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1. PACU PACU Monitor Mesin Anestesi

2. INITIAL SETTING Once it has been determined that mechanical ventilation is indicated for a patient who needs help with oxygenation and/or ventilation , then you must know how to properly input the initial ventilator setting Support can be provided in the form of: Ventilation oxygenation

3. BASIC VENTILATOR SETTINGS Ventilator mode Tidal volume Frequency/rate I:E ratio Tpause PEEP FiO2 Pmax Inspiratory flow rate Trigger s ensitivity Ventilator alarms

4. Ventilator Mode Essentially, a ventilator mode is a way of describing how the mechanical ventilator assist a patient with inspiration The characteristics of a particular mode control how the ventilator functions First determine if the patient needs full or parti al ventilatory support You can select A/C if the patient needs full ventilatory support You can select SIMV if they only need partial support

5. \ A/C Pressure Control Synchronous Intermitten Mandatory Ventilation (SIMV) Pressure support ventilation (PSV) Continuous Positive Airway Pressure (CPAP) Volume Support (VS) Control Mode ventilation (CMV)

6. Tidal Volume TV refers to the volume of air that is inhaled and exhaled from the lungs during normal breathing If the patient is in a VC mode the delivered TV can be adjusted by increasing or decreasing the TV setting If the patient in in a PC mode , delivered TV can be adjusted by increasing or decreasing the pressure setting The initial tidal volume is around 6- 8 ml/kg of the patient IBW Smaller tidal volumes may be appropriate for patients with Acute Respiratory Distress Syndrome (ARDS). MV = TV x RR

7. Frequency (Respiratory Rate) The freq. setting on the ventilator determine how many breaths are delivered to the patient (per minute) by the machine Provides adequate minute ventilation for most patients The initial Freq. setting should be 10-20 breaths/min Average: 12 breaths/min for adults.. Severe sepsis or high metabolic rate → may require higher minute ventilation and respiratory rate. Compliance (C) = Δ Volume / Δ Pressure

8. Fraction of Inspired Oxygen (FiO 2 ) This refers to the concentration of oxygen that is being inhaled by the patient Start at 1.0 to minimize the risk of hypoxemia. After stable ventilation is achieved, adjust according to blood gas analysis to reach the desired PaO2 (8-12 kPA or 60-90 mmHg) or maintain SpO2 at 90- 98%." The goal shoul be to wean the FiO2 down to the lowest possible level that still provides adequate oxygenation FiO2 > 60% for a long period of time  increase of oxygen toxicity

9. Flow Rate This setting controls how fast the tidal volume is delivered to the patient by the ventilator The setting can be adjusted depending on the patients inspiratory demands The initial flo w setting should be 40-60 L/min If set too low  patient- ventilatory dysynchrony and increased WOB If set too high  mean airway pressures

10. Inspiratory to Expiratory Ratio (I:E Ratio) Ratio of the inspiratory porsion compared to the expiratory porsion of the breathing cycle The initial I:E Ratio setting should be between 1:2 – 1:4 A Larger I:E Ratio may be delivered if a patient is need of a longer expiratory time due the possibility of air trapping

11. Adjust the patient I:E ratio by making changes to the following settings: Flow rate Inspiratory time Expiratory time TV Freq.

12. Trigger sensitivity The sensitivity controls is what determines how much effort the patient must generate in order to trigger a breath from the machine Triggering detects the patient's effort to inhale , based on flow or pressure. Flow- based triggering tends to provide better synchronization than pressure- based triggering. More sensitive trigger settings improve synchronization, but excessive sensitivity can cause inappropriate triggering when the patient isn't actually trying to breathe. Start with pressure trigger at - 1 or - 2 cmH₂O or flow trigger with moderate sensitivity.

13. Pressure triggering: the patient’s inspiratory effort causes the breathing circuit pressure to drop, which the ventilator detects and cycles to inspiration. Setting: −1 cm H2O (very sensitive) and −20 cm H2O (very insensitive). - 1 to - 2 cmH2O If the setting is too sensitive, minor fluctuations in breathing circuit pressure (e.g. from cardiac pulsations) can trigger the ventilator inappropriately. Flow triggering: Setting: 1 (very sensitive) - 10 (insensitive) litres/minute. Neurally Adjusted Ventilatory Assist (NAVA): A modified nasogastric tube that contains two electrodes to record the diaphragmatic electrical activity is used to sense the patient’s respiratory efforts.

