Airway Management

AIRWAY MANAGEMENT

Dr. Susi Handayani, M.Sc, Sp.An

JALAN NAFAS ATAS

1. HIDUNG2. FARING3. LARING4. TRAKEA

LARYNG (VOICE BOX)

- separates pharyng and trachea- cartilages, membrane, ligaments

- ♂ 45 mm long, Ø 35 mm

- ♀ 35 mm long, Ø 25 mm

FUNCTION- Patent airway

- To act as a switching

mechanism to route air and food into the proper channels- Voice production

9 Pieces of cartilages form the larynx1. Thyroid cartilage (Adam’s Apple)

2 fused plates of hyaline cartilage that form the anterior wall of the larynx Connected to the hyoid bone by the thyrohyoid membrane

2. Epiglottis, elastic cartilage covered with epitheliumFunctions like a trap door by covering the glottis (the opening to the larynx)The glottis the vocal folds in the larynx and the space between them

3. Cricoid Cartilage, ring of hyaline cartilage forming the inferior wall of larynx

Attached to trachea by cricotracheal ligamentLandmark for making an emergency or long term airway (tracheotomy)

4&5. Arytenoid Cartilage6&7. Corniculate Cartilage8&9. Cuneiform Cartilage

CRICOTHYROTOMY

- acute, life threatening upper airway obstruction- intubation not possible- conventional airway management not possible

SELLICK’S MANEUVREUsed to prevent gastric distention

TechniqueApply slight pressure anteriorly over cricoid cartilageCloses off esophagus

SELLICK’S MANUEVER

The intrinsic muscles of the larynx attach to the arytenoid cartilage, and allow for movement of the vocal cords.

MOVEMENTS OF VOCAL CORDS

Glottis & Epiglottis

glottis

epiglottis

Respiratory Respiratory PhysiologyPhysiology

Breathing• Pulmonary Ventilation the movement of air into

and out of the lungs

• Gas exchange occurs due to a pressure gradient (partial pressures of gas)

• Two phases

• Inspiration: Breathing in• Active process

• Expiration: Breathing out• Passive process

INTUBATION

Death occurs from failure to Ventilate, not failure to Intubate !!

AIRWAY & RESPIRATION

CARDIOVASCULAR

BRAIN

Fig. Three main organs influenced by anesthetic agents.

SUATU SEBAB

PENDERITATAK SADAR

RELAKSASIOTOT

HILANG REFLEKSPERLINDUNGAN

LIDAH “KLEP”

SUMBATANJALAN NAFAS

MUNTAHREGURGITASI

ASPIRASI

SUMBATAN JALAN NAFASSUMBATAN JALAN NAFAS

• Look / Lihat Perubahan Status Mental

Agitasi / gelisah HipoksemiaObtundasi / teler Hiperkarbia

Gerak NafasNormalSee saw / rocking

Retraksi Deformitas Debris

Darah / sekretMuntahanGigi

Sianosis

PEMBEBASAN JALAN NAFASPEMBEBASAN JALAN NAFAS

PENYEBAB LIDAH• Manual :

- Non trauma :Head tiltNeck liftChin liftJaw thrust

- Trauma :Chin liftJaw thrust

Dengan in-line manual immobilization” ataupasang cervical collar

• Bantuan Alat- Oropharyngeal airway- Nasopharyngeal airway

PEMBEBASAN JALAN NAFASPEMBEBASAN JALAN NAFAS

PENYEBAB BENDA ASING• Manual

• Penghisap • Definitive airway

• Pada chocking : Back blows Abdominal thrust (Heimlich manuver) Thoracal thrust Cricothyroidotomy

EVALUASI JALAN NAFAS

RIWAYAT:- Medical- Surgical- Anesthetic

DEFINISI

Jalan nafas sulit :- Kondisi klinis jalan nafas dimana ventilasi

sungkup muka dan / atau intubasi trakea sulit dilakukan oleh dokter spesialis anestesi yang terlatih dan berpengalaman

- “Cannot intubate cannot ventilate”

Ventilasi sulit :- Kesulitan untuk mempertahankan sat O2 >90%

dengan sungkup muka dan O2 inspirasi 100%, dimana sebelum ventilasi sat O2 normal

Intubasi sulit :- Intubasi yang dilakukan lebih dari 3 kali

percobaan atau lebih dari 10 menit

EVALUASI KESULITAN VENTILASI

Kriteria ventilasi sulit (Langeron et al) 2 dari:OBESE1. Obese (BMI>26 kg/m2)2. Bearded3. Elderly (>55 th)4. Snorers5. Edentulous

EVALUASI KESULITAN INTUBASI

Kriteria :- Skala LEMON atau MELON- LM MAP- 4 D- Wilson Risk Scale- Magboul 4M

SKALA LEMON ATAU MELON

Look externallyEvaluate 3-2-1 ruleMallampatiObstructionNeck mobility

TABEL SKALA LEMON

• Evaluates ability to visualize glottic opening• Patient seated with neck extended• Open mouth as wide as possible• Protrude tongue as far as possible• Look at posterior pharynx• Grade based on visual field

• Grades 1,2 have low intubation failure rates

• Grades 3,4 have higher intubation failure rates

LM-MAP

Look for external face deformitiesMallampatiMeasure 3-3-2-1 fingersAtlanto-occipital extensionPathological obstructive conditions

