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GAWAT DARURAT

RESPIRASI

dr. Mirsyam Ratri Wiratmoko, Sp.P, FCCP, FAPSR

Fakultas Kedokteran dan Kesehatan


Universitas Muhammadiyah Jakarta S
ANATOMI

www.medicinenet.com
www.medicinenet.com
Levitzky. Pulmonary physiology.
2007.
Bronchial Tree
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Ernst. Introduction to bronchoscopy.


2007
www.medicinenet.com
RESPIRASI

§  Ventilasi

§  Difusi

§  Perfusi
VENTILASI

Peristiwa masuk dan keluar


udara ke dalam paru
~ Inspirasi
~ Ekspirasi
VENTILASI
q  Inspirasi: aktif karena konstraksi
otot-otot pernapasan

q  Ekspirasi: pasif karena elastik recoil


paru (daya elastisitas paru)
DIFUSI

Peristiwa perpindahan:
S O2 dari alveol ke kapiler dan
S CO2 dari kapiler ke alveol
www.medicinenet.com/
Perfusi

Levitzky. Pulmonary physiology.


2007.
Gawat Darurat Respirasi

S  Kelainan sistem respirasi yang membahayakan jiwa

S  Kegawatdaruratan respirasi:
S  Haemoptisis
S  Pneumotoraks
S  Serangan asma
S  Terapi oksigen
HEMOPTISIS

S
Istilah hemoptisis

Ekspektorasi darah:
S  Perdarahan pada saluran napas di bawah laring,
atau
S  Perdarahan yg keluar ke saluran napas di bawah
laring.
Etiologi

S  Kelainan Cor : stenosis mitral, endokarditis trikuspid


S  Infeksi : tuberkulosis, necrotizing pneumonia
(Staphyllococcus, Klebsiella, Legionella), jamur, parasit
& virus.
S  Kelainan paru seperti bronkitis, bronkiektasis, emboli
paru, kistik fibrosis, emfisema bulosa
S  Neoplasma : kanker paru, adenoma bronkial, tumor
metastasis
S  Trauma : jejas toraks, ruptur bronkus, emboli lemak
Etiologi

S  Kelainan pembuluh darah : hipertensi pulmoner, malformasi


arterivena, aneurisma aorta
S  Kelainan hematologis : disfungsi trombosit, trombositopenia,
disseminated intravascular coagulation
S  Iatrogenik : bronkoskopi, biopsi paru, kateterisasi Swan-Ganz,
limfangiografi
S  Kelainan sistemik : sindrom Goodpasture, idiopathic pulmonary
hemosiderosis, systemic lupus erithematosus, vaskulitis (granulomatosis
Wegener, purpura Henoch-Schoenlein, sindrom Chrug-Strauss)
S  Obat/toksin : aspirin, antikoagulan, penisilamin, kokain
S  Lain-lain : endometriosis, bronkolitiasis, fistula bronkopleura,
benda asing, hemoptisis kriptogenik, amiloidosis
Kriteria hemoptisis

S  Berbagai literatur bervariasi


  Bleeding rate 100 – 1000/24 jam

1.  Hemoptisis ringan : < 25 cc/24 jam

2.  Hemoptisis berat : 25 – 250 cc/24 jam

3.  Hemoptisis masif


Hemoptisis Masif

RSUP Persahabatan:

•  Batuk darah sedikitnya 600 mL /24 jam

•  Batuk darah < 600 mL/24 jam, tapi lebih dari 250 mL/24
jam, Hb < 10 g% dan masih terus berlangsung

•  Batuk darah < 600 mL/24 jam, tapi lebih dari 250 mL/24
jam, Hb > 10 g% dalam 48 jam belum berhenti.
Diagnosis Hemoptisis

S  Anamnesis teliti
Bedakan dengan hematemesis,
epistaksis dan perdarahan gusi

S  Pemeriksaan Fisik
Selain toraks, periksa organ lain THT,
abdomen dll
Hemoptisis vs hematemesis

