Dys-synchrony

b. Kelamaan triggering atau ketidakefektifan triggering.

• Yaitu terjadi kelamaan antara respon mesin dan trigger dari pasien.
• Penyebabnya:
• Ada hiperinflasi dinamik, akibat :
Keelastisitetan paru yang menurun
Tidal volume yang kebesaran
Tahanan aliran ekspirasi yang tinggi
Waktu ekspirasi terlalu pendek
• Kelemahan otot pernafasan
2. Terjadi pada fase inspirasi dan akhir inspirasi
• Karena ketidaksesuaian seting “rise time”
• Karena ketidaksesuaian bantuan volume dan usaha nafas pasien
(sering pada mode PSV)
• Karena ketidaksesuaian antara seting “cycling off” dan akhir
inspirasi pasien
3. Terjadi pada fase ekspirasi
• Karena katup ekspirasi terbuka terlalu lama/dini
 Penyelesaian dyssynchrony
1. Evaluasi dengan grafik pressure-time, flow-time dan volume-time
secara serentak
2. Analisa mengapa terjadi demikian
3. Kelola penyebabnya
PERTANYAAN ?
How Mechanical Ventilation
Works ?

PERDICI
 Overview of the Mechanical Ventilator
System and Classification
• Physical Characteristics of Ventilator
• Power source (input)
• Electrically-powered
• Pneumatically-powered
• Combined power
• Pressure delivery
• Positive
• Negative-pressure ventilators
• Control systems and circuits
• Open and closed-loop systems to control ventilator function
• Control panel (user interface)
• Pneumatic circuit
• Power transmission and conversion system (Drive mechanisms)
• Volume-displacement, pneumatic designs
• Flow-control valves
• Basic Component of Breath Delivery
 Chatburn’s Mechanical Ventilator
Classification
• Basic functions of ventilator
• Power input
• Drive mechanisms
• Control scheme
• Output (pressure, volume, and flow (waveforms)
• Alarm systems
 Overview of the Mechanical Ventilator
System and Classification
• Physical Characteristics of Ventilator
• Power source (input)
• Electrically-powered
• Pneumatically-powered
• Combined power
• Pressure delivery
• Positive
• Negative-pressure ventilators
• Control systems and circuits
• Open and closed-loop systems to control ventilator function
• Control panel (user interface)
• Pneumatic circuit
• Power transmission and conversion system (Drive mechanisms)
• Volume-displacement, pneumatic designs
• Flow-control valves
• Basic Component of Breath Delivery
 Power Input
• Electrically-powered
• Use AC electrical power, can then be converted to DC to power the
electronic control circuits
• Electricity : to power internal motors, air compressors, pistons,
solenoids, transducers and microprocessors
• Pneumatically-powered
• Relying on high pressure gas source to ventilate the patient
• Combined-power
• Most common: pneumatically powered and microprocessor-
controlled
 Overview of the Mechanical Ventilator
System and Classification
• Physical Characteristics of Ventilator
• Power source (input)
• Electrically-powered
• Pneumatically-powered
• Combined power
• Pressure delivery
• Positive
• Negative-pressure ventilators
• Control systems and circuits
• Open and closed-loop systems to control ventilator function
• Control panel (user interface)
• Pneumatic circuit
• Power transmission and conversion system (Drive mechanisms)
• Volume-displacement, pneumatic designs
• Flow-control valves
• Basic Component of Breath Delivery
 Overview of the Mechanical Ventilator
System and Classification
• Physical Characteristics of Ventilator
• Power source (input)
• Electrically-powered
• Pneumatically-powered
• Combined power
• Pressure delivery
• Positive
• Negative-pressure ventilators
• Control systems and circuits
• Open and closed-loop systems to control ventilator function
• Control panel (user interface)
• Pneumatic circuit
• Power transmission and conversion system (Drive mechanisms)
• Volume-displacement, pneumatic designs
• Flow-control valves
• Basic Component of Breath Delivery
 Control Circuits
• Is the subsystem responsible for controlling the drive mechanism
and/or the output control valve. A ventilator may have more than one
control circuit, which may be of several types.
• Mechanical, pneumatic, fluidic, electric, and electronic
 Control Scheme
• A ventilator can directly control only one variable at a time: pressure,
volume, or flow
• Consists of:
• Control circuits
• Control variables
• Phase variables
• Modes of ventilation and conditional variables
 Control Systems & Circuits Pneumatic
Circuit
• Internal circuit
• Single circuit
• Gas supply that power the ventilator is the same that goes to the
pt
• Double circuit
• Gas source compressing a bag or bellow
• External circuit
 Overview of the Mechanical Ventilator
System and Classification
• Physical Characteristics of Ventilator
• Power source (input)
• Electrically-powered
• Pneumatically-powered
• Combined power
• Pressure delivery
• Positive
• Negative-pressure ventilators
• Control systems and circuits
• Open and closed-loop systems to control ventilator function
• Control panel (user interface)
• Pneumatic circuit
• Power transmission and conversion system (Drive mechanisms)
• Volume-displacement, pneumatic designs
• Flow-control valves
• Basic Component of Breath Delivery
 Power Transmission Systems
(Drive Mechanism)
• Volume-displacement, pneumatic designs
• Diaphragm, venturi entrainer, fluidic system
• Piston and cylinder
• Bellows
• Rotating vane
• Flow-control valves
• Used to regulate the flow of gas to the patient
 Overview of the Mechanical Ventilator
System and Classification
• Physical Characteristics of Ventilator
• Power source (input)
• Electrically-powered
• Pneumatically-powered
• Combined power
• Pressure delivery
• Positive
• Negative-pressure ventilators
• Control systems and circuits
• Open and closed-loop systems to control ventilator function
• Control panel (user interface)
• Pneumatic circuit
• Power transmission and conversion system (Drive mechanisms)
• Volume-displacement, pneumatic designs
• Flow-control valves
• Basic Component of Breath Delivery
 Basic Component of Breath Delivery
Equation of Motion
Muscle Pressure + Ventilator Pressure = Elastic Recoil Press + Flow Resistance
Or
Pmus + PTR = V/C + (Raw x flow)
Pmus + PTR = PA +PTA

