Weaning ventilasi mekanis merupakan proses atau usaha untuk menurunkan dukungan ventilasi mekanis yang diterima pasien dari ventilator. Proses weaning atau penyapihan termasuk menurunkan dukungan ventilator, menilai respons pasien, dan ekstubasi pasien. Weaning dimulai sesaat setelah pasien terintubasi contohnya menurunkan fraksi O2 (FiO2) dari 100% ke 90% pasca intubasi. Oleh karena itu proses weaning menjadi kesatuan dengan stabilisasi airway pasien.
Kenapa kita perlu melakukan weaning pasien padahal lebih enak bagi pasien bila terpasang ventilasi mekanik? Pasien tidak perlu bersusah payah bernafas, sehingga kita fokus pada pengobatan penyakit pasien?
Jawabannya adalah semakin lama pasien memakai ventilasi mekanik maka semakin menurunkan motivasi pasien untuk bernafas mandiri. Dengan kata lain pasien bisa kehilangan kekuatan alaminya untuk bernafas. Sama seperti bayi yang tidak dilatih untuk berjalan, sampai besarpun tidak akan bisa berjalan.
Prinsip weaning:
- Weaning harus dilakukan sedini mungkin
- Pasien dikategorikan sebagai simple, difficult, dan prolonged weaning.
- Percobaan Spontaneous Breathing Trial (SBT) adalah percobaan (test) utama untuk menentukan apakah pasien dapat dilakukan ekstubasi atau tidak.
- SBT awal harus selama 30 menit dengan T-piece atau low level pressure support.
- Pasien yang gagal SBT diberikan ventilasi mode pressure support atau assist support.
Tim keperawatan mempunyai peran yang penting dalam menilai kesiapan pasien untuk dilakukan weaning, peran ini akan berlanjut sampai ekstubasi dan observasi post ekstubasi.
Kriteria kesiapan pasien yang akan dilakukan weaning.
| Penilaian Subjektif |
|---|
| Batuk yang cukup |
| Tidak mendapat terapi agen penghambat neuromuskuler |
| Tidak adanya sekresi trakea-brokial yang berlebih |
| Reversal penyebab yang mendasari gagal nafas |
| Tidak mendapat terapi sedasi terus menerus |
| Pengukuran objektif |
| Status kardiovaskular yang stabil |
| Denyut jantung ≤ 140/ menit |
| Tidak ada iskemia miocard aktif |
| Tingkat HB yang memadai (≥8gr/dL |
| Tekanan darah sistolik 90-160 mmHg |
| Tidak ada demam (suhu 36-38c) |
| Tidak ada atau dosis minimal vassopressor dan atau initropik (dosis < 5mikro dopamin/dobutamin) |
| Oksigensasi yang adekuat |
| Volume tidal >5mL/kg |
| Kapasitas vital >10 mL/kg |
| Upaya inspirasi yang baik |
| Frekuensinpernafasan ≤35x/mnt |
| PaO2 ≤60 dan PaCO2 ≤60 mmHg |
| Tekanan akhir ekspirasi positif (PEEP) ≤8cmH2O |
| Tidak ada asidosis respiratorik yang signifikan (pH ≥7.30) |
| Tekanan inspirasi maksimal(MIP) ≤-20 s/d -25 cmH2O |
| SatO2 >90% pada FIOW ≤0,4 (atau PaO2 |
| Indeks pernafasan dangkal cepat (frekuensi pernafasan/volume tidal) < 105 |
Resiko pasien tidak di lakukan weaning
- Meningkatnya resiko kejadian Ventilator-induced lung injury (VILI)
- Meningkatnya resiko kejadian Ventilator Aquired Pneumonia (VAP)
- Menurunnya motivasi pasien untuk bernafas mandiri
- Melemahnya otot pernafasan
- Prolong ventilator yang berdampak pada hospital longstay
Protokol Weaning Ventilasi Mekanik
[table “16” not found /]Cara melakukan weaning
- Menurunkan FiO2 secara bertahap dan pantau Saturasi pasien bila spO2 ≥ 95% maka FiO2 dapat diturunkan kembali. Bila ragu lakukan pemeriksaan gas darah untuk mengkonfirmasi PaO2
- Menurunkan Pressure support (Ps) dan pantau dari monitoring internal ventilasi mekanik (trend data) untuk mengetahui adekutnya Tidak volume dengan pressure support yang di berikan.
- Mengalihkan mode ventilasi mekanik dari Volume Control ke SIMV, SIMV ke SPN/CPAP
- Pada mode SPN/CPAP bila FiO2 sudah 40% dan Ps ≤ 4 cmH2O, lakukan SBT dengan t-piece selama 30-120 menit. Cara kedua dengan mode SPN/CPAP FiO2 40% dan Ps 0 cmH2O langsung dilakukan extubasi.
- SBT yang sukses, pada pasien dengan kesadaran dibawah GCS 8 atau pasien dengan leher pendek atau obesitas lakukan tes stridor dengan mengempiskan balon Ett, dan dengarkan adanya nafas stridor atau tidak.
- Pasien dengan SBT sukses lakukan ekstubasi.
Daftar Pustaka
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