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How MV Works – Volume Displacement

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 The Four Phases of Breath

1 2 3 4 Phases of Breath

Flow

Time

Triggering Inspiration Cycling Expiration Phase Variables

• Manual • Volume • Volume • PEEP
• Machine • Pressure • Pressure
• Patient • Time
• Pressure • Flow
• Flow

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 Inspiratory Trigger

• Manual Button
User Inisiatif (Begging) / Inspiratory Hold

• Machine Inisiatif
RR Setting, Periodically every 60/RR second
(Ex : RR=10, Triggered Periodically ever y 6 second)

• Patient Inisiatif
Trigger Sensitivity Setting : Pressure or Flow Trigger
(Ventilator Sensitivity in detecting Patient’s Triggers)

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 Inspiratory Trigger
Patient Trigger  Pressure vs Flow Trigger
• P-trigger (minus, cmH2O)
• Sensitive, but may be affected by noise (self-cycling)
• Any associated base-flow, intrinsic PEEP or Deadspace
worsens the performance (Increased WOB in triggering)

• F-trigger (liter/min)
• More Sensitive, and only rarely affected by noise
• Any associated base-flow improves the performance
but need Leakage Identification and Compensation

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 Inspiration

• Volume Breath
• Tidal Volume (Square Flow x Ti)

• Pressure Breath
• Pressure Inspirasi (Nilai diatas 0) atau
• Pressure Control (Pinsp = PEEP + PC) atau
• Pressure Support (PASB = PEEP + PS)

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 Cycling

Perpindahan dari fase inspirasi ke ekspirasi.

Katup ekspirasi terbuka sehingga terjadi proses ekspirasi.

• Volume (Flow x Ti)

• Pressure
• Time (Ti)
• Flow

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 Expiration

Pengaturan pada saat akhir ekspirasi:

a. Tanpa tekanan, berarti pada akhir ekspirasi,
alveoli hampir colaps
b. Dengan tekanan (PEEP), berarti pada akhir ekspirasi,
alveoli tetap mengembang, karena ada tekanan udara

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 Patient’s Breath
(from Apnea to Spontaneous Breath)

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 Ventilation Modes/Parameter following
the Patient’s Spontaneous Breath

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 Controlled Ventilation Modes

Full Controlled Modes :

Trigger Sensitivity = OFF  All patient’s Trigger unaccepted

Assist Controlled Modes :

Trigger Sensitivity = SET  All patient’s Trigger will be assisted with Controlled Breath (VT or Pinsp)

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 Intermittent Ventilation Modes

Intermittent Modes :
Trigger Sensitivity = SET  All patient’s Trigger will be Supported with Pressure Support (PS) Breath

Intermittent Modes is combination of Controlled Breath (VT or Pinsp) and Supported Breath (PS)

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 Spontaneous Ventilation Modes

Spontaneous Modes :
No Controlled Breath (VT or Pinsp) will be given
Trigger Sensitivity = SET  All patient’s Trigger will be Supported with Pressure Support

Continuous Positive Airway Pressure (CPAP) Modes :

Maintain PEEP as CPAP Level while No Support on any patient’s Triggers

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 Ventilation Graph
Perbandingan Mode Full Control, Assist Control, Intermittent & CPAP/ASB

Full Control Mode (IPPV )

Example :
PEEP=5cmH2O, VT=500 ml,
Ti = 2 sec, RR=10 bpm (TE=4 sec)
 I:E Ratio = TI:TE = 1:2
Trigger = Off  Tidak ada Trigger Detection

Assist Control Mode (IPPV Assist)

Example :
PEEP=5cmH2O, VT = 500 ml,
Ti = 2 sec, RR=10 bpm (TE=4 sec)
 I:E Ratio = TI:TE = 1:2
Trigger = 5 lpm (Set)  Sensitivitas Trigger

Intermittent Mode (SIMV or BIPAP/ASB)

Example :
PEEP=5cmH2O, PC = 20 cmH2O,
Ti = 2 sec, RR = 6 bpm (TE=8 sec)
Trigger = 5 lpm (Set)  Sensitivitas Trigger
PS = 12 cmH2O

Spontaneous Mode (CPAP/ASB)

Example :
PEEP=5cmH2O
PS = 12cmH2O

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 Ventilation Setting & Graph

F (Rate) = 60 / (Ti + Te) TI determine Inspiratory Time on Mandatory

and Assisted Breathing.
TE determine Expiratory Time on Mandatory
Breathing or Patient Triggers Window on
Assisted & Supported Breathing.

