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ACUTE RESPIRATORY FAILUREACUTE RESPIRATORY FAILURE
RespirationRespiration
VentilationVentilation
OxygenationOxygenation
• • • • • • • • • • CO2CO2
• • • • • • • • • • O2O2
Anatomy of respiratory systemAnatomy of respiratory system
Respiratory mechanicRespiratory mechanic
EXPIRATIONEXPIRATION
ribsribs
sternumsternum
diafragmadiafragma
vertebralvertebralcolumncolumn
INSPIRATIONINSPIRATION
ribsribs
sternumsternum
diafragmadiafragma
vertebralvertebralcolumncolumn
Glomus karotikum & aortikum
Kemosensitif rostral & kaudal
Kemoreseptor
- 10- 10
- 7- 7
- 4- 4
+ 4+ 4
INSPIRATIONINSPIRATION EXPIRATIONEXPIRATION
IntraIntrapulmonalpulmonal
IntraIntrathoracalthoracal
airair airair
- 4- 4 + 2+ 2
Air flowAir flow
Lung VolumeLung Volume6.06.0
2.72.7
2.22.2
1.21.2
0.00.0Volume (L)Volume (L)
Tidal VolumeTidal Volume
Residual VolumeResidual Volume
Expiratory Reserve VolumeExpiratory Reserve Volume
Inspiratory Reserve VolumeInspiratory Reserve Volume
Dead SpaceDead Space
Tipe-1Tipe-1
Tipe-1ITipe-1I
ALVEOLIALVEOLI
Gas transportationGas transportation
PlasmaPlasma
O2 + Hb O2 + Hb HbO2 HbO2
CO2CO2
O2O2
LungLung
HbO2 HbO2 Hb + O2 Hb + O2
Cl- Cl- HCO3- + H+ HCO3- + H+ H2CO3 H2CO3 H2O + CO2 H2O + CO2
HHb HHb H+ + Hb- H+ + Hb-
CO2CO2
O2O2
TissueTissue
Cl-Cl-
CO2 + H2O CO2 + H2O H2CO3 H2CO3 H+ + HCO3- H+ + HCO3-
HHb HHb H+ + Hb- H+ + Hb-
O2O2 40.0 40.0CO2CO2 46.0 46.0H2OH2O 47.0 47.0NN 573.0573.0
O2O2 95.0 95.0CO2CO2 40.0 40.0H2OH2O 47.0 47.0NN 573.0573.0
O2O2 40.0 40.0CO2CO2 46.0 46.0H2OH2O 47.0 47.0NN 573.0573.0
O2O2 158.0158.0CO2CO2 0.3 0.3H2OH2O 5.7 5.7NN 596.0596.0
O2O2 116.0116.0CO2CO2 32.0 32.0H2OH2O 47.0 47.0NN 565.0565.0O2O2 100.0100.0
CO2CO2 40.0 40.0H2OH2O 47.0 47.0NN 573.0573.0
kapilerkapiler
jaringanjaringan
venavena arteriarteri
inspirasiinspirasi expirasiexpirasi
jantung kananjantung kanan jantung kirijantung kiri
alveolialveoli
ruang rugiruang rugi
Struktur dan fungsi toraks belum sempurnaStruktur dan fungsi toraks belum sempurna Saluran nafas sempitSaluran nafas sempit Alveolus belum berkembangAlveolus belum berkembang Defisiensi surfaktanDefisiensi surfaktan Kelainan bawaanKelainan bawaan Rentan (mudah infeksi saluran nafas)Rentan (mudah infeksi saluran nafas)
Faktor predisposisiFaktor predisposisi
Anatomical & Physiological differenceAnatomical & Physiological differenceNeonate vs AdultNeonate vs Adult
• Lung weight, gLung weight, g• of trachea, mmof trachea, mm• of bronchioles, mmof bronchioles, mm• of alveolus, of alveolus, • Numbers of alveolus, 10Numbers of alveolus, 1066
• Number of airways, 10Number of airways, 1066
• Total alveolar surface area, M2Total alveolar surface area, M2• Total flow resistance, cm H2O/L/secTotal flow resistance, cm H2O/L/sec• Respiratory rate/minRespiratory rate/min• Tidal Volume, ml/kgTidal Volume, ml/kg
NeonateNeonate505088
0.10.150-10050-100
24241.51.5
446868404066
AdultAdult8008001818
0.20.2200-300200-300
29629614148080
