Professional Documents
Culture Documents
HANDBOOK CVCU
CVCU
LENTA
LENTA FERNANDO
FERNANDO
Dedicated to CVCU
April, 2010
Dedicated to mykynaocca
SINDROMA KORONER
AKUT
Dedicated to mykynaocca
SINDROMA KORONER
AKUT ( SKA )
5 SUBSET/MANIFESTASI IHD :
- Silent angina ( asimtomatis )
- Angina Pektoris Stabil ( APS )
- Angina Pektoris tak stabil ( APTS )
- Infark miokard NSTEMI ( Non Q )
- Infark miokard ST Elevasi ( STEMI /Q
Karakteristik Nyeri :
APS :
nyeri dicetuskan aktifitas ttt
Dalam 30 hr tdk ada perubahan frekuensi,
lama, fc pencetus
Lama nyeri </= 15 menit
APTS :
o Terdapat perubahan pola : frekuensi, durasi,
beratnya nyeri & fc pencetus ( PROGRESIF &
CRESENDO ), perlu obat dg dosis lebih besar
o Rest angina
o Lama > 20 menit
o Angina berat onset baru ( CCS III )
DIAGNOSIS INFARK :
o Ax : karakteristik nyeri dada ( > 20 mnt, tak
berhub dg aktif & tdk hilang dg nitrat )
o Perubahan khas EKG
o Perub enzim > 1 kali
CKMB meningkat ( tjd stlh 4 jam )
Troponin T lebih spesifik
NOTE :
Dosis heparin 500, 750, 1000, 1250, 1500 sss PTTK
Monitor PTTK / 12 jam. EKG / 24 jam
Diberikan selama 4 5 hari
KI RELATIF
o Kehamilan
o Menstruasi
o Punksi arteri atau baru cabut gigi
o Resusitasi jantung paru yang lama
o Hipertensi tidak terkontrol
o Alergi thd streptokinase (gunakan Reteplase rPA atau
Alteplase )
o Pemberian streptokinase > 5 hari sebelumnya
( gunakan Reteplase rPA )
o Retinopati diabetik proliferasi
o Gg hemostasis ( Trombo < 20.000, > 50.000 dg
perdarahan ) atau
mendapat antikoagulan warfarin.
Yanfile
JIKA NYERI DADA >> :
Infark Anterior
o Anteroseptal ( V1-V3 ) LAD
o Anterolateral ( I, aVL, V5, V6 ) LCx
o Anterior Ekstensif ( I, aVL, V1-V6 ) LAD, LCx
Komplikasi :
Gagal jantung
Aritmia maligna
Trombus di apex
Dedicated to mykynaocca
Impedance
Cardiac output
Dedicated to mykynaocca
Dedicated to mykynaocca
Pre load
Efek arterial sekunder
Diuretika : pre load , elektrolit ,
CO , SRA , impedance
Kombinasi gagal + dobutamin
Dedicated to mykynaocca
OBAT AFTER LOAD & IMPEDANCE
Kelompok nitrat
Dilatasi V sistem + paru
Morfin : simpatikolitik
Pomp resp + flebot farmakolo (+)
venous return
Dedicated to mykynaocca
PRINSIP TATALAKSANA
Tabel 2. Obat-obat tambahan untuk GJ akibat IMA berdasarkan kelas killip
Kelas klinik Obat tambahan
I Kaptopril
II Kaptopril, nitrat (parentral)
III Kaptopril, nitrat (parentral), morfin,
furosemid (parentral), dobutamin,
IV dopamin (dosis rendah)
Nitrat (parentral), furosemid (parentral),
dobutamin, dopamin (dosis tinggi),
digitalis (?)
