Intensive care unit Physical therapy by: Slamet Sumarno.

Fisioterapi ICU Intensive Care Unit = Perawatan intensif. ICU umumnya rawat kond kritis Cardiorespirasi dan banyak menggunakan alat bantu serta ditangani secara team. Siapa yang harus di rawat di ICU. ? Gejala gagal nafas (krirtis pernafasan). Indikasi memerlukan alat bantu pernafasan. Tidak stabilnya pernafasan . Kritis trauma capitis. Kondisi yg memerlukan perawat intensive.

Gagal nafas. Pengertian. Gagal nafas diartikan sebagai kegagalan pertukaran gas dlm paru yg ditandai dengan turunnya kadar oksigen di arteri (hipoksimia) atau naiknya kadar karbondiaksida (hiperkarbia) atau kombinasi keduanya.

Kriteria diagnosa gagal nafas. PaO2 < 60mmHg, PaCO2 > 49 mmHg tanpa gangguan alkalosis metabolik primer (Muhadi,OE Tampubolon, 1989)

Pemeriksaan lab Gas Darah Asidosis acut respiratory acidosis a 7.1 metabolik acidosis r 7.2 chronic respiratory t 7.3 acidosis e 7.4 r 7.5 metabolik alkalosis I 7.6 respiratory alkalosis 7.7 2 4 6 8 10 12 Alkalosis PH= 7,35-7,4 PCO2= 5-6 kpa

Etiologi Gagal nafas. Penyakit akut atau kronik kembali akut. Acut dan Acut on chonic respiratory failure (hipersekresi, spasme bronkus, edema mukosa). Spasme bronkus pada: Asma, bronkitis kronik yg berkembang menjadi emfisema

Lanjutan. Otak: Neoplasma, Epilepsi, Hematoma subdural, Keracunan morfin dan CVA. Susunan neuromuskular: Miastenia gravis, Polyneuritis, Analgesia spinal tinggi, kelumpuhan otot respirasi. Dinding thorak, diapragma: Trauma thorak. Paru: Asma, infeksi paru, Aspirasi, pneumonia, edema paru. kardiovaskuler: Gagal jantung, emboli paru. Pasca bedah: laparatomi dll

Komplikasi rawat ICU. Peningkatan resiko infeksi nosocomial  atelectasis Mechanics ventilasi pasien yang memungkinkan terjadi penurunan FRC dan CL , V/Q nya tidak sebanding۬ immobilisasi pada pasien dengan penyakit kritis yang menderita muscle deconditioning, peningkatan resiko DVT, pressure sore FRC=fungsional reserve capacity. CL = lung capacity V/Q = volume/ cordiac out put. DVT=penurunan volumr total

Problem Koknetif Manusia gerak sikap

Physiotherapy Assessment Cognition, motivation, patients own goals Previous level of function & independence Posture, movement, strength, balance, pain Functional ability; sitting, standing, transferring, walking, turning, reaching, bed mobility, stairs, getting up from floor, arm & hand function, exercise tolerance Use of Objective measures

Physiotherapy programme Exercises to address specific problems, e.g. loss of joint movement, muscle weakness, balance problem. Functional activity, in a safe, supervised environment, to improve performance and confidence Provision of and practise using appropriate mobility aids

Problematik umum 1. Gangguan pernafasan. 2. Gangguan Jantung dan sirkulasi. 3. Gangguan Hormonal dan bufer. 4. Gangguan sistem syaraf. 5. Kecerdasan menangkap perintah. 6. Ganguan perilaku.

PROBLEM PERNAFASAN. Oleh karena: Gangguan systen neurologi. Gangguan Sangkar thorak. Gangguan jalan nafas / obtruktif. Gangguan pleurae. Gangguan perfusi / restriktif. Gangguan system sirkulasi pulmonal. Gabungan satu sampai enam

Tujuan Fisioterapi ICU meningkatkan/mempertahankan A.fungsi cardiopulmonari: 1. Posisioning. 2. Membuka jalan nafas. 3. Oksigen terapi. 4. Meningkatkan ventilasi. 5. Fasilitasi dan stimulasi breathing. 4 a. mekanik ventilasi b. Breathing exercises

B. Fungsi Musculoskeletal 1. Joint function / movement 2. Performance kerja otot. 3. Balance, coordination, komunikasi 4. Performance fisik : ambulation / ADL