5.55.5202077
EtiologiEtiologi
CroupCroupSumbatan benda asingSumbatan benda asingBronkitisBronkitisAsmaAsmaPnemoniaPnemoniaEdema paruEdema paru
Deformitas toraksDeformitas toraksHernia diafragmatikaHernia diafragmatikaFraktur igaFraktur igaEfusi pluraEfusi plura
Anemia berat/intoksikasiAnemia berat/intoksikasiRenjatanRenjatanGagal jantungGagal jantung
Trauma/infeksi batang otakTrauma/infeksi batang otakPoliomielitisPoliomielitisTrauma lahir (n.prenikus)Trauma lahir (n.prenikus)
Gangguan jalan nafasGangguan jalan nafas
Gangguan mekanik PernafasanGangguan mekanik Pernafasan
Gangguan transportasi gasGangguan transportasi gas
Gangguan neurologikGangguan neurologik
Criteria for respiratory failureCriteria for respiratory failure
ClinicalClinicalDecreased or absent inspiratory breath soundsDecreased or absent inspiratory breath soundsSevere inspiratory retractionsSevere inspiratory retractionsCyanosis in 40 % O2Cyanosis in 40 % O2Depressed level of consciousnessDepressed level of consciousnessPoor skeletal muscle tonePoor skeletal muscle tone
PhysiologicPhysiologicPaCO2 > 75 mmHgPaCO2 > 75 mmHgPaO2 < 100 mmHg in 100 % O2PaO2 < 100 mmHg in 100 % O2
Three clinical + One physiologic criterion = ARFThree clinical + One physiologic criterion = ARF
ManagementManagement SupportiveSupportive
DefinitiveDefinitive
SupportiveSupportive
RespiratoryRespiratory Circulatory/HematologicCirculatory/Hematologic Fluid/Electrolyte/CaloricFluid/Electrolyte/Caloric
VENTILATORVENTILATOR
Negative pressureNegative pressure
Positive pressurePositive pressure
(Air shield isolatte)(Air shield isolatte)
Pressure limitedPressure limitedVolume limitedVolume limitedI/E ratio limitedI/E ratio limitedTime limitedTime limited
High frequencyHigh frequency
Time cycleTime cycle
P -P - P +P +
Negative pressure ventilatorNegative pressure ventilator Positive pressure ventilatorPositive pressure ventilator
The steps in managing of mechanical ventilationThe steps in managing of mechanical ventilation
• Choose appropriate goals for ventilation and oxygenationChoose appropriate goals for ventilation and oxygenation• Select the modes of ventilationSelect the modes of ventilation• Determination of initial ventilatory parametersDetermination of initial ventilatory parameters• Set the selected parametersSet the selected parameters• Initiate the ventilatory supportInitiate the ventilatory support• Confirm the appropriateness of initial setting and make Confirm the appropriateness of initial setting and make adjustments accordinglyadjustments accordingly• Anticipate complicationsAnticipate complications• Start weaning when ventilatory support no more requiredStart weaning when ventilatory support no more required
RespirationRespiration
VentilationVentilation
OxygenationOxygenation
Minute VolumeMinute Volume• RateRate• Tidal VolumeTidal Volume
• FiO2FiO2• Mean Airway Mean Airway Pressure (MAP)Pressure (MAP)
• pHpH• PaCO2PaCO2• ETCO2ETCO2
• PaO2PaO2• SaO2SaO2