Suction Oleh: Slamet Sumarno 251207.

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1 Suction Oleh: Slamet Sumarno 251207

2 Pengantar Suction adalah salah satu cara untuk membersihkan jalan nafas yang mengalami hambatan karena sputum, mukus atau skret sehingga jalan nafas menjadi bersih dan kebutuhan gas dapat terpenuhi. Suction harus dilakukan secara tepat, benar dan aman sehingga dilakukan dengan proses dan dianalisa tepat dilakukan suction.

3 TUJUAN: Mempertahankan jalan nafas yang bebas (hegienis).
Untuk membersihkan sekret pada pasien yang tidak mampu batuk.

4 Indikasi Pasien tidak mampu batuk :
neonatus, tracheatomi, indotracheal tube Pasien tidak mampu batuk efektif: Retensi skret, neonatus, gagal nafas. Membersihkan berfungsi tube.

5 Komplikasi Parengeal suction akan merangsang syaraf sympatis (N. vagus) menimbulkan aktif sympatik dan menyebabkan bradicardi dan henti jantung dan henti nafas ( vagal reflek).

6 Keterangan umum/Perhatian
Sekret yang menggangu jalan nafas harus segera dikeluarkan krn dapat menyebabkan gagal nafas. Digunakan tehnik aseptik dan alat steril. Penghisapan sekret harus dilakukan dengan prosedur yang tepat untuk mencegah infeksi, luka, spasme, udema serta perdarahan jalan nafas.

7 Keterangan umum/Perhatian
Lama penghisapan lendir tidak boleh lebih dari: dt untuk bayi dan anak dt untuk dewasa, Vacum presure: ,6 kPa ( mmHg) untuk bayi – 20 ( mmHg) untuk anak kPa ( mmHg untuk dewasa. Botol penampung sekret harus diisi dengan cairan aseptik kira-kira ¼ bagian dicatat selama 24 jam dan diganti.

8 Keterangan umum/Perhatian
Untuk menjegah bradikardi selama suction harus dilakukan pencegahan dengan pre suction pemberian oksigen pada pasien, Gunakan kateter suction seperti indotrache cube. Suction dapat menstimulasi batuk bila tidak ada gangguann Vagus dengan disertai batuk maka mobilisasi scret lebih mudah.

9 Suction pada bayi dan anak
Sebelum memberikan suction sebaiknya dibberikan Oksigenasi untuk memperbaiki Hypoksia, Inspirasi ooksigen pada gangguan nafas hanya meningkat k/l 10% pada bayi, hypoksia jangka pendek dapat menyebabkan Retinopathy (bayi prematur) (Robutan 1997)

10 Intervensi Vacum presure diberikan tidak terlalu tinggi tetapi cukup kuat untuk menarik mukus ke luar dengan intensitas antara 8-20 kPa ( mmHg). Kateter yg digunakan antara 6-8(french gange) FG. Ukuran 5 FG atau dibawahnya tidak efektif, ukuran >10 untuk anak dan dewasa >10Th Diameter kateter tidak digunakan 50% dari diameter jalan nafas.

11 Prosedur Terangkan prosedur yang akan dilakukan pada pasien.
Letakkan alat-alat disamping tempat tidur pasien. Jika mungkin buat posisi semi fowler. Cuci tangan anda dengan aseptik. Hidupkan sumber penghisap dengan tekanan sesuai kebutuhan. Ukur kateter sepanjang ujung hidung sampai telinga.

12 Membersihkan melalui mulut.
Hubungkan sumber penghisap dinding dengan penghisap logam. Masukkan penghisap logam kedalam mulut tanpa memberi tekanan penghisap, kemudian lakukan penghisapan sekret dengan hati-hati. Hindarkan mata pasien dari percikan sekret jalan nafas. Bersihkan kateter logam dengan larutan steril. Berikan oksigen pada pasien dan lakukan penghisapan lagi bila perlu.

13 Membersihkan memalui hidung.
Hubungkan sumber penghisap dengan kateter penghisap. Berikan pelicin pada ujung kateter penghisap. Masukkan kateter penghisap melalui lubang hidung atau dapat juga melalui mulut dengan hati-hati tanpa memberikan tekanan pada penghisap, kemudian lubang penghisap ditutup dan sekret dihisap sambil kateter ditarik perlahan-lahan. Bersihkan kateter penghisap dengan larutan steril. Berikan oksigen pada pasien dan lakukan pengisapan lagi bila perlu.