C. Fungsi Neuromuskular. Sensasi, stimulasi, Inhibisi. D. Edukasi . E. Mencapai goul (harapan). F. Evaluasi .

Assessment /reassessment Mesurment. / remesurment PROSES FISIOTERAPI Assessment /reassessment Mesurment. / remesurment Analysis of findings Intervensi/Implementation of treatment / modifikasi Problems identification Planning of treatment Diagnosa fisioterapi

Evidence Based Practice Falls – strength & Balance training NSF, NICE, CSP Guidelines Locally developed guidelines; walking aids, falls prevention education leaflets, group exercise, resistance training for osteoporosis

Evidence Based Medicine (EBM) “Menggunakan segala pertimbangan bukti ilmiah (evidence) yang sahih yang diketahui hingga kini untuk menentukan pengobatan pada penderita yang sedang kita hadapi”. Merupakan penjabaran bukti ilmiah lebih lanjut setelah obat dipasarkan dan seiring dengan pengobatan rasional.

Lima tahap evidence based Memformulasikan pertanyaan tentang masalah fisioterapi yang dihadapi Menelusuri bukti-bukti terbaik yang tersedia untuk mengatasi masalah tersebut Mengkaji bukti, validitas dan keseuaiannya dengan kondisi praktek Menerapkan hasil kajian Mengevaluasi penerapannya (kinerjanya)

Assessment FT Kritis Di ICU Baca status riwayat dan keadaan sekarang. 1. Posisi pasien: Sudah memudahkan proses pernafasan. Sudah membantu sirkulasi. Sudah menguntungkan bila terjadi kekakuan. Sudah mencegah dekubitus. Sudah memudahkan / memfasilitasi pernafasan dan gerak fungsional.

2. Kenali alat dan monitor yg ada Sounde. Tentukan ukuran soude yang masuk oesophagus. Thrachea tube : tentukan ukuran panjang yang masuk thrachea. 18, 19, 20, 21, 22 dst biasanya dewasa 22 cm. Tentukan apakah monitor EKG berfungsi dengan baik ( terutama elektrode yg terpasang pada dada dan tangan atau kaki biola ada. Tentukan ventilator berfungsi dengan baik, menggunakan inhalasi atau tidak, Monitor Vital sign.

Assesment / mesurment. Vital sign. Fungsi tingkat kesadaran. Fungsi jalan nafas dan paru Fungsi jantung dan sirkulasi. Fungsi sangkar torak : sendi, otot dan tl Fungsi umum: sendi, otot, gerak

Kesadaran. Kesadaran diobsevasi dari mata. Tidak mampu membuka mata. Mampu membuka mata dengan rangsang sentuhan nyeri. Membuka mata dengan rangsang lebih keras. Membuka mata dengan rangsang ringan dan lama (spontan)

Glasgow coma scale Eye Opening E spontaneous 4 to speech 3 to pain 2 no response 1 Best Motor Response M To Verbal Command: obeys 6 To Painful Stimulus: localizes pain 5 flexion-withdrawal 4 flexion-abnormal 3 extension 2 no response 1 Best Verbal Response V oriented and converses 5 disoriented and converses 4 inappropriate words 3 incomprehensible sounds 2 no response 1 E + M + V = 3 to 15

GLASGOW COMA SCALE * Clients who are unable to cooperate can be evaluated using this scale Best Score = 15 Worse = 3 Scoring E4 V5 M6 ES - Eyes swollen Untestable = (+) dressing ET TR Paresis Plegia Traction Cast Subscale EYE OPENING (E) VERBAL RESPONSE (V) MOTOR RESPONSE (M) Description Spontaneously To Speech To Pain Do not Open Oriented Confused Inappropriate Speech Unintelligible speech No verbalization Obeys Command Localizes Pain Withdraws from pain Abnormal Flexion Abnormal Extension No Motor Response Score 4 3 2 1 5 6

LOC Verbal Tactile Pain Conscious (+) (+) (+) Lethargic (+) (+) (+) * FORMS OF STIMULI VERBAL VOICE SHOUT TACTILE TOUCH TAP/ SHAKE PAIN SUPERFICIAL DEEP LOC Verbal Tactile Pain Conscious (+) (+) (+) Lethargic (+) (+) (+) * Stuporous (-) (-) (+) Comatose (-) (-) (-)

