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Nonivasive Mechanical
Ventilation
By:
Sugianto Parulian Simanjuntak
Anestesiologi dan Reanimasi
FK Unair/RSU dr. Sutomo
Constant Pressure/Flow
Source.
Variabel Kendali
Biasanya Tekanan atau Volum (Flow)
Variabel Fase
Mengacu kpd Trigger, Limit & Cycle (TLC)
Variabel Kondisional
Biasanya Usaha pasien , Waktu atau Tidal/Minute Volume
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
-------------------------------------------------------------------------------
Kendali Tekanan
Cycle = Waktu
Limit = Aliran
Variabel
kendali
Limit = Tekanan
Variabel
Kendali
Trig =
Waktu
Trig =
Waktu
Cycle = Waktu
Limit = Pressure
Limit = Flow
Patient
Patient
Patient
Patient
(Mesin)
Patient
(Machine)
Patient
Trigger
INTRODUCTION
Noninvasive ventilation (NIV) the provision of ventilatory
assistance without an artificial airway effective in acute
respiratory failure
Acute
Cardiogenic
Pulmonary
Edema (ACPE)
Introduction..
Ventilator Support
for ACPE
Recent years :
Noninvasive positive
pressure ventilation (NPPV)
Traditionally :
Endotracheal Intubation
& Mechanical
Ventilation
Advantages :
Patient comfort
Maintenance of airway defense mechanisms
Ability to eat & speak
Avoid complications associated with endoteacheal intubation
Beneficial Effects in ACPE Improve oxygenation, Increase CO,
14
& reduce the work of breathing
NONINVASIVE VENTILATION
(NIV)
The recent increase in use of NIV in the
acute care setting reduce
complications of Invasive Ventilation
15
Modalities of NIV
Negative Pressure Ventilation
Support ventilation by lowering the pressure surrounding
the chest wall during inspiration & reversing the pressure to
atmospheric level during expiration
Not readily accepted by patients because of their awkward
size & their propensity to cause upper airway obstructions in
some patients
16
Hillberg,1997
17
Liesching et al.
2003
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Clinical Inclusion
Criteria
Signs or symptoms of
acute respiratory distress
Moderate to severe
dyspnea, increase over
usual
RR > 24x/minute
Accessory muscle use
Abdominal paradox
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Contraindications
Factors
Predictive of
Success
Respiratory arrest
Inability to use mask because of trauma or
surgery
Excessive secretions
Hemodynamic instability or life-threatening
arrtytmia
High risk of aspiration
Impaired mental status
Uncooperative or agitated patient
Life-threatening refractory hypoxemia
Younger age
Lower acuity of illness (lower APACHE score)
Patient able to cooperate
Ability to coordinate breathing with ventilator
Moderate hypercapnia (PaCO2 > 45 but < 92
mmHg)
Moderate acidemia (pH > 7,10 but < 7,35)
Improvement in gas exchange & heart & RR
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within first 2 hours
Acute Cardiogenic
Pulmonary Edema
acidosis &
level of consciousness
21
Decreased
pulmonary capillary
hydrostatic
pressure
Reduces fluid
transudation into
the
pulmonary
interstitium &
Reduction of
systemic vascular
resistance
(afterload
reduction)
Increased CO &
improves renal
perfusion, which
allows for diuresis
in patient with
fluid overload
Inotropic
Support
Maintain adequate
blood pressure
Patient with severe
LV dysfunction or
acute valvular
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disorders
HYPOXEMIA
23
Continuous positive
airway pressure (CPAP)
is maintained
throughout all phases
of the respiratory cycle
25
Nava et al (2003)
& Gray et al
(2008)
CPAP
Vs.
BiPAP
Application of CPAP
ACPE
CPAP
Improve oxygenation & cardiac
function
Decrease respiratory work
Main physiological benefit :
Decreased LV pre-load & afterload owing to increased intrathoracic
pressure
Increase in functional residual capacity reopens collapsed alveoli27
Application of CPAP..
Table 3. Summary of Trials Using CPAP in Acute Pulmonary Edema
MONITORING
Patients 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
saturation
Blood gas analysis after 1-2 hours of NIV & after 46 hours if the earlier sample showed little
improvement
COMPLICATIONS OF NPPV
Most common problems :
Local damage to facial tissue
Mild gastric distention
Eye irritation & sinus pain
Barotrauma is uncommon
Unsuccessful NIV :
Hemodynamic instability
Deteriorating mental status
Increasing respiratory rate
Increasing respiratory acidosis
Inability to maintain adequate oxygen saturation
Problem with respiratory secretions
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CONCLUSIONS
Recent studies shows that NIV is an
effective treatment for selected patients
with acute respiratory failure, including
acute
edema
NIV cardiogenic
Lower ratespulmonary
of endotracheal
intubation or tracheostomy, fewer
complications, & improved survival
Two types of NIV for ACPE CPAP &
BiPAP
CPAP is the preferred methods when
NIV is used for respiratory distress in
acute cardiogenic pulmonary edema
31
Ware et al,2005
Ware et al,2005
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