Fisiologi Sistim Respirasi Ag

8/8/2019 Fisiologi Sistim Respirasi Ag

1/58

PEMAHAMAN FISIOLOGI SISTIM

RESPIRASI DALAM TATALAKSANA

VENTILASI MEKANIK

Anang Achmadi, SpAn

ICU Bedah Jantung

RS Pusat Kardiovaskuler Nasional

Harapan Kita-Jakarta


2/58

SISTIM RESPIRASISISTIM RESPIRASI

MEMENUHI KEBUTUHANMETABOLISME SEL AKAN O2 DAN

MENGELUARKAN CO2 SEBAGAI SISA

METABOLISME SEL


3/58

STRUKTUR ANATOMI

KONTROLRESPIRASIPERTUKARAN

GAS

VENTILASI PARUTRANSPORT

GAS

SISTIM RESPIRASISISTIM RESPIRASI


4/58

STRUKTUR ANATOMI

STRUKTUR ANATOMI

Lubanghidung

Bronkus

Faring

Laring

Ronggahidung

Trakea

ORGAN2 SISTIM RESPIRASI

ORGAN2 SISTIM RESPIRASI


5/58

STRUKTUR ANATOMI

STRUKTUR ANATOMIPLEURA DAN PARU

PLEURA DAN PARU

PLEURAVISERAL

KAVITAS PLEURA+ CAIRANPLEURA DIAFRAGMA

PLEURAPARIETAL

PARU PARU


6/58

Trakea

Bronkus

primerBronkussekunder

Bronkiolusterminalis

Saccusalveolii

Zona

konduk

si

Z

ona

respirasi

Bronkustersier

Bronkiolus

Bronkiolusrespiratori

Dari lubang hidung sampaibronkiolus terminalis disebutarea konduksi (penghantar),sedangkan dari bronkiolus sampaialveoli disebut area respirasi(tempat pertukaran gas)

Dari bronkiolus sampai br.Terminalis lebih banyakmengandung otot polos u/regulasi aliran udara

Dari trakea sampaibronkiolus banyakmengandung supportingcartilage (tlg rawan) ygberfungsi menjaga agarjalan nafas tetapterbuka

STRUKTUR ANATOMI

STRUKTUR ANATOMI

CABANG BRONKUS

CABANG BRONKUS


7/58

PROSES MEKANIK, KELUAR MASUKNYAUDARA DARI LUAR KE DALAM PARU DANSEBALIKNYA YAITU BERNAFAS

TERJADI ANTARA UDARA DALAM ALVEOLUSDENGAN DARAH DALAM KAPILER, PROSESNYADISEBUT DIFUSI

PROSESRESPIRASI

PROSESRESPIRASI

VENTILASI PARU

PERTUKARAN GAS

EKSTERNAEKSTERNA

INTERNAINTERNA

UTILISASI O2

PERTUKARAN GAS

PEMAKAIAN OKSIGEN DALAM SEL PADAREAKSI PELEPASAN ENERGI

PERTUKARAN GAS ANTARA DARAH DENGANSEL JARINGAN/TISUE


8/58

DEFINISIDEFINISI

Ventilasi: proses keluar masuknya udara (gas)dari dan ke dalam paru.

Tidal Volume (VT): jumlah gas ekspirasi perkali nafas biasanya 500 ml (5-10 ml/kgBB)

Minute Volume (VE):

RR X TIDAL VOLUME

VENTILASI PARUVENTILASI PARU


9/58

HUKUM BOYLEHUKUM BOYLE PRESSURE DARIGAS BERBANDINGTERBALIK DGN VOLCONTAINER

VOLUME

PRESSURE

VOLUME

PRESSURE

PERUBAHAN VOLUMEMENYEBABKAN

PERUBAHAN PRESSURE

TABRAKAN PARTIKEL2 GAS

KE DINDING KONTAINER

MENIMBULKAN PRESSURE



10/58

INSPIRASIINSPIRASI

MEKANISME INSPIRASI

KONTRAKSI DIAFRAGMA & INTERKOSTALIS EKST

VOLUME INTRATORAKS >>

INTRAPLEURAL PRESSURE >> NEGATIF

PARU EKSPANSI (MENGEMBANG)

