Kompilasi Materi Pembicara 1-4 Webinar iLA-PERDICI - v2

M AT E R I W E B I N A R
CLINICAL MANAGEMENT OF SEVERE ACUTE

RESPIRATORY INFECTION IN COVID-19 PATIENT
29 AGUSTUS 2020
Supported by:
DIFFICULT AIRWAY MANAGEMENT
IN COVID-19 PATIENT
– dr. Adhrie Sugiarto, Sp.An-KIC
HIGH FLOW OXYGEN THERAPY

IN COVID-19 PATIENT
– dr. Navy G.H. Lolong Wulung, Sp.An-KIC
WEBINAR
HEMODYNAMIC MONITORING:
TOPICS OPTIMIZING OXYGEN DELIVERY
IN COVID-19 PATIENT WITH SEPTIC SHOCK
– dr. Rudy Manalu, Sp.An-KIC
LUNG PROTECTIVE VENTILATION

IN COVID-19 PATIENT
– dr. Bambang Wahjuprajitno, Sp.An-KIC
DIFFICULT AIRWAY MANAGEMENT
IN COVID-19 PATIENT
– dr. Adhrie Sugiarto, Sp.An-KIC
Difficult
Airway
Management
in COVID-19
Adhrie Sugiarto
Difficult airway
• An airway is considered difficult Patient
when oxygenation and
ventilation cannot be achieved in
the desired manner
• ‘The difficult airway’ represents
a complex interaction between Difficult
patient factors, the clinical Airway
setting, and the skills and
preferences of the practitioner Clinical
Practitioner
setting
Difficult airway
Incidence of failed intubation :

✓ ~ 1 in 1–2000 in the elective setting
✓ ~ 1 in 300 during rapid sequence intubation in the

obstetric setting
✓ ~ 1 in 50–100 in the emergency department (ED),

intensive care unit (ICU), and pre-hospital settings
“Normal” Algorithm
New Normal
COVID-19
• Contact and droplet transmission
• Saliva and respiratory secretions
• Coughs, sneezes, talks
• Airborne transmission
• Medical procedures that generate aerosols
• High flow oxygen, Non-invasive positive pressure
ventilation, Intubation, Extubation
• Fomite transmission
• Can contaminate surfaces and objects, creating fomites
(contaminated surfaces)
Poll: Apakah anda pernah menemui kasus
jalan nafas sulit pada pasien COVID-19?
• YA
• TIDAK
• RAGU-RAGU
COVID-19 cases are difficult airway
PATIENT
- Oxygenation
problems
- Cardiovascular
problems
Difficult
Airway
CLINICAL SETTING PRACTITIONER
- Urgent - Skill &
- Equipment Experience
- PPE - Teamwork ?
Intubasi pada COVID-19
• COVID-19 di Indonesia > 160 ribu kasus konfirmasi, kematian > 6900
orang
• 2,3 % kasus → Intubasi
• Data Yao et al dari Wuhan, Tiongkok, first pass success intubation dapat
dilakukan pada sebagian besar kasus (89,1%)
• Meng et al → beban psikologis dalam melakukan intubasi dalam
keadaan emergensi menambah kesulitan intubasi
• Kematian dalam 24 jam pasca intubasi adalah 10.4%
Yao W et al. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China:
lessons learnt and international expert recommendations. BJA 2020;Article in press
Meng L, Qiu H, Wang L, Ai Y, Xue Z, Guo Q. Intubation and Ventilation amid the COVID-19
Outbreak Wuhan’s Experience. Anesthesiology 2020;Article in press
Yao W et al. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan,
China: lessons learnt and international expert recommendations. BJA 2020;Article in press
Personal Protective Equiment
PRE-INTUBATION
Sullivan, E.H., Gibson, L.E., Berra, L. et al. In-hospital airway management of COVID-19 patients.
Crit Care 24, 292 (2020). https://doi.org/10.1186/s13054-020-03018-x
Poll: Alat airway apa yang tersedia di tempat
anda bekerja? (boleh lebih dari satu)
❑ LMA / Sungkup laring
❑ Intubating LMA
❑ Bougie
❑ Video laryngoscope
❑ Flexible bronchoscope
❑ Set Krikotiroidotomi
INTUBATION
Yao W et al. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan,
China: lessons learnt and international expert recommendations. BJA 2020;Article in press
Videolaryngoscopes
Channeled Non -channeled

Difficult or Failed Airways
POST-INTUBATION
Sullivan, E.H., Gibson, L.E., Berra, L. et al. In-hospital airway management of COVID-19 patients.
Crit Care 24, 292 (2020). https://doi.org/10.1186/s13054-020-03018-x
Terima Kasih
References:
1. Verghese C., Ramaswamy B.
BJA 2008; 101 (3): 405-410.
2. Sharma V. et al. BJA 2010;
105 (2): 228-232.
3. Cook T.M. et al. Anaesthesia 2009;
64: 555-562.
Softer bite block Thicker 4. Van Zundert A., Brimacombe J.
Anaesthesia 2008; 63: 202-213.
fixation tab
Helps to reduce
potential dental damage. Provides greater Clinical
security during evidence
tape down.
For the latest
Elongated cuff clinical evidence on
LMA Supreme™
Tip Now a single piece with a curved
LMA Evolution
LMA Supreme ™
A 10˚ slant allows
back plate providing a smoother
profile to aid insertion. Curve™
the cuff to follow www.lmaco.com/evidence
A second generation SAD with an innovative Second Seal™. the contour of A more pliable
the oesophageal airway tube facilitates make-a-switch.com
sphincter to greater anatomical For more
optimise placement. compliance. information on
making the
switch to second
generation SADs
www.make-a-switch.com
™ (oropha
LMA Supreme™ is a second generation, gastric Seal ry n
ge Second Seal™ First Seal™
t a
Consider using rs
access device which forms an effective First
ls
Fi
Oesophageal seal. Oropharyngeal seal. For the latest
LMA Supreme™ for:
ea
digital case reports,
Seal™ with the oropharynx (oropharyngeal seal)
l)
Mild to moderately educational videos
obese patients and clinician
and an innovative Second Seal™ with the upper testimonials
Abdominal 2 Separate Routes LMA Supreme™: Product specification
oesophageal sphincter (the oesophageal seal). procedures
www.youtube.com/
Mask size Product code Patient size Maximum Largest size LaryngealMaskAirway
Se
Controlled reflux cuff volume (air)* OG tube
a l)
co
se
nd
Soft, elongated cuff designed to support an effective Positive pressure Se al 1 175010 Neonates/infants up to 5 kg 5 ml 6 Fr
First Seal™ and Second Seal™ 1, 2, 3 ventilation (PPV)
al (
™ o eso pha ge
1.5 175015 Infants 5-10 kg 8 ml 6 Fr
2 175020 Infants 10-20 kg 12 ml 10 Fr For the latest
Elliptical and anatomically shaped LMA Evolution Curve ™ Unexpected difficult airways
news from LMA
(airway tube) facilitates insertion success 2 2.5 175025 Children 20-30 kg 20 ml 10 Fr
Plastic surgery procedures
3 175030 Children 30-50 kg 30 ml 14 Fr
Fixation tab and integral bite block 1
4 175040 Adults 50-70 kg 45 ml 14 Fr
5 175050 Adults 70-100 kg 45 ml 14 Fr www.facebook.com/
LMAInternational
First Seal™ Second Seal™ *These are maximum volumes that should never be exceeded. It is recommended
that the cuff be inflated to a maximum of 60 cm H20 intracuff pressure.
OG = orogastric
LMA Supreme™ delivers measured oropharyngeal leak LMA Supreme™ enables passive drainage or active
pressures up to 37cm H2O. 4 management of digestive tract contents independent of
Distributed by: TELEFLEX HEADQUARTERS INTERNATIONAL, IRELAND For product
ventilation. 3
The First Seal™ is important for: Teleflex Medical Europe Ltd., IDA Business and Technology Park, information and
The Second Seal™ is designed to: Dublin Road, Athlone, Co Westmeath, Ireland access to product
Ventilation performance Phone +353 (0)9 06 46 08 00 Fax +353 (0)14 37 07 73 instructions for use
PAJ-2500-036 Rev B IW 201402

orders.intl@teleflex.com
Advanced uses of the device such as in patients with Improve safety vs a first generation device
decreased thoracic compliance, in mild-to-moderately obese www.lmaco.com
Secure the distal tip of the LMA Supreme™ at the upper Manufactured by:
patients and in certain procedures requiring mechanical oesophageal sphincter to maintain the patency of the drain The Laryngeal Mask Company Limited
Le Rocher, Victoria, Mahé, Seychelles
ventilation where higher seal pressures are required tube
For information on
Reduce the risk of insufflation during ventilation Consult IFU on this website:
other products
www.LMACO.com
within the Teleflex
Reduce the risk of regurgitated gastric content leaking product portfolio
around the tip of the mask Teleflex www.teleflex.com LMA www.lmaco.com
Copyright © 2014 Teleflex Incorporated. All rights reserved. LMA, LMA Supreme, First Seal, Second Seal, www.teleflex.com
LMA Better by Design are trademarks or registered trademarks of Teleflex Incorporated or its affiliates.
XX XX XX – XX XX XX . XXX XX/XX . XX/X . XX XX XX

The gastric drain tube enables References:
confirmation of correct mask 1. Evans N.R. et al. CJA 2002; 49: 413-416.
placement and sealing with the 2. Hohlrieder M. et al. BJA 2007;
upper oesophageal sphincter. 99: 576-580.
A patent drain tube reduces 3. Cook T.M., Gibbison B. BJA 2007;
the risk of stomach insufflation. 99: 436-439.
4. Mark D.A. CJA 2003; 50: 78-80.
5. Brain A.I.J. et al. BJA 2000; 84: 650-654.
6. 4th National Audit Project of the Royal
15 mm connector College of Anaesthetists and the Difficult
Airway Society: Major Complications of
Airway Management in the United
Kingdom. Report and findings: March
2011. Editors: Dr Tim Cook, Dr Nick
Bite block Drain tube Woodall and Dr Chris Frerk.
An optimised distal tip Clinical

