7 anesthesi ventilation perfusion

8/12/2019 7 Anesthesi Ventilation Perfusion

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Departemen/SMF Anestesiologi dan Reanimasi

FK-USU/RSUP.H. ADAM MALIK

M E D A N

VENTILATION PERFUSION

RELATION SHIPS


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PROSES PERNAFASAN

Gabungan mekanisme yang berperandalam suplai oksigen keseluruh sel

dan eliminasi karbon dioksidaKOMPONEN YANG BERPERAN

Ventilasi

Difusi

Perfusi


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3 Processes:

1. Ventilation - movement of air in & out --depends on system of open (clear) airways

& movement of respiratory muscles,

primarily the diaphragm which is innervated

by the phrenic nerve.

2. Diffusion - exchange & transport gases(need perfusion/pulmonary circulation)

3. Perfusion


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HUBUNGAN VENTILASI/PERFUSI

1. Ventilasi : jumlah dari semua volume udara

yang diekshalasi dalam 1 menit

Minute Volume = VT X Frek. Nafas

Ventilasi Alveolar = Frek. Nafas x (VTVD)

DEAD SPACE

Non Respirasi (Anatomik Dead Space)

Non Perfusi (Alveolar Dead Space)

Physiological

Dead

Space


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VENTILASIJumlah udara / gas yang mengadakan

pertukaran dalam alveoli setiap menit

Dipengaruhi oleh :

Patensi jalan nafas

Posisi tubuh

Volume paruDead space

Shunting


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Patensi Jalan Nafas :obstruksi

Infeksi

tumor

Volume Paru :otot pernafasan

penyakit paru

space occupying lesiontekanan intra abdominal

nyeri, obat

Posisi Tubuh :tegak

terlentang

miring


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VENTILATION

Proses transport gas antara alveolus dan atsmosfir

Pertukaran gas ini akan berkurang pada ;

obstructive

restrictive

combined ventilation disordersContoh :

Laparotomi abdomen atas

COPD (Chronic Obstructive Pulmonary Disease)

Status Asthmaticus

CNS dan obat- obatan : sedation, intoxication

Neuromuscular : myasthenia gravis, muscle relaxant


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PERFUSIONAliran darah paru yang bertanggung jawab

membawa CO2 ke alveoli dan sebaliknya

membawa O2dari alveoli ke jantung

Perfusion disorder :

Pulmonary embolismSumbatan pada mikrosirkulasi paru

karena agregasi platelet dan granulosit :

septicemia

peritonitis

acute pancreatitis

Extra pulmonary : reduced CO pada gagal

jantung, atau pada kondisi syok


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Pori-poriKohn

Alveoli

Bronkiolus

respiratorius

Bronkiolusterminalis


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SIRKULASI PULMONER

Sifat :

Tekanan pembuluh darah rendah, MAP 8 - 15mmHg

Mudah mengembang (distensible)

Resistensi rendah

Dalam keadaan istirahat, perfusi pulmoner, sekitar

= 70 ml x 80 x / mnt = 5,6 L / mnt

Pintasan Fisiologis = jumlah darah yang melintasdari kanan ke kiri tanpa mendapat oksigenisasi dan

dekarboksilasi paru (sekitar 5 % curah jantung)


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The three-zone model of the lung. A :Upright position. B:Supine position.


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DiffusionTransport of gases between the alveoli and

(pulmonary) capillaries and eventually fromthe capillaries to the tissues

diffusion dependent on perfusion and thepartial pressure (pp) exerted by each gas (each

gas in a mixture of gases exerts a partial

pressure, a property determined by the

concentration of the gas)

gases diffuse from area of conc. (pp) to

conc. (pp)


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concentrationpp of gas

diffusion

CO2more soluble than O2, therefore

it diffuses faster


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MEMBRAN ALVEOLO-KAPILER: - adalah

permukaan antar alveoli dan endotel kapiler

- Tempat O2berdifusi dari

alveoli kekapiler darah

/CO2berdifusi

dari kapiler ke

alveol


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Factors Affecting Diffusion

surface area in the lung (e.g., lobectomy,atelectasis, emphysema)

thickness of alveolar-capillary membrane

(e.g., edema, pneumonia)

differences in partial pressure of gases on

either side

Characteristics of the gas (CO2diffuses

faster)