Beda Hemoptisis Hematemesis


Gejala Diikuti dengan batuk atau mungkin Dapat didahului dengan mual
didahului suara seperti berkumur

Warna Merah segar dan berbusa Merah gelap atau hitam

Konsistensi Dapat bercampur dahak Dapat bercampur dengan makanan

PH Basa Asam
LABORATORIUM

S  Darah rutin : Hb, leko, Ht

S  Faal hemostasis

S  Sputum BTA, MO & jamur

S  Sitologi sputum
RADIOLOGIS

S  Foto toraks PA dan lateral

S  CT Scan toraks
Manajemen hemoptisis

Tujuan:

™  Cegah asfiksia

™  Lokalisir sumber perdarahan

™  Hentikan perdarahan

™  Cari sebab perdarahan (etiologi)

™  Terapi kausal
Batuk darah

Penatalaksanaan konservatif

Observasi dlm 24 jam

Ringan Berat Masif

Terapi sesuai diagnosis BDMO/Bedah cito Embolisasi


Penatalaksanaan Batuk Darah

1 Pembebasan jalan napas & stabilisasi:


™  Tenangkan dan istirahat (tirah baring), jangan takut
membatukkan darah

™  Jaga potensi jalan napas → suction, bronkoskopi

™  Resusitasi cairan (kristaloid / koloid)


Pembebasan jalan napas & stabilisasi:

S  Hb < 10 g/dL, Ht↓ < 25–30%, masih berlangsung: transfusi


darah

S  Hemostatik (kontroversial): as. tranexamat, karbazokrom, Vit


K, Vit C

S  Gelisah → sedasi ringan, batuk eksesif → penekan batuk

S  Faal hemostasis → koreksi


Tindakan saat hemoptisis

§  KU dan refleks batuk:


•  Baik → duduk, pimpin batuk
•  Berat, refleks batuk tidak adekuat → Trendelenberg
ringan, lateral dekubitus sisi sakit, intubasi dg ETT
> 7,5
§  Gagal napas → ventilator
2 Lokalisir dan cari sumber perdarahan

Setelah stabil lokalisasi


sumber

Ro PA dan lateral
CT scan toraks (+ kontras)
Bronkial angiografi
Bronkoskop serat optik
Bronkoskop rigid
3 Terapi Spesifik

Tujuan: hentikan & cegah berulang


Dengan bronkoskop (rigid / BSOL)
S  Bilas NaCl 0,9% dingin → vasokonstriksi

S  Bilas epinefrin (1:20.000)

S  Trombin, trombin – fibrinogen

S  Tamponade endobronkial (kateter balon)

S  Koagulasi laser atau elektrokauter pada lesi endobronkial


PNEUMOTORAKS

S
Pendahuluan

S  1803, pneumotoraks pertama kali diperkenalkan oleh


Itard (murid Laennec).

S  1819, Laennec memberikan gambaran klinis


pneumotoraks.

Henry M. BTS Guidelines for the


management of spontaneous
pneumothorax . Thorax 2003; 58:
S  Insidens pneumotoraks spontan primer
S  laki-laki 18-28/100.000/tahun
S  perempuan 1,2-6/100.000/tahun.

S  Angka kematian
S  laki-laki 1,26/juta/tahun
S  perempuan 0,62/juta/tahun

Henry M. BTS Guidelines for the


management of spontaneous
pneumothorax . Thorax 2003; 58:
S  Pneumotoraks sering terjadi pada
S  laki-laki
S  Usia 10-34 tahun
S  berbadan kurus dan tinggi
S  Perokok

Henry M. BTS Guidelines for the


management of spontaneous
pneumothorax . Thorax 2003; 58:
Definisi

S  Udara di rongga pleura

S  Pneumotoraks diklasifikasikan sebagai


S  Pneumotoraks spontan
S  Trauma
S  Iatrogenik.