Wire-reinforced with gastric access
evidence
airway tube designed to functionally
seperate the digestive For the latest
clinical evidence on
LMA ProSeal ™ and respiratory tracts. 3
LMA ProSeal™
First Seal™
Proven versatility.
Oropharyngeal seal. www.lmaco.com/evidence
make-a-switch.com
For more
information on
making the
switch to second
Manual vent generation SADs
www.make-a-switch.com
LMA ProSeal™ is a re-usable second Post anaesthesia care unit outcome data up to 24 hours 2 Second Seal™ Make sure the manual vent is
open during sterilisation to
generation, gastric access device which LMA ProSeal™ Oesophageal seal. prevent herniation of the cuff.
50
forms an effective First Seal™ with the ETT For the latest
educational videos
oropharynx (oropharyngeal seal) and an and clinician
LMA ProSeal™: Product specification testimonials
innovative Second Seal™ with the upper
oesophageal sphincter (oesophageal seal). 40 Mask size Product code Patient size Maximum
cuff volume (air)*
Largest size
OG tube/salem
pump
www.youtube.com/
LaryngealMaskAirway
30
1 150010 Neonates/infants up to 5 kg 4 ml 2.7 mm / 8 Fr
1.5 150015 Infants 5-10 kg 7 ml 3.5 mm / 10 Fr
The most versatile re-usable airway 2 150020 Infants/children 10-20 kg 10 ml 3.5 mm / 10 Fr For the latest
news from LMA
20
Peace of mind – Passive regurgitation can occur 2.5 150025 Children 20-30 kg 14 ml 4.9 mm / 14 Fr
unexpectedly intraoperatively. LMA ProSeal™ enables the 3 150030 Children 30-50 kg 20 ml 5.5 mm / 16 Fr
regurgitated fluid to pass up the drainage tube without 4 150040 Adults 50-70 kg 30 ml 5.5 mm / 16 Fr
leaking into the glottis 1 www.facebook.com/
5 150050 Adults 70-100 kg 40 ml 6.0 mm / 18 Fr
Patient comfort – LMA ProSeal™ reduces the likelihood of

throat irritation and stimulation, and reduces post-operative
10 *These are maximum volumes that should never be exceeded. It is recommended
that the cuff be inflated to a maximum of 60 cm H20 intracuff pressure.
OG = orogastric
LMAInternational
0
nausea and vomiting by as much as 40% compared to
an ETT 2 Distributed by: TELEFLEX HEADQUARTERS INTERNATIONAL, IRELAND
Teleflex Medical Europe Ltd., IDA Business and Technology Park,
For product
Sore throat (%) Vomiting (%) Nausea (%) Dublin Road, Athlone, Co Westmeath, Ireland information and
Performance – LMA ProSeal™ achieves a high seal Phone +353 (0)9 06 46 08 00 Fax +353 (0)14 37 07 73 access to product
PAB-2500-007 Rev B IW 201402

pressure, with a median seal pressure of 32cm H2O 3 orders.intl@teleflex.com instructions for use
★ Sore throat P<0.0001 vs. LMA ProSeal™ group.
Aspiration – LMA ProSeal has a built-in drain tube that
™ ▲ Vomiting P<0.004 vs. LMA ProSeal™ group.
Manufactured by: www.lmaco.com
allows expelled gastric content to bypass the pharynx. ♦ Nausea P<0.0001 vs. LMA ProSeal™ group. The Laryngeal Mask Company Limited
Le Rocher, Victoria, Mahé, Seychelles
This specific feature is designed to decrease the risk of Post-operative sore throat, nausea and vomiting were
aspiration 4, 5 measured via patient interviews in a blind fashion. For information on
Consult IFU on this website:
www.LMACO.com other products
within the Teleflex
product portfolio
Teleflex www.teleflex.com LMA www.lmaco.com
“The LMA ProSeal™ currently has the broadest evidence to support its efficacy and safety profile.” Copyright © 2014 Teleflex Incorporated. All rights reserved. LMA, LMA ProSeal, First Seal, Second Seal, www.teleflex.com
LMA Better by Design are trademarks or registered trademarks of Teleflex Incorporated or its affiliates.
NAP4 report, 2011
94 06 90 - AP 00 01 · REV B · LMA / PDF · 10 14 PDF
LMA Protector Airway with Cuff Pilot Technology
Ability to intubate
Dual gastric access
Silicone airway tube

with dynamic curve
Phthalate free
LMA Protector Airway

Revolutionizing Airway Access
Second Seal Technology

(facilitates esophageal seal)
MR safe*
The LMA Protector Airway is the most advanced second generation airway from Teleflex.
First Seal Technology Cuff Pilot Technology

Dual gastric channels Silicone Cuff Pilot Technology (facilitates oropharyngeal seal)
The only laryngeal mask that The airway tube and cuff are An integrated cuff pressure indicator
combines a pharyngeal chamber 100% silicone, phthalate free and for single use airway management
LMA Protector Airway
and dual gastric drainage designed to conform to the ana- devices that enables continuous cuff Product code Product code mask size Patient weight maximum maximum largest size
with cuff Pilot technology with Pilot balloon intracuff Pressure** ett id (mm) og tube
channels, designed specifically tomy. Silicone cuffs have been pressure monitoring at a glance and
192030 195030 3 30–50 kg 60 cm H20 6.5 16 Fr.
to channel gastric content away shown to reduce risk of sore throat 1 facilitates easy, accurate adjustment
192040 195040 4 50–70 kg 60 cm H20 7.5 18 Fr.
from the airway. and achieve higher seal pressures.2 when necessary. 3
192050 195050 5 70–100 kg 60 cm H20 7.5 18 Fr.
ett=endotracheal tube | og=orogastric tube
* LMA Protector Airway with Cuff Pilot Technology only.
Second Seal Technology Ability to intubate ** It is recommended that the cuff be inflated to a maximum intracuff pressure of 60 cm H20.
The elongated cuff facilitates the upper esophageal seal. Allows direct intubation using visual guidance.
References:
1. William A, Chambers NA, Erb T.O, Ungern-Sternberg BS. Incidence of sore throat in children following use
of flexible laryngeal mask airways – impact of an introducer device. Pediatric Anesthesia. 2010; 839-843.
[Pubmed: 20716076].
2. Jagannathan N, Sohn LE, Sawardekar A, Gordone J, Langen KE, Anderson K. A randomized comparison of
the LMA Supreme and LMA ProSeal in children. Anaesthesia. 2012; 67:632-639. [Pubmed: 22420717].
3. E.Bick, I. Bailes, A.Patel, A.I.J.Brain Editorial: Fewer sore throats and a better seal: why routine manometry www.lmaco.com
The Clinician Your Institution The Patient for laryngeal mask airways must become the standard of care Anaesthesia 2014, 69, 1299–1313.
Benefits
Excellent seal pressures, dual Designed to help Phthalate free

gastric channel and continuous reduce airway-related silicone cuff
cuff pressure monitoring complications and improve designed for Teleflex, the Teleflex logo, Cuff Pilot, First Seal, LMA, LMA ProSeal, LMA Protector, LMA Supreme, and Second Seal are trademarks or registered trademarks of Teleflex Incorporated or
inspires confidence. procedural efficiencies. patient comfort. its affiliates, in the U.S. and/or other countries.
Information in this material is not a substitute for the product Instructions for Use. Not all products may be available in all countries. Please contact your local representative.
Revised: 04/2016 © 2017 Teleflex Incorporated. All rights reserved.
94 08 37 - 00 00 01 · REV A · 09 17 01
Distributed by:
Teleflex Headquarters International, Ireland · Teleflex Medical Europe Ltd. · IDA Business & Technology Park
Dublin Road · Athlone · Co Westmeath · Tel. +353 (0)9 06 46 08 00 · Fax +353 (0)14 37 07 73 · orders.intl@teleflex.com
United Kingdom Tel. +44 (0)14 94 53 27 61 · info.uk@teleflex.com
South Africa Tel. +27 (0)11 807 4887 · assist.africa@teleflex.com
PORTEX® PDT Kit
Percutaneous Dilatational Tracheostomy Kit
Portex® PDT kit merupakan set alat untuk tindakan pemasangan tracheostomy dengan
metode Percutaneous Dilatational Tracheostomy.
Produk ini tersedia dalam paket yang lengkap sesuai dengan kebutuhan pemasangan.
Key Features
• Dilengkapi dengan kanul tracheostomy lengkap dengan 2 inner cannula dan fiksasinya
• Single-use mencegah terjadinya infeksi silang
• Cuff pada tracheostomy yang berbentuk apple, high volume low pressure
sehingga meminimalkan risiko terjadinya trauma pada trakea akibat penekanan pada cuff
• Bahan yang lembut sehingga memudahkan saat insersi
• Blue line radiopaque
Code Product Name