Respon pupil thd cahaya Normal = 5 Lambat= 4 Respon tidak sama = 3 Besar tidak sama = 2 Tidak ada respon = 1

Reflek saraf cranial Semua ada= 5 Bulu mata tidak ada= 4 Kornea tidak ada = 3 Doll’s tidak ada =2 Karina (semua) tidak ada= 1

Kejang (skor terbaru). Kejang tidak ada = 5 Kejang fokal = 4 Umum , intermiten = 3 Umum kontinue = 2 Flaksid = 1

Nafas spontan Normal = 5 Periodik =4 Hiperventilasi central = 3 Iregular/hipoventilasi = 2 Apnu = 1 Toatal skor = 35 terburuk = 7

Pain Stimulus NAIL BED COMPRESSION fine pressure with thumb over pencil on the base of the cuticle Test bilaterally N=(+)Crushing pain STERNAL RUB DSP use knuckle over sternum as if “grinding a pill” for 5 sec. N=20-30 sec. Posturing (initial reaction) Wait for at least 30 seconds TRAPEZIUS SQUEEZE using thumb & 2 fingers, grasp 2 inches of the muscle & then twist SUPRAORBITAL PRESSURE use thumb C/I: Cranial fracture

Oxygenation Assess respiratory status. Maintain patent airway & adequate ventilation. Watch for S/S of hypoxia & hypercapnia…

Oxygenation Note for S/S of Hypoxia/ hypoxemia (-) Spontaneous respiration Restlessness/ irritability Peripheral cyanosis Use of accessory muscles of respiration Ala Nase flaring Angina Tachycardia Tachypnea GIT/ Renal Dysfunction (Late sx) Dx/ Lab results: Pulse Oximetry Capnography ABG Hematology (hct; hgb)… Oxygenation

Motor Function Assess integration of consciousness & voluntary movement. Look for purposeful or non-purposeful response. Also assess muscle tone, size, strength. Observe for symmetric, spontaneous movement of arms & legs…

MUSCLE STRENGTH GRADING Abn= tics, tremors = stress, long term use of psychotropic drugs, neurologic disorders (Parkinson’s, MS, or HC) atrophy, paresis, plegia, flaccidity, spasticity, rigidity = motor neuron or muscle disease unresponsive clients hemiplegia - corticospinal tract damage decorticate - upper corticospinal tract damage decerebrate – brainstem damage MUSCLE STRENGTH GRADING Grade Description 0 No contraction 1 Slight contraction 2 Full passive ROM 3 Full ROM 4 Full ROM against some resistance 5 Full ROM against full resistance

Pupils Pupillary Size Assess for size, shape & reaction to light. Controlled by: CN-III Brainstem Midbrain Pupillary Assessment Size Reaction Shape… Assess for size, shape & reaction to light. Observe for ptosis… Pupillary Size N= 1.5-6mm (3.5 avg.) Anisocoria N=17%; Abn=Herniation…

Pupillary Reaction Abn= SRTL – early CN III compression NRTL/ Fixed N= BRTL Direct Consensual Light response Abn= SRTL – early CN III compression NRTL/ Fixed Fixed Dilated=  ICP, Prolonged diffuse hypoxia, Atropine Pinpoint pupil = Narcotics (Morphine, Demerol), Long Acting analgesia (Fentanyl) Hippus – cannot sustain constrict then redilates with light on Bilateral Hippus Abn= Seizure, Meningitis Ipsilateral Abn=(+)lesion/ brain tumor

Ocular Movement Pupillary Shape Assess for deviation to one side. N=Round Abn=oval –  ICP (15-20mmHg) post frontal / anterior temporal lesions Contusions… Assess for deviation to one side. Also assess voluntary & spontaneous movement… EOM – controlled by CN III, IV, VI…

Signs Assess V/S. Observe for significant trends. Look for Cushing’s reflex: PR, RR, Widened Pulse Pressure…

Urinary Output Assess for increased output, possible S/S of impaired water regulation. Also assess for electrolyte imbalance, especially hyponatremia… Oliguria ( below 30 cc)…

Reflexes Assess for pathologic reflexes, especially babinski & loss of corneal or gag reflex… Corneal Pons Medulla Gag/ Cough CN IX CN X…