14 Untuk pasien dengan pipa entratrakea terpasang
Perlu 2 orang untuk penghisapan bila mungkin, terutama pada anak yang aktif. Satu memberikan oksigenasi. Tekan tombal alrm ventilator jika perlu. Lepaskan hubungan dengan sirkuit ventilator atau pipa humidifer jika pasien mempergunakan alat tersebut. Gunakan ballon pemompa dan beri oksigen 3-5 kali inflasi dengan konsentrasi F1O2: ………

15 = 10% lebih besar dari konsentrasi O2 yang digunakan untuk neonatus dengan berat badan kurang dari 3 kg. =100% untuk pasien lain kecuali ada ketentuan lain. Selama prosedur, jaga agar gerakan dada tetap adekuat dan jika diberikan ventilator jaga agar tetap dalam tekanan positif, Hindari tekanan yang berlebihan. Bila berat badan bayi kurang dari 2kg harus dipasang pengukur tekanan pada sirkuit.

16 Orang ke dua. melakukan penghisapan
Hidupkan penghisap dinding dengan tekanan sesuai kebutuhan. Pasang sarung tangan dan letakkan pengalas diatas dada pasien. Hubungkan penghisap dengan kateter penghisap dengan tangan kanan. Jaga agar kateter tetap steril. Masukkan kateter kedalam lumen pipa trakea dengan cepat sejauh mungkin tanpa dipaksa, dengan lubang kateter terbuka dalam keadaan tidak menghisap.

17 Lakukan penghisapan sekret dengan menutup lubang penghisap yang ada disamping.
Kateter penghisap ditarik perlahan-lahan untuk beberapa cm pertama, kemudian ditarik secara cepat sambil diputar (rotasi). Bila kateter sulit ditarik mungkin menempel pada dinding bronkus, buka lubang penghisap dan ulangi penghisapan dengan tekanan lebih rendah. Selama penghisapan pipa endotrakea dipegang dengan tangan kiri untuk mempertahankan posisi. Hubungkan pipa endotrakea dengan balon pemompa dan berikan oksigen.

18 Pada neonatus dengan berat badan kurang dari 3 kg konsentrasi O2 10% lebih tinggi dari yang sedang digunakan. Pada pasien yang lain berikan oksigen 100% kecuali ada intruksi khusus. Ulangi seluruh prosedur dengan tehnik yang sama sampai jalan nafas relatif bersih dari sekret. Selama penghisapan perhatikan warna kulit dan denyut nadi pasien. Bila terjadi kelainan hentikan penghisapan dan berikan ventilasi dengan segera. Kateter penghisap dari endotrakea boleh digunakan untuk dari mulutatau hidung sebaiknya tidak boleh. Kembalikan pasien ke sirkuit ventilator atau pipa humidifer bila sebelumnya tidak digunakan. Matikan sumber penghisap, slang dalam keadaan bersih Peralatan dikembalikan dalam keadaan bersih dan pasien dalam posisi semula.

19 Frekuensi penghisapan
Dilakukan tiap 2 jam bila perlu. Atau setelah dilakukan chest fisioterapi. Segera laporkan bila terdapat: Kesulitan memasukkan kateter penghisap. Bila skret sudah tidak bisa dihisap. Sekret yang pekat dan banyak. Sekret campur darah, berbusa dan atau berbau. Penderita sianotik, keadaan menurun, apnnu dll

20 Hal-hal yg perlu dicatat
Waktu penghisapan. Keadaan skret: jumlah, warna, bau dan konsentrasi Hal-hal yang terjadi selama penghisapan: Posisi, keadaan selama penghisapan: Hipoksia, bradikardi

21 Sekian Terima Kasih. Slamet Sumarno.

22 Respiratory Anatomy Nose and mouth :
(Menghangatkan, melembabkan dan menyaring udara). Pharynx Oropharynx Nasopharynx Epiglottis Trachea (windpipe Cricoid cartilage Larynx (voice box). Bronchi Lungs Visceral pleura (surface of lungs) Parietal pleura (internal chest wall) Interpleural space (potential space)