100-561-070 PDT Kit 7 mm Single Stage
100-561-080 PDT Kit 8 mm Single Stage
PORTEX® SuctionPro72™ PORTEX® Suction Above the Cuff PORTEX® PORTEX® Our Portfolio
Closed Ventilation Suction System Tracheal Tube (SACETT™) Suction Aid Pressure Gauge for Airway Management
Ventilator Associated Pneumonia
Prevention Product Portex® Endotracheal Tube Clear Cuffed
ETT dengan cuff high volume low pressure yang dapat
meningkatkan kenyamanan pada pasien.
Airway Management Tersedia ukuran dengan internal diameter 5 mm – 8 mm.
Reduce Infection Code : 100-150
Reduce Patient Stay
Portex® Endotracheal Tube Pro Soft Seal®
Reduce Costs Clear Cuffed
ETT dengan resting diameter cuff yang lebih besar
sehingga memberikan kenyamanan maksimal pada
pasien. Soft Seal® cuff-nya terbuat dari bahan PVC lembut
dengan tujuan meminimalisir risiko trauma.
Tersedia ukuran dengan internal diameter 5 mm – 8.5 mm.
Portex® SuctionPro72™ Closed Ventilation Suction System adalah alat yang Portex® Suction Above the Cuff Tracheal Tube (SACETT™) merupakan Portex® Blue Line Ultra Suction Aid adalah tracheostomy tube yang dilengkapi
digunakan untuk membersihkan jalan nafas dari slem dengan cara menghisap endotracheal tube yang dilengkapi suction line di atas cuff (subglottic dengan suction line di atas cuff (subglottic secretions drainage), sehingga Code : 100-199
slem untuk menghilangkan sekresi dari trakeobronkial pada pasien dewasa secretions drainage), sehingga memungkinkan dilakukannya suction pada memungkinkan dilakukannya suction pada sekret yang terkumpul diatas cuff
yang menggunakan ventilator. sekret yang terkumpul di atas cuff, yang tidak terjangkau oleh metode yang tidak terjangkau oleh metode konvensional.
Portex® Blue Line Ultra Tracheostomy
konvensional.
SuctionPro72 didesain untuk pemakaian hingga 72 jam.
™
Suction Aid memfasilitasi untuk mencegah terjadinya VAP yang terjadi
tekanan balon/cuff. Tube Kit
Penggunaan SACETT™ mencegah terjadinya VAP (Ventilator Associated pada penggunaan tracheostomy, terutama pasien dengan penggunaan Key Features Set trakeostomi yang dilengkapi inner canula dan sikat
Key Features Pneumonia) pada pasien yang diperkirakan akan dirawat dengan tracheostomy jangka panjang.
menggunakan alat bantu pernapasan selama lebih dari 72 jam. • Digunakan untuk mengembangkan cuff dengan ukuran yang akurat untuk pasien. Soft Seal® Cuff yang mempunyai bentuk
• Pemakaian hingga 3 hari • unik, untuk meminimalisasi tekanan pada trakea. Cuff
• Dengan closed system untuk mencegah terjadinya pemaparan langsung Key Features •
Key Features Unfenestrated Tube didesain untuk pasien dengan
kepada petugas dan pasien • Portable dan memungkinkan dilakukannya mobilisasi ventilator.
• Penggunaan single-use mencegah terjadinya resiko infeksi silang • Penggunaan single-use mencegah terjadinya resiko infeksi silang • Penggunaan single-use mencegah terjadinya resiko infeksi silang Tersedia ukuran dengan internal diameter 6 mm – 8 mm.
• Tersedia varian SuctionPro72™ untuk pasien dengan ETT maupun dengan • Soft Seal® Cuff high volume low pressure dapat meningkatkan kenyamanan • Flange lembut untuk kenyamanan pasien
tracheostomy pasien dan membantu dalam pengumpulan sekresi • Soft Seal® Cuff high volume low pressure dapat meningkatkan kenyamanan Code Product Name Code : 100-810
• Selang suction sistem tertutup dengan kualitas tinggi • pasien dan membantu dalam pengumpulan sekresi 100-568-000
• Bahan plastik PVC-Silikon transparan tidak menimbulkan suara gaduh menjaga tekanan cuff tidak berubah • Central channel pada pilot balon, untuk mencegah terjadinya kolaps
Portex® Blue Line Ultra Fen Tracheostomy
• Dilengkapi dengan kunci pelepas konektor untuk memudahkan dalam • Lumen suction yang kompatibel dengan syringe pada saat penarikan sekret pada pilot balon yang berakibat pada tidak akuratnya volume udara yang
Tube Kit
melepas konektor dari ETT atau tracheostomy • dimasukan dalam cuff
• Dilengkapi dengan swivel konektor untuk memudahkan manuver pada tube • Set trakeostomi yang dilengkapi inner canula dan sikat
proses suction sehingga lebih nyaman bagi pasien • Suction line kuning memungkinkan visualisasi sekresi
• untuk pasien. Cuff Fenestrated Tube didesain untuk pasien
Code Product Name
berkembang biak dalam proses weaning.
100-870-060 BLU Suctionaid Kit Trach 6 Tersedia ukuran dengan internal diameter 6 mm – 8 mm.
Code Product Name
100-870-070 BLU Suctionaid Kit Trach 7
100-189-060 Portex SACETT 6
Code Product Name 100-870-075 BLU Suctionaid Kit Trach 7.5 Code : 100-812
100-189-065 Portex SACETT 6.5
Z110-10 SuctionPro 72 Single Lumen 10Fr 100-870-080 BLU Suctionaid Kit Trach 8
Z210-12 SuctionPro 72 Duel Lumen 12Fr
Z210-14 SuctionPro 72 Duel Lumen 14Fr Distributed by:
Z215-14 SuctionPro 72 Duel Lumen 14Fr Tr
JAKARTA, INDONESIA HEAD OFFICE

PT IDS Medical Systems Indonesia
Wisma 76 17th & 22nd Floor, Jl. Letjend. S. Parman kav. 76
Slipi, Jakarta 11410, Indonesia
T: +62 21 2567 8989 F: +62 21 5366 1038 E: idninfo@idsmed.com
www.idsMED.com
Airway Management Ventilation
TM
Thomas Tube Holder
Never worry about tape fastening again! The Thomas Tube Holder is the only tube holder with a quick-set
screw for a secure hold after tube placement. Not only does the Thomas Tube Holder accommodate
Combitubes® and LMAs, its special bite block feature protects the patient and the tube. No wonder it is
one of the most effective tube holders on the market today!
Hook and loop padded strap provides

security and comfort. Will not stretch
or shrink when wet. Color-coded for
ease of identification between adult and
Pediatric Thomas Tube Holder versions.
Slide stick facilitates fast,

efficient application of the head
strap around the patient’s neck
without movement of the head.
Larger access opening to allow

for ease of suctioning and visual
inspection of mouth.
Quick-set screw system securely
holds tubes in place and facilitates
fast, easy adjustment or removal of
the Thomas Tube Holder.
Larger opening allows for
application of a wide-range of single
and double-lumen airway tubes.
Ventilations may continue during $GXOW
application, adjustment, and removal
of the Thomas Tube Holder.
3HGLDWULF
600-30000 Thomas Tube Holder Adult, Green (qty. 1)

600-10000 Thomas Tube Holder Adult (qty. 1)
600-20000 Thomas Tube Holder Pediatric (qty. 1)
Only sold in cartons of 25 each.
Visit www.laerdal.com or contact your Authorized Laerdal Distributor 117

HIGH FLOW OXYGEN THERAPY
IN COVID-19 PATIENT
– dr. Navy G.H. Lolong Wulung, Sp.An-KIC
High Flow Oxygen Therapy in
COVID-19 Patient
NAVY LOLONG WULUNG
INDONESIA
WHAT IS HAPPENING
IN COVID-19 ???
Oxygenation is disrupted
PROSES N2 H2O
DIFUSI PAN2:
573 mmHg
PAH 2O:
47 mmHg
terganggu PAO2: PACO2:

104 mmHg 40 mmHg PaO2
O2 O2 CO2 O2
Pulmonary Artery Pulmonary Vein
PvO2:
40 mmHg CO2 CO2
PcCO2: 45 PcCO2: 40
PcO2: 100 mmHg
TROMBUS mmHg
mmHg
Oxygenation
UDARA BEBAS:
PiO2 : 40% x 760 = 160 mmHg
PiCO2 : 0.04 % x 760 = 0.3 mmHg
PiN2 : 58,6% x 760 = 420mmHg
ALVEOLUS
PiH2O : 0.46 % x 760 = 3.5 mmHg
N2 H2O
PAN2:
420 mmHg
PAH 2O:
47 mmHg
KAPILER
PROSES PARU
DIFUSI PAO2:
140 mmHg
PACO2:
40 mmHg PaO2
TERGANGGU O2 O2 CO2 O2
Pulmonary Artery Pulmonary Vein
PvO2:
40 mmHg CO2 CO2
PcCO2: 45 PcCO2: 40
mmHg PcO2: 100 mmHg
mmHg
\ PAO2  PcO2
TERAPI OKSIGEN
SECARA UMUM
TERAPI OKSIGEN
PADA COVID - 19
No EVIDENCE
•To date, no evidence of optimal
oxygen treatment for COVID-19
patients is known, neither in
terms of a method for
administration nor for target
saturation (SpO2).
BUT THERE ARE
RECOMMENDATIONS
WHO RECOMMENDATION in COVID-19
• in adult, non-pregnant patients with COVID-
19,
• target SpO2 should be >90% when the
patient is stabilized,
• while in critically ill patients (with shock,
coma, seizures, risk of respiratory arrest), an
SpO2 > 94% should be the target
Surviving Sepsis Campaign: Guidelines on the
Management of Critically Ill Adults with COVID-19
23.In adults with COVID-19, we suggest starting
supplemental oxygen if the peripheral oxygen
saturation (SPO2) is < 92% (weak
recommendation, low quality evidence), and
recommend starting supplemental oxygen if
SPO2 is < 90% (strong recommendation,
moderate quality evidence).
24.In adults with COVID-19 and acute
hypoxemic respiratory failure on oxygen,
we recommend that SPO2 be maintained
no higher than 96% (strong
recommendation, moderate quality
evidence).
SSC in COVID-19
•reasonable SPO2 range for
patients receiving oxygen
is 92% to 96%
COPD ?
•That target SpO2 in COVID-19
patients without known chronic lung
disease should be 92–96%
•That target SpO2 in COVID-19
patients with known chronic lung
disease (COPD) should be 88–92%
PROTOKOL
OKSIGENASI & VENTILASI
COVID-19
RAPAT TIM TREATMENT
RSUP PERSAHABATAN
7 APRIL 2020
PPPASIEN POSITIF / PDP COVID-19
GANGGUAN SESAK NAFAS HIPOKSEMIA, SpO2 <93% (FiO2 21%),

