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DISAMPAIKAN OLEH; GOODMAN BIN MOSITI PENOLONG PEGAWAI PERUBATAN U29 (BIUS) DEWAN BEDAH, HOSPITAL PITAS KURSUS “BASIC LIFE SUPPORT” (BLS)

AIRWAY ADJUNCT

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  • 1.DISAMPAIKAN OLEH;GOODMAN BIN MOSITI PENOLONG PEGAWAI PERUBATAN U29 (BIUS) DEWAN BEDAH, HOSPITAL PITAS KURSUS BASIC LIFE SUPPORT (BLS)

2. PENGENALAN

  • Sebahagian peralatan tambahan / bantuan yang digunakanbagi pengendalian dan pengurusan salur pernafasan mangsa.
  • Membantu membuka saluran pernafasan pesakit / mangsa semasa tidak sedarkan diri dan memudahkan dalam pemberian oksigen (ventilasi) kepada.

3. Mekanisma Semasa Pesakit Tidak Sedar Diri

  • Pesakit tidak dapat menjaga salur pernafasan sendiri.
  • Salur pernafasan akan tersumbat oleh;
  • -Lidah(Flacid tongue)
  • - Relaxed hypopharyngeal
  • -Epligotis
  • -Muntah
  • -Gigi palsu
  • -Dsb

4. ALGORITHM AIRWAY OPENING Unresponsive Patient Manual Maneuver Definitive Airway ABC (AIRWAY OPENING / CARE) Airway Adjunct

  • Oropharyngeal
  • Nasophryngeal
  • LMA
  • Proceal
  • Intubating LMA
  • Combitube
  • Surgical Airway
  • Head Tilt Chin Lift
  • Jaw Trust
  • Modifed Jaw Trust
  • Endotracheal Tube (ETT)

-Oral -Nasal -Jet Insufflation -Cricothyroidotomy -Tracheostomy 5. JENIS-JENIS OROL AIRWAY 6. OROPHARYNGEAL AIRWAY

  • Oral Airway / OPA / Guedel Airway
  • Dicipta olehArthur E. Guedel(1883-1956)
  • Size: 000,00,0,1,2,3,4,5,6 /C o l o u rCode
  • Kebaikan:- Mudah didapati / dikendali
  • - MemudahkanSuction
  • -Bite Block(mengelak pesakit
  • menggigit tiub ETT )
  • -Kurang Allergen

7. OROPHARYNGEAL AIRWAY

  • INDIKASI;
  • -Pesakit yangtidak sedar diri
  • -Pesakitspontaneusly breathing
  • - Total hilanggag reflex
  • - Digunakan sebagaibite block
  • KONTRAINDIKASI;
  • -Pesakit sedar, ada gag reflex, susah buka mulut, masive oral trauma
  • -Mandibulo-maxillary wiring
  • KOMPLIKASI;
  • -Terlalu panjang: Menekan epligotis
  • -Terlalu pendek : Menolak lidah ke belakang
  • -Menyebabkan batuk, muntah danlaryngospasme
  • -Aspiration

8. OROPHARYNGEAL AIRWAY

  • Menentukan Size OPA:
  • i) Coner of mouth to earlobe
  • ii) Against patients face to
  • angle of the mandible

9. OROPHARYNGEAL AIRWAY

  • Tatacara memasukkan OPA
  • -Bersihkan oral pesakit(suctioning)
  • Teknik 1)Gunatongue bladeuntuk menekan lidah pesakit dan masukan OPA ke belakang (disarankan untuk infant).
  • Teknik 2)Insert the oral airway upside down until the softpalate is reached. Rotate the device 180 degrees and slip it over the tongue.
  • step 1step 2step 3st ep 4

10. NASOPHARYNGEAL AIRWAY

  • Dikenali juga sebagai NPA / nasal trumpet
  • Diperbuat daripada getah / plastik lembut
  • Mula diperkenalkan pada 1972.
  • INDIKASI;
  • -Pesakitspontaneously breathing
  • -Pesakit yang dikontraindikasi bagi Guedel airway
  • -Boleh digunakan walaupun pesakit ada gag reflex
  • -Pesakit tidak di intubasi.
  • KONTRAINDIKASI;
  • -Kakitangan tidak terlatih
  • -Kecederaan kepala / muka yang
  • teruk
  • -Basal Skull fracture
  • -Hidung tersumbat / jangkitan
  • -Struktur Kongenital, bleeding disorder

