
 SYNCHRONIZED INTERMITTENT
MANDATORY VENTILATION (SIMV)

1. CMV secara intermiten yang disesuaikan

dengan saat inspirasi pasien.
2. Diantara Fdak ada bantuan nafas (CMV)
pasien diberi kesempatan untuk bernafas
sendiri (spontan)
 IMV and SIMV
Volume-cycled modes typically augmented with Pressure Support

IMV
Pt receives a set number of
ventilator breaths
Different from Control: pt can
initiate own (spontaneous) breaths
Different from Assist: spontaneous
breaths are not supported by
machine with fixed TV
Ventilator always delivers breath,
even if pt exhaling
SIMV
Most commonly used mode
Spontaneous breaths and
mandatory breaths
If pt has respiratory drive, the
mandatory breaths are
synchronized with the pts
inspiratory effort
Pressure Support Ventilation (PSV)

Pasien sudah mampu bernapas tetapi

belum adekuat

Mekanisme:

- inisiasi : Pressure

- limitasi : Pressure (sesuai yang disetting)

- cycle : Flow (minimal flow)

 ion 3) Figure 1

ystem.

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iratory
elayed
isk of

Schematic tracing of a pressure support (PS) cycle, highlighting its

four key phases.
spects
e of a
 this Figure 2
ease

icro-
mize
f the
the
D, at
auto-
urally
the
agm
d its
and
dies Conceptual diagram illustrating the adverse effects of both insufficient
rove and excessive levels of pressure support (PS) on the respiratory
muscle workload. PEEPi, intrinsic positive end-expiratory pressure.
Positive End Expiratory Pressure (PEEP)
PEEP : tekanan yang diberikan pada akhir masa ekspirasi

Menyebabkan alveoli tetap akan dalam keadaan terbuka pada

akhir ekspirasi

Dapat diberikan bersamaan dengan semua modus ventilator

Dampak PEEP :

- Perbaikan oksigenasi

- Volume paru bertambah

- Barotrauma

- Menurunkan aliran balik vena (penurunan curah jantung)

Continuous Positive Airway Pressure (CPAP)

Pasien bernafas spontan, namun pada akhir

ekspirasi alveoli tidak kolaps sebab selalu ada
tekanan (PEEP)
 CPAP and BiPAP
CPAP is essentially constant PEEP; BiPAP is CPAP plus PS

Parameters
CPAP PEEP set at 5-10 cm H2O
BiPAP CPAP with Pressure Support (5-20 cm H2O)
Shown to reduce need for intubation and mortality in
COPD pts
Indications
When medical therapy fails (tachypnea, hypoxemia,
respiratory acidosis)
Use in conjunction with bronchodilators, steroids, oral/
parenteral steroids, antibiotics to prevent/delay
intubation
Weaning protocols
Obstructive Sleep Apnea
 Alternative Modes
I:E inverse ratio ventilation (IRV)
ARDS and severe hypoxemia
Prolonged inspiratory time (3:1) leads to
better gas distribution with lower PIP
Elevated pressure improves alveolar
recruitment
No statistical advantage over PEEP, and
does not prevent repetitive collapse and
reinflation
Prone positioning
Addresses dependent atelectasis
Improved recruitment and FRC, relief of
diaphragmatic pressure from abdominal
viscera, improved drainage of secretions
Logistically difficult
No mortality benefit demonstrated
ECMO
Airway Pressure Release (APR)
High-Frequency Oscillatory
Ventilation (HFOV)
High-frequency, low amplitude
ventilation superimposed over
elevated Paw
Avoids repetitive alveolar open and
closing that occur with low airway
pressures
Avoids overdistension that occurs at
high airway pressures
W e l l t o l e r a t e d , c o n s i s t e n t
improvements in oxygenation, but
unclear mortality benefits
Disadvantages
Potential hemodynamic compromise
Pneumothorax
Neuromuscular blocking agents
Thank You