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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