IMA Disf sistol GJ
Tujuan terapi : beban ,
kongs paru ,
kontraktil
Urutan obat : kurangi beban,
bila gagal baru kontraktil
Bila semua gagal LVAD
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ARITMIA
Dedicated to mykynaocca
APPROACH :
1.Macam disritmia ( nilai EKG 12 lead )
2.Ada tdknya ggg hemodinamik ancam jiwa
3. Manifestasi : - kelainan jtg organik
- gg ekstra kardial ( ggg elektrolit, obat,
tirotoksikosis )
4. Terapi yg terbaik ? Co : pada AF tdk sll hrs konversi ke
sinus
SA AV Berkas his cab ka/ki serabut
purkinye
FREKUENSI yg dihasilkan :
SA : 60 100 x / mnt
AV : 40 60 x / mnt
Ventrikel : 20 40 x / mnt
Panjang Gel Normal :
PR int : 0,10 0,20
QRS compl : 0,04 0,12
Dedicated to mykynaocca
NSR
A
Flutter
SINUS BRADIKARDI
A Fibrilasi
VT VF
AV Block 2 First Degree
VES salvo
VES
R on T
Dedicated to mykynaocca
PENANGANAN
ARITMIA
SVT :
Gel P tersembunyi dlm gel T ok frekuensi
sgt cepat
( 151 250 x / menit )
VT
asal dari 1 tempat di ventrikel ( Frek : 41 250 )
Gel P (-)
QRS lebar & bizzare
VF :
asal dari byk tempat di ventrikel
tdk ada waktu depol/gel P (-) & repol/ QRS (-), PR
int (-), PP
RR int (-)
grs2 gel kacau
TORSADE : VT yg mendekati VF
Dedicated to mykynaocca
PENGELOLAAN VT :
Umum : - rawat ICU
- O2 2 3 ltr/mnt
- Infus line D5%
- diet Lunak
KHUSUS :
Hemodinamik baik : XYLOCAIN : Bolus 1 1,5 mg / kg
BB diencerkan
tunggu 15 mnt
Hemodinamik BURUK :
Pulse (+) : DC shock 50 100 J ( sincronized:
deteksi QRS )
Pulseless : terapi sss VF, DC shock 200 300 J
asincronized 360 J
ditambah ADRENALIN 1 mg bolus 3x
ulang tiap 1 s/d
5 mnt
BLOK ( ggg penghantaran impuls ) Dedicated to mykynaocca
- Blok sinoatrial
- BLOK AV :
1.AV blok derajat I : P sinus,QRS comp&T
normal,PR int > 0,20 det
Terapi : -
Dihentikan bila:
Urine < 30 cc/jam Antidotum :
Glukonas Calcicus
Depresi nafas(RR<16x/mnt)
Reflek patela turun
Curah jantung
Auto regul
Tekanan darah
Misal :
TD saat datang : 200 / 140 mmHg
MAP : 200 + ( 2 x 140 ) = 160
3
Sasaran 2 jam I : 75 % x 160 = 120 mmHg
( diastolik )
PRINSIP PEMILIHAN OBAT GDH
Dedicated to mykynaocca
Dedicated to mykynaocca
EDEMA PARU
AKUT
Dedicated to mykynaocca
PROSES :
Stage 1 terjadi peningkatan perpindahan cairan
ke dalam intetestital paru, karena aliran limfatik
juga meningkat & tidak terjadi peningkatan
volume interstitial.
Stage 2 Kapasitas limfatik tidak mampu
mengeluarkan cairan, cairan terakumulasi dalam
ruang intertstitial yang mengelilingi bronkiolus
dan vaskuler paru ( rontgent : edema interstitial)
Stage 3 karena cairan terus meningkat, terjadi
Dedicated to mykynaocca
ETIOLOGI
I. Altered capillary permeability
B. Noncardiac causes
1. Pulmonary venous fibrosis
2. Congenital stenosis of the origin of the pulmonary veins
3. Pulmonary venoocclusive disease
C. Overinfusion of fluids
Dedicated to mykynaocca
Diagnosis
1. Pemeriksaan darah: darah rutin dg
dif count, eletrolit, BUN, kreatinin dan
konsentrasi protein serum
2. Urianalisis dan pemeriksaan
mikroscopik urin: dapat ditemukan
proteinuria
3. Analasis gas darah arteri: pertama
terjadi penurunan PO2 and PCO2.