23

24 Larynx

25 Upper Airway Epiglottis Tongue Glottis

26 Lower Airway

27 Sistem persarafan pada jalan nafas

28 V - Trigeminal Nerve Sensoriknya ke daerah wajah (touch, pain and temperature) dan motoriknya ke Temporal, massester Bila terganggu n. V sensasi & motorik terganggu or dapat menimbulkan nyeri = trigeminal neuralgia

29 Trigeminal neuralgia

30 VII - Facial Nerve Ekpresi wajah, sensasi lidah anterior 2/3’s, salivary glands and tear, nasal & palatine glands Kerusakan otot-otot fasial & penyampaian sensasi(missing sweet & salty) called Bell’s Palsy

31 IX - Glossopharyngeal Nerve
Provides control over swallowing, salivation, gagging, sensations from posterior 1/3 of tongue, control of BP and respiration Damage results in loss of bitter & sour taste & impaired swallowing.

32 X - Vagus Nerve The wonderer
Provides swallowing, speech, regulation of 2/3 of GI tract Damage causes impaired voice, swallowing and digestion

33 Sensory supply of upper airway
1) Mucouse membrane of nose : n. cranial. V (trigeminal .)  ophthalmic div. V1 (ant. Ethmoidal n. ) : ant. part of nose  maxillary div. V2 (sphenopaltine n.) : post. part of nose 2) Soft and hard palate : palatine n. 3) Tongue  br. of mandibular div V3 (lingual n.) : ant. 2/3 general sensation  dan 1/3 oleh n. IX (glossopharyngeal n.)  branch of VII ( facial n.) & IX : sensation of taste

34 Sensory supply of upper airway
4) Glossopharyngeal n (IX) : pharynx roof, tonsil soft, palate under-surface innervation 5) Vagus n.(X) : epiglottis , airway , sensation  Sup. Laryngeal br. : ext. br (motor) int. br (sensory) epiglottis, vocal cord , sensory supply  Recurrent laryngeal n. : vocal cord , trachea , sensory supply

35 ANATOMY

36 Laryngeal n. injury 1) Sup. laryngeal n. (ext. laryngeal n. motor n. 로 cricothyroid m)  unilat. : minimal effect  bilat. : hoaresness, tiring of voice (but airway effect voice) 2) Recurrent laryngeal n.  unilat. : ipsilat. Vocal cord paralysis (voice quality )  bilat . : acute : stridor, respiratory distress chronic : aphonia 3) Vagus n.  unilat. :hoarseness  bilat. : aphonia

37 Respiratory physiology
Diaphragm Inhalation (active process) Diaphragm and intercostal muscles contract, increasing the size of the thoracic cavity. Diaphragm moves slightly downward, ribs move upward and outward. The negative pressure in the chest cavity causes air flow into the lungs.

38 Respiratory physiology
Exhalation (passive process) Diaphragm and intercostal muscles relax decreasing the size of the thoracic cavity. Diaphragm moves upward, ribs move downward and inward. The positive pressure inside the chest cavity causes air flow out of the lungs.

39 Respiratory Physiology
Oxygenation - blood and the cells become saturated with oxygen Hypoxia - inadequate oxygen levels in the blood Signs of Hypoxia Increased or decreased heart rate Altered mental status (early sign) Agitation Initial elevation of B.P. followed by a decrease Cyanosis (often a late sign)

40 Alveolar Gas Exchange Oxygen-rich air enters the alveoli during each inspiration. Oxygen enters the blood in the capillaries as carbon dioxide enters the alveoli for exhalation.

41 Infant and Child Considerations
Mouth and nose - generally all structures are smaller and more easily obstructed than in adults. Pharynx - infant’s and children’s tongues take up proportionally more space in the mouth than adults. Trachea - (windpipe) Infants and children have narrower tracheas that are obstructed more easily by swelling. Trachea is softer and more flexible in infants and children.

42 Infant and Child Considerations
Cricoid cartilage - like other cartilage in the infant and child, the cricoid cartilage is less developed and less rigid. It is the narrowest part of the infant’s or child’s airway. Diaphragm - chest wall is softer, infants and children tend to depend more heavily on the diaphragm for breathing.