Sahn SA. Spontaneous


pneumothorax. N Engl J Med 2000;
342: 868-74.
S  Pneumotoraks spontan primer terjadi pada pasien tanpa
kelainan klinis penyakit paru

S  Pneumotoraks spontan sekunder merupakan kompllikasi


penyakit paru yang sudah ada sebelumnya.

Sahn SA. Spontaneous


pneumothorax . N Engl J Med 2000;
342: 868-74.
S  Pneumotoraks iatrogenik disebabkan oleh komplikasi
tindakan intervensi diagnostik atau terapi.

S  Pneumotoraks trauma disebabkan oleh trauma pada dada


baik tumpul maupun tajam

Sahn SA. Spontaneous


pneumothorax . N Engl J Med 2000;
342: 868-74.
Etiologi

S  Spontan primer S  Spontan sekunder


S  Bulla subpleura pada S  PPOK
76-100% VATS dan S  Pneumocystis carinii
torakotomi pneumonia (PCP)

Sahn SA. Spontaneous


pneumothorax . N Engl J Med 2000;
342: 868-74.
S  Spontan primer S  Spontan sekunder
S  degradasi serabut S  Emfisema
elastik paru S  Pe é Palv
S  Bulla S  Robekan p. parietal
S  Pe é Palv S  Robekan p. viseral :
S  Robekan p. parietal PCP

Sahn SA. Spontaneous


pneumothorax . N Engl J Med 2000;
342: 868-74.
Tekanan alveolar meningkat

Robekan dinding alveoli

Udara bocor keluar

Intertisial paru

Septa lobuler
Perifer Sentral
↓ ↓
Bulla Pneumomediastinum

Distensi

Patofisiologi
Pecah

Pneumotoraks

Sahn SA. Spontaneous pneumothorax . N Engl J Med 2000; 342: 868-74.


ANAMNESIS

S  Spontan primer S  Spontan sekunder


S  Istirahat. S  Sesak napas selalu
S  tiba-tiba sesak napas ada, biasanya berat
dan nyeri dada S  Semua pasien
pleuritik ipsilateral. mengalami nyeri dada
S  Nyeri dada bisa ipsilateral.
menghilang setelah 24 S  Gejala tidak
jam menghilang atau
berkurang pada
Sahn SA. Spontaneous
pneumotoraks
pneumothorax . N Engl J Med 2000;
342: 868-74.
spontan sekunder.
Tension pneumotoraks

™ Mekanisme katup 1 arah


™ Inspirasi udara masuk, ekspirasi tidak dapat
berbalik
™ Tekanan intrapleural melebihi tekanan atmosfir
saat inspirasi maupun ekspirasi
™ Kompresi mediastinum menurunkan cardiac
output shg berkurangnya venous return
TENSION PNEUMOTORAKS

Ó  Gejala pneumotoraks

Ó  Gejala kompresi pada jantung

Ó  Gejala hipoksia otak


PEMERIKSAAN FISIK PARU

S  Inspeksi: - statis : asimetris, bagian yg


sakit cembung
- dinamis: yg sakit tertinggal
S  Palpasi: - sela iga melebar
- fremitus melemah
S  Perkusi: - hipersonor
S  Auskultasi: - suara napas melemah - hilang

Sahn SA. Spontaneous


pneumothorax . N Engl J Med 2000;
342: 868-74.
PEMERIKSAAN RADIOLOGIS

Foto Rö toraks PA:


S  Garis kuncup/kolaps paru (halus)
S  Bayangan radiolusen/avaskular
S  Kolaps paru
S  Pendorongan mediastinum

Sahn SA. Spontaneous


pneumothorax . N Engl J Med 2000;
342: 868-74.
Tension Pneumotoraks
Needle Thoracosentesis
PENATALAKSANAAN UMUM

•  Mengeluarkan udara dari rongga pleura:


•  Dekompresi
•  WSD

•  Mencegah timbulnya pneumotoraks ulang

Sahn SA. Spontaneous


pneumothorax . N Engl J Med 2000;
342: 868-74.
Trocar chest tube (conventional)
Operative tube thoracostomy
Prosedur trocar tube
thoracostomy (inner trocar)