INTRAPULMONAL PRESSURE >> NEGATIF

UDARA MENGALIR KE DALAM PARU



11/58


INSPIRASIINSPIRASI

KONTRAKSI OTOT INTERKOSTALIS EKSTERNAIGA TERANGKAT

KONTRAKSI DIAFRAGMADIAFRAGMABERGERAK INFERIOR

EKSPIRASIEKSPIRASI

RELAKSASI OTOT INTERKOSTALIS EKSTERNA

IGA KE POSISI SEMULA

RELAKSASI DIAFRAGMA DIAFRAGMABERGERAK KE POSISI SEMULA

INTRATORAKVOLUME

PRESSURE

VOLUME

PRESSURE

INSERT


12/58


INSPIRASIINSPIRASI

PERUBAHAN TEKANAN DALAM PLEURA(INTRAPLEURAL PRESSURE)

KONTRAKSI

DINDING

DADA

PARU

VOLUME PARU

MENJADI LEBIH

BESAR762

761

760

759

758

757

756

755

754

753

1

0

-2

-1

-3

-4

-5

-7

-6

0

0.5

INSPIRASI EKSPIRASI

5 DETIK

TIDAL

VOLUME

INTRAPULMONA

RY PRESSURE

INTRAPLEURAL

PRESSURE

TEKANAN

PLEURA LEBIH

NEGATIF

TRANSPULMONARY

PRESSURE

INSPIRASI


13/58

PRESSUREPRESSURE

TIMETIME

InspirasiInspirasi EkspirasiEkspirasi

PLATEAUPLATEAU

PRESSUREPRESSURE

PEAK PRESSUREPEAK PRESSURE

00

KURVA NAFAS SPONTANKURVA NAFAS SPONTAN

DAN VENTILASI MEKANIKDAN VENTILASI MEKANIK


14/58

AIRWAY

RESISTANCE (RAW)

AIRWAY

RESISTANCE (RAW)

COMPLIANCE

(COMPL)

COMPLIANCE

(COMPL)


CL

RAW

LUNG

AIRWAY


15/58

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 adalah

meningkatkan usaha nafas (WoB = RR >>, otot bantu

nafas >>)

AIRWAY RESISTANCE

(RAW)

AIRWAY RESISTANCE

(RAW)


16/58

FLOW =

PRESSURE

RESISTANCE

BRONKUSNORMAL

AIRWAY RESISTANCE

(RAW)

AIRWAY RESISTANCE

(RAW)


17/58

FLOW =PRESSURE

RESISTANCE

BRONKODILATASI:EPINEFRINAMINOFILIN

BETA 2 AGONIS

AIRWAY RESISTANCE

(RAW)

AIRWAY RESISTANCE

(RAW)


18/58

FLOW =PRESSURE

RESISTANCE

BRONKOKONSTRIKSI:

HISTAMIN

OBSTRUKSI:

MUKUS/SEKRET

AIRWAY RESISTANCE

(RAW)

AIRWAY RESISTANCE

(RAW)


19/58

FLOW =PRESSURE

RESISTANCE

BRONKOSPASME

TUMOR/SEKRET

ETT TERLALUKECIL

KOLAPS/ATELEKTASIS

AIRWAYRESISTANCE (RAW)

AIRWAYRESISTANCE (RAW)


20/58

Kaku Elastis

LOWCOMPLIANCE

HIGHCOMPLIANCE

BALON

COMPLIANCE (COMPL)COMPLIANCE (COMPL)


21/58

DefinisiRasio perubahan volume akibat terjadinya perubahan pressure

V/ PTerbagi 2;

Compl paru (edema paru, fibrosis, surfactan : u/memasukkan volume yang diinginkan dibutuhkan pressure

yg lebih besar.High compliance

Muscle relaxant, COPD, open chestdgn pressure ygkecil dapat tidal volume yg masuk besar

COMPLIANCE (COMPL)COMPLIANCE (COMPL)


22/58

P-V LOOP

15 30

250

500

0

P

Vol

500 500

250 250

15 30 15 30

LOWCOMPLIANCE

HIGHCOMPLIANCENORMAL

PEEP 5INSPIRASI

EKSPIRASI

NAFASSPONTAN


23/58

PERTUKARAN GAS


24/58

ALVEOLUS

KAPILER PARU

UDARA BEBAS:

PiO2 : 20.9 % x 760 = 159 mmHg

PiCO2 : 0.04 % x 760 = 0.3 mmHg

PiN2 : 78.6 % x 760 = 597mmHg

PiH2O : 0.46 % x 760 = 3.5 mmHg

N2 H2O

O2

PAO2:

104 mmHg

CO2

PACO2:

40 mmHg

O2

PaO2:

40 mmHg

O2

PaO2:

104 mmHg

CO2PaCO2:

45 mmHg

CO2

PaCO2:

40 mmHg

PROSES DIFUSI

PAN2:

573 mmHg

PAH2O:

