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