Light RW. Chest tubes. In: Light RW,


ed. Pleural diseases. 2001.p.378-90.
Lokasi
ICS 5
Mid axillar line (MAL)

Lateral sites: medial axillar


line

Sahn SA. Spontaneous


pneumothorax . N Engl J Med
2000; 342: 868-74.
•  Sistem drainage yang menjamin
tekanan intra pleura tetap
negatif
•  Ujung drain harus selalu
terendam
•  Seluruh pipa dan botol harus
steril
•  Cairan antiseptik: betadin dalam
Nacl 0,9%
Light RW. Chest tubes. In: Light RW,
ed. Pleural diseases. 2001.p.378-90.
Indikasi
™ Pneumotoraks
sederhana

™ Hidro/
piopneumotoraks

™ Suction
Light RW. Chest tubes. In: Light RW, ed. Pleural diseases. 2001.p.378-90.
Three bottle system

3 2 1

3 2 1
WSD

Selang WSD

Botol
WATER SEALED DRAINAGE (WSD)

Empat hal yang harus dinilai :

S  Undulasi

S  Bubbles (gelembung)

S  Produksi cairan

S  Warna cairan
ASMA AKUT

S
Definisi

S  Asma: inflamasi saluran napas kronik yg


melibatkan banyak sel.
S  Inflamasi kronik disertai dg saluran napas yg
hiperesponsif menyebabkan kejadian:
S  mengi,
S  sesak napas,
S  chest tightness
S  batuk berulang

S  terutama pd malam dan pagi dini hari.


Definisi

Asma akut(serangan asma, asma eksaserbasi):


S  kejadian peningkatan sesak napas,
S  batuk,
S  mengi atau
S  chest tightness yg progresif atau kombinasi
gejala tersebut.
Apa yang terjadi saat Asma ?
Apa yang terjadi?

Saluran Asma ringan/


napas Asma berat
sedang
normal
Managing exacerbations in primary care
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?

ASSESS the PATIENT Risk factors for asthma-related death?


Severity of exacerbation?

MILD or MODERATE SEVERE


Talks in phrases, prefers Talks in words, sits hunched
LIFE-THREATENING
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) <90%
PEF >50% predicted or best PEF ≤50% predicted or best URGENT

START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg While waiting: give inhaled SABA
and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE


Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler
best or predicted technique, adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 5–7 days
(3-5 days for children)
Resources at home adequate
Follow up: within 2–7 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?

GINA 2015, Box 4-3 (1/7)


PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

LIFE-THREATENING
Drowsy, confused
or silent chest

URGENT

TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA and
ipratropium bromide, O2, systemic
corticosteroid

GINA 2015, Box 4-3 (2/7) ©


© Global
Global Initiative
Initiative for
for Asthma
Asthma
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE


Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) <90%
PEF >50% predicted or best PEF ≤50% predicted or best URGENT

TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA and
ipratropium bromide, O2, systemic
corticosteroid

GINA 2015, Box 4-3 (3/7) ©


© Global
Global Initiative
Initiative for
for Asthma
Asthma
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?

MILD or MODERATE SEVERE


Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) <90%
PEF >50% predicted or best PEF ≤50% predicted or best URGENT

START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING While waiting: give inhaled SABA and
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg ipratropium bromide, O2, systemic
Controlled oxygen (if available): target corticosteroid
saturation 93–95% (children: 94-98%)

GINA 2015, Box 4-3 (4/7) ©


© Global
Global Initiative
Initiative for
for Asthma
Asthma
START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA and
50 mg, children 1–2 mg/kg, max. 40 mg ipratropium bromide, O2, systemic
Controlled oxygen (if available): target corticosteroid
saturation 93–95% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE


Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate

GINA 2015, Box 4-3 (5/7) © Global Initiative for Asthma


START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA and
50 mg, children 1–2 mg/kg, max. 40 mg ipratropium bromide, O2, systemic
Controlled oxygen (if available): target corticosteroid
saturation 93–95% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE


Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 5–7 days
Resources at home adequate (3-5 days for children)
Follow up: within 2–7 days

GINA 2015, Box 4-3 (6/7) © Global Initiative for Asthma


START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
Prednisolone: adults 1 mg/kg, max. WORSENING
While waiting: give inhaled SABA
50 mg, children 1–2 mg/kg, max. 40 mg and ipratropium bromide, O2,
Controlled oxygen (if available): target systemic corticosteroid
saturation 93–95% (children: 94-98%)

CONTINUE TREATMENT with SABA as needed


WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)

IMPROVING

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE


Symptoms improved, not needing SABA Reliever: continue as needed
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique,
best or predicted adherence
Oxygen saturation >94% room air Prednisolone: continue, usually for 5–7 days
Resources at home adequate (3-5 days for children)
Follow up: within 2–7 days

FOLLOW UP
Reliever: reduce to as-needed
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?

GINA 2015, Box 4-3 (7/7) © Global Initiative for Asthma


Managing exacerbations in acute care settings

INITIAL ASSESSMENT Are any of the following present?


A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest

NO
YES

Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation

MILD or MODERATE SEVERE


Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best

Short-acting beta2-agonists Short-acting beta2-agonists


Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 93–95% (children 94-98%) saturation 93–95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat as


severe and re-aassess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY


MEASURE LUNG FUNCTION
in all patients one hour after initial treatment

FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or


personal best and symptoms improved personal best,or lack of clinical response
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning and reassess frequently

GINA 2015, Box 4-4 (1/4)


INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest

NO
YES

Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation

MILD or MODERATE SEVERE


Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best

GINA 2015, Box 4-4 (2/4) © Global Initiative for Asthma


MILD or MODERATE SEVERE
Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best

Short-acting beta2-agonists Short-acting beta2-agonists


Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 93–95% (children 94-98%) saturation 93–95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

GINA 2015, Box 4-4 (3/4)


Short-acting beta2-agonists Short-acting beta2-agonists
Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 93–95% (children 94-98%) saturation 93–95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS

If continuing deterioration, treat as


severe and re-assess for ICU

ASSESS CLINICAL PROGRESS FREQUENTLY


MEASURE LUNG FUNCTION
in all patients one hour after initial treatment

FEV1 or PEF <60% of predicted or


FEV1 or PEF 60-80% of predicted or
personal best,or lack of clinical response
personal best and symptoms improved
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning
and reassess frequently

GINA 2015, Box 4-4 (4/4) © Global Initiative for Asthma


Terapi Oksigen

S
Terapi Oksigen

S  Pemberian oksigen tambahan untuk


koreksi atau mencegah terjadinya
hipoksemia.

Pierce LNB. Guide to: mechanical


ventilation and intensive respiratory
care. Philadelphia: WB Sauders;
Oxygen = obat
™  Dosis

™  Dosis toksik

™  Lama pemberian

™  Indikasi

™  Jenis

™  Kontraindikasi

™  Efek samping

http://balabasnia.narod.ru/optimal/
Tujuan terapi oksigen
(Dosis)

Meningkatkan :

S  PaO2 > 60 mmHg, atau

S  Saturasi O2 > 90 %

dengan memberikan dosis O2 terendah

Pierce LNB. Guide to: mechanical


ventilation and intensive respiratory
care. Philadelphia: WB Sauders;
Indikasi:

S  Koreksi hipoksemia
S  Perbaikan oksigenasi
S  Meningkatkan reabsorbsi pada rongga
badan.