Emergency Evaluate assessment findings to determine whether emergency exists. If so report findings to doctor STAT…

Test for attention, concentration & calculation. Ask to count backward from 100, subtracting by seven each time (”100, 93, 86…”). N=Can count back into the 50s within one minute…

Memory Test for short-term memory Name 3 unrelated objects (e.g. car, garbage can, alarm clock) then ask for these words again for within a few minutes Test for long term memory Ask client’s mother’s maiden name. Memory Loss – abnormal & signal disease, infection or temporal lobe trauma…

Logic, Judgment, Reasoning & decision-making ability Test for Logic & Judgment Ask “What would you do if you were inside a burning building?” N=sound judgment. Abn=Frontal Lobe damage, dementia, psychosis, mental retardation. Test for reasoning & decision-making ability answering questions appropriately Ask the meaning of a proverb such as “A stitch in time saves nine.” Abn=low intellect, dementia, schizophrenia…

Emotional Stability, Speech & Language Moods, Feeling, Thought process Speech & Language Voice quality, Articulation, Content, Comprehension N=Spontaneous & well paced speech; logical content Ask to read a sentence form age-& education-appropriate material; write name or simple sentence. Abn=Aphasia (speech), dysarthria (articulation & rate), dysphonia ( voice), apraxia (conversion of thought into motor sound), agraphia ( writing), alexia (written language comprehension)…

Cerebellar function Gait Ask to walk a straight heel-to-toe line. Abn=staggering, shuffling, tiptoe walking, foot slap, leg drag. Uncoordinated gait & loss of balance = motor, sensory, vestibular or cerebellar dysfunction. Cerebellar ataxia – unsteady gait with legs spread wide. Scissors gait – short, stiff steps with thighs overlapping. Foot drop - lifts knee high then slaps foot down Parkinsonian shuffle – accompanied by stooped posture Spastic paralysis - arms flexed & held to the body, client “throws” each leg forward…

Cerebellar function Balance Romberg’s test arms at sides, feet together, eyes closed for 20 seconds. Watch for loss of balance. Stand close enough to prevent falling. N=slight swaying. Abn loss of balance (+) Romberg cerebellar ataxia, alcohol intoxication, MS, impaired visual functioning, or loss of proprioception. Test for coordination, muscle strength, & cerebellar function Ask to stand on 1 foot & do a shallow knee-bend, or hop,. Abn= Cerebellar dysfunction or lack of physical fitness…

Cerebellar function (Rapid alternating movements; Accuracy of movement; Balance; Gait) Rapid Alternating Movement (RAM) of the hands & fingers - assesses coordination & dexterity. Pat knees with the palms, then flip & do so with the back of the hands, first slowly then faster. N=smooth & bilateral movement Abn=slow, awkward movement= cerebellar dysfunction Ask to touch thumb to each finger from index to 5th finger & back again, slowly at first then faster. Repeat on the other hand. Abn=Dyssenergy (lack of coordinated muscle movement) =upper neuron weakness, cerebellar disease, EP dysfunction. Finger-to-nose coordination test Ask to touch index finger to nose then to the examiner’s outstretched vertical finger to different points. Abn=Dyssnergy, Dysmetria (misjudgment of distance, speed & force of movement = cerebellar dysfunction…

Sensory function Superficial Pain & Touch Sensation test distal points on arms & legs Eyes closed. Examine Arms, Legs & Abdomen. Assess sensitivity to light touch with a wisp of cotton (distal to proximal). Ask to say “now” when each sensation is felt. Sharp object (opened paper clip). Ask whether she feels a sharp or dull sensation. Temperature sensitivity - 2 test tubes (1 filled with hot & 1 with cold water, along the same routes. Abn=Peripheral nerve problem: paresthesia & impairment in touch sensation (Anesthesia, Hypoanesthesia). Pain sensitivity – analgesia, hypalgesia, hyperalgesia…

Proprioception, Vibratory sensation Proprioception – (tested on great toe & hands) – sense motion, position, & vibration Hands (sides of index finger between thumb & index finger). Eyes closed. Move finger up or down. Ask client to describe direction. Repeat on other hand & in both great toes. If (+) abn proceed to next proximal joint. Abn=peripheral neuropathy or lesion in the posterior spinal column, sensory cortex, or thalamus. Vibratory sensation – stem of vibrating tuning fork against client’s distal finger or great toe. Ask to say “now” if vibration is felt. Proceed to next proximal joint if abn…