Kemudian terjadi penurunan PO2
sedangkan PCO2 meningkat. Bila nilai
PO2 < 50 mmHg and PCO2 > 50 mmHg
merukakan keadaan yang berat dan
memerlukan ventilasi mekanik
Dedicated to mykynaocca
PENGOBATAN
Anamnesis yang jelas, pemeriksaan fisik dan
tes laboratororium untuk mengetahui
penyebab, sehingga dapat diobati secara
spesifik.
Posisi setengah duduk pernafasan lebih
mudah dan untuk mengurangi aliran vena ke
jantung
Oksigen 100% diberikan dengan masker
untuk memastikan oksigenasi yang cukup.
Morfine (2 - 5 mg IV bolus, yang dapat
diulang hingga maksimum15 mg) ><
naloxone (0.8 to 2.0 mg IV bolus)
Furosemide (40 to 100 mg IV bolus)
venodilaytasi dan kemudian sebagai
Dedicated to mykynaocca
Acute
Acutepulmonary
pulmonary Volume
Volumeproblem
problem Pump
Pumpproblem
problem Rate
Rateproblem
problem
edema
edema
11ststAcute
Acutepulmonary
pulmonaryedema
edema Administer
Administer: :
Furosemide iv 0.5 1.0 mg/kg Fluids Bradicardia
Furosemide iv 0.5 1.0 mg/kg Fluids Blood
Blood Bradicardia Tachycardia
Tachycardia
Morphine iv 2 4 mg Blood transfusions See algorithm See algorithm
Morphine iv 2 4 mg Blood transfusions
Nitroglycerin SL Cause-specific interventions Pressure?? See algorithmSee algorithm
Pressure
Nitroglycerin SL Cause-specific interventions
Oxygen/intubation as needed Consider
Oxygen/intubation as needed Considervasopressors
vasopressors
Systolic Systolic
SystolicBP
SystolicBPBP nd Systolic
SystolicBP
BP Systolic
SystolicBPBP Systolic
SystolicBPBP >>100 mmHg
BP
BP
BP defines22nd
defines <<7070mmHg
mmHg 7070toto100
100mmHg
mmHg 7070toto100
100mmHg
mmHg 100 mmHg
Line
Lineofofaction
action Signs/symptoms
Signs/symptoms Signs/symptoms
Signs/symptoms No sign/symptoms
No sign/symptoms
(see below)
(see below) ofofshock
shock ofofshock
shock ofofshock
shock
Dedicated to mykynaocca
Dedicated to mykynaocca
Systolic
SystolicBPBP nd Systolic
SystolicBP
BP Systolic
SystolicBPBP Systolic
SystolicBPBP Systolic
SystolicBP
BP
BP
BP defines22nd
defines <<7070mmHg
mmHg 7070toto100
100mmHg
mmHg 7070toto100
100mmHg
mmHg >>100 mmHg
100 mmHg
Line
Lineofofaction
action Signs/symptoms
Signs/symptoms Signs/symptoms
Signs/symptoms No sign/symptoms
No sign/symptoms
(see below)
(see below) ofofshock
shock ofofshock
shock ofofshock
shock
22ndnd- -Acute
Acutepulmonary
pulmonaryedema
edema
Nitroglycerin / nitroprusside if BP > 100mmHg
Nitroglycerin / nitroprusside if BP > 100mmHg
Dopamine if BP 70 100 mmHg, signs/symptoms of shock
Dopamine if BP 70 100 mmHg, signs/symptoms of shock
Dobutamine if BP > 100 mmHg, no signs/symptoms of shock
Dobutamine if BP > 100 mmHg, no signs/symptoms of shock
Further
Furtherdiagnostic
diagnostic/ /therapeutic
therapeuticconsideration
consideration
Pulmonary artery catheter
Pulmonary artery catheter
Intra-aortic balloon pump
Intra-aortic balloon pump
Angiography for AMI / ischemia
Angiography for AMI / ischemia
Additional diagnostic studies
Additional diagnostic studies
Dedicated to mykynaocca
1. Gagal jantung kongestif akut dengan tanda dan gejala AHF yang
ringan dan tidak memenuhi kriteria cardiogenic shock, pulmonary
oedema atau hypertensive crisis.