Pierce LNB. Guide to: mechanical


ventilation and intensive respiratory
care. Philadelphia: WB Sauders;
Efek samping

S  Hipoventilasi dan CO narcosis

S  Absorption atelectasis

S  Pulmonary oxygen toxicity

S  Retrolental fibroplasia

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders;
1995.
Pemberian Terapi O2

1. Low flow devices


1. Kanul hidung
2. Masker : - simpel
- rebreathing
- nonrebreathing

2. High flow devices


1. Venturi
2. CPAP
KANUL HIDUNG

Ø  Suatu pipa plastik lunak, ujung buntu à dikaitkan ke


telinga & bawah leher

Ø  Digunakan bayi, anak, dewasa

Ø  Kecepatan aliran 1-5 L/mnt, FiO2 0,24-0,40

Ø  Komplikasi : kerusakan kulit, kekeringan &


ketidaknyamanan
S  Untung:

Kanul hidung S  Murah


S  Sederhana & nyaman
S  Dpt makan dan minum
S  PPOK
S  Dpt menggunakan pelembab

S  Rugi:
S  Luka akibat tekanan
S  Mukosa hidung kering &
iritasi

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders;
1995.
MASKER

S  Masker digunakan à level O2 yang diberikan


lebih tinggi dibandingkan kanul hidung

S  Perangkat dari plastik ringan menutupi hidung

& mulut
Masker Simpel

Ø  Masker à digunakan pada wajah,

Ø  Masker à tidak menyebabkan tekanan yang

menyakitkan wajah, tulang pipi

Ø  Kecepatan aliran 5-8 L/mnt, FiO2 0,4 – 0,6


S  Untung:
S  Sederhana, ringan
S  Dapat dilembabkan
S  FiO2 sampai 0,6

S  Rugi:
S  Tdk nyaman bagi
pembicara yg senang
menyingkirkan masker
S  Sulit buang dahak dan
makan
S  Tdk nyaman pd trauma
wajah
S  Mata kering/iritasi

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders;
1995.
MASKER RESERVOIR

2 tipe masker reservoir :


- Rebreathing
- Nonrebreathing
Masker à ringan à plastik transparan dengan
reservoir dibawah dagu
Kecepatan aliran 7 –15 L/mnt
Perbedaan kedua masker à katup

Katup / klep masker non rebreathing à pada


ekspirasi udara keluar à lubang samping katup
dan reservoir à inspirasi hanya O2 yang dihisap
dari reservoir
Masker Rebreathing

S  Untung S  Rugi

S  Aliran yg kurang: rebreathing


S  FiO2 sampai > 0,6 CO2
S  Oksigen ekspirasi dr dead S  Claustrophobia
space terjaga
S  Tdk bisa makan, minum &
buang dahak

S  15 L/m < sesak nps berat

S  Mata kering/iritasi
Pierce LNB. Guide to: mechanical
ventilation and intensive respiratory
care. Philadelphia: WB Sauders;
Tanpa klep

Tanpa klep
Masker Nonrebreathing

S  Untung S  Rugi
S  FiO2 > 0,8 S  Tdk nyaman
S  Claustrophobia
S  Tdk bisa makan, minum &
buang dahak
S  Mata kering/iritasi
S  Katup masker lengket

Pierce LNB. Guide to: mechanical


ventilation and intensive respiratory
care. Philadelphia: WB Sauders;
Masker

Klep 1 Klep 2

Reservoir

Selang O2
High flow devices

Venturi
S  Konsentrasi oksigen à dalam masker dengan
udara didalamnya à oksigen diberikan
dengan angka pasti
S  Alat digunakan nonaerosol à persen tetap
(24%, 28%, 31%, 36%, 40%, 50%)
Pemilihan jenis alat berdasarkan FiO2
No. Jenis alat Aliran (L/m) FiO2
1. Kanul hidung 1 0,24
2 0,28
3 0,32
4 0,36
5 0,40
6 0,44
2. Simple Mask 5-6 0,4
6-7 0,5
7-8 0,6
3. Rebreathing Mask 7 0,65
8-15 0,7-0,8
4. Nonrebreathing Mask Atur reservoir jgn 0,85-1,0
kempes

Pierce LNB. Guide to: mechanical ventilation and intensive respiratory care. Philadelphia: WB Sauders;
1995.
CONTINOUS POSITIVE AIRWAY
PRESSURE (CPAP)