OR

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 Ventilation Graph
Mandatory & Assisted Breathing Comparison

Mandatory Breath Assisted Breath

Inspiratory Trigger : Ventilator Rate=60/(Ti+Te) Patient Trigger
Inspiratory Breath : Pinsp Pinsp
Inspiratory Time : TI TI
Expiratory Time: TE TE=Patient Trigger Window
(If there is no Trigger then
Mandatory Breathing will be given)

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 Ventilation Graph
Assisted & Supported Breathing Comparison

Assisted Breath Supported Breath

Inspiratory Trigger : Patient Trigger Patient Trigger
Inspiratory Breath : Pinsp Pressure Support (PASB-PEEP)
Inspiratory Time : TI Expiratory Trigger (15%PeakFlow)
Expiratory Time: TE=Patient Trigger Window Patient Trigger Window
(If patient is Apnea then Mandatory Breathing will be given)

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 Ventilation Graph
Perbandingan Mode Full Control, Assist Control, Intermittent & CPAP/ASB

Full Control Mode (IPPV )

Example :
PEEP=5cmH2O, VT=500 ml,
Ti = 2 sec, RR=10 bpm (TE=4 sec)
 I:E Ratio = TI:TE = 1:2
Trigger = Off  Tidak ada Trigger Detection

Assist Control Mode (IPPV Assist)

Example :
PEEP=5cmH2O, VT = 500 ml,
Ti = 2 sec, RR=10 bpm (TE=4 sec)
 I:E Ratio = TI:TE = 1:2
Trigger = 5 lpm (Set)  Sensitivitas Trigger

Intermittent Mode (SIMV or BIPAP/ASB)

Example :
PEEP=5cmH2O, PC = 20 cmH2O,
Ti = 2 sec, RR = 6 bpm (TE=8 sec)
Trigger = 5 lpm (Set)  Sensitivitas Trigger
PS = 12 cmH2O

Spontaneous Mode (CPAP/ASB)

Example :
PEEP=5cmH2O
PS = 12cmH2O

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 Draeger Ventilation Modes

Evita 4 Edition Pressure Volume

Controlled Modes Full PCV+ CMV
(Trigger=HIGH, Pinsp) (Trigger=OFF)
Assist PCV+ CMV
(Trigger=SET, PEEP+PS=Pinsp) (Trigger=SET, VT)
Intermittent Modes PCV+ SIMV
(Trigger=SET, PEEP+PS < Pinsp) (Trigger=SET, VT & PS)
Spontaneous Modes Spont Psupp
(Trigger=SET, PS=SET)
CPAP Psupp
(Trigger=SET, PS=0)

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 Waveform

Rectangular Sinusoidal Ascending Ramp

(Square)

Descending Ramp Exponential (rise) Exponential (decay)

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 Resistance & Compliance
AIRWAY

LUNG COMPLIANCE (COMPL)

AIRWAY RESISTANCE (RAW) 1. Rasio Perubahan Volume akibat terjadinya Perubahan

Pressure  ∆V/∆P
2. Kategori areanya
1. Obstruksi Jalan Nafas (Membatasi Aliran Gas) - Compl Paru (Edema Paru, Fibrosis)
2. Flow = Pressure / Resistance - Compl Dinding Dada (Obesitas, Distensi Abdomen)
(Jika Resistensi Meningkat maka Flow turun)
3. Kategori nilainya
3. Ditentukan oleh besarnya diameter jalan nafas - Low Compliance (Volume kecil pada Pressure besar
4. Pada nafas spontan, jika Resistance meningkat  ARDS, Edema Paru, Pneumonia berat,
maka response tubuh adalah meningkatkan usaha Hematopneumotoraks, Efusi Pleura, Abdominal
nafas (WOB dan RR meningkat) Pressure
- High Compliance (Volume besar pada Pressure
kecil)  COPD, Open Chest, Muscle relaxant
ETT
Terlalu kecil V
Tumor
Pressure
Bronkospasme /Sekret Peningkatan Penurunan
Peak

Resistensi Compliance
Pressure

Penurunan Peningkatan
Peak

Resistensi Compliance
Kolaps/
Atelektasis P

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 Compliance – Pressure & Volume Correlation

Pressure Control Volume Control

Target Pemberian Nafas adalah Pressure
(Pressure Konstan) tapi Volume yang dihasilkan
dapat berubah-ubah sesuai perubahan
Compliance Paru pasien.
Antisipasi Volutrauma dengan Alarm Tidal Volume
V
V
Target Pemberian Nafas adalah Volume
(Volume Konstan) tapi Pressure yang dihasilkan
dapat berubah-ubah sesuai perubahan
Compliance Paru pasien.
Antisipasi Barotrauma dgn Alarm Peak Pressure

T T
P P

T T
Peningkatan Compliance
Peningkatan Volume pd Pressure yg sama
Penurunan Pressure pd Volume yg sama

Penurunan Compliance
Penurunan Volume pd Pressure yg sama
Peningkatan Pressure pd Volume yg sama
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 Free Breathing with PCV+ (BIPAP) and AutoFlow®

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 CPAP Concept :
Free Breathing on PEEP/CPAP Level

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 Inspiratory Phase on
Conventional PCV VS PCV+ (BIPAP)

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 Conventional PCV VS PCV+ (BIPAP)

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 Pressure & Volume Modes

Pressure Modes Volume Modes

Control/Assist PCV+ (BIPAP) CMV with AutoFlow
(=BIPAP with Volume Target)
Intermittent PCV+ (BIPAP) with PS SIMV with AutoFlow
(=BIPAP/ASB with Volume Target)
Spontaneous Psupp

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 Dual Control Modes
(Conventional)

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 Volume Modes with AutoFlow

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 Terima Kasih

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