Pmus : pressure generated by muscles of ventilation (0 if not active)

PTR : transrespiratory pressure
V : volume delivered
C : respiratory system compliance
V/C : elastic recoil pressure
Raw : respiratory system resistance
Flow : gas flow during inspiration
PTA : transairway pressure
PA : alveolar pressure
 Type of Breath Delivery
• Mandatory breath
The ventilator does all the work of breathing (starts the
breath, controls insp. gas delivery, and ends inspiration)
• Assisted breath
Inspiration is begun by the pt, but the ventilator controls insp.
Phase and ends inspiration
• Spontaneous breath
Pt control the breath
 Basic Components of Breath Delivery
• The four phases of breath during mechvent
1. End of expiration and beginning of inspiration
2. Delivery of inspiration
3. End of inspiration and beginning of expiration
4. Expiratory phase
• In each phase a particular variable is measured and used to start,
sustain, and end the phase
 Phase Variables
Baseline Variable
• Baseline variable is the variable that is controlled during the
expiratory time
• Pressure is the most practical value to control and is used by all
commonly used ventilators
• PEEP, CPAP
 Conditiional Variables
• Conditional variables can include pressure, tidal volume, inspiratory
flow, minute ventilation, time, etc.
• If the value of a conditional value reaches some pre-set threshold,
then some action occurs to change the ventilatory pattern, e.g., MA-1
vent. When giving a sigh breath (the conditional variable is time), or
as in SIMV if vent. Detects pt. Effort and “window” is open then spont.
Breath
 Output
• The study of ventilatory operation requires the examination of output
waveforms
• The waveforms we look at are pressure, volume, and flow
• Waveforms are grouped into 4 basic categories :
• Rectangular
• Ramp
• Exponential
• Sinusoidal
 Inspiratory Trigger
• Pressure trigger

• Flow trigger with Expiratory Base Flow

 Pressure Trigger vs Flow Trigger
Consider
• P-trigger maximum sensitivity (0.5 cmH2O)
• Very sensitive
• May be affected by noise (self-cycling)
• Any associated base-flow worsens the performance
• F-trigger maximum sensitivity (0.5 l/min)
• Very sensitive
• Only rarely affected by noise (after Galileo warm-up)
• Any associated base-flow improves the performance
 Pressure Trigger vs Flow Trigger
Remember
• Equal values for sensitivity setting are not comparable, between
different triggers
• Check stimulation :
• 0.5 cmH2O vs 0.5 l/min
• 2 cmH2O vs 2l/min
• When PEEP is present, the problem is elsewhere!
THANK YOU FOR YOUR ATTENTION