Glyceryl Tolerance on
trinitrate, 5- Acute heart failure, when blood Start 20 g/min, Hypotension, continuous
mononitrate pressure is adequate increase to 200 g/min headache use
Tolerance on
Isosorbide Acute heart failure, when blood Start with 1 mg/h, Hypotension, continuous
dinitrate pressure is adequate increase to 10 mg/h headache use
Hypotension,
Hypertensive crisis, cardiogenic isocyanate Drug is light
Nitroprusside shock combined with intoropes 0.35g/kg/min toxicity sensitive
Bolus 2 g/kg +
Acute decompensated heart infusion 0.015
Dedicated to mykynaocca
OBAT- OBATAN
RESUSITASI
Dedicated to mykynaocca
EPINEPHRINE
Meningkatkan :
Resistensi vaskuler sistemik
TD diastolik & sistolik
Electrical activity in the myocardium
Coronary and cerebral blood flow
Strength of myocardial contraction
Myocardial oxygen requirements
Automaticity
INDIKASI :
Cardiac arrest from : VF or Pulseless VT
unresponsive to initial
countershocks, asystole, PEA
Symptomatic bradycardia
DOSIS & CARA PEMBERIAN :
o 1 mg IV, repeated every 3-5 minutes
o During cardiac arrest and symptomatic bradycardia
profound hypotension :
continuous infusion, 30 mg Epinephrine HCl added to 250
mL of normal saline
Dedicated to mykynaocca
ATROPINE
A parasympatholytic drug
Enhances both sinus node automaticity and AV conduction via
its vagolytic action
INDIKASI :
Initial therapy for symptomatic bradycardia
In 1st degree AV block, Mobitz type I AV block and brady-
asystoloc cardiac arrest :
excessive vagal stimulation.
DOSIS & CARA PEMBERIAN :
Without cardiac arrest : 0.5 1 mg,IV. Repeated at 5 minutes
interval.
Brady-asystolic cardiac arrest : 1 mg IV. Repeated every 3 5
minutes.
HATI - HATI :
Induce tachycardia
Administered with caution in the setting of myocardial
infarction
Excessive doses can cause : anti-cholinergic syndrome of
delirium, tachycardia,
come, flushed, hot skin and blurred vision
LIDOCAINE Dedicated to mykynaocca
Suppresses ventricular arrhythmias by decreasing automaticity
Terminates re entrant ventricular arrhythmias
Elevates the fibrillation threshold
INDIKASI :
Ventricular ectopy, wide complex tachycardias, ventricular
tachycardia and VF.
Pulseless VT and VF that is refractory to electrical therapy and
epinephrine.
Patient with significant risk factors for malignant ventricular
arrhythmia.
DOSIS & CARA
Routine PEMBERIAN
prophylactic :
Lidocaine therapy in patient with AMI can
Initial
no longerdose
be : 1,0 1,5 mg / kg I.V. bolus
Via ETT : 2 2,5 x IV dose
recommended.
Second bolus : 0,5 0,75 mg / kg after 10`
Additional bolus : 0,5 0,75 mg/kg every 5 ` -10` (if arrhythmia
persists), until total
dose: 3 mg/kg.
Continuous iv infusion: 2-4 mg/min (spontaneous circulation).
HATI - HATI :
Neurological change
Myocardial & circulatory depression
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ADENOSINE
Slows conduction through the AV node
Interrupts AV nodal re entry pathways
Restores normal sinus rhythm in patients with PSVT
Short-lived pharmacologic response
INDIKASI :
Terminating SVT that involve a re-entry pathways including
the AV node
Atrial tachycardia ( II b)
INDIKASI :
Ventricular rate control of rapid atrial arrhythmia in
patients with severely impaired LV function, and in
patients with accessory pathway conduction.