11. NASOPHARYNGEAL AIRWAY

  • Size;
  • -12F, 14F, 16F, 18F34F, 36F
  • -Guna ukuran Internal diammeter (I.D)
  • -Pilihan size; ? sama besar dengan jari klingking pesakit
  • -Penjang (mm); Tip of nose to tragus of
  • the ear

12. NASOPHARYNGEAL AIRWAY

  • Tatacara;
  • -Pilih saiz yang sesuai
  • -Sapukan NPA dengan Lignocaine jel
  • -Pilih lubang hidung yang tidak tersumbat
  • -Masukkan dengan berhati-hati (elak kecederaan)
  • -Jika terdapat resistant, pusing sedikit NPA
  • -Kekalkan Head tilt

13. NASOPHARYNGEAL AIRWAY

  • KOMPLIKASI;
  • -Terlalu Panjang:- Kecederaan pada epligotis / vocal cord / vagal stimulation
  • -Injured nasal mucosa; pendarahan
  • -Alahan
  • -Kurang Selesa

14. LARYNGEAL MASK AIRWAY

  • Supraglottic airway management device.
  • Also called LMA
  • Designed between1981 and 1988 by Dr. Archie I. J. Brain.
  • Cuff device that provides sufficient seal to allow for positive pressure ventilation to be delivered
  • Tiga komponen utama:airway tube, mask, and inflation line
  • Alternative airway device used for anesthesia and airway support in emergency (difficult intubation).
  • It is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation.
  • All parts are latex-free.

15. LARYNGEAL MASK AIRWAY

  • Indications:
  • -The Laryngeal Mask Airway is an appropriate airway
  • choice when mask ventilation can be used but
  • endotracheal intubation is not necessary.
  • -Guide for endotracheal intubation (Fastrach)
  • -Unanticipated difficult intubations
  • -Failed intubation
  • -Intubation of patients with limited head/neck
  • movement

16. LARYNGEAL MASK AIRWAY Type of LMA Description

  • LMA Classic (CLMA)
  • LMA (ambu)
  • he original LMA airway with the basic features and components
  • Designedbase an oral structure
  • LMA Unique
  • A disposable version of the CLMA
  • LMA ProSeal (PLMA)
  • An advanced form of LMA that has been specifically designed for use with positive pressure ventilation (PPV) with and without muscle relaxants at higher airway pressures
  • LMA Flexible
  • Single Use LMA Flexible
  • Both of these feature a wire-reinforced, flexible airway tube that allows it to be positioned away from the surgical field
  • LMA Fastrach
  • An intubating LMA that is designed to facilitate intubation with a special flexible cuffed endotracheal tube (ETT)
  • LMA Ctrach
  • A variant of the LMA Fastrach with an integrated fiberoptic system that allows visualization of the anatomical structures immediately in front of the aperture of the mask via a detachable, portable color display screen

17. LARYNGEAL MASK AIRWAY Proceal LMA LMA Classic LMA Fastrach LMA Unique ETT for LMA Fastrach Handle of Proceal 18. LMA Classic 19. LMA Ambu 20. LARYNGEAL MASK AIRWAY Proceal LMA Fastrach LMA 21. PANDUAN SAIZ LMA 22. LARYNGEAL MASK AIRWAY Advantages Disadvantages

  • Increased speed and ease of placement by inexperienced personnel

Lower seal pressure

  • Increased speed of placement by anesthetists

Higher frequency of gastric insufflation

  • Improved hemodynamic stability at induction and during emergence
  • Minimal increase in intraocular pressure following insertion
  • Reduced anesthetic requirements for airway tolerance
  • Lower frequency of coughing during emergence
  • Improved oxygen saturation during emergence
  • Lower incidence of sore throats in adults

23. Contraindications to LMA Use

  • Non-fasted including patients whose fasting cannot be confirmed
  • Grossly or morbidly obese
  • >14 weeks pregnant
  • Multiple or massive injury
  • Acute abdominal or thoracic injury
  • Any condition associated with delayed gastric emptying
  • Patients with a fixed decreased pulmonary compliance
  • Patients where the peak inspiratory pressures are anticipated to exceed 20-30 cm H 2 O
  • Adult patients who are unable to understand instructions or cannot adequately answer questions regarding their medical history

24. TATACARA MEMASUKKAN LMA 25. LANGKAH-LANGKAH MEMASUKAN LMA 1. Press the mask up against the hard palate. Note the flexed wrist. 2. Slide the mask inward, extending the index finger 3. Press the finger towards the other hand, which exerts counter-pressure 4. Advance the LMA cuff into the hypopharynx until resistance is felt 5. Hold the outer end of the airway tube while removing the index finger Correct position of LMA 26. COMPLICATION USE LMA