Cortical sensation (stereognosis, graphesthesia, 2-point discrimination) Stereognosis – recognizing objects by feel. Eyes closed. Identify familiar objects (e.g. key). Repeat on other hand with different object. Abn=Astereognosis = parietal lobe problems Graphesthesia – identify shapes, numbers, or letters traced on the skin. Eyes closed. Use blunt object such as closed paper clip to draw shape, letter or number on the palm. Repeat on the other palm. Abn=Graphanesthesia = parietal lobe problems. 2-point discrimination – touching 2 identical sharp objects (e.g. Opened paper clips) to the skin in close proximity, while eyes closed. Ask whether she feels 1 or 2 points, noting distance between 2 points. Repeat test on arms, legs, face & abdomen, decreasing the actual distance between the points until client feels 2 points as one. N=distance-2 to 20 mm. Abn=parietal lobe problem…

Superficial /Cutaneous Reflexes Abdominal, Plantar Abdominal Reflex T8-T10 spinal nerves - controls upper abdominal muscles T10-T12 – lower abdominals Dorsal Recumbent. Blunt tipped object (cotton swab). Scratch each abdominal quadrant lightly (lateral to midline, high to low) N=muscle contraction & slight shift of umbilicus towards the stimulus. Plantar Reflex (Babinski) controlled by L4 & L5, S1 & S2 Stroke foot sole with the handle of a reflex hammer. Run the edge along the outer heel up to the ball of the foot. Repeat on the other foot. N=toe flexion (except in infant) Abn=Dorsiflexion of big Toe, Fanning of Little Toes (except in infant) Pyramidal Tract / Upper Motor Neuron Damage…

Superficial /Cutaneous Reflexes Cremasteric, Anal Cremasteric Reflex T12 – L2 For genitourinary complaints only in men. Lightly stroke the inner thigh N=scrotal elevation on the stimulated side Anal Reflex S3-S5 Gently touching around the anus with a cotton swab or gloved finger N=contraction of rectal sphincter…

Deep Tendon Reflexes Biceps, Triceps, Patellar, Achilles, Brachioradialis Requires practice & a relaxed client. Sitting with feet dangling. Easier if used with distractions. Pointed hammer – small tendons Flat end – larger tendons Compare bilateral responses If any of the DTRs are hyperactive = test for ankle clonus(rhythmic contraction). Lift 1 of the client’s legs & support the flexed knee with non-dominant hand. Grasp the foot & quickly dorsiflex the toes. N=(-)Pain & involuntary movement Abn= Clonus=motor neuron dysfunction Deep Tendon Reflexes (DTR) GRADING DTR GRADE Response 0 Absent reflex 1+ Diminished 2+ Normal 3+ Slightly increased 4+ Hyperactive

Jenis intervensi FT ICU Posisioning. Oksigen terapi Stimulasi/ fasilitasi dan inhibisi. Breathing. Chest FT. Inhalasi. Mobilisasi/ ambulasi Edukasi.

Chest Fisioterapi 1. P D. 2. Topotement / klepping 3. Breathing 4. Coughing/huffing. 5. assisted coughing hafing. Chest PT dapat dilakukah pre medikasi dengan: stimulasi, inhalasi, rileksasi dll Post chest PT dpt dilakukan: mobilisasi ambulasi dan tranvers.

Pembersihan Jalan Napas Inhalasi. Chest fisioterapi. Mobilisasi Ambulasi Educasi

Retained secretions Partially occlude Complete occlude Uneven distribution of ventilation Shunting blood V/Q mismatching V/Q mismatching Hypoxemia

Postural drainage position (PD) Posisi dengan meluruskan segmen bronchi dengan gravitasi , jadi sekresi diakumulasi pada segmen bronchopulmonari bergerak ke arah central dan dikeluarkan dengan batuk , dan dengan mudah meludah

Posisi paru atas

Upper lobe Half supine lying = Atas depan R/L. Half prone lying = Atas belakang R/L Half supine lying R up = Atas depan R Half Supine lying L up = Atas depan L Half prone lying R up = Atas belakang R Half prone lying L up = Atas belakang L Half Right side lying = Atas samping kiri Half Left side lying = Atas samping kanan.