43 Opening the Mouth Crossed-finger technique Inspect the mouth
Vomit Blood Secretions Foreign bodies Be extremely cautious Fingers Gag or vomit

44 Opening the Airway Head-tilt, chin lift maneuver Jaw thrust maneuver
Adults vs.. Infants and Children Jaw thrust maneuver

45 Techniques of Suctioning
Dasar intervensi suction: precautions Maksud/ tujuan Mengalirkan benda asing dlm saluran nafas spt: blood, liquids, and food particles. Patient needs to be suctioned dengan segera saat pasien ada suara meneguk

46 Types of Suction Units 1. Mounted Suction Devices
Fixed on-board the ambulance 300mmHg pull on gauge when tubing is clamped Should be adjustable (disesuaikan) for infants and children

47 2. Portable Suction Devices
Electric - battery powered Oxygen - powered Hand - powered Each device must have Wide-bore, thick walled, nonkink tubing Plastic collection bottle, supply of water Enough vacuum to clear the throat

48 3. Suction Catheters Catheter keras (yankaeur) Penyulit pemakaian :
Masuk lewat mulut. Terhambat Tonsil dan lidah. Used to suction mouth and oropharynx Inserted a limited depth Use caution on infants and children Soft tissue damage

49 Suction Catheters Soft catheter (French catheter)
Used to suction mouth or nose and nasopharynx Measured from tip of the nose to the tip of the ear. Not inserted beyond the base of the tongue

50 Techniques of Suctioning
Posisikan pasienn yg baik terlentang atau miring kan kepala dan badan bila bayi/anak. (Best positioned at patient’s head) Perhatikan perubahan suction unit Pilih catheter yg pas ukurannya, diameter catheter 50% Diameter jalan nafas. Ukur/periksa dan berapa dalam chateter dapat masuk Suction from side to side Dewasa tidak lebih 15 seconds Infants & children Kurang dari 15 seconds (5-10) Bilas catheter dengan air desinfectance.

51 Special Considerations (pertimbangan khusus).
Bila Secret tidak dapat terhisap dianjurkan dibantu dengan dibersihkan dengan jari. Patient producing frothy secretions as rapidly as suctioning can remove them Suction 15 seconds Positive pressure with supplemental oxygen for 2 minutes then suction again and repeat the process Residual air removed from lungs, monitor pulse and heart rate

52 Suction The importance of readiness can not be overstated.

53 Study of suction equipment utilization.
Prehosp Emerg Care 1997 Apr-Jun; 1(2):91-5 Kozak RJ, Ginther BE, Bean Study of suction equipment utilization. The paramedics reported: carrying suction equipment to the scene of medical aid calls less than 25% of the time. suction equipment is utilized during 50% of advanced airway procedures. WS.

54 Suction - Key Points Diingatkan agar memahami dasar-dasar pemberian suction. Suctions are limited in what they remove Immediate action is needed Have a secondary device

55 Oropharyngeal Airway (OPA)
Used to maintain a patent airway only on deeply unresponsive patients No gag reflex Designed to allow suctioning while in place Must have the proper size If patient becomes responsive and starts to fight the OPA remove it...

56 Inserting the OPA Select the proper size (corner of the mouth to tip of the ear) Open the patient’s mouth Insert the OPA with the tip facing the roof of the mouth Advance while rotating 180° Continue until flange rests on the teeth Infants and children insertion

57 Nasopharyngeal Airway (NPA)
Nose hose, nasal trumpet Used on patients who are unable to tolerate an OPA or is not fully responsive Do not use on suspected basilar skull fracture Still need to maintain head-tilt chin lift or jaw thrust when inserted Must select the proper size Made to go into right nare or nostril

58 Inserting the NPA Select the proper size in length and diameter
Lubricate Insert into right nostril with bevel always toward the septum Continue inserting until flange rests against the nostril Insertion into left nostril

59 Assessment of Breathing
After establishing an airway your next step should be to assess breathing Look Breathing pattern regular or irregular Nasal flaring Adequate expansion, retractions

60 Assessment of Breathing
Listen Shortness of breath when speaking Unresponsive place ear next to patients mouth Is there any movement of air?