  • Oral trauma
  • Laryngo-spasm
  • Aspiration
  • Incorrect position; hypoxia
  • Dislodge

27. COBRA LMA TERBARU.!!!! 28. COMBETUBE

  • The Combitube is a twin lumen device designed for use in emergency situations and difficult airways. It can be inserted without the need for visualization into the oropharynx, and usually enters the esophagus. It has a low volume inflatable distal cuff and a much larger proximal cuff designed to occlude the oro- and nasopharynx
  • If the tube has entered the trachea, ventilation is achieved through the distal lumen as with a standard ETT. More commonly the device enters the esophagus and ventilation is achieved through multiple proximal apertures situated above the distal cuff. In the latter case the proximal and distal cuffs have to be inflated to prevent air from escaping through the esophagus or back out of the oro- and nasopharynx.

29. COMBITUBE 30. COMBITUBE

  • Used effectively in cardiopulmonary resuscitation andpatient with difficult airways secondary to severe facial burns, trauma, upper airway bleeding and vomiting where there was an inability to visualize the vocal cords.
  • It can be used in patients whose cervical spine has been immobilized with a rigid cervical collar.
  • The Combitube can only be used in the adult population as no pediatric sizes are available.
  • Complications of the Combitube include an increased incidence of sore throat, dysphagia and upper airway hematoma when compared to endotracheal intubation and LMA.
  • Esophageal rupture is a rare complication but has been described.

31. ENDOTRACHEAL TUBE

  • Called ETT / ET Tube
  • Used in GA, ICU, EM,
  • Invasive Airway management
  • Mechanical Ventilation
  • Sir Ivan Whiteside Magill(1888-1986)

32. TRACHEAL INTUBATION

  • Oral
  • Nasal
  • Fiberopticendoscopy

33. INDICATIONS

  • Provide patent airway
  • Prevent aspiration
  • Facilitate IPPV
  • Operative positions
  • Difficultairway maintenance
  • Suctionof respiratorytract
  • Thoracicoperations
  • Disease involving upper airway

34.

  • PERALATAN UNTUK INTUBASI
  • Laryngoscopeandspare
  • ET tubes/connector
  • Stilette
  • Magillforceps
  • 20 mlsyringe
  • Securingtapes /bandage
  • LA 4 % lignocanespray
  • Cocainegel -nasal
  • Lubricant
  • Throat packs
  • GA machine, facemask,airways

35. PREPARATION

  • Assess patients
  • Oralversusnasalintubation?
  • Checkequipment
  • Assistantrequired
  • Check Ventilator / BVM
  • checksuction pump
  • Correctsizesofscopes andblades
  • Correct sizesof ET tubes

36. Equipment Required for Successful Intubation (F.E / M.A.L.E.S) 37.

  • TYPE OF INDUCTION
  • Rapidsequenceinduction
  • 2. Normal sequenceinduction

38.

  • OROTRACHEAL INTUBATION
  • 1. Positionofthepatient
  • -Heightoftable
  • -Elevatepatientshead
  • -Useofheadring/ padunder occiput

39. Technique of Endotracheal Intubation 40.

  • -Sniffingposition
  • -Align oral,pharyngealandlaryngeal axis
  • -Lipstoglottic opening- straight line
  • -Open patientsmouthwithrightthumb
  • 2.Direct laryngoscope
  • -Hold laryngoscopein Lthand
  • -InsertbladeintoRtsideof mouth
  • -Deflectthetongueto the left

41.

  • 3. VISUALIZETHE EPIGLOTTIS
  • -Advancebladeinthemidline
  • -Untilepiglottisvisualized
  • -Advancetipofbladeinto vallecula
  • -Orbeneathepiglottis -straightblade
  • -Forward& upwardmovement
  • -Elevateepiglottis
  • -Exposeglotticopening
  • -Depression ofthyroidcartilage
  • -Exposureofglotticopening

42.

  • 4.PLACEMENTOF ETTUBE
  • -Introducetubewith Rthand
  • -ThroughRtsideofmouth
  • -Advancetubethroughglottic opening
  • -Until calfjustpassesvocalcord
  • -Removescopeblade
  • -Inflatethecuff
  • -IPPV absenceofair leak

43.

