Ventilasi Mekanis Noninvasif

Chapter 38 Nonivasive Mechanical VentilationBy:Sugianto Parulian SimanjuntakAnestesiologi dan ReanimasiFK Unair/RSU dr. Sutomo

Ventilasi Mekanis NoninvasifPendahuluanTeknologi ventilasi mekanis non-invasifModus ventilasi mekanik non-invasifIndikasi dan kontraindikasiMelakukan ventilasi mekanis non-invasifButir-butir pemahamanPenelitian pendukung

Diagram skematis Ventilator/Pasien:Constant Pressure/Flow Source.Total Compliance & ResistanceParameter: Tekanan, Volum, Aliran & Waktu

Beberapa singkatan lazim dalam Ventilasi Mekanik

Controlled Mechanical Ventilation (CMV)Continuous Mandatory Ventilation (CMV)Intermittent Pos Pres Ventilation (IPPV)Volume Controlled Ventilation (VCV)Assist Control Ventilation (ACV)Pressure Control Ventilation (PCV)Pres Regulated Volume Control (PRVC)Intermittent Mandatory Ventilation (IMV)Sync Interm Mandatory Ventilation (SIMV)Auto Flow (AF)Biphasic Pos Airway Pressure (BiPap)Continuous Repetitive Airway Pressure (CRAP)

Airway Pres Release Vent (APRV)Pressure Support Ventilation (PSV)Proportional Assist Ventilation (PAV)Pressure Augmented Ventilation (PAV)Adaptive Support Ventilation (ASV)Assisted Spontaneous Ventilation (ASV)Volume Support Ventilation (VSV)Volume Assured Pressure Supp (VAPS)SIMV (VCV)+PSVSIMV (PCV)+PSVContinuous Airway Pressure (CAP)Continuous Pos Airway Pres (CPAP)

Definisi Modus Ventilator

Modus adalah metode bantuan ventilasi berkaitan dengan hantaran nafas spontan atau diperintah. Bisa disebut sebagai sekumpulan variabel kendali, fase dan kondisional tertentu. Variabel KendaliBiasanya Tekanan atau Volum (Flow)

Variabel FaseMengacu kpd Trigger, Limit & Cycle (TLC)Variabel KondisionalBiasanya Usaha pasien , Waktu atau Tidal/Minute Volume

Seluruh interaksi antara pasien dan ventilator bisa dijabarkan dalam 4 modus dasar yaitu: Dalam modus CMV Variabel Kendali bisa berupa Tekanan atau Volum sementara Trigger bisa berupa Mesin (biasanya) atau Pasien (yang digabung dengan trigger) 1. Continuous Mandatory Ventilation (CMV)2. Sync Intermittent Mandatory Ventilation (SIMV)3. Pressure Support Ventilation (PSV)4. Continuous Positive Airway Pressure (CPAP)

TIPE PERNAFASAN

Ada empat tipe pernafasan dasar:-------------------------------------------------------------------------------Tipe Nafas Variabel Fase Trigger Limit Cycle-------------------------------------------------------------------------------1.MANDATORY Mesin Mesin Mesin

2.ASSISTED Pasien Mesin Mesin

3.SUPPORTED Pasien Mesin Pasien

4.SPONTANEOUS Pasien Pasien Pasien-------------------------------------------------------------------------------

Continuous Mandatory Ventilation (CMV) Cycle = Waktu

Sync Intermittent Mandatory Ventilation (SIMV)

Pressure Support Ventilation (PSV)

Continuous Positive Airway Pressure (CPAP)

SIMV/BIPAP with Auto Flow

*Noninvasive ventilation (NIV) the provision of ventilatory assistance without an artificial airway effective in acute respiratory failureINTRODUCTIONAcute Cardiogenic Pulmonary Edema (ACPE)Some patient require ventilatory support for respiratory distress & hypoxemia

*Ventilator Support for ACPETraditionally :Endotracheal Intubation & Mechanical VentilationRecent years :Noninvasive positive pressure ventilation (NPPV)Introduction..Advantages :Patient comfortMaintenance of airway defense mechanismsAbility to eat & speakAvoid complications associated with endoteacheal intubationBeneficial Effects in ACPE Improve oxygenation, Increase CO, & reduce the work of breathing

*NONINVASIVE VENTILATION (NIV)The recent increase in use of NIV in the acute care setting reduce complications of Invasive VentilationPatients must be selected carefully because the risk of complications could be increased if NIV is used inappropriately.

*Modalities of NIVNegative Pressure VentilationSupport ventilation by lowering the pressure surrounding the chest wall during inspiration & reversing the pressure to atmospheric level during expirationNot readily accepted by patients because of their awkward size & their propensity to cause upper airway obstructions in some patientsNoninvasive Positive-Pressure Ventilation (NPPV)Delivered by a nasal or face mask eliminating intubation or tracheostomyNPPV may be used as an intermittent mode of assistance depending on patients clinical situation The total duration of ventilator use varies with the underlying disease>> advantage compare to invasive ventilator

*Noninvasive Positive-Pressure Ventilation..Hillberg,1997

*Noninvasive Positive-Pressure Ventilation..Table 2. Evidence To Support Use of NPPV for Different Types of Acute Respiratory FailureLiesching et al. 2003

