Airway Management in Adults

dedi atila
Outline

Providing adequate oxygen concentration

Triple airway maneuver

Establishing a patent airway and secure airway

How to ventilate (deliver positive pressure ventilation)

CICV (can’t intubate can’t ventilate)

 Providing adequate oxygen concentration

Mitoko ATP = energy

ndria

O2
Sel
O2
O2 O2

O2 O2
O2
Providing adequate oxygen concentration

 Oxygen concentration O2
 Atmosphere pressure
 Airway patency
PATENT AIRWAY
OPEN THE AIRWAY
Lateral xanogram of the head &
neck in neutral position. Patient is
awake & supine.
Medial sagittal view of upper
airway showing site of upper
airway obstruction in sedated
patient.
 Patient positioning

Techniques to Head-tilt & Chin-lift

open airway
maneuver
Jaw-thrust maneuver
“Sniffing” position

•Flexing the cervical spine approx

15 degrees, and
•Extending the atlantooccipital Patient
joint maximally positioning

Lateral decubitus position

OPENING
AIRWAY (HEAD
POSITION)
HEAD-TILT
AND CHIN-
LIFT
Head-tilt and Chin-lift
Jaw thrust

 The operator is positioned at the head of

patient
 Places their fingers on the angel of
mandible bilaterally
 Displaces the mandible anteriorly
Jaw-thrust
Open mouth

 Open the Mouth using finger/thumb

 Indication : expiratory obstruction after head-

tilt
HEAD-TILT, JAW
THRUST AND
OPEN MOUTH
KNOWN AS
“TRIPLE AIRWAY
MANOUVER”
ESTABLISHING
A PATENT AIRWAY
AND SECURE AIRWAY
OROPHARYNGEAL
AIRWAY TYPES
Oropharyngeal
insertion
 Merupakan silinder panjang yg berbentuk lengkungan dan
lentur.

Nasopharyngeal Terbuat dr plastik atau karet lembut.

airway Panjang & lebar bervariasi.
Sirip proksimal mencegah overinsersi
NASO-
PHARYNGEAL
TUBE

Tidak merangsang
muntah
Hati-hati pada
pasien dengan
fraktura basis cranii
Ukuran u/ dewasa 7
mm atau jari
kelingking kanan
Nasopharyngeal
insertion
Nasopharyngeal
insertion
LARYNGEAL
MASK
AIRWAYS
(LMA)
• Ditemukan oleh Dr. Archie Brain di London
Hospital, Whitechapel pada tahun 1981
• Terdiri dari dua bagian:
– Sungkup/Mask
– Pipa / Tube
LMA telah terbukti sangat efektif dalam
tatalaksana jalan nafas pd keadaan kritikal
LMA TYPES
• Disain LMA :
– Pemasangan “bentuknya oval akan menempel di
sekitar saluran laring“, setelah LMA terpasang dan
balon dikembangkan.
– LMA akan terletak di persimpangan saluran
pencernaan dan pernapasan.
LMA
Teknik
Pemasangan
Masalah pada Pemasangan
LMA

 Gagalnya untuk mendorong sungkup di

bagian palatum durum atau lubrikasi atau
deflasi yang tidak adekuat dapat
menyebabkan ujung sungkup terlipat
kembali.
Masalah pada Pemasangan
LMA

 Setelah ujung sungkup sudah mulai terlipat,

ini bisa berlanjut, mendorong epiglotis ke
dalam posisi yang terlipat ke bawah
menyebabkan obstruksi mekanik
Masalah pada Pemasangan LMA

 Jika ujung sungkup

dikempiskan ke depan maka
dapat menekan epiglotis
menyebabkan obstruksi
 Jika sungkup deflasi tidak
cukup juga.
 