  • 5.CONFIRMATION OFETTUBE PLACEMENT
  • -Co2 in exhaledgases
  • -Bilateralbreathsounds
  • -Epigastric auscultation
  • -Foggingofwatervapour intube
  • -MaintenanceofO2saturation

44.

  • 6. Secure tube withtape/bandage
  • 7.ContinueIPPPV
  • NASAL INTUBATION
  • -Dental / ENT operations
  • -Longtermintubation
  • -Pre- formednasaltube
  • -Smallerinsize

45.

  • -Choosenostrilthat breath moreeasily
  • -Lubricatetube
  • -Inserttubethroughnostril
  • -Advancetubeuntil tip visualized inthe orophargynx
  • -AdvancedistilendofET tube intotracheal throughvisualizes glotticopening

46.

  • -Usedofmagillforceps
  • -Avoiddamageto cuff
  • -Confirmtube placement
  • -Cufftube
  • -Insertionofmoistgauzepack
  • -Securetube

47.

  • FIBREOPTIC INTUBATION
  • Difficultairway/ intubation
  • Glottic openingcannotbevisualised
  • Awake intubation
  • Oralornasal

48.

  • ORAL ET TUBE SITE GUIDELINE

AGE INTERNAL DIAMETER(mm) LENGTH(cm) Premature 2.5 10 neonate 3.0-3.5 10-11 6-12mth 11-12 3.5-4.0 2 years 4.5 13 4 years 5.0 14 6 years 5.5 15 8 years 6.0 16 10 years 6.5 17 12 years 7.0 18 49.

  • ORALETTUBESIZE GUIDELINES

AGE ADULT INTERNALDIAMETER (mm) LENGTH ( CM ) Female 7.0-7.5 18-20 Male7.5-9.0 22-24 50.

  • FORMULA : For paediatric :
  • Internal diameter : 4+agemm
  • length : 12 +agemm ( oral )
  • nasal: 15 +agemm

4 2 2 51.

  • COMPLICATIONSOFENDOTRACHEAL INTUBATION
  • 1.During intubation
  • Aspiration
  • Malpositioning
  • Esophagealintubation
  • Endobronchial intubation
  • Aspiration
  • Dental damage
  • Injury to lipsand gums

52.

  • Activationof sympathetic nervoussystem
  • Bronchospasm
  • Sore throat
  • Dislocated mandible
  • 2. AFTER EXTUBATION
  • Aspiration
  • Laryngospasm
  • Transientvocalcordincompetence
  • Glotticor subglottic oedema
  • Pharyngitis ortracheitis

53.

  • DIFFICULT INTUBATION
  • 1 in65 patients
  • Difficultywith laryngoscopy
  • Causeof mobidity & mortality
  • sequelae
  • - dental&airwaytrauma
  • - pulmonaryaspiration
  • -hypoxaemia

54.

  • CAUSESOFDIFFICULTINTUBATION
  • Inadequateassessment
  • Inadequateequipmentpreparation
  • Inexperience
  • Poor technique
  • Equipment
  • -Malfunction
  • -Unavailability
  • -Notrainedassistant

55.

  • PATIENT
  • Congenital
  • -syndromes (Downs, Pierre Robin)
  • Achondroplasia
  • Cystichygroma
  • Encephalocele
  • Acquired
  • -Reducedjawmovement
  • i)Trismus
  • ii) Fibrosis

56.

  • - tumours
  • - Jawwiring
  • Reducedneckmovement
  • - Rheumatoid / osteoarthritis
  • - ankylosingspondylitis
  • - cervical # /fusion
  • Airway
  • -oedema
  • - compression
  • - scarring

57.

  • - tumours/polyps
  • - Foreignbody
  • - Nervepalsy
  • Others
  • - mobidobesity
  • - pregnancy
  • - acromegaly

58.

  • ANATOMICALFACTOR : DIFFICULTLARYNGOSCOPY
  • Shortneck
  • Protudingincisions
  • Longhigharchedpalate
  • Recedinglowerjaw
  • Poormobilityof mandible
  • anteriordepthofmandible
  • Reducedjawopening
  • Reducedneckextension

59.

  • DIFFICULT INTUBATION KIT
  • Airway adjuncts
  • Gumelastic bougies/ ETtubes
  • Cricothyrotomyneedle
  • Jetventilation
  • Maccoy Blade

60. Extreme Clinical Situations

  • Tracheostomy
  • LA

61. CLASSIFICATION OF MALLAMPATI TEST 62. FAIL INTUBATION PROTOCOL Kong Thau Chin 63. 64. THANK YOU