HENTI JANTUNG
JALAN NAFAS RR >30/MENIT PaO2/FiO2 <300 mmHg
1. Apakah kondisi sedang memburuk progresif? TIDAK

NRM 15 lpm
2. Apakah diyakini akan memburuk?
YA HFNC 30 LPM FiO2 100%
TIDAK 1. Compos Mentis, komunikasi lancar, DAN YA Evaluasi dalam 2 jam, apakah:
2. RR 20-30/menit, DAN 1. Penurunan kesadaran, ATAU
3. SpO2 >88% 2. RR >30/MENIT, ATAU
3. SpO2 <90% (92% komorbid)
TIDAK YA
HFNC 30 LPM FiO2 100%

Evaluasi per 2 jam
INTUBASI
PROTOKOL
COVID-19
PERDATIN
8 APRIL 2020
APRIL 2020 PPPASIEN POSITIF / PDP COVID-19
GANGGUAN SESAK NAFAS HIPOKSEMIA, SpO2 <93% (FiO2 21%),

HENTI JANTUNG
JALAN NAFAS RR >30/MENIT PaO2/FiO2 <300 mmHg
1. Apakah kondisi sedang memburuk progresif? TIDAK NRM 15 lpm

2. Apakah diyakini akan memburuk? Evaluasi per 1 jam
YA HFNC 30 LPM FiO2 100%, POSISI TELUNGKUP

Evaluasi dalam 1 jam, apakah:
TIDAK 1. Compos Mentis, komunikasi lancar, DAN YA 1. Penurunan kesadaran, ATAU
2. RR 20-30/menit, DAN 2. RR >30/MENIT, ATAU
3. SpO 2 <92% (<95% bila komorbid), ATAU
3. SpO2 >90% 4. Peningkatan kerja otot napas bantu, ATAU
5. Nadi >120/menit
HFNC 30 LPM FiO2 titrasi TIDAK YA

Evaluasi per 2 jam
NIV
Evaluasi dalam 1 jam, seperti HFNC
YA
INTUBASI → VENTILATOR
PROTOKOL
COVID-19
PERDATIN / 5 0P / BNPB / KEMENKES
29 AGUSTUS 2020
PPPASIEN SUSPEK/PROBABLE/TERKONFIRMASI COVID-19
GANGGUAN SESAK HIPOKSEMIA,

HENTI JANTUNG RR >30/MENIT
NAFAS SpO2 <93% (FiO2 21%),
JALAN NAFAS
PaO2/FiO2 <300 mmHg
1. Apakah kondisi sedang memburuk progresif?
TIDAK O2 Nasal Kanul s/d NRM.
2. Apakah diyakini akan memburuk? Target SpO2 92-96%
YA SpO2<92% Titrasi dan Evaluasi per 1 jam
1. Compos Mentis, komunikasi lancar, DAN HFNC 30-60 LPM atau NIV
2. RR <30/menit, DAN YA FiO2 40-100%
3. SpO2 >90%, DAN dan POSISI TELUNGKUP
4. Tidak syok Titrasi dan Evaluasi dalam 1 jam
TIDAK EVALUASI, Apakah:

1. Penurunan kesadaran, ATAU
Lanjutkah HFNC / NIV 2. RR >30/MENIT, ATAU
3. SpO2 <92% (<95% bila komorbid), ATAU
Evaluasi per 2 jam 4. Peningkatan kerja otot napas bantu, ATAU
5. Nadi >120/menit, ATAU
6. ROX index <3,85
TIDAK
YA
- PaO2/FiO2 <60 mmhg selama >6 jam

Pertimbangkan ECMO bila tidak ada
- pH <7,2 dan PaCO2 >80 mmHg >6 jam kontraindikasi dan faskes memadai

JALAN NAFAS
PaO2/FiO2 <300 mmHg

JALAN NAFAS
PaO2/FiO2 <300 mmHg
2. Apakah diyakini akan memburuk?

JALAN NAFAS
PaO2/FiO2 <300 mmHg
Titrasi dan Evaluasi per 1 jam

JALAN NAFAS
PaO2/FiO2 <300 mmHg
1. Compos Mentis, komunikasi lancar, DAN

2. RR <30/menit, DAN
3. SpO2 >90%, DAN
4. Tidak syok

JALAN NAFAS
PaO2/FiO2 <300 mmHg
1. Compos Mentis, komunikasi lancar, DAN

2. RR <30/menit, DAN
3. SpO2 >90%, DAN
4. Tidak syok
TIDAK

JALAN NAFAS
PaO2/FiO2 <300 mmHg
TIDAK
HFNC 30-60 LPM atau NIV
FiO2 40-100%
dan POSISI TELUNGKUP
Titrasi dan Evaluasi dalam 1 jam
HFNC Nasal Kanul
Biasa
• FiO2 lebih tinggi
• Tekanan positif
membantu
pernapasan
30-60 Liter/menit 1-15 Liter/menit

Masalahnya…
• Semakin tinggi Flow, oksigen medis semakin dingin dan kering
High Flow Nasal Cannula
FLOWMETER PENGHANGAT PELEMBAB NASAL KANUL

KHUSUS KHUSUS
High Flow Nasal Cannula vs Non Invasive Ventilation
HFNC NIV
High Flow Nasal Cannula vs Non Invasive Ventilation
Dalam parameter NIV

menyerupai HFOT
•CPAP 5 cmH2O
•FiO2 100% titrasi

JALAN NAFAS
PaO2/FiO2 <300 mmHg

2. RR >30/MENIT, ATAU
4. Peningkatan kerja otot napas bantu, ATAU
6. ROX index <3,85
EVALUASI, Apakah:
1.Penurunan kesadaran, ATAU
2.RR >30/MENIT, ATAU
3.SpO2 <92% (<95% bila komorbid), ATAU
4.Peningkatan kerja otot napas bantu, ATAU
5.Nadi >120/menit, ATAU
6.ROX index <3,85
ROX INDEX
ROX index = SpO2/(FiO2 × respiratory rate)
ROX index ≥ 4.88 → success
• The initial oxygen concentration was set at 100%.
• After 2 hours of HFNC treatment, the rate of oxygenation (ROX) index
was calculated as SpO2/(fraction of inspired oxygen × respiratory rate)
in accordance with the method used by Roca et al. 3
• The ROX indices were ≥ 4.88 in all patients; the patients were
monitored continuously for 12 hours, and the ROX indices remained ≥
4.88, indicating a high success rate of HFNC treatment.
• After 24 hours, the SpO2 was maintained between 95% and 100%; the
P/F increased to 280–450 mmHg.
Risk of intubation, based on ROX at 2, 6 and
12 hours after initiation of HFNC
• Predictors of HFNC failure with need for intubation include
• ROX < 2.85 at 2 hours,
• ROX < 3.47 at 6 hours,
• ROX < 3.85 at 12 hours
After HFOT started, RR should be
LESS THAN:
SpO2 92%
ROX < 2.85 at 2 hours 32
LESS THAN:
SpO2 92% 94%
ROX < 2.85 at 2 hours 32 33
ROX < 3.47 at 6 hours 26 27
ROX < 3.85 at 12 hours 23 24
LESS THAN:
SpO2 92% 94% 90%
ROX < 2.85 at 2 hours 32 33 31
ROX < 3.47 at 6 hours 26 27 25
ROX < 3.85 at 12 hours 23 24 23

JALAN NAFAS
PaO2/FiO2 <300 mmHg

6. ROX index <3,85
TIDAK
YA

JALAN NAFAS
PaO2/FiO2 <300 mmHg

6. ROX index <3,85
TIDAK
YA

Pertimbangkan ECMO bila tidak ada
- pH <7,2 dan PaCO2 >80 mmHg >6 jam kontraindikasi dan faskes memadai
ANZICS guidelines on COVID-19 state the following:
“High flow nasal oxygen (HFNO) therapy (in ICU): HFNO

is a recommended therapy for hypoxia associated with
COVID-19 disease, as long as staff are wearing optimal
airborne PPE.”
“The risk of airborne transmission to staff is low with