Cardiac arrest with pulseless VT or VF ( after
defibrillation and epinephrine )
hemodinamically stable VT
polymorphic VT
Wide-complex tachycardia of uncertain origin
AMIODARONE
DOSIS & CARA PEMBERIAN :
Dedicated to mykynaocca
Dedicated to mykynaocca
VASOPRESSIN
INDIKASI :
Shock-refractory VF ( II b)
Buffer agent
CO2 generated, during CPR when the transport of CO2 to and
from the lung is
decreased
INDIKASI :
Tissue acidosis resulting acidemia during cardiac arrest and
CPR, it depends on the duration of cardiac arrest and the level
of blood flow during CPR
DOSIS & CARA PEMBERIAN :
1 mEq/kg, I V bolus as initial dose
Give half dose every 10 minutes.
Check acid base status with blood gas analysis
May be administered by continuous infusion: use 5%
NaHCO3 solution
HATI HATI :
PCO2 should be emphasized
Negative inotropic
Hypernatremia and hyperosmolality
Dedicated to mykynaocca
DOPAMINE
Low dose (1-2 microgram/kg/min) : stimulate
dopaminergic receptors to produce cerebral, renal and
mesenteric vasodilation but venous tone is increase
INDIKASI :
Significant hypotension in the absent of
hypovolemia
HATI HATI :
Increased HR may induce arrhythmia
Even at low doses can exacerbate pulmonary congestion and
compromise cardiac
output
Nausea and vomiting are frequent side effects especially in high
dose
Cutaneous tissue necrosis if extravasation
Inactivated in alkaline pH; do not added to solution containing
sodium bicarbonate
Aminophyline, phenytoin and sodium bicarbonate can be
administered over a short
period through the same venous catheter.
DOBUTAMINE Dedicated to mykynaocca
Inotropic effect ; increases cardiac output
Decrease peripheral vascular resistance
Less induces tachycardia than dopamine or isoproterenol
Increase renal and mesenteric blood flow by increasing
cardiac output
Combination with Dopamine
INDIKASI :
Pulmonary congestion with low cardiac output
Hypotensive patients with pulmonary congestion
Left ventricular dysfunction that can not tolerate vasodilators
HATI HATI :
May cause tachycardia, arrhythmia, fluctuation in BP
Can provoke myocardial ischemia
MORPHIN SULPHATE Dedicated to mykynaocca
Reduce anxiety
Reduce pain and ischemia
Increase venous capacitance
Decrease systemic vascular resistance
Lead to reduced oxygen demands, less ischemia and
infarct extension
INDIKASI :
o Pain and anxiety associated with AMI
o Acute cardiogenic pulmonary edema
HATI HATI :
Respiratory depressant
Excessive narcosis can be reverse by : Naloxone ( 0.4
0.8 mg )
Hypotension and inappropriate heart rate response
Dedicated to mykynaocca
NITROGLYCERIN
Decrease the pain of ischemia
Increase venous dilation
Decrease venous blood return to the heart
Decrease preload and oxygen consumption
Dilates coronary arteries
Increase cardiac collateral flow
HATI HATI :
Extreme caution if systolic < 90 mmHg.
MAP decreases to 10% if the patient normotensive, 30%
if the patient
hypertensive.
Headache, blood pressure drop, syncope, tachycardia.
Right ventricular infarction
Dedicated to mykynaocca
ASPIRIN
Anti-platelet aggregation
Block the formation of thromboxane A2
Reduce overall mortality from acute MI
Reduce nonfatal reinfarction
Reduce nonfatal stroke
KAPAN DIBERIKAN :
As soon as possible !
Standard therapy for all patients with new pain
suggestive of acute M I
Give within minutes of arrival
DOSIS & CARA PEMBERIAN :
160 320 mg tablet, as soon as possible
Emergency or pre-hospital
Dedicated to mykynaocca
RKP / CPR
Dedicated to mykynaocca
CPR
|
pijat jantung 100 x pm
nafas 12 x pm atau
sinkronisasi 15:2
(satu atau dua penolong)
|
pasang monitor ECG
siap DC-shock
| |
VF/VT Asystole / PEA
| |
DC shock CPR terus 3 mnt
Dedicated to mykynaocca
DEFIBRILATION
DC shock
Un - Synchronized Synchronized
VF / VT Pulseless AF - SVT
Asystole-withness
kardioversi
Dedicated to mykynaocca
1. Mesin DC shock
2. EKG monitor
3. Jelly elektrode
4. Alat / obat resusitasi
5. Oksigen
6. Peralatan suction dengan
kateter suction
Dedicated to mykynaocca
CPR 3 mnt | |
bradycardia normal
atropin 1-1-1 sp 3 mg / obat klasDedicated to mykynaocca
Dedicated to mykynaocca
Cardiac arrest =
carotis (-)
Asystole
= ECG flat,
tak ada gelombang
UNshockable
CPR + adrenalin
(+atropin?)