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PERTUKARAN GAS


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ALVEOLUS

KAPILER PARU

UDARA BEBAS:

PiO2 : 21% x 760 = 160 mmHg

PiCO2 : 0.04 % x 760 = 0.3 mmHg

PiN2 : 78.6 % x 760 = 597mmHg

PiH2O : 0.46 % x 760 = 3.5 mmHg N2 H2O

O2

PAO2:

104 mmHg

CO2

PACO2:

40 mmHg

O2

PvO2:40 mmHg

O2

PcO2: 100mmHg

CO2

PcCO2: 45mmHg

CO2

PcCO2: 40mmHg

PROSES DIFUSI

PAN2:

573 mmHg

PAH2O:

47 mmHg

PAO2PcO2

PaO2

Pulmonary Artery

Pulmonary Vein

Oxygenation


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VENTILASI

DIFUSIPERFUSI

Airway

Alveoli

Kapiler darah


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No VENTILASI

PERFUSI

Airway

Alveoli

Kapiler darahBlood flow

SHUNT UNIT (PERFUSIONWITHOUT VENTILATION)

Sumbatan


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SHUNT UNIT


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The distribution of / ratios for the whole lung (A ) and according to height (B) in the upright position.

Note that blood flow increases more rapidly than ventilation in dependent areas.

(Reproduced, with permission, from West JB: Ventilation/Blood Flow and Gas Exchange,3rd ed.

Blackwell, 1977.)


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SHUNTING

(Intrapulmonary Right-to-Left Shunt)

ANATOMICAL FUNCTIONAL

Bronchial

Pleural

Thabesian

CHD (Congenital Heart Disease)

Tumor Paru

Arteriovenous Anastomosis

Atelectasis

Pneumothorax

Hematothorax

Pleural effusion

Pulmonary edema

Pneumonia

Acute Respiratory

Failure (ARDS)


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SHUNT %

0

FiO2

PaO2

100

50%

20%

30%

10%2-3%

100

200

300

400

500

21 40 60 80


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DEAD SPACE

Volume udara yang di hirup dalamsatu kali bernafas yang tidak turut

berdifusi dalam alveolus

FUNCTIONAL DEAD SPACE

ANATOMICAL ALVEOLAR


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VENTILASI

NO PERFUSI

Airway

Alveoli

Kapiler darahNo Blood flow

DEAD SPACE UNIT

(VENTILATIONWITHOUT PERFUSION)


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DEAD SPACE UNIT


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ANATOMICALDEAD SPACE

ALVEOLARDEAD SPACE

PHYSIOLOGICAL

DEAD SPACE

VENOUS ADMIXTURE

(SHUNT)

V/Q =

V/Q > 1

V/Q = 1

V/Q < 1

V/Q = 0

Hubungan Ventilasi (V) dan Perfusi (Q)

TRAKEA

KAPILERPARU MECHANICAL

DEAD SPACE:

TUBE

CONNECTOR

ET CO2

BREATHING

CIRCUIT

NORMAL


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~0.8


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h


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Optimum gas exchange

requires:

Ventilation/perfusion match (high V/Q ratio)

In healthy lungs this ratio is close to 1:1

Perfusion greater in dependent areas of the

lung

Ventilation also greater in dependent areas of

the lung

Measure adequacy of V/Q match through ABGs


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V/Q mismatches

In areas where perfusion > ventilation,

a shuntexists. Blood bypasses the

alveoli without gas exchange occurring(e.g., pneumonia, atelectasis, tumor,

mucus plug)

All cause obstruction in the distal

airways, decreasing ventilation


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In areas where ventilation > perfusion,

dead spaceresults. The alveoli do not havean adequate blood supply for gas exchange

to occur (e.g., pulmonary emboli,

pulmonary infarct, cardiogenic shock).

In areas where both perfusion and

ventilation are limited or absent, a silentunitexists (e.g., pneumothorax, severe

ARDS).