Paru bagian tengah

Paru bagian bawah

Perkusi dan Vibrasi = Manipulasi eksternal dari area toraks yang berfungsi untuk mobilisasi untuk membantu proses sekresi. Perkusi : Tepukan yang cepat, cupping ( dengan tangan berbentuk mangkok ) dari bagian eksternal thorax, secara langsung tepat diatas saluran segmen paru . Mekanika perkusi : Gelombang mekanik dari energi yang dihasilkan dipercaya akan ditransmisi sepanjang dinding paru untuk menghilangkan mukus dari saluran jalan napas ( Gelombang berkisar 4 – 5 Hz ).

Percusi

Breathing

Coughing/huffing /fibrasi/ konpresi

Vibrasi : Gerakan yang menyebabkan getaran dilakukan secara manual dari gerakan menekan langsung pada area ribs dan soft fissure dada normal bergerak selama exhalasi (pengeluaran napas)

Bantuan / latihan batuk/ huffing.

Pasien dengan trachea cube Dilakukan suction

Summary Pada ICU bedside -Baca status dengan teliti dan perhatikan a . Vital Sign monitor. b. ventilation parameter c. Alat-alat medis lain : EKG, Infus, Sounde dll - Mengaplikasikan teknik FT yang tepat - Closed observation and continuously monitored selama Rx - Mengassesment kembali pada akhir Rx - Sebelum meninggalkan pasien, FT harus memastikan bahwa semua alarm sudah di aktifkan, VS stabil, pasien merasa aman dan nyaman. Summary

Hal-hal yang menjadi pertimbangan untuk FT. pada ICU Closed observation and continuously monitoring - patient ‘s ability to tolerate PT Rx - ventilated patient / penerunan tingkat kesadaran / jeleknya gag (sumbatan) reflex aspiration - perawatan yang tepat minimize cross-infection - peningkatan tekanan aliran darah - tingginya PAP - arrhythmia - vital sign - level of ICP - tingkat kesadaran , sedation dll.

ICU: Mempunyai masalah komplek. Dikerjakan secara team. FT harus ingat perasaan dan rasa takut pasien yang dapat membuat mereka tidak natural terhadap lingkungannya - ketidakmampuan untuk bicara - loss of perception of time - suffer from chronic sleep deprivation

Thank you For Your attention

What are the 3 objects shown a while ago? The END ! Any questions ? What are the 3 objects shown a while ago? GOOD DAY ! and THANK YOU FOR LISTENING !

Kombinasi (penggabungan) treatment FT : Postural Drainage dengan perkusi dan vibrasi memfasilitasi pergerakan sekresi : Perkusi sendiri dapat menyebabkan : FEV1 menyebabkan hypoxemia tetapi efek negatifnya dapat dicegah jika breathing exercises tergabung ke dalam program Rx

Selama perkusi dan vibrasi FT harus observasi ekspresi wajah pasien karena nyeri atau tidak nyaman Konsekuensi nyeri : - muscle splinting - meningkatkan kerja pernapasan - konsumsi O2 meningkat - bronkospasme

Breathing exercises (BE) Otot2 ventilasi`terdiri dari otot diaphragma dan otot intercostal, bertindak sebagai “pump muscles” yang berfungsi menggerakan tulang thorax, menyebabkan intrathoracic pressure, lalu hasilnya aliran udara masuk ke paru2, Otot larynx and pharynx bertindak sebagai “valves (katup)” yang membantu mengatur dan menjaga aliran udara

Inspirasi Aktif - antero – posterior - transverse - longitudinal  Expansi paru-paru pada 3 bagian : - antero – posterior - transverse - longitudinal  Pump handle movement terjadi pada upper ribs  Bucket handle movement terjadi pada lower ribs  abdominal berpindah ke downward (ke bawah)

Teknik Pembuangan Sekresi Batuk Huffing. dll. Suction (penyedotan)

Pola-pola BE - Costal BE (thoracic expansion exercise) - Diaphragmatic BE - Costal BE (thoracic expansion exercise) - Pursed lips breathing (PLB) - Sustained maximal inspiration (SMI) - Deep BE etc.

Collateral ventilation Channels of Martin (interbronchiolar channel) Channels of Lambert (bronchiole-alveolar channel) - Pore of Kohn (interalveolar channel)