Ø  Sistem CPAP à Mengalirkan udara terus


menerus melalui flow meter à masker à alat
dengan tekanan 2,5 –20 cm H2O

Ø  Masker dipasang diwajah dengan pengikat


kepala
CPAP
PEMBERIAN O2 DIRUMAH

Perlu diperhatikan pada pemberian O2 antara lain :

1. Indikasi

2. Alat yang digunakan

3. Cara pemberian

4. Tehnik pemberian
Silinder

•  Bentuk besar dengan ukuran 240-622 liter


•  Lama pemberian 2 - 5,5 jam bila digunakan
dengan kecepatan aliran 2 liter/menit
•  Digunakan pada pasien yang tidak banyak
bergerak
•  Harga relatif murah
•  Diperlukan penggantian silinder
Sistem Oksigen Liquid (portable)

S  Ringan
S  Bila digunakan dengan kecepatan aliran 2
L/’ lama pemberian 7 hari
S  Dapat dibawa sambil berjalan
S  Harga > mahal
S  Dapat diisi ulang
Konsentrator

S  Mengambil udara ruangan,


memiliki sistem filtrasi
partikel besar, bakteri, gas
non O2
S  Menggunakan listrik
S  Tidak membutuhkan
pengisian ulang
Menentukan dosis oksigen
yang diberikan dengan rumus
150 + AaDO2
FiO2 = x 100% = ….%
760

AaDO2 = PA O2 - PaO2

PA O2 = (Patm - PH2O) xFiO2 - PaCO2 x 1.25


=(760 - 47) xFiO2- PaCO2 x 1.25

= 713 x FiO2 – PaCO2 x1,25

PaO2 nilai diambil dari hasil AGDA

PaCO2 nilai diambil dari hasil AGDA


Formula
1.  PAO2 = (713xFiO2) – (PaCO2 x 1.25)

2.  PaO2 = PaO2 target

PAO2 PAO2 new

PAO2 new = (PAO2 x PaO2 target)

PaO2

3. PAO2 new = (713xFiO2) – (PaCO2 x 1.25)

FiO2 = PAO2 new + (PaCO2 x 1.25)

713
KONSENTRASI OKSIGEN
BERDASARKAN ALAT YANG DIGUNAKAN

Alat yang digunakan O2 (l/mnt) FiO2

Kanula hidung 2 0,21-0,24


2 0,23-0,28
3 0,27-0,34
4 0,31-0,38
5-6 0,32-0,44
Venturi tergantung alat
Simpel 5-6 0,30-0,45
7-8 0,40-0,60
Rebreathing 7 0,35-0,75
10 0,65-1,00
Non rebreathing 4-10 0,40-1,00
Contoh Kasus-1

Seorang laki-laki 25 tahun datang ke IGD RS dengan keluhan


sesak napas. Dokter jaga merencanangkan pemeriksaan
analisis gas darah dengan hasil sbb :
pH : 7.245
PCO2 : 25.1
PO2 : 64.5
HCO3 : 21.5
Saturasi O2 : 93.7
Contoh kasus-2

Seorang perempuan 30 tahun datang ke IGD RS dengan


keluhan sesak napas. Dokter jaga memberikan terapi awal
oksigen nasal kanul 3 liter/m. dokter merencanangkan
pemeriksaan analisis gas darah dengan hasil sbb :
pH : 7.245
PCO2 : 30.1
PO2 : 58,7
HCO3 : 21.5
Saturasi O2 : 91.7
Theoretical FIO2 Via Nasal Cannula

lpm FIO2

1 0.24
2 0.28
3 0.32
4 0.36
5 0.40
6 0.44
Theoretical FIO2 Via Simple Mask, Partial
Rebreathing Mask and Nonrebreathing Mask

Mask lpm FIO2

Simple ≥5 0.40 - 0.60

Partial ≥8 ≥ 0.60
Rebreathing

Non ≥ 10 ≥ 0.80
Rebreathing

FIO2 : fraction of inspired oxygen ; Ipm : liters per


minute

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