ROSC < 10%
( Recovery of
Spontaneous
Circulation )
Dedicated to mykynaocca
PEA =
EMD
ada gelombang mirip ECG
normal
TETAPI nadi carotis tidak teraba
terapi sama seperti Asystole
P-ulseless E-lectro
E-lectrical M-echanical
A-ctivity D-issociation
VT / Ventricular Tachycardia
|
| |
carotis (+) carotis (-)
Lidocain
DC shock
1 mg/kg iv
200 Joules
cepat
Dedicated to mykynaocca
Dedicated to mykynaocca
VF / VT
pulseless
Bentuk gelombang khas
shockable, harus segera DC-shock
CPR menunggu DC-shock, CPR saja sukar ROSC
DC-shock < 5 mnt bisa mencapai > 50% ROSC
tanpa DC-shock akan memburuk jadi asystole
Dedicated to mykynaocca
Dedicated to mykynaocca
DC shock 200
ROSC
Joules
| |
masih VF/VT ROSC
ROSC carotis (+)
| |
200/300 JoulesROSC pertahankan
oksigenasi
| pertahankan
tensi
CPR 1 menit, intubasi,
masih iv line, adrenalin 1 mg
VF/VT
intravena, intra-trachea, intra-osseus
|
RESUME
DC shock 200
CPR 1- menit,
200/300 - 360
Joules intubasi,
iv line, adrenalin 1 mg
ROSC
|
masih VF/VT
ROSC
|
DRUGS
Hipoksia
4H Hipovolemia
Hiperkalemia
Hipotermia
Tamponade jantung
Tension
4T pneumothorax
Thromboemboli
paru
Toxic overdose
MA B-block, Ca-block
Digitalis, Tricyclic
AD
Dedicated to mykynaocca
GAGAL NAFAS
Dedicated to mykynaocca
GAGAL NAPAS
Penyebab :
1. ARDS
2. Asma
3. COPD
oo
Dedicated to mykynaocca
VENTILATOR
Dedicated to mykynaocca
Ventilator ~ ventilasi
Ventilasi = keluar masuknya udara dari atmosfer ke alveolus
Ventilator = menghantarkan (delivery) udara
udara/gas
/gas TEKANAN
POSITIF ke dalam paru
Ventilasi semenit = TV x RR (frekuensi
(frekuensi nafas)
nafas )
TV = 5-7 cc/kgBB
cc/ kgBB
RR = 10 12 kali/menit
kali/ menit
TUJUAN FISIOLOGIS
Indications for
Mechanical Ventilation
Oxygenation abnormalities
Refractory hypoxemia
Need for positive end-
expiratory pressure (PEEP)
Excessive work of
breathing
Dedicated to mykynaocca
Continuous
Continuous Positive
Positive Airway
Airway Pressure
Pressure
(CPAP)
(CPAP)
No
No machine
machine breaths
breaths delivered
delivered
Allows
Allows spontaneous
spontaneous breathing
breathing atat elevated
elevated baseline
baseline
pressure
pressure
Patient
Patient controls
controls rate
rate and
and tidal
tidal volume
volume
Assist-Control
Assist-Control Dedicated to mykynaocca
Ventilation
Volume
Volume or
or time-cycled
time-cycled breaths
breaths + + minimal
minimal ventilator
ventilator rate
rate
Additional
Additional breaths
breaths delivered
delivered with
with inspiratory
inspiratory effort
effort
Advantages:
Advantages: reduced
reduced work
work ofof breathing;
breathing; allows
allows patient
patient
to
to modify
modify minute
minute ventilation
ventilation
Disadvantages:
Disadvantages: potential
potential adverse
adverse hemodynamic
hemodynamic effects
effects
or
or inappropriate
inappropriate hyperventilation
hyperventilation
Pressure-Support
Pressure-Support
Ventilation
Ventilation
Pressure assist during spontaneous inspiration with flow-cycled
breath
Pressure assist continues until inspiratory effort decreases
Delivered tidal volume dependent on inspiratory effort and
resistance/compliance of
lung/thorax
Dedicated to mykynaocca
Pressure-Support Ventilation
Potential
Potential advantages