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MEASURED

PARAMETERS

CALCULATED

PARAMETERS

Arterial Oxygen Tension (PaO2)

Arterial Carbon Dioxide Tension

(PaCO2)

Arterial Oxygen Saturation

(SaO2or SpO2)

Mixed Venous Oxygen Saturation

(SvO2)

Venous Oxygen Tension (PvO2)

Hemoglobin (Hgb)

Cardiac Output (CO)

Pulmonary Capillary Oxygen

Content (CcO2)

Arterial Oxygen Content (CaO2)

Venous Oxygen Content (CvO2)

Arterial-Venous Oxygen Content

Difference (Ca-vO2)

Oxygen Utilization Coefficient (OUC)

Oxygen Delivery Index (DO2I)

Oxygen Consumption Index (VO2I)

Intrapulmonary Shunt (Qs/Qt)

Cardiac Index (CI)

6 K i d


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Nervous Syst

Humoral

Local Control

6 Key steps in oxygen cascade

Oxygenation

Carrying capacity

Cardiac Output

Autoregulation

Distance

Mitochondria

Uptake in the Lung

Delivery

Organdistribution

Diffusion

Cellularuse

DO2

PaO2

SaO2- Ht

Flow rate -

O2

Haemoglobin

CaO2

Contraction

VO2

TISSUE OXYGEN TION


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Oksigen ditranspor ke jaringan

dalam 2 bentuk

Terlarut dalam plasma

Berikatan dengan hemoglobin


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OXYGEN DELIVERY

DO2 = oxygen deliveryVO2 = oxygen consumption

SaO2 = arterial oxygen saturation

SvO2 = mixed venous oxygen saturation

Q = cardiac outputHb = hemoglobin concentration

PaO2 = arterial oxygen tension

PvO2 = mixed venous oxygen tension

DO2 = CO X CaO2(ml / menit) (ml O2 / 100 ml Blood)

= 1000 ml O2 / menit

CaO2 = (SaO2 x Hb x 1,341) + (PaO2 x 0,0003)

= 20 ml O2 / 100 ml Blood


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Oxygen Content dalam

darah= Hb bound plus dissolved

CaO2= [Hb] x 1.34 x % saturation

+PO

2x 0.003 ml O

2/ dl / mm Hg


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Kurva Disosiasi Hemoglobin


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Oxygen Dissociation Curve

Karena pengikatan oksigen jarang menimbulkan

masalah, maka perhatian khusus diarahkan

terhadap pelepasan oksigen oleh Hb di jaringan.

Acidemia, hiperkarbia, dandemam akan

menggeser kurva disosiasi ke kanan sehingga akanmemperbaiki / mempermudah pelepasan oksigen

di jaringan


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O2Sat(%)

PO2(mm Hg)

100

50

75

25

10 30 50 70 9020 40 60 80 100

27, 50%

40, 75%

60, 90%100, 97%

Oxygen Dissociation Curve


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10 20 30 40 50 60 70 80 90 100

PO2(mm Hg)

O2Sat

(%)

100

80

60

40

20

flat portion of curve:large changes of PO2result in

very small changes in oxygensaturation or content.


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Hydrogen Ion


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Hydrogen Ion

BetterUnloading

Inhibited

Unloading


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Temperature


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Temperature


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GANGGUAN SISTEM PERNAFASAN & PENYEBAB


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TRAUMA

NARKOTIKA

DEPRESSANT / ANESTHETIC INFEKSI , PERDARAHAN

GUILLAIN BARRE

POLIOMYELITIS , POLINEUROSIS

MYASTHENIA GRAVIS

TETANUS

RELAXANT / CURARE

OTAK

SYARAF

OTOT

ALVEOLI RONGGA THORAX

FRACTURE COSTAE

PNEUMOTHORAX

HEMATOTHORAX

EDEMA PARU

ATELEKTASIS

GANGGUAN SISTEM PERNAFASAN & PENYEBAB

JALAN NAFAS

ASTHMABRONCHIALE


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7 anesthesi ventilation perfusion

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