well fitted newer HFNO systems when optimal PPE and
other infection control precautions are being used.
Negative pressure rooms are preferable for patients
receiving HFNO therapy.”
WHO guidelines on COVID-19 state that
“Recent publications suggest that newer
HFNC and NIV systems with good
interface fitting do not create widespread
dispersion of exhaled air and therefore
should be associated with low risk of
airborne transmission.”
• HFNC supplies gas at a rate of ~40-60
liters/minute, whereas a normal cough achieves
flow rates of ~400 liters/minute (Mellies 2014).
• Therefore, it's doubtful that a patient on HFNC is
more contagious than a patient on standard
nasal cannula who is coughing.
• One possible compromise might be to use HFNC with
a moderate rate of flow (e.g. 15-30 liters/minute,
rather than 40-60 liters/minute). Since 15-30
liters/minute flow is close to a baseline minute
ventilation for a sick respiratory failure patient, adding
this level of flow is unlikely to affect matters
substantially.
•BUT, I ALWAYS START AT 60 LPM
evidence base for HFNC
• HFNC is generally a rational front-line approach to
noninvasive support in patients with ARDS (based partially
on the FLORALI trial).
• One case series from China suggested that HFNC was
associated with higher rates of survival than either
noninvasive or invasive ventilation (of course, this could
reflect its use in less sick patients)(Yang et al, see table 2).
• A management strategy for COVID-19 by a French group
used HFNC preferentially, instead of BiPAP (Bouadma et al.).
TAMBAHKAN
DEXAMETHASONE
TAMBAHKAN
PROFILAKSIS
ANTIKOAGULAN
TAMBAHKAN
PRONE POSITION
We’re learning proning
• For adults with COVID-19 who are receiving supplemental
oxygen, recommends close monitoring for worsening
respiratory status and that intubation, if it becomes
necessary, be performed by an experienced practitioner in a
controlled setting (AII).
• For patients with persistent hypoxemia despite increasing
supplemental oxygen requirements in whom endotracheal
intubation is not otherwise indicated, the Panel recommends
considering a trial of awake prone positioning to improve
oxygenation (CIII).
•The Panel recommends against using
awake prone positioning as a rescue
therapy for refractory hypoxemia to
avoid intubation in patients who
otherwise require intubation and
mechanical ventilation (AIII).
High Flow Oxygen Therapy
High Flow Oxygen Therapy standard pada Hamilton-S1 dan dapat di
upgrade pada Hamilton C1,T1,C3,G5 Mode terapi oksigen aliran tinggi
(flow rate sampai dengan 80 Liter / menit)
Fitur :
• Untuk semua kelompok pasien
• Penggunaan untuk single limb
dan dual limb sirkuit.
• Beralih dari Ventilasi invasif,
noninvasif, high flow oxygen
therapy tanpa mengubah sirkuit
pernapasan.
• Mengubah mode ventilator dan
interface saja.
HEMODYNAMIC MONITORING:
OPTIMIZING OXYGEN DELIVERY
IN COVID-19 PATIENT WITH SEPTIC SHOCK
– dr. Rudy Manalu, Sp.An-KIC
Mekanisme ?
Alveoli
Ventilasi = V
Venula Paru membawa darah yang kaya

oksigen
Arteriol Paru membawa darah yang kaya

karbondioksida
Perfusi = Q
SKEMATIK Ventilasi Saat istirahat,
(V) V = 4 liter/menit
Rasio Ventilasi /Perfusi
V / Q = 4/5 = 0,8
CO2
O2
O2
CO2
CO2
O2 Perfusi
Normal = Matching = sesuai (Q)
0,8 ̴ 1
Saat istirahat,
Q = 5 liter/menit
Keseimbangan
SKEMATIK Ventilasi Saat istirahat,
(V) V = 4 liter/menit
Rasio Ventilasi /Perfusi
V / Q = 4/5 = 0,8
CO2
O2
O2
CO2
CO2
O2 Perfusi
Normal = Matching = sesuai (Q)
0,8 ̴ 1
Saat istirahat,
Mismatch = ketidaksesuaian, bila
ratio V/Q nilainya Rendah atau Tinggi Q = 5 liter/menit
Ratio
Phenotypes dari Covid - 19
V/Q
Gattinoni,L.,Chiumello,D., & Rossi,S., (2020) COVID-19 pneumonia : ARDS or not ? Critical care (London, England), 24 (1),154
V/Q Rendah V/Q Sangat Rendah
V:↓ ̴0
Q:↑
Q:↑
multiple, focal,
possibly overperfused patchy ARDS-like pattern
ground glass opacities
V/Q Rendah V/Q Sangat Rendah
V:↓ ̴0
Q:↑ Q:↑
Sesuai dengan Severe ARDS :

Fenotipe L - Hipoksemia Fenotipe H
- Infiltrat bilateral
- Low elastance (elastansi Paru rendah) - High elastance
- Compliance rendah
- Low V/Q ratio (rasio ventilasi-perfusi rendah) - High Right meningkat
to Left shunt
- Berat paru-paru
- Low lung weight (paru paru ringan) - High lungperekrutan
weight (>1,5 kg)
- Potensi untuk meningkat
- Low lung recruitability (rekrutmen paru rendah) - High lung recruitability
Gattinoni,L.,Chiumello,D., & Rossi,S., (2020) COVID-19 pneumonia : ARDS or not ? Critical care ( London, England), 24 (1),154
Prof. Robba et all. “Distinct phenotypes require distinct respiratory management strategies in severe covid-19
Respiratory Physiology and neurobiology.doi: 10.1016/j.resp.2020.103455
V/Q Rendah V/Q Tinggi V/Q Sangat Rendah
V:↓ ̴0
Dead Space
Q:↑ Q :↓ ̴ 0 Q:↑
multiple, focal, inhomogeneouslym distributed

possibly overperfused atlectasis and peribronchial patchy ARDS-like pattern
ground glass opacities opacities
V/Q Rendah V/Q Tinggi V/Q Sangat Rendah
V:↓ ̴0
Dead Space
Q:↑ Q :↓ ̴ 0 Q:↑
Non Invasif : - High Flow Nasal Cannula Intubasi : Tidal volume 4-6 ml/kg PBW
- CPAP / NIV Antikoagulan ? PEEP Tinggi ̴ hemodinamik
Intubasi : - Tidal volume 6- 8 ml/kg PBW Posisi tengkurap
- PEEP 6 -10 Manuver rekrutmen paru
Cairan konservatif
Fenotipe L Sepsis-induced Coagulopathy Fenotipe H

- Low elastance +++ D dimer - High elastance
- Low V/Q ratio ++ Fibrinogen - High Right to Left shunt
- Low lung weight + PT/PTT/INR - High lung weight (> 1,5 Kg)
- Low lung recruitability - Trombosit - High lung recruitability
SISTEM KARDIOVASKULER
KOMPLEKS
SISTEM KARDIOVASKULER
KOMPLEKS
Apa yang ingin kita

ketahui
Yang ingin kita
ketahui :
Volume Hipo – Normo - Hiper ?
Pembuluh
Normal – Vasoplegi (vasodilatasi) – Vasokonstriksi ?
darah
Pompa Jantung Kontraktilitas memadai ?

KOMPLEKS SEDERHANA
- SVV
1 - Berikan cairan
PRELOAD
- PPV
- Berikan diuretik
- CVP/PAOP?
STROKE - CO
2
Berikan
Kontrak-
- SV
tilitas
VOLUME INOTROPIK
- CI
SVV = Stroke Volume Variation

PPV = Pulse Pressure Variation
CVP = Central Venous Pressure - SVR Vasoactive Drugs
3
PAOP = Pulmonary Artery Occlusion Pressure - Vasopressor
AFTER
LOAD
CO = Cardiac Output - LVEDP
SV = Stroke Volume - MAP ? - Vasodilator
CI = Cardiac Index
SVR = Systemic Vascular Resistance
LVEDP = Left Ventricular End Diastolic Pressure
MAP = Mean Arterial Pressure MONITOR TERAPI
Frank Starling Law of the Heart
Otto Frank Ernest Starling

STROKE VOLUME
(SV)
Mengoptimalkan PRELOAD : Hukum Frank Starling
Δ SV
STROKE VOLUME
Preload-iindependence
(SV)
Δ SV
Preload-dependence
Terapi cairan pada syok septik ?
Volume
Four phases fluid management
RESUSCITATION
Principles Life saving
Phenotype Shock 10. For the acute resuscitation of adult with covid-19 and shock
we recommend using crystalloids over colloids.
Goals Correct shock
11. For the acute resuscitation of adult with covid-19 and shock
Fluid Fluid bolus we suggest using buffered/balanced crystalloids over unbalanced
crystalloids.
Time Minutes
we recommend against using hydroxyethyl.
we suggest against gelatins.
Malbrain et al. Ann.Intensive Care (2018) 8:66
https:doi.org/10.1186/s13613-018-0402-x
Monitoring fluid management
RESUSCITATION
Minimum monitoring
Blood Pressure SBP
Heart Rate +
Capillary Refill +
Lactate +
Urine Output -
Fluid Balance -
Optimum monitoring
CVP -
ScvO2 -
Fluid responsiveness -
Cardiac Output -
Br J Anaesth. 2014 Nov;113(5):740-7

N Engl J Med 2013;369:1726-34
R O
RESUSCITATION OPTIMIZATION
Principles Life saving Organ rescue
Phenotype Shock Unstable
Goals Correct shock Optimize and

maintain perfusion
Fluid Fluid bolus Titrate and fluid

challenges
Time Minutes Hours

https:doi.org/10.1186/s13613-018-0402-x
RESUSCITATION OPTIMIZATION
Minimum
Blood Pressure
monitoring
SBP MAP
Heart Rate + +
Capillary Refill + +
Lactate + +
Urine Output - +
Fluid Balance - +
Optimum monitoring
CVP - ±/?
8. In adults with covid-19 and shock we suggest using
ScvO2 - + dynamic parameters, skin temperature, capillary refill time,
Fluid responsiveness - + and/or serum lactate measurement over static parameters in
order to assess fluid responsiveness
Cardiac Output - +
Br J Anaesth. 2014 Nov;113(5):740-7

N Engl J Med 2013;369:1726-34
OPTIMAL
Pemberian cairan Pemberian cairan
restriktif liberal
Risiko kompilkasi
OPTIMAL
Dehidrasi Overhidrasi
Caranya
MENGUKUR PRELOAD
Bagaimana mengukur Preload ?
Responsiveness
(respon jantung terhadap pemberian
Preload Alternatives
volume)
MFC / PLR / EEO/
Parameter Klasik Parameter Dinamis - MFC = Mini Fluid Challenge

- PLR = Passive Leg Raising
Parameter Statis - EEO = End Expiratory Occlusion
Filling Pressures Responsiveness

(respon jantung terhadap pemberian
CVP / PCWP
volume)
Volumetric Preload SVV / PPV / SPV