61 Assessment of Breathing
Feel Check the volume of breathing by placing you ear and cheek next to the patient’s mouth

62 Assessment of Breathing
Auscultate Stethoscope Mid clavicular about the second intercostal space and the fourth or fifth anterior midaxillary line or next to sternum Check both sides Present and equal bilaterally Diminished or absent

63 Adequate Breathing Normal rate Rhythm Adult 12 - 20/min
Child /min Infant /min Rhythm Regular Irregular

64 Ventilation Volume Tidal volume-air inspired in each breath
Minute volume-tidal volume multiplied by the respiratory rate

65 Adequate Breathing Quality Depth (tidal volume)
Breath sounds present and equal Chest expansion adequate and equal Effort of breathing use of accessory muscles predominately in infants and children Depth (tidal volume) Adequate chest rise and fall Full breath sounds heard

66 Inadequate Breathing Rate Rhythm Outside the normal limits
Tachypnea (rapid breathing) >20 Badypnea (slow breathing) <12 Rhythm Irregular breathing pattern

67 Inadequate Breathing Quality Depth
Breath sounds diminished, noisy or absent Excessive use of accessory muscles, retractions Reduced air flow at nose/mouth Inadequate chest expansion Nostril flaring (infants & children) Depth Shallow (impaired depth) breathing Agonal respirations - occasional gasping respirations

68 Inadequate Breathing Skin Color Retractions
“Seesaw” breathing (abd & chest move in opposite directions) Any of these signs is by itself may be reason to ventilate a patient without delay

69 Positive Pressure ventilation
The practice of artificially ventilating, or forcing air into a patient who is breathing inadequately or not breathing at all

70 Techniques of Artificial Ventilation
In order of preference Mouth to mask Two-person bag-valve-mask Flow-restricted oxygen-powered ventilation device One-person bag-valve-mask

71 Considerations When Using Artificial Ventilation
Maintain a good mask seal Device must deliver adequate volume of air to sufficiently inflate the lungs Supplemental oxygen must be used

72 Adequate Artificial Ventilations
Chest rises and falls with each ventilation Rate of ventilations are sufficient Heart rate returns to normal Color improves

73 Inadequate Artificial Ventilations
Chest does not rise and fall Ventilation rate is too fast or slow Heart rate does not return to normal Color is not improved

74 Mouth-to-Mouth Ventilation
Air we breath contains 21% oxygen 5% used by the body 16% is exhaled Danger of infectious disease

75 Mouth-to-Mask Eliminates direct contact with patient
One-way valve system Can provide adequate or greater volume than a BVM Oxygen port (should be connected to 15 lpm)

76 Bag-Valve-Mask (BVM) EMT-B can feel the lung compliance
Consists of self-inflating bag, one-way valve, face mask, intake/oxygen reservoir valve, and an oxygen reservoir. By adding oxygen and a reservoir close to 100% oxygen can be delivered to the patient When using a BVM an OPA/NPA should be used if possible

77 Bag-Valve-Mask Cont... Volume of approximately 1,600 milliliters
Provides less volume than mouth-to-mask Single EMT may have trouble maintaining seal Two EMT’s more effective Pop-off valve must be disabled Available in infant, child, and adult sizes

78 Bag-Valve-Mask Cont... Breaths should be 1.5 to 2 seconds
Guard against overinflation Monitor the seal Bring the jaw to the mask

79 Bag-Valve-Mask Cont... Assisted ventilations for hyper or hypoventilating patients Explain procedure Place the mask Squeeze bag on inhalation Over next 5 to 10 breaths slowly adjust rate and tidal volume to desired rate and volume

80 Sellick Maneuver

81 Sellick Maneuver

82 Mask ventilation will be made difficult by:
poor mask seal -- beards facial burns facial scarring/cuts facial dressings edentulous patients any evidence of airway obstruction neck instability penetrating neck trauma repeated failed direct laryngoscopy obesity/bull neck

83 Other ventilation techniques will be made difficult by:
lack of knowledge and experience lower airway obstruction neck instability penetrating neck injury

84 Flow-Restricted, Oxygen-Powered Ventilation Device
Known as a demand-valve device Can be operated by patient or EMT Unable to feel lung compliance With proper seal will deliver 100% oxygen Designed for use on adult patients Gastric distension Rupture of the lungs A trigger positioned to allow EMT to keep both hands on the mask

85 Automatic Transport Ventilators
Deliver 100% oxygen Provide and maintain a constant rate and tidal volume during ventilation Advantages Frees both hands Rate, & tidal volume can be set Alarm for low oxygen tank Disadvantages Oxygen powered not used in children under 5 Cannot feel increase in airway resistance

