Nama : Dewi Sri Fitriani

NIM : 406172091
FK UNTAR

1. Jelaskan mengenai prinsip circuit mesin anestesi: breathing ciricuit, aliran O2,
ambu bag, APL (applicable press loss)

COMPONENTS OF BREATHING SYSTEMS

A breathing system is made up of components that connect the patient to the

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anaesthetic machine , and is usually composed of some or all of the following
components:

1. The Adjustable Pressure Limiting (APL) valve allows a variable pressure within
the anaesthetic system using a one-way, spring-loaded valve. At a pressure
above the opening pressure of the valve, a controlled leak of gas is allowed
from the system, which enables control of the patient’s airway pressure. The
minimum pressure required to open the valve is 1cm H2O. A safety
mechanism exists to prevent pressure from exceeding 60cm H2O, however, be
aware that pressures below this can lead to barotrauma. 


2. The reservoir bag allows collection of fresh gas flow during expiration, which in
turn minimises the amount of fresh gas required to prevent rebreathing. In
addition, it allows the anaesthetist to monitor the breathing pattern of a
spontaneously breathing patient. These are usually plastic or rubber, and can
come in sizes between 0.5 litres to 6 litres. However, the most common size in
the adult system is 2 litres. Laplace’s Law states that pressure is equal to twice
the radius divided by the radius of the bag. Therefore, as the bag increases, the
pressure within it reduces. This is an important safety measure as the
expansion of the bag to accommodate gas limits pressure within the system.



3. The inspiratory limb allows passage of fresh gas flow to the patient for inspiration.
The expiratory limb allows passage of expired gas from the patient. Although
 tubing length varies depending on the system in use, the diameter is of
standard size: 22mm for adult and 18mm for paediatric systems. 


CIRCLE SYSTEMS

A circle system improves the efficiency of anaesthetic gas delivery by recycling gas
that is expired from the patient and thus reducing the amount of fresh gas flow
required.

Fresh gas flow leaves the anaesthetic machine and passes to the patient via a one-way
valve during inspiration. As expiration occurs, the exhaled gases from the patient pass
via a one-way valve to the APL valve, then on to the reservoir bag (or ventilator).
Before this expired gas is mixed with the fresh gas flow and delivered to the patient, it
passes through soda lime, which absorbs carbon dioxide. Initially, a high fresh gas
flow is required in order to fill the breathing system with the desired mixture and to
equilibrate the system, after which a minimal flow of 0.5 litres per minute can be
used.

A circle system can be semi-closed or closed. In a semi-closed circle, the APL valve
is opened, and allows excess gas to be removed from the system and reduce the risk
of barotrauma. However, the relatively high fresh gas flow allows a vaporiser outside
circle (VOC) to be used, which can introduce a higher percentage and more precise
anaesthetic gas into the mixture.

In a closed circle, the APL valve is completely closed. Although this is the most
efficient anaesthetic breathing system, it leaves little margin for error as the fresh gas
flow must meet the exact patient requirements, and the soda lime must absorb all
expired carbon dioxide. The minimal flow in this system only allows the use of a
vaporiser inside circle to be used. A detailed description of vaporisers is beyond the
scope of this article.

One of the most important components of the circle system is soda lime. This is a
mixture of 80% calcium hydroxide, 4% sodium hydroxide, and 16% water. It also
contains a pH-sensitive dye, which indicates when the granules are exhausted. Soda
lime granule are described as 4-8 mesh, which means that each granule will fit
through a mesh that has 4 openings per inch, but not one that has 8. The following
exothermic reaction occurs:

CO2 + 2NaOH Na2CO3 + H2O Na2CO3 + Ca(OH)2 2NaOH + CaCO3

Important facts to note about circle systems:

 The one-way valves can become stuck by water vapour within the system
leading to an increase in dead space. 

 The one-way valves increase the resistance to breathing in the system. 

 The lower the fresh gas flow rate, the longer it takes for changes made to the
anaesthetic gas mixture to occur. 

 Monitoring the gas composition within the circle is essential. 

 Use of sevoflurane at low flow rates below 1 litre/minute can generate
Compound A by reaction with soda lime. Although this is nephrotoxic in rat
models there is currently no evidence of harm in humans. 

 One must be familiar which the colour of the pH-sensitive dye as different
manufacturers use different colours to indicate that the soda lime is exhausted.


Uneven distribution of soda lime granules in the canister causes gas to flow
unevenly and reduces the efficiency of the soda lime. 


GAS SUPPLY

Most machines have gas inlets for oxygen, nitrous oxide, and air. Compact models
often lack air inlets, whereas other machines may have a fourth inlet for helium,
heliox, carbon dioxide, or nitric oxide. Separate inlets are provided for the primary
pipeline gas supply that passes through the walls of health care facilities and the
secondary cylinder gas supply. Machines therefore have two gas inlet pressure gauges
for each gas: one for pipeline pressure and another for cylinder pressure.

Pipeline Inlets

Oxygen and nitrous oxide (and often air) are delivered from their central supply
source to the operating room through a piping network. The tubing is color coded and
connects to the anesthesia machine through a noninterchangeable diameter-index
safety system (DISS) fitting that prevents incorrect hose attachment.
Noninterchangeability is achieved by making the bore diameter of the body and that
of the connection nipple specific for each supplied gas. A filter helps trap debris from
the wall supply and a one-way check valve prevents retrograde flow of gases into the
pipeline supplies. It should be noted that most modern machines have an oxygen
(pneumatic) power outlet that may be used to drive the ventilator or provide an
auxiliary oxygen flowmeter. The DISS fittings for the oxygen inlet and the oxygen
power outlet are identical and should not be mistakenly interchanged. The
approximate pipeline pressure of gases delivered to the anesthesia machine is 50 psig.

Cylinder Inlets

Cylinders attach to the machine via hanger-yoke assemblies that utilize a pin index
safety system to prevent accidental connection of a wrong gas cylinder. The yoke
assembly includes index pins, a washer, a gas filter, and a check valve that prevents
retrograde gas flow. The gas cylinders are also color-coded for specific gases to allow
for easy identification. In North America, the following color-coding scheme is used:
oxygen = green, nitrous oxide = blue, carbon dioxide = gray, air = yellow, helium =
brown, nitrogen = black. In the United Kingdom, white is used for oxygen and black
and white for air. The E-cylinders attached to the anesthesia machine are a high-
pressure source of medical gases and are generally used only as a backup supply in
case of pipeline failure. Pressure of gas supplied from the cylinder to the anesthesia
machine is 45 psig. Some machines have two oxygen cylinders so that one cylinder
can be used while the other is changed. At 20°C, a full E-cylinder contains 600 L of
oxygen

at a pressure of 1900 psig, and 1590 L of nitrous oxide at 745 psig.

ANESTHESIA RESERVOIR BAG OR “BREATHING BAG.” The anesthesia
reservoir bag, or “breathing bag,” provides several important functions, including (1)
serving as a reservoir for exhaled gas and excess fresh gas, (2) provid- ing a means of
delivering manual ventilation or assisting spontaneous breathing, (3) serving as a
visual or tactile means of monitoring a patient’s spontaneous breath- ing efforts, and
(4) partially protecting the patient from excessive positive pressure in the breathing
system such as in the case of inadvertent closure of the APL valve or an obstruction
of the scavenge line (Fig. 29-33). The reservoir bag is the most compliant part of the
breathing system. The pressure-volume characteristics of this bag are such that it in
ates to a maximal pressure and then slightly decreases to a plateau as it continues to ll

even to high volumes.122,128,129 Anesthesia reservoir bags must adhere to pressure

standards, which allow a minimal pressure of approximately 30 cm H2O and a
maximal pressure of approximately 60 cm H2O when the bag is lled to four times its

stated capacity.130 Although most bags adhere to these standards, some latex-free

bags have exceeded this maximal value.129 Classically, the reservoir bag was
excluded from the breathing circuit when the ventila- tor was in use. However, on
some contemporary work- stations, such as the Dräger Fabius and Dräger Apollo, the
reservoir bag is integral to circuit function during mechanical ventilation, where it

serves as an exhaled and fresh gas reservoir.41,131

ADJUSTABLE PRESSURE-LIMITING VALVE. The APL valve is an operator-

adjustable relief valve that vents excess breath- ing circuit gas to the scavenging
system and provides control of the breathing system pressure during sponta- neous
and manual modes of ventilation. Switching the workstation to a ventilator mode

excludes or closes the valve.127 Several other common names exist for these devices,

including “pop-off” valve and pressure relief valve.122 The two basic types of
pressure-limiting valves are the variable-resistor (or variable-ori ce) type and the
pressure-regulating type. The variable-type functions as a needle valve, much like a
ow control valve (Fig. 29-31). The operator adjusts the outlet ori ce size, so the
resultant breathing system pressure at any given adjust- ment is directly related to the
fresh gas ow rate. Modern machines now mostly use pressure-regulating–type APL
valves (Fig. 29-32). This type of APL valve has an adjust- able internal tension spring
and an external scale indicat- ing approximate or relative opening pressure. When the
pressure in the system exceeds spring tension, a disk opens and gas is vented (see Fig.
29-32, B). In this manner, the operator can adjust the circuit pressure, which remains
stable even as the fresh gas ow is increased. Continu- ous positive airway pressure
(CPAP) can be more reliably controlled using this type of APL valve; however,
circuit pressure should be carefully monitored. This type of valve usually has a fully
open position for spontaneous breath- ing whereby the valve is open to the
atmosphere (see Fig. 29-32, C). Gas is prevented from returning from the scav-
enging system by a downstream check valve. When the valve is placed in the manual
mode, spring pressure is applied to the valve in an amount proportional to the desired

maximal circuit pressure as described before.41,122

 2. Jelaskan mengenai ABC

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273374/pdf/ijgm-5-117.pdf
 3. Jelaskan mengenai recovery position

Recovery position mengacu ke salah satu dari serangkaian variasi pada berbaring
lateral atau posisi tiga perempat pronasi tubuh, di mana korban tidak sadar tetapi
bernapas, dan ditempatkan sebagai bagian dari pertolongan pertama.

Tujuan Recovery position untuk mencegah kekurangan oksigen karena obstruksi jalan
napas, yang bisa terjadi pada pasien terlentang dan tidak sadar.

4. Setting ventilator
Pengaturan Ventilasi Mekanik ( Setting)


Parameter yang harus ditetapkan sangat bervariasi tergantung pada mode ventilasi
yang digunakan. Beberapa parameter tersebut antara lain:

a. Laju pernapasan (respiratory rate) 


Rentang laju pernapasan yang digunakan pada ventilator mandatori cukup
luas. Hal ini tergantung pada nilai sasaran ventilasi semenit (minute
ventilation) yang berbeda-beda pada tiap individu maupun kondisi klinis
tertentu. Secara umum, rentang laju pernapasan berkisar antara 4 sampai 20
kali tiap menit dan pada sebagian besar pasien-pasien yang stabil, berkisar
antara 8 sampai 12 kali tiap menit. Pada pasien dewasa dengan sindroma
distres pernapasan akut, penggunaan volume tidal yang rendah harus
diimbangi dengan peningkatan laju pernapasan sampai 35 kali tiap menit
untuk mempertahankan ventilasi semenit yang adekuat. 

b. Volume tidal 

Pada beberapa kasus, volume tidal harus lebih rendah terutama pada sindroma
distres pernapasan akut. Pada saat mengatur volume tidal pada mode tertentu,
perkiraan kasarnya berkisar antara 5 sampai 8 ml/kg berat badan ideal. Pada
pasien dengan paru-paru normal yang terintubasi karena alasan tertentu,
 volume tidal yang digunakan sampai 12 ml/kg berat badan ideal. Volume tidal
harus disesuaikan sehingga dapat mempertahankan tekanan plato di bawah 35
cm H2O. Tekanan plato ditentukan dengan manuver menahan napas selama
inspirasi yang disebut dengan istlah tekanan alveolar akhir inspirasi pada
pasien-pasien yang direlaksasi. 
Peningkatan tekanan plato tidak selalu
meningkatkan risiko barotrauma. Risiko tersebut ditentukan oleh tekanan
transalveolar yang merupakan hasil pengurangan antara tekanan alveolar
dengan tekanan pleura. Pada pasien-pasien dengan edema dinding dada,
distensi abdomen atau asites, komplians dinding dada menurun. Hal ini
menyebabkan tekanan pleura meningkat selama pengembangan paru.
Peningkatan tekanan 
transalveolar jarang terjadi pada pasien yang memiliki
komplians paru yang normal.
c. Tekanan inspirasi

Pada ventilasi tekanan terkontrol (PCV) dan ventilasi pressure- support,

tekanan inspirasi diatur sedemikian rupa sehingga tekanan plato kurang atau
sama dengan 35 cm H2O. Volume tidal juga harus dipertahankan pada rentang
yang telah ditetapkan sebelumnya.

d. Fraksi oksigen terinspirasi (FiO2)

Pada sebagian besar kasus, FiO2 harus 100% pada saat pasien diintubasi dan
dihubungkan dengan ventilator untuk pertama kali. Ketika penempatan pipa
endotrakea sudah ditetapkan dan pasien telah distabilisasi, FiO2 harus
diturunkan sampai konsentrasi terendah yang masih dapat mempertahankan
saturasi oksigen hemoglobin , karena konsentrasi oksigen yang tinggi dapat
menyebabkan toksisitas pulmonal. Tujuan utama ventilasi adalah
mempertahankan nilai saturasi 90 % atau lebih. Kadang-kadang nilai tersebut
bisa berubah, misalnya pada keadaan-keadaan yang membutuhkan suatu
proteksi terhadap paru-paru dari volume tidal, tekanan dan konsentrasi
oksigen yang terlalu besar. Pada keadaan ini, target saturasi oksigen dapat
diturunkan sampai 85% saat faktor-faktor yang berperan pada penyaluran
oksigen sedang dioptimalkan. 


e. Tekanan positif akhir ekspirasi (Postive end-expiratory pressure/PEEP)

 Sesuai dengan namanya, PEEP berfungsi untuk mempertahankan tekanan
positif jalan napas pada tingkatan tertentu selama fase ekspirasi. PEEP
dibedakan dari tekanan positif jalan napas kontinyu (continuous positive
airway pressure/ CPAP) berdasarkan saat digunakannya. PEEP hanya
digunakan pada fase ekspirasi, sementara CPAP berlangsung selama siklus
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respirasi. 