advantages
Patient
Patient comfort
comfort
Decreased
Decreased work
work of
of breathing
breathing
May
May enhance
enhance patient-ventilator
patient-ventilator synchrony
synchrony
Used
Used with
with SIMV
SIMV to
to support
support spontaneous
spontaneous breaths
breaths
Pressure-Support Ventilation
Potential
Potential disadvantages
disadvantages
Variable
Variable tidal
tidal volume
volume ifif pulmonary
pulmonary resistance/compliance
resistance/compliance
changes
changes rapidly
rapidly
If
If sole
sole mode
mode of
of ventilation,
ventilation, apnea
apnea alarm
alarm mode
mode may
may be
be only
only
backup
backup
Gas
Gas leak
leak from
from circuit
circuit may
may interfere
interfere with
with cycling
cycling
Dedicated to mykynaocca
Volume
Volume oror time-cycled
time-cycled breaths
breaths at
at a
a preset
preset rate
rate
Additional
Additional spontaneous
spontaneous breaths
breaths at
at tidal
tidal volume
volume and
and
rate
rate determined
determined byby patient
patient
Used
Used with
with pressure
pressure support
support
Potential
Potential advantages
advantages
More
More comfortable
comfortable for
for some
some patients
patients
Less
Less hemodynamic
hemodynamic effects
effects
Potential
Potential disadvantages
disadvantages
Increased
Increased work
work of
of breathing
breathing
ntrolled Mechanical Ventilation
Preset rate with volume or time-cycled breaths
No patient interaction with ventilator
Advantages: rests muscles of respiration
Disadvantages: requires sedation/neuro-muscular
blockade, potential adverse hemodynamic effects
Dedicated to mykynaocca
Inspiratory Time: Expiratory Time Relationship (I:E ratio)
Spontaneous
Spontaneous breathing
breathing I:E
I:E =
= 1:2
1:2
Inspiratory
Inspiratory time
time determinants
determinants with
with volume
volume breaths
breaths
Tidal
Tidal volume
volume
Gas
Gas flow
flow rate
rate
Respiratory
Respiratory rate
rate
Inspiratory
Inspiratory pause
pause
Expiratory
Expiratory time
time passively
passively determined
determined
Expiratory
Expiratory time
time too
too short
short for
for exhalation
exhalation
Breath
Breath stacking
stacking
Auto-PEEP
Auto-PEEP
Reduce
Reduce auto-PEEP
auto-PEEP by by shortening
shortening inspiratory
inspiratory time
time
Decrease
Decrease respiratory
respiratory rate
rate
Decrease
Decrease tidal
tidal volume
volume
Increase
Increase gas
gas flow
flow rate
rate
Dedicated to mykynaocca
Permissive
Hypercapnia
Acceptance
Acceptance of
of an
an elevated
elevated PaCO
PaCO22,, e.g.,
e.g., lower
lower tidal
tidal volume
volume
to
to reduce
reduce peak
peak airway
airway pressure
pressure
Contraindicated
Contraindicated with
with increased
increased intracranial
intracranial pressure
pressure
Consider
Consider in
in severe
severe asthma
asthma and
and ARDS
ARDS
Critical
Critical care
care consultation
consultation advised
advised
Auto-PEEP
Auto-PEEP
Can
Can be
be measured
measured on on some
some ventilators
ventilators
Increases
Increases peak,
peak, plateau,
plateau, and
and mean
mean airway
airway pressures
pressures
Potential
Potential harmful
harmful physiologic
physiologic effects
effects
Dedicated to mykynaocca