14. Sensitivity too high  it will cause the ventilator to initiate auto triggering and increase the total Freq. of breaths Sensitivity too low  the patient could have a difficult time initiating a breath

15. Positive End Expiratory Pressure (PEEP) Peep is essentially an amount of positive pressure th a t is delivered during the expiratory phase of the breathing cycle. It helps prevent the closure of alveoli in the lungs which allows an increased amount of time for oxygen exchange to occure The most common indication for peep is the patient with refractory hypoxemia and those who have not responded well to a high FiO2 setting The initial PEEP setting should be Start with PEEP around 5 cmH₂O. Higher PEEP is often needed for patients with acute pulmonary edema or ARDS. PEEP = is recommended for patients with asthma or COPD who cannot breathe spontaneously.

16. Initial Setting Parameter Assist Control Pressure Control Pressure Support SIMV PS FiO2 ✓ ✓ ✓ ✓ Frequency ✓ ✓ ✓ Tidal Volume ✓ ✓ Inspiratory Pressure ✓ ✓ ✓ Inspiratory Flow ✓ * ✓ * I:E Ratio ✓ * ✓ ✓ * Inspiratory Pause ✓ * ✓ * SIMV Period ± PEEP ✓ ✓ ✓ ✓ Trigger ✓ ✓ ✓ ✓

17. Ventilator alarms serve a very important purpose in respiratory care because they alert us as medical professionals whenever an issue is present between the patient and the ventilator Ventilator alarm is a safety mechanism on the ventilator mechanism that uses a set parameters to provide alerts whenever there is a potential problem related to the patient ventilator interaction the alarms can be visual or both depending on the ventilator setting and the patient condition High pressure Low Pressure Low expired volume High frequency Apnea High PEEP Low PEEP

18. MAC Konsentrasi gas anestesi di alveolus yang dibutuhkan untuk mencegah respons gerak (movement) pada 50% pasien setelah stimulus nyeri ( biasanya insisi kulit ).

19. Kapnograf adalah alat medis yang digunakan untuk mengukur dan menampilkan konsentrasi karbondioksida (CO2) dalam udara yang dihembuskan ( ekshalasi ). Kapnograf menghasilkan grafik atau kurva yang disebut kapnogram , yang menunjukkan perubahan kadar CO2 secara real-time selama siklus pernapan

20. Kapnogram terdiri dari 4 fase utama, yaitu: Fase I (Inspiratory Baseline): Mewakili gas yang terhirup, yang biasanya tidak mengandung karbon dioksida (CO2). Fase II (Expiratory Upstroke) : Transisi antara udara ruang dead space berpartisipasi dalam pertukaran gas, yang dengan tidak gas alveolar dari bronkiolus respiratori dan alveoli. Fase III (Alveolar Plateau): Bagian datar kapnogram yang mencerminkan kadar CO2 di alveoli. Tekanan parsial CO2 dari gas alveolar terakhir yang diukur pada pembukaan jalan napas disebut PETCO2 (End- Tidal CO2). Fase (Inspiratory Downstroke): Penurunan tajam yang menandai awal inspirasi berikutnya. FASE

21. KAPNOGRAF Hasil dari kapnograf adalah EtCO2 yang dapat dilihat pada akhir fase ekspirasi

22. High Pressure Alarm Triggered  circuit pressure exceeds Preset Pressure Limit during in inspiratory phase This is common in respiratory conditions that decrease lung complian and/or airway resistance Preset high pressure limit typically set 10 cmH2O above the Peak Inspiratory Pressure (PIP) HPA causes: coughing, secretion accumulation, patient biting ET tube, a kink in the circuit

23. Causes: Ventilator problems inappropriate settings excessive tidal volume excessive flow or excessively short inspiratory time high airway pressure alarm limit too low ventilator malfunction - rare Circuit problems fluid pooling in circuit fluid pooling in filter kinking of circuit

24. Problems with the ventilator and circuit can be differentiated from issues with the endotracheal tube (ETT) or patient by disconnecting the patient from the ventilator and manually ventilating. If easy to ventilate: The issue is likely with the ventilator or circuit. If difficult to ventilate: The problem is likely with the ETT or patient

25. Low Pressure Alarm Triggered  PIP falls below preset designated level This commonly occurs whenever there is a leak or disconnection in the system Preset low pressure level typically 5-10 cm H2O below the PIP If Cause unknown  Manually ventilated