4 D

Dentition(prominent upper incisor, receding chin)Distortion(edema, blood, vomits, tumor, infection)Disproportion(short chin, bull neck, large tongue,

small mouth)Dysmobility(TMJ, cervical spine)

WILSON RISK SCORE

Weight (0=<90kg,1=90-110kg,2=>110kg)Head and neck movement

(0=>90°,1=90°,2=<90°)Jaw movement (0=IG>5cm,SL>0,

1=IG<5cm,SL=0, 2=IG<5cm,SL<0)Receding mandible (0=normal, 1=moderate,

2=severe)Buck teeth (0=normal, 1=moderate, 2=severe)Total max 10 points

MAGBOUL 4 MS

MallampatiMeasurementMovementMalformation of STOP

(Skull,Teeth,Obstruction,Pathology)

EVALUATE 3-3-2

• Temporal Mandibular Joint• Should allow 3 fingers between incisors• 3-4 cm

EVALUATE 3-3-2

• Mandible• 3 fingers between mentum & hyoid bone• Less than three fingers

• Proportionately large tongue • Obstructs visualization of glottic opening

• Greater than three fingers• Elongates oral axis• More difficult to align the three axis

EVALUATE 3-3-2

• Larynx• Adult located C5,6• If higher, obstructive view of glottic opening• Two fingers from floor of mouth to thyroid cartilage

PERSIAPAN DASAR INTUBASI SULIT

- Laringoskop berbagai ukuran- ETT berbagai ukuran- Introducer (stylet, elastic bougie)- Oral dan nasal airway- Set krikotirotomi- Suction- Assistant yang terlatih- LMA berbagai ukuran

- Preoksigenisasi 100% O2 - Posisi pasien optimal untuk ventilasi dan intubasi- Konfirmasi ETT setelah intubasi dilakukan

TEHNIK MEMEGANG MASK DENGAN SATU TANGAN

MEMEGANG SUNGKUP DENGAN DUA TANGAN

INTUBASI ENDOTRAKEA

INDIKASI:- Proteksi jalan nafas- Menjaga patensi jalan nafas- Pulmonary toilet- Memberi PEEP- Menjaga oksigenasi yang adekuat

KOMPLIKASI INTUBASI

- TRAUMA PADA GIGI, GUSI, BIBIR- SPASME LARING,SPASME BRONKUS- ASPIRASI- HIPOKSEMIA DAN HIPERKARBIA- HIPERTENSI, TAKIKARDIA, DISRITMIA- PADA ANAK DPT TERJADI BRADIKARDI- ISKEMIA JANTUNG, GAGAL JANTUNG- TIK MENINGKAT, HERNIASI BATANG OTAK

DIFFICULT AIRWAY ALGORITHM

• Consider the relative merits & feasibility of basic management choices:

A. Awake intubation vs Intubation attempts after induction of general anesthesia.

B. Noninvasive technique for initial approach to intubation vs Invasive technique for initial approach to intubation.

C. Preservation of spontaneous ventilation vs Ablation of spontaneous ventilation.

DIFFICULT AIRWAY ALGORITHM (CON’T)

• Develop primary & alternative strategies:

Awake Intubation

Airway approached by noninvasive intubation

Airway secured by invasive access

Succeed Fail

Cancel case

Consider feasibility of other options

Invasive airway access

A

DIFFICULT AIRWAY ALGORITHM (CON’T)

• Intubation attempts after induction of General Anesthesia:

Intubation successful

Face mask ventilation Adequate

From this point onward consider:1. Call for help.2. Returning to spontaneous ventilation.3. Awakening the patient.

Intubation unsuccessful

Face mask ventilation not AdequateLMA

adequateLMA not adequateC D

B

DIFFICULT AIRWAY ALGORITHM (CON’T)

• Nonemergency pathway:

Ventilation adequate, intubation unsuccessful

Alternative approaches to intubation

Intubation successful

Fail after multiple attempts

Invasive airway ventilation

Awaken patient

Consider other options

C

DIFFICULT AIRWAY ALGORITHM (CON’T)

• Emergency pathway:

Ventilation Inadequate, intubation unsuccessful Call for

help

Ventilation successful

Fail Emergency invasive airway access.

Invasive airway ventilation

Awaken patient

Consider other options

D

Emergency noninvasive airway ventilation

The most important part of success in the management of a difficult airway is preparation !!!

CASE DISCUSSION:

• Male, 57th years, Goiter, elective total thyroidectomy or RND.

• Difficult ventilation:+

• Difficult intubation:+

• Cooperate: +• Difficult

tracheostomy: +

CONCLUSION

• Airway management is unequivocally the most important responsibility of the emergency physician. No matter how prepared for the task, no matter what technologies are utilized, there will be cases that are difficult.

CONCLUSION (CON’T)

• The most important part of success in the management of a difficult airway is preparation.

• When the patient is encountered, it is too late to check whether appropriate equipment is available, whether a rescue plan has been in place, and what alternative strategies are available for an immediate response.

TERIMA KASIH

Universal emergency airway algorithm

Main emergency airway algorithm

Crash airway algorithm

Difficult airway algorithm

Failed airway algorithm