86 Oxygen Therapy Oxygen is a drug that can be given by the EMT-B
“Generally speaking”, a patient who is breathing less than 12 and more than 24 times a minute needs oxygen

87 Oxygen Dangers Oxygen supports combustion, (it is not flammable)
Avoid contact with petroleum products Smoking Handle carefully since contents are under pressure

88 Oxygen Cylinders All of the cylinders when full are the same pressure of 2,000 psi. Usually green or aluminum grey D cylinder liters E cylinders liters M cylinders - 3,000 liters G cylinders - 5,300 liters H cylinders - 6,900 liters

89 High-Pressure Regulator
Provides 50 psi to an oxygen-powered, ventilation device. Flow rate cannot be controlled

90 Low Pressure/Therapy Regulator
Permit oxygen delivery to the patient at a desired rate in liters per minute Flow rate can go from 1 to 25 liters/min.

91 Oxygen Humidifiers Dry oxygen is not harmful in the short term
Generally not needed in prehospital care Transport time of an hour or more humidifier should be considered

92 Changing Oxygen Bottle
Check cylinder for oxygen remove protective seal Quickly open and shut tank to remove debris Place regulator over yoke and and align pins. Make sure new O ring is in place Hand tighten the T screw Open to check for leaks

93 Nonrebreather Mask Preferred method of giving oxygen to prehospital patients Up to 90% oxygen can be delivered Bag should be filled before placing on patient Flow rate should be adjusted to 15 liters/min. Patients who are cyanotic, cool, clammy or short of breath need oxygen Concerns of too much oxygen Different size masks

94 Nasal Cannula Provides limited oxygen concentration
Used when patients cannot tolerate mask Prongs and other uses Concentration of 24 to 44% Flow rate set between 1 to 6 liters For every liter per minute of flow delivered, the oxygen concentration the patient inhales increases by 4%

95 Nasal Cannula Flow Rates
1 liters/min. =24% 2 liters/min. = 28% 3 liters/min. = 32% 4 liters/min. = 36% 5 liters/min. = 40% 6 liters/min. = 44%

96 Simple Face Mask No reservoir Can deliver up to 60% concentration
Rate 6 to 10 liters/min. Not recommended for prehospital use

97 Partial Rebreather Mask
Similar to nonrebreather except it has a two-way valve allowing patient to rebreath his exhaled air. Flow rate 6 to 10 liters/min. Oxygen concentration between 35 to 60%

98 Venturi Mask Provides precise concentrations of oxygen
Entrainment valve to adjust oxygen delivery Mostly used in the hospital setting for COPD patients

99 Special Situations

100 Inhaler Therapy History Medical Direction
Review of specific bronchodilator medication

101 Laryngectomies (Stomas)
A breathing tube may be present If obstructed, suction it Some patients may have partial laryngectomies Be sure to close the mouth and nose to prevent air escaping

102 Infants and Child Patients
Neutral position infant Just a little past neutral for child Avoid hyperextension of head Avoid excessive BVM pressure Gastric distension more common in children Oral or nasal airway may be considered when other procedures fail to clear the airway

103 Obstruction Anything (food, blood, swollen tissue, vomit) that blocks the airway will cause some level of decrease of available oxygen to the body.

104

105 Obstruction The size of obstruction affects the
available air exchange. For example, snoring will reduce air Exchange while a food bolus can actually stop air exchange.

106

107 Obstruction When obstruction persists, repeat FBAO procedures three times and transport as soon as possible.

108 Facial Injuries Rich blood supply to the face
Blunt injuries and burns to the face result in severe swelling Bleeding into the airway can be a challenge to manage

109 Jaw Thrust

110 Technique Suction. Gunakan cateter steril untuk mencegah nasocomial (infeksi dirumah sakit). Sebelum suction informasikan ke keluarga/pasien apa maksud anda melakukan suction. Siapkan alat siap pakai. Sebelum dan sesudah suction dapat diberikan terapi oksigen untuk mencegah vagal reflek. Lakukan dengan waktu suction 3-5 detik untuk anak dan atau detik untuk dewasa. Vacum presure = mmHg untuk dewasa dan mmHg untuk anak ( kPa dewasa) kPa anak (Tergantung kepekatan mukus). Dengan nafas dalam akan merangsang batuk pada sebagian pasien.