*Blood Gas FindingsClinical Inclusion Criteria

Signs or symptoms of acute respiratory distressModerate to severe dyspnea, increase over usual RR > 24x/minuteAccessory muscle use Abdominal paradoxNoninvasive Positive-Pressure Ventilation..Guidelines for the Use of NPPV in Patients with Acute Respiratory FailurePaCO2 > 45 mmHgpH < 7,35 but more than 7,10PaO2 & FiO2 < 200

*ContraindicationsFactors Predictive of SuccessYounger ageLower acuity of illness (lower APACHE score)Patient able to cooperateAbility to coordinate breathing with ventilatorModerate hypercapnia (PaCO2 > 45 but < 92 mmHg)Moderate acidemia (pH > 7,10 but < 7,35)Improvement in gas exchange & heart & RR within first 2 hoursNoninvasive Positive-Pressure Ventilation..Guidelines for the Use of NPPV in Patients with Acute Respiratory FailureRespiratory arrestInability to use mask because of trauma or surgeryExcessive secretionsHemodynamic instability or life-threatening arrtytmiaHigh risk of aspirationImpaired mental statusUncooperative or agitated patientLife-threatening refractory hypoxemia

*Symptoms : Sudden onset of extreme shortness of breath, takipneu, takikardi, severe hypoxemia respiratory distressCardiogenic Pulmonary EdemaDue to increased capillary hydrostatic pressure secondary to elevated pulmonary venous pressureAccumulation of fluid with a low-protein content in lung interstitium & alveoli

Initial management ABCs resuscitation Oxygen SaO2 > 90% Patient remain hypoxic despite supplemental oxygenation ventilatory support O2 delivery depend on hypoxemia, acidosis & level of consciousness NIV types BiPAP or CPAPAcute CardiogenicPulmonary EdemaACUTE CARDIOGENIC PULMONARY EDEMA

*Medical therapy focuses on 3 main goals :Reduction of pulmonary venous return (preload reduction) Decreased pulmonary capillary hydrostatic pressure Reduces fluid transudation into the pulmonary interstitium & alveoliReduction of systemic vascular resistance (afterload reduction)Increased CO & improves renal perfusion, which allows for diuresis in patient with fluid overloadInotropic Support Maintain adequate blood pressure Patient with severe LV dysfunction or acute valvular disorders Acute Cardiogenic Pulmonary Edema..

*APPLICATION NIV FOR ACUTE CARDIOGENIC PULMONARY EDEMA

*Noninvasive pressure support ventilation (NPSV) :Maintains the patency of the fluid-filled alveoli & prevents them from collapsing during exhalation patient saves the energy spent trying to reopen collapsed alveoliImproves pulmonary air exchangeIncrease intrathoracic pressure with reduction in preload & afterload

Several Studies :Decreased length of stay ICU, mechanical ventilation & hospital costsFaster improvement of oxygen saturation in patients with CPEMore superior than standard therapy Application NIV for ACPE..

*Two types of NPPVContinuous positive airway pressure (CPAP) Bilevel positive airway pressure (BiPAP) single airway pressure is maintained throughout all phases of the respiratory cycle high pressure applied during inspiration & low pressure during expirationApplication NIV for ACPE..

*Nava et al (2003) & Gray et al (2008)Both CPAP & BiPAP rapid improvement dyspnea & RR; reduced endotracheal intubation rate compared to standard therapyNIV as adjunctive therapy in patient ACPE with respiratory distress & no clinical improvement with pharmacologic therapyOne small study BiPAP associated with more rapid improvement in vital sign but an increased rate of myocard infarctions

CPAPVs.BiPAPApplication NIV for ACPE..Another study NOT show any increased rate of myocard infarction in patients with CPAP or BiPAP

*Application of CPAPACPELV dysfunction Acute increased in extravascular lung water reduces lung volume & lung compliance & increase airway pressureCPAPBoth work & oxygen cost of breathing rise Improve oxygenation & cardiac function Decrease respiratory workMain physiological benefit :Decreased LV pre-load & afterload owing to increased intrathoracic pressureIncrease in functional residual capacity reopens collapsed alveoli

*Application of CPAP..Table 3. Summary of Trials Using CPAP in Acute Pulmonary EdemaMehta et al. 2001

*MONITORINGPatients must be carefully monitored & attention :Patients comfort, mental state, chest wall movement, accessory muscle recruitment, coordination of respiratory effort with the ventilator, heart rate, respiratory rate & oxygen saturationBlood gas analysis after 1-2 hours of NIV & after 4-6 hours if the earlier sample showed little improvement

If no improvement NIV should be discontinued & invasive ventilation considered

*Unsuccessful NIV :Hemodynamic instabilityDeteriorating mental statusIncreasing respiratory rate Increasing respiratory acidosisInability to maintain adequate oxygen saturationProblem with respiratory secretionsCOMPLICATIONS OF NPPV

*CONCLUSIONSNIV Lower rates of endotracheal intubation or tracheostomy, fewer complications, & improved survival

Recent studies shows that NIV is an effective treatment for selected patients with acute respiratory failure, including acute cardiogenic pulmonary edemaTwo types of NIV for ACPE CPAP & BiPAP

CPAP is the preferred methods when NIV is used for respiratory distress in acute cardiogenic pulmonary edema

Ware et al,2005

Ware et al,2005

*

*

*

*

*

*

*

*

****************************