- CVP melalui CVC
- PCWP melalui Pulmonary GEDV / ITBV
Arterial Catheter - SVV = Stroke Volume Variation
- PPV = Pulse Pressure Variation
Pressure bukanlah Volume !!! - GEDV = Global End Diatolic Volume - SPV = Systolic Pressure Variation
Faktor yang mempengaruhi : - ITBV = Intrathoracic Blood Volume
- Komplain Ventrikel
- Posisi dari Kateter
- Ventilasi Mekanik
- Hipertensi intra abdomen
Apakah pasien saya volume responsive ?
Dimana posisi pasien saya pada kurva Frank-Starling ?
PASIEN dengan STROKE VOLUME VARIATION (SVV)
VENTILASI MEKANIS
STROKE VOLUME ? VARIATION

Volume sekuncup :
Volume darah yang dipompakan ventrikel kiri
dalam satu kali kontraksi.
Kenapa bervariasi ? Heart Lung Interactions
Dapat dilihat dari perubahan bentuk gelombang arteri

pada fase pernapasan (Inspirasi dan Ekspirasi).
→ Pulse Contour Method (PCM)
Fase INSPIRASI : SV Meningkat STROKE VOLUME

Fase EKSPIRASI : SV Menurun VARIATION (SVV)
Heart Lung Interaction
Pemakaian Ventilasi Mekanis

(pemberian tekanan positif)
Kenaikan tekanan transpulmonal

dan tekanan pleura
Heart-Lung Interactions : effects of Mechanical Ventilation
Stroke Volume maximum

SVmax
Stroke Volume minimum
SVmin
at the end of inspiration
at during expiratory period
at
inspira expiration
tion
Pada keadaan hipovolemia Variasi besar
Pada keadaan normovolemia Variasi minimal

• Pasien dengan Ventilasi Mekanis
• Mode : Kontrol
• TV > 8 ml/ kg
• EKG : irama sinus
45
cmH2O ……………………….
Airway
Pressure
Inspiration Expiration
5
SVmax
120
mmHg SVmin
Arterial
Pressure
Stroke Volume Variation (SVV)
Normal Heart
SVV : 9 – 13 % ?
SVV < 9 %
Don’t give
fluids !!!
Stroke
Volume Fluid non- responsiveness
predictive of
SVV > 13 % positive response
Give fluids ! to fluid challenge
- Sensitivity 86 %
Fluid responsiveness - Specificity 82 %
- AUC 0.84
LVEDV (mL)
Preload LVEDV (mL)

10 %
24 %
Tidak punya alat untuk mengukur SVV
9. For the acute resuscitation of adults with covid-19 and shock we suggest
using conservative over a liberal fluid strategy.
R O S
RESUSCITATION OPTIMIZATION STABILIZATION
Principles Life saving Organ rescue Organ support
Phenotype Shock Unstable Stable
Goals Correct shock Optimize and Zero/negative

maintain perfusion balance
Fluid Fluid bolus Titrate and fluid Minimal infusion

challenges If oral inadequate
Time Minutes Hours Days

https:doi.org/10.1186/s13613-018-0402-x
RESUSCITATION OPTIMIZATION STABILIZATION
Minimum monitoring
Blood Pressure SBP MAP MAP
Heart Rate + + +
Capillary Refill + + +
Lactate + + +
Urine Output - + +
Fluid Balance - + +
Optimum monitoring
CVP - ±/? -
ScvO2 - + -
Fluid responsiveness - + -
Cardiac Output - + -
Br J Anaesth. 2014 Nov;113(5):740-7

N Engl J Med 2013;369:1726-34
R O S E
RESUSCITATION OPTIMIZATION STABILIZATION EVACUATION
Principles Life saving Organ rescue Organ support Organ recovery
Phenotype Shock Unstable Stable Recovering
Goals Correct shock Optimize and Zero/negative Fluid evacuation

maintain perfusion balance
Fluid Fluid bolus Titrate and fluid Minimal infusion Oral intake, avoid
challenges If oral inadequate Unnecessary iv
fluids
Time Minutes Hours Days Days to weeks

https:doi.org/10.1186/s13613-018-0402-x
RESUSCITATION OPTIMIZATION STABILIZATION EVACUATION
Minimum monitoring
Blood Pressure SBP MAP MAP MAP
Heart Rate + + + +
Capillary Refill + + + +
Lactate + + + +
Urine Output - + + +
Fluid Balance - + + +
Optimum monitoring
CVP - ±/? - -
ScvO2 - + - -
Fluid responsiveness - + - -
Cardiac Output - + - -
Br J Anaesth. 2014 Nov;113(5):740-7

N Engl J Med 2013;369:1726-34
Evacuation
Oxygen Delivery (D02)
HR ▪ Nerves
▪ Hormones
Heart rate
Oxygen
Oxygen Delivery (DO2) C0
Consumption
SV ▪ Preload
▪ Contractility
Stroke Volume
▪ Afterload
Hgb ▪ Quantity O2
bound to
SaO2 hemoglobin
▪ Quantity O2
PaO2 dissolved in
Ca02
plasma
GE Healthcare
Carescape One
Special Features
• Battery Capacity - Running time on battery up to 7 hours and also the battery itself has indicator lights
• CARESCAPE One Parameters :
- ECG - 3-, 5-, 6-, 10-leadset
- SpO2 - GE TruSignalTM , Masimo, Nellcor
- CO2 - Respironics LoFloTM
- Temp - Dual Channel
- Invasive Pressure
- Non Invasive Blood Pressure (NIBP)
• Flexible System - Standardized medical USB ports for all parameters enables dynamic parameter recognition
to instantly adapt to patient acuities and care area needs
• Display Size - 7 inch with DragontrailTM glass capacitive touch screen
• Durable Design
environments
• Water resistant IP41 - Resistant to solid particles > 1 mm
• Powerful Transport - With a lightweight intuitive design (1.85 kg with battery), every patient monitor is
ready for intra-hospital transport
4
Vygon
MostcareUp Hemodynamic Monitor
Delivery 4-6 Minggu

Connections Connections
Connectivity and data transfer patient’s side
merupakan Advanced
kondisi hemodinamik pada pasien-pasien kritis, seperti pada pasien sepsis (shock) akibat Covid-19/
severe pneumonia karena rusaknya jaringan paru, serta terganggunga proses difusi gas dengan
parameter PPV, SV, SVI, CO, CI, DO2, DO2(I), CPO, CCE, dp/dt.
Special Features
resistive
• Termasuk battery, bertahan hingga 1 jam

• Tidak membutuhkan kalibrasi internal
• Tidak membutuhkan kateter khusus
• Cukup menggunakan minimal 1 arteri line (femoral/ radial/ brachial)
• Data pasien dapat ditransfer dengan mudah
• Fleksibel, mudah dibawa keman-mana
• Dapat dikoneksikan dengan monitor utama (GE, Philips, etc) melalui Y cable
• Mudah dalam penggunaan
LUNG PROTECTIVE VENTILATION
IN COVID-19 PATIENT
– dr. Bambang Wahjuprajitno, Sp.An-KIC
Webinar "Clinical Management of Severe Acute Respiratory Infection in Covid-19 Patient” August 29, 2020
Lung Protective Ventilation in

Covid-19 patient
Bambang Wahjuprajitno - Dept. of Anesthesiology & Reanimation Univ. of Airlangga - Dr. Soetomo General Hospital
Pokok Bahasan
• Apakah yang dimaksud dengan Lung Protective Ventilation Strategy (LPVS)?
• Apa dasar pemikiran dan tujuannya?
• Bagaimana melaksanakannya?
• Apakah secara patofisiologi COVID-19 sama dengan ARDS?
• Apakah LPVS bisa digunakan pada kasus COVID-19?
• Apakah MV dini dan LPVS bisa merubah perjalanan pasien?
• Pengalaman di ICU RIK RSUD Dr. Soetomo
Infeksi yang disebabkan virus SARS-CoV-2
Varian penyakit yang baru ➞ banyak hal yang belum diketahui ➞

Perlu belajar dari pengalaman sendiri & yang pernah mengalami
(literatur) sampai terapi definitif bisa ditemukan atau pandemi berhenti
Ventilasi mekanis bukan solusi terapeutik, tetapi tindakan suportif!
untuk “membeli waktu”!
Menjaga Oxygen Balance - Tindakan resusitasi
↓ O2 Delivery) ↑ O2 Demand
• ↓O 2 content:
• ↓ Hgb
• ↓ O sat
2
• ↓ PaO (V/Q mismatch, shunt)

2
• ↑ patient WOB
• ↓ ↑preload
cardiac output • ↑R edema
aw,
• • loss of PPV & PEEP

• ↑afterload • secretion
• ↓contractility • ↑ metabolism:
• fever, sepsis, exercise
Ventilasi mekanis − Double-Edged Sword
Ventilator-Induced Lung Injury:
Barotrauma
Volutrauma
Atelectrauma
Biotrauma
O2 toxicity Mengatasi Gagal Napas:
VAP Gangguan pertukaran gas
Mengurangi WoB
Mengurangi WoH
Terapi kausal
Lung Protective Ventilation Strategy
• Didefinisikan sebagai strategi ventilasi mekanis yang menggabungkan tidal volume
rendah dan respiratory rate yang relatif tinggi dengan menggunakan positive end
expiratory pressure (PEEP) bersama FIO2 yang tepat untuk mencegah atelectrauma
dan hypoxia pada volume control mode pada pasien dengan intubasi tracheal yang
terhubung pada mechanical ventilator
Aplikasi LPVS pada pasien dengan ARDS
• Tidal volume lebih kecil (4 - 6 ml/kg PBW) → mencegah overdistensi (VILI)
• Naikkan rate napas
• Pplat < 30 cmH2O → mencegah overdistensi
• Gunakan PEEP → menurunkan intrapulmonary shunting
• Menerima hypercapnia bila perlu
• Minimalisasi FIO2 < 0.6 → menurunkan resiko keracunan oksigen
• Driving pressure < 15 cmH2O (Amato)
• Dalam perkembangannya dianjurkan juga pada kasus non-ARDS