47 mmHg


25/58

SHUNT DAN DEADSHUNT DAN DEAD

SPACESPACE


26/58

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

Hubungan Ventilasi (V) dan Perfusi (Q)Hubungan Ventilasi (V) dan Perfusi (Q)

TRAKEA

KAPILER

PARU MECHANICALDEAD SPACE:

TUBE

CONNECTOR

ET CO2

BREATHING

CIRCUIT

NORMAL


27/58

SHUNT %SHUNT %

00FiOFiO22

PaOPaO22

100100

50%

20%

30%

10%2-3%

100100

200200

300300

400400

500500

2121 4040 6060 8080

Norm

alshunt


28/58

VARIABEL PENTINGVARIABEL PENTING

DALAM VENTILASI MEKANIKDALAM VENTILASI MEKANIK


29/58

FiO2 :

FRAKSI KONSENTRASIOKSIGEN INSPIRASI YG

DIBERIKAN (21 100%)

TIDAL VOLUME (VT):

JUMLAH GAS/UDARA YG

DIBERIKAN 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)


30/58

- 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 selesaidalam waktu 6 dtk.

6 dtk 6 dtk

Ins +Eksp

Ins +Eksp

T I M E = WAKTU

frekuensi

T I M E = WAKTU

frekuensi


31/58

SensitivitySensitivity

Setelan sensitifitas akan menentukan variabel triggerSetelan sensitifitas akan menentukan variabel trigger

Variabel trigger menentukan kapan ventilator mengenali adanyaVariabel trigger menentukan kapan ventilator mengenali adanya

upaya nafas pasienupaya nafas pasien

Ketika upaya nafas pasien dikenali, ventilator akan memberikanKetika upaya nafas pasien dikenali, ventilator akan memberikan

nafasnafas

Variabel trigger dapat berupa pressure atau flowVariabel trigger dapat berupa pressure atau flow


32/58

Pressure TriggeringPressure Triggering

Upaya nafas pasien dimulai saat terjadi kontraksi otot diafragma

Upaya nafas ini akan menurunkan tekanan (pressure) di dalam

sirkuit ventilator (tubing)

X X


33/58

Pressure TriggeringPressure Triggering 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.

Baseline

Trigger

Patient effort

Pressure


34/58

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


35/58

Flow Triggering

Ventilator secara kontinyu memberikan flow rendahke dalam sirkuit pasien (open system)

Delivered flowReturned flow

No patient effort


36/58

Flow Triggering

1. Upaya nafas dimulai saat kontraksi diafragma

2. Saat pasien bernafas beberapa bagian flow didiversi ke

pasien

Delivered flowLess flow returned


37/58

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

Tim

e

Pressure


38/58

Pressure Trigger vs. Flow

TriggerConsider P-triggermaximum sensitivity (0.5 cmH2O)

Sangat sensitif

Dapat dipengaruhi oleh kebisingan (noise) dapat

menyebabkan (self-cycling)

Any associated base-flow worsens the performance

F-triggermaximum sensitivity (0.5 l/min)

Sangat sensitif

Jarang dipengaruhi leh kebisingan Any associated base-flow improves the performance


39/58

Remember

Equal values for sensitivity setting are not comparable, between

different triggers

Check simulation:

0.5 cmH2O vs. 0.5 l/min

2 cmH2O vs. 2 l/min

When PEEPi is present, the problem is elsewhere !

Pressure Trigger vs. FlowTrigger


40/58

PEEP

DEFINISI

POSITIVE END EXPIRATORY PRESSURE

SEWAKTU AKHIR EXPIRATORY, AIRWAYPRESSURE TIDAK KEMBALI KETITIK NOL

DIGUNAKAN BERSAMA DENGAN MODE LAINSEPERTI; SIMV, ACV ATAU PS

DISEBUT CPAP JIKA DIGUNAKAN PADA MODENAFAS SPONTAN


41/58

- Ventilator provides a fixed positive

airway pressure at the end of expiration- PEEP will not correct underlying

disorder, it only supports oxygenation

- PEEP 3-5 cmH2O physiologic when it is

applied to patients with artificial airways,Purporting that it mimics the amount of

PEEP usually created by the glottic.