Penggunaan PEEP selama ventilasi mekanik memiliki manfaaat yang
potensial.Pada gagal napas hipoksemia akut, PEEP meningkatkan tekanan
alveolar rata-rata, meningkatkan area reekspansi atelektasis dan dapat
mendorong cairan dari ruang alveolar menuju interstisial sehingga
memungkinkan alveoli yang sebelumnya tertutup atau terendam cairan, untuk
berperan serta dalam pertukaran gas. Pada edema kardiopulmonal, PEEP dapat
mengurangi preload dan afterload ventrikel kiri sehingga memperbaiki kinerja
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jantung.
Pada gagal napas hiperkapnea yang disebabkan oleh obstruksi jalan napas,
pasien sering mengalami kekurangan waktu untuk ekspirasi sehingga
menimbulkan hiperinflasi dinamik. Hal ini menyebabkan timbulnya auto-
PEEP yaitu tekanan akhir ekspirasi alveolar yang lebih tinggi dari tekanan
atmosfer. Bila didapatkan auto-PEEP, maka dibutuhkan pemicu ventilator
(trigger) berupa tekanan negatif jalan napas yang lebih tinggi dari sensitivitas
pemicu maupun auto-PEEP. Jika pasien tidak mampu mencapainya, maka
usaha inspirasi menjadi sia-sia dan dapat meningkatkan kerja pernapasan
(work of breathing). Pemberian PEEP dapat mengatasi hal ini karena dapat
mengurangi auto-PEEP dari tekanan negatif total yang dibutuhkan untuk
memicu ventilator. Secara umum, PEEP ditingkatkan secara bertahap sampai
usaha napas pasien dapat memicu ventilator secara konstan hingga mencapai
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85% dari auto-PEEP yang diperkirakan.
f. Sensitivitas Pemicu (trigger sensitivity)
Sensitivitas pemicu adalah tekanan negatif yang harus dihasilkan oleh pasien
untuk memulai suatu bantuan napas oleh ventilator. Tekanan ini harus cukup
rendah untuk mengurangi kerja pernapasan, namun juga harus cukup tinggi
untuk menghindari sensitivitas yang berlebihan terhadap usaha napas pasien.
Tekanan ini berkisar antara -1 sampai -2 cmH2O. Pemivu ventilator ini timbul
 7
bila aliran napas pasien menurun 1 sampai 3 l/menit.
g. Laju aliran (flow rate)
Hal ini sering dilupakan pada mode yang bersifat volume-target. Laju aliran
ini penting terutama untuk kenyamanan pasien karena mempengaruhi kerja
pernapasan, hiperinflasi dinamik dan auto-PEEP. Pada sebagian besar
ventilator, laju aliran diatur secara langsung. Pada ventilator lainnya, misalnya
Siemen 900 cc, laju aliran ditentukan secara tidak langsung dari laju
pernapasan dan I:E ratio.


Contohnya adalah sebagai berikut:

Laju pernapasan = 10
Waktu siklus respirasi = 6 detik
I:E ratio = 1:2
Waktu inspirasi = 2 detik
Waktu ekspirasi = 4 detik
Volume tidal = 500 ml
Laju aliran = volume/ waktu inspirasi = 500 ml tiap 2 detik
h. Perbandingan waktu inspirasi terhadap waktu ekspirasi
Sejalan dengan laju aliran inspirasi, ahli terapi respirasi mengatur I:E ratio
tanpa permintaan dari dokter. Tetapi para klinisi dituntut untuk mengerti
tentang perubahan ini yang dapat mempengaruhi mekanika sistem respirasi
dan kenyamanan pasien. I:E ratio yang umum digunakan adalah 1:2. Pada
gagal napas hipoksemia akut, perbandingan ini dapat meningkat dengan
adanya pemanjangan waktu inspirasi, tekanan jalan napas rata-rata atau alveoli
yang terisi cairan yang dapat memperbaiki oksigenasi. Pada hipoksemia berat,
I:E ratio kadang-kadang terbalik menjadi 2:1, sehingga kewaspadaan harus
dipertahankan untuk mengatasi akibat yang merugikan terhadap hemodinamik
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dan integritas paru-paru.
5. Pemeriksaan fisik berdasarkan American Society of Anesthesiologist
6. Difficult airway management