Aplikasi Lung Protective Ventilation Strategy
Lower Inflection Point Upper Inflection Point
Safe
Zone Protective ventilation :
• Limit = VT 4 - 6 ml/kg
• PPlat ≤ 30 cmH2O
• Best PEEP
• Driving pressure ≤ 14 cmH2O
• Lowest FiO2
VT = 12 ml/kgBW Limit the
Volume
VT = 4 - 6 ml/kgBW
• Permisive hypercapia bila perlu
Limit the Driving Pressure

Least lung damage
Prevent atelectasis & RACE
Limit the Presure
Use (best) PEEP

Scaling of the Lung in Mammals
Whale
Dugong
100
Manatee
SLOPE = 1.02 Bear
Cow
Pig
Porpoise
10 Goat MAN
liter
Dog
Racoon
VOLUME,
1 Cat
Rabbit Monkey
Marmot Armadillo
.1
LUNG
Guinea Pig
Rat
.01
Lung Volume = 6.3% BW

Tidal Volume = 6.3 mL/kg
Mouse
.001
Shrew
Bat
.01
.01 .1 1 10 100
BODY WEIGHT, kg K Schmidt-Nielsen, 1972
Adapted from SM Tenney & JE Remmers, Nature 1963;197:54-6;

ARDS clinical managements implications new definition
ECMO
ECCO2-R
HFOV
iNO
Intensity of Intervention
Neuromuscular
Blockade
Prone Positioning
Low-Moderate PEEP
Higher PEEP
NIV
Low Tidal Volume Ventilation

Increasing Severity of Injury
Mild ARDS Moderate ARDS Severe ARDS
300 350 200 150 100 50
PaO2/FiO2
Ferguson ND, et al. Intensive Care Med 2012;38(10):1573-1582
Data dari berbagai negara
Wuhan
• 16 Desember 2019 - 2 januari 2020
• 41 pasien MRS di Jin Yintan Hospital
(Wuhan, China)
• 13 dari41 (31.7%) masuk ICU, 4 memerlukan
IMV dengan 2diantaranya memerlukan
7
ECMO karena refractory hypoxemia
• Angka kematian di ICU: 5 dari 13 (38.5%),
3 tapi secara keseluruhan merupakan 5 dari 6
(83.3%) kematian di RS
Huang C, et al. Lancet. 2020;395(10223):497-506. doi:10.1016/S0140-6736(20)30183-5

Wuhan
• 138 pasien yang MRS dengan
confirmed COVID-19 di
Zhongnan Hospital of Wuhan
University di Wuhan, China,
dari 1 January sampai 28
January 2020
• 36 pasien (26.1%) masuk ICU
BGA shunting
mirip ARDS
Wang D, et al. JAMA. 2020;323(11):1061-1069. doi:10.1001/jama. 2020.1585

469 COVID-19 pasien MRS
antara Februari 2020 - akhir Maret
2020 pada 13 ICU di Wuhan.
Tidak dicantumkan parameter
ventilasi pada saat masuk ICU pad
studi tersebut.
Alasan
Kesimpulan
Hua J, et al. Crit Care 2020;24:348. https://doi.org/10.1186/s13054-020-03044-9
Lombardy
In this case series of critically ill patients admitted to ICUs in Lombardy, Italy, with laboratory-confirmed COVID-19
from February 20 to March 18, 2020, the majority were older men, a large proportion required mechanical ventilation
and high levels of PEEP, and ICU mortality was 26%
Seattle Region
Pd 23 Maret 2020:
• 24 dirawat, total 12 pasien meninggal (50%), 4
permintaan DNR sebelum MRS dan 6 DNR
setelah MRS
• 18 pasien dengan Invasive MV, 9 meninggal
(50%)
• 6 pasien dgn MV berhasil di-ekstubasi
• 3 pasien masih dengan MV
• 5 pasien sudah KRS
• Semua pasien sudah diikuti paling sedikit 14
hari
Bhatraju PK, et al. NEJM 2020;382:2012-22. DOI: 10.1056/NEJMoa2004500

Seattle Region:
ICU-Level Therapies
and Clinical Outcomes
Parameter ventilasi
mirip dengan ARDS biasa!
N Engl J Med 2020;382:2012-22. DOI: 10.1056/NEJMoa2004500

Respiratory
Respiratory Physiology parameters
mirip dengan
ARDS biasa!
March 11 to March 30, 2020, 66 patients with laboratory-

confirmed COVID-19 were intubated and admitted to
ICUs at Massachusetts General Hospital and Beth Israel
Deaconess Medical Center:
Day Patients with COVID-19 respiratory failure in our series

exhibited gas exchange values, respiratory system
No. of pts
mechanics, and responses to prone ventilation similar to

those observed in large cohorts of patients with ARDS.
Although further study is needed to elucidate the biology
and unique features of this disease, our findings provide a
pathophysiologic justification for the use of established
ARDS therapies, including low VT and early prone
ventilation, for COVID-19 respiratory failure
Ziehr DR, et al. AJRCCM 2020;201 (12):1560-1564. https://doi.org/10.1164/rccm.202004-1163LE

Dua issue utama studi epidemiologi MV pada COVID-19
• Kapan melakukan intubasi dan penilaian laju intubasi dan laju pasien yang mendapat MV
(persentase)
• Terlalu dini
• Terlalu lambat
• Pelaporan mortalitas/survival pasien yang mendapat MV ➞ masalah perhitungan statistik
• Yang sembuh pulang/mati
• Yang sembuh masih dirawat RS
Masalah utama penyebab:

• Pandemi: kasus menyebar cepat dan luas
• Ketimpangan antara sumber daya, jumlah kasus, beratnya penyakit, faktor resiko dll
Ketidak seragaman laporan data ➞ Perbedaan hasil
Wunsch H. AJRCCM 2020;202:1-4. https://doi.org/10.1164/rccm.202004-1385ED

Ketidak seragaman laporan data ➞ Perbedaan hasil

“The goal of using invasive mechanical
ventilation for patients with COVID-19 is
universal: to save lives and to reduce mortality
to ensure it is low for everyone!”
Pro dan Kon: ARDS atau Bukan?
Pro dan Kon: MV dini atau lambat?
Akan mempengaruhi pengelolaan VM dan hasilnya
Karakteristik khas CT pada COVID-19
Gambar:
1. Gambar 1, Gambar 2: spot-spot ground glass opacities (GGO);
2. Gambar 3: Nodul dan eksudasi yang tidak merata; Terapi oksigen, HFNC, NIV
3. Gambar 4, Gambar 5: lesi gabungan multifokal;
4. Gambar 6: Lesi gabungan menyebar, "paru-paru putih" Dilema: Non-invasive MV vs. Invasive MV?
Liang, T. (eds.). Buku Pegangan Pencegahan dan Penatalaksanaan COVID-19 . Alibaba Cloud
Many Faces of COVID-19
Hypoxemia
P-SILI
↓Palv
Dysregulation of ↑Vt, Pendelluft

Pulmonary edema
pulmonary perfusion Increased Pes swings Collapse - “ARDS Like”
Non-Invasive • Low lung elastance • High lung elastance

Invasive
• Low V/Q Pulmonary • High R ⇾ L shunt
O2 Tx • Low recruitability
Micro-Thrombosis • High recruitability LPVS
HFNC • Limited “PEEP response” • Higher “PEEP response”
Sed - NMB
NIV “silent/happy hypoxia” severe hypoxia Positioning
Positioning ECMO
Phenotype L Transition Phenotype H
Recovery
Reversibilitas Mortalitas
Dilema Gattinoni 2020 (modified)

• Ada disosiasi antara beratnya hypoxemia dan relatif terjaganya respiratory mechanics yang tetap baik
• Secara cukup jelas bisa dilihat pada CT scan atau bila tidak tersedia, dari respiratory system
compliance dan mungkin responsnya terhadap PEEP:
• Type 1(“nonARDS”): Komplians pulmoner hampir normal disertai isolated viral pneumonia
• Type 2 (“ARDS”): Penurunan pulmonary compliance
Type 1 Type 2
Type 1: Type 1:
• lung weight (1192 g) • lung weight (1441 g)
• gas volume (2774 ml) • gas volume (1640 ml)
• % of non-aerated tissue (8.4%) • % of non-aerated tissue (39%)
• venous admixture (56%) • venous admixture (49%)
• P/F (68), • P/F (61),
• respiratory system compliance (80 ml/ • respiratory system compliance (43 ml/
cmH2O) cmH2O)
Gattinoni L, Chiumello D, Rossi S. Gattinoni et al. Critical Care 2020;24:154

Kapan Intubasi? (pendekatan rasional saat ini)
• Keputusan untuk melakukan intubasi dan memasang MV pada pasien dengan
COVID-19 tidak jelas dan begitu pula hasilnya
• Hypoxemia sendiri bukan lagi merupakan indikasi intubasi bila pulmonary
mechanics masih terjaga
• Sebaliknya, kompensasi napas yang berkepanjangan (spontaneous/assisted dgn
NIV), dengan perburukan status mental status disertai respiratory acidosis ➞
merusak tubuh
• Usaha monitoring fase transisi diperlukan bagi mereka yang memerlukan intubasi
dan ventilasi mekanis. Penundaan intubasi ➞ Prognosis jelek!
• Sangat penting, harus ada tailored institutional protocol untuk pengelolaan klinis
pasien disamping itu harus menjamin keselamatan petugas
Navas-Blanco and Dudaryk. BMC Anesthesiology 2020;20:177. https://doi.org/10.1186/s12871-020-01095-7