PEEP


42/58

PEEP

(Positive End Expiratory Pressure)

PEEP

(Positive End Expiratory Pressure)

PEEP 5

REDISTRIBUSI CAIRAN

EKSTRAVASKULAR PARU

MENINGKATKAN V OLUMEALVEOLUS

MENGEMBANGKAN ALVEOLI YGKOLAPS (ALVEOLI RECRUITMENT)

PEEPPEEP


43/58

REDISTRIBUSI CAIRANEKSTRAVASKULAR PARU

+1

0

0

A B

PEEP(Positive End Expiratory

Pressure)


Pressure)

PEEPPEEP


44/58

MENINGKATKANVOLUME ALVEOLUS

+2

0

+1

0

0

A B C


Pressure)


Pressure)

PEEPPEEP


45/58

MENGEMBANGKANALVEOLI YG KOLAPS(ALVEOLI

RECRUITMENT)

0

+5

+10

+1

5

+1

5

+10

+5

0


Pressure)


Pressure)


46/58

Advantages:

(1) opens closed alveolar units thusimproving lung compliance and

oxygenation

(2) Decreases intrapulmonary Shunting(3) Increases The FRC

(4) Can reduce right ventricular venous

return and also lower left ventricular

afterload

(5) Can be given on the ventilator or via a

CPAP mask in the non-intubated patient


47/58

Disadvantages:

- Barotrauma

- Can be risky and counterproductive in patients

with obstructive airways disease

- May worsen hypoxemia in patients with

localized (as opposed to diffuse) lung disease(eg, pneumonia)

- Hypotension and reduced cardiac output

- Increased cardiac shunt

- Increased intracranial pressure- Decreased renal perfusion

- Hepatic congestion


48/58

Effect of application of PEEPon the alveoli

Contraindications


49/58

Contraindications

- No absolute contraindication

- Relative contraindication :

- Unilateral lung disease

- Pneumothorax

- Bronchopleural fistula- Hypovolemia

- Intracardiac shunt

- Increased ICP- Bronchospasme

- Instability haemodynamic


50/58

Intrinsic PEEP

- Is also known as pulmonary gas trapping,

endogenous PEEP, occult PEEP, intrinsic PEEP orinadvertent PEEP.

- Is the spontaneous development of PEEP as a

result of insufficient expiratory time

- Inadequate expiratory time causes gases tobecome trapped in the lung.

- Normally at end expiration the lung volume is

equal to FRC

- When PEEPi occurs the lung volume at end

expiration is greater then FRC

- Cause of auto PEEP include : rapid RR, high

minute ventilatory demand, airflow obstruction,

inverse I:E ratio ventilation


51/58

Auto-PEEP in COPD patient

Auto PEEP / Intrinsic

PEEP = Air trapping

Causes: Airway disease

Bronchospasm

Secretions

Ventilator settings

NO PEEP

Effect ventilator setting to COPD patient


52/58

- Auto PEEP cannot readily be detected by

reading the pressure manometer on theventilator without special maneuver.

- autoPEEP should be suspected when:

. any patient with obstructive airways disease

is receiving mechanical ventilation. any patient with unexplained hypotension

after initiating mechanical ventilation

. any patient with unexplained tachycardia

after initiating mechanical ventilation


53/58

- autoPEEP can be inferred by any of three

findings:

. an expired air volume that is less than theinspired volume (trapped air)

. a flow-time graphic (available on many newer

ventilators) showing that flow never reaches

baseline before the next breath (in otherwords, the patient is still expiring when the

next breath is delivered)

. chest auscultation demonstrating that

expiratory noises (wheezing, etc.) are audibleall

the way up until the next breath is delivered

-Is measured in a relaxed patient with an


54/58

Is measured in a relaxed patient with an

end expiratory hold maneuver on

mechanical ventilator immediately before

the onset of next breath- Adverse effect :

. predisposes to barotraumas

. predisposes hemodynamiccompromise

. diminishes the efficiency of the force

generated by respiratorymuscles

. augment WOB

. augment the effort to trigger the

ventilator

Reduction in auto PEEP


55/58

Reduction in auto PEEP

. shortening the inspiratory time

extending the expiratorytime

. decreasing RR and tidal

volume

. increasing the peak

inspiratory flow rate. bronchodilator


56/58

Best PEEP : Lowestintrapulmonary shunt

- Was defined as the level of

PEEP that enables the bestoxygenation and reduced

oxygen toxicity


57/58

Oxygen contentOxygen content

Oxygen deliveryOxygen delivery

Cardiac outputCardiac output

PEEP cmH2OPEEP cmH2O

00 55 1010 1515


58/58

Optimal PEEP : max DO2

-is the PEEP level that will provide thebest blood gases with the least

detrimental impact on cardiopulmonary

function.

-determining optimal PEEP is crusial

and will change from patient to patient,

from pathophysiology to

pathophysiology and depending upon

the stage an severity of disease

Fisiologi Sistim Respirasi Ag

Documents

Transcript of Fisiologi Sistim Respirasi Ag