Pengelolaan Ventilasi
Type 1 (“nonARDS”, phenotype L) patients:
• PEEP harus dipertahankan rendah pada pasien dengan pulmonary compliance yang tinggi
• Batas Tidal Volume tidak dibatasi pada 6 ml/kg
• Respiratory rate tidak melebihi 20 kali/menit
• Pasien harus dibiarkan “quiet”; menghindari melakukan sesuatu yang berlebihan lebih
menguntungkan dibandingkan melakukan intervensi dengan segala resiko yang bisa terjadi
Type 2 (“ARDS”, phenotype H):

• Digunakan pengelolaan standard untuk ARDS berat (LPVS):
• tidal volume rendah
• (prone) positioning
• PEEP relatif tinggi
Gattinoni L, Chiumello D, Rossi S. Gattinoni et al. Critical Care 2020;24:154
Strategi ventilasi untuk
pasien dengan COVID-19
Decision to intubate
• Increased Work of breathing (RSB)
• Worsening mental status
• Respiratory acidosis
Möhlenkamp S, Thiele H. Herz. 2020 Apr 20 : 1–3.
doi: 10.1007/s00059-020-04923-1 [Epub ahead of print]

Pengalaman dari ICU RIK RS Dr. Soetomo
per 15 Agustus 2020
Data dipasok dari Dr. Bambang Pujo Semedi SpAnKIC
Ka. Instalasi Rawat Intensif
ICU RIK RSDS
CUT OFF RIK 1 PER 29 APRIL – 15 AGUSTUS 2020
Parameter Jumlah Pasien Persentase
Mortalitas
Total yang Meninggal 79 Pasien 47,9%
Total yang survive 86 Pasien 52,1%
Usia Pasien meninggal (n=79) 2 anak (2 dan 3 tahun) 2,5%
57 pasien dewasa (25 – 59 72,2%
tahun)
20 pasien lansia ( 60 – 76 25,3%
tahun)
Total yang Pernah Dirawat 165 Pasien

PDP 25 Pasien
Konfirmasi 140 Pasien
Kelompok Meninggal Hidup TOTAL
Non Ventilator Tanpa terapi oksigen 0 (0%) 4 (2,4%) 4 (2,4%)

Nasal Canulle 0 (0%) 8 (4,9%) 8 (4,9%)
Simple Mask 0 (0%) 4 (2,4%) 4 (2,4%)
Nonrebreathing Mask 0 (0%) 7 (4,2%) 7 (4,2%)
HFNC murni 0 (0%) 14 (8,4%) 14 (8,4%)
NIV murni 1 (0,6%) 8 (4,9%) 9 (5,5%)
Belum ada data 0 (0%) 9 (5,5%) 9 (5,5%)
Ventilator 78 (47,3%) 32 (19,4%) 110 (66,7%)
TOTAL 79 (47,9%) 86 (52,1%) 165 (100%)
Pasien yang masuk kategori Ada 1 pasien yang masuk RIK 1

Pasien yang masuk kategori
ventilator pada tabel ini termasuk kurang dari 1 hari, tidak sempat
NIV murni pada tabel ini
pasien yang switch NC masuk Morning Report, pasien
termasuk pasien yang
↔Ventilator, HFNC↔Ventilator, sudah dipindah.
switch HFNC↔NIV
dan NIV ↔Ventilator
Kelompok Meninggal Hidup TOTAL
Ventilator 78 (71,9%) 32 (29,1%) 110 (100%)
Rata-rata Nilai SOFA

Outcome Ventilator Mean ± SD Percentage Range
Pasien Ventilator 6,14 ± 3,236 48% 1-15
Meninggal Non 5,25 ± 4,031 2,6% 2-11
Ventilator
Pasien Ventilator 4,73 ± 2,022 16,9% 0-10
Survive Non 3,56 ± 2,022 32,5% 0-9
Ventilator
Rata-rata Nilai APACHE
Outcome Ventilator Mean ± SD Percentage Range

Meninggal Non Ventilator 5,0 ± 0,816 3,0% 4-6
Survive Non Ventilator 6,39 ± 5,038 28,2% 0-24
Persentase Komorbid
Outcome Obese DM Tipe 2

Survive 8 (9,30%) 27 (31,4%)
Meninggal 11 (13,92%) 24 (30,38%)
Persentase
19 (11,52%) 51 (30,91%)
Keseluruhan
Persentase penggunaan CRRT
Hidup 2 (2,33%)
Meninggal 19 (24,05%)
Persentase 21 (12,73%)
Keseluruhan pasien
P/F ratio
• P/F ratio
• Mean: 133,4 ± 84,276
• Range: 32 – 515
Komplikasi pada Pasien yang N=79
meninggal
Gagal Napas 79 (100%)
Syok Septik 27 (35,07%)
AKI 25 (32,46%)
Hipoalbumin 19 (24,68%)
Sepsis 6 (7,79%)
Post Cardiac Arrest 4 (5,2%)
ARDS 3 (3,9%)
Hipokalemi 3 (3,9%)
Asidosis Metabolik 2 (2,6%)
Anemia 2 (2,6%)
Edema Paru Akut 1 (1,3%)
“ventilator management should be
individualised to each patient's physiology”
COVID-19 merusak paru-paru. Jangan meremehkan!
The surgeon said the damage was among the worst he’d seen
https://www.sciencenews.org/article/coronavirus-covid-19-critically-ill-patient-double-lung-transplant
Are you ready to fight COVID-19?
Stay the distance
or die!
Stay healthy
Stay safe
Stay clean
ASV ®
Adaptive Support Ventilation
Semua ventilator Hamilton Medical dilengkapi mode ventilasi cerdas Adaptive
Support Ventilation (ASV). ASV menyesuaikan laju pernapasan, volume tidal, dan
waktu inspirasi terus menerus sesuai dengan mekanika paru dan usaha nafas. ASV
menyesuaikan ventilasi napas demi napas, 24 jam sehari, dan dari intubasi hingga
ekstubasi.
ASV secara otomatis menggunakan
prinsip “Lung Protective Strategy” untuk
meminimalkan komplikasi dari AutoPEEP
dan volutrauma / barotrauma. Mencegah
apnea, takipnea, dead space, dan napas
yang terlalu besar. Dengan prinsip Lung
Protective Strategy ini, ASV mendorong
pasien untuk bernapas secara spontan.
Sejak 1998 ASV telah menjadi mode
standar di banyak unit di seluruh dunia.
ASV telah berhasil digunakan pada
berbagai kelompok pasien - termasuk
pasien pasca operasi, COPD, dan ARDS
(Celli 2014, Agarwal 2013, Kirakli 2011,
Gruber 2008, Sulzer 2001).
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M AT E R I W E B I N A R

CLINICAL MANAGEMENT OF SEVERE ACUTE

HIGH FLOW OXYGEN THERAPY

LUNG PROTECTIVE VENTILATION

Incidence of failed intubation :

✓ ~ 1 in 300 during rapid sequence intubation in the

✓ ~ 1 in 50–100 in the emergency department (ED),

Channeled Non -channeled

PAJ-2500-036 Rev B IW 201402

XX XX XX – XX XX XX . XXX XX/XX . XX/X . XX XX XX

An optimised distal tip Clinical

Patient comfort – LMA ProSeal™ reduces the likelihood of

PAB-2500-007 Rev B IW 201402

Dual gastric access

Silicone airway tube

LMA Protector Airway

Second Seal Technology

First Seal Technology Cuff Pilot Technology

Excellent seal pressures, dual Designed to help Phthalate free

Code Product Name

JAKARTA, INDONESIA HEAD OFFICE

Hook and loop padded strap provides

Slide stick facilitates fast,

Larger access opening to allow

600-30000 Thomas Tube Holder Adult, Green (qty. 1)

Only sold in cartons of 25 each.

Visit www.laerdal.com or contact your Authorized Laerdal Distributor 117

terganggu PAO2: PACO2:

GANGGUAN SESAK NAFAS HIPOKSEMIA, SpO2 <93% (FiO2 21%),

1. Apakah kondisi sedang memburuk progresif? TIDAK

HFNC 30 LPM FiO2 100%

GANGGUAN SESAK NAFAS HIPOKSEMIA, SpO2 <93% (FiO2 21%),

1. Apakah kondisi sedang memburuk progresif? TIDAK NRM 15 lpm

YA HFNC 30 LPM FiO2 100%, POSISI TELUNGKUP

HFNC 30 LPM FiO2 titrasi TIDAK YA

GANGGUAN SESAK HIPOKSEMIA,

TIDAK EVALUASI, Apakah:

- PaO2/FiO2 <60 mmhg selama >6 jam

GANGGUAN SESAK HIPOKSEMIA,

GANGGUAN SESAK HIPOKSEMIA,

GANGGUAN SESAK HIPOKSEMIA,

GANGGUAN SESAK HIPOKSEMIA,

1. Compos Mentis, komunikasi lancar, DAN

GANGGUAN SESAK HIPOKSEMIA,

1. Compos Mentis, komunikasi lancar, DAN

GANGGUAN SESAK HIPOKSEMIA,

30-60 Liter/menit 1-15 Liter/menit

FLOWMETER PENGHANGAT PELEMBAB NASAL KANUL

Dalam parameter NIV

GANGGUAN SESAK HIPOKSEMIA,

TIDAK EVALUASI, Apakah:

GANGGUAN SESAK HIPOKSEMIA,

TIDAK EVALUASI, Apakah:

GANGGUAN SESAK HIPOKSEMIA,

TIDAK EVALUASI, Apakah:

- PaO2/FiO2 <60 mmhg selama >6 jam

“High flow nasal oxygen (HFNO) therapy (in ICU): HFNO

“The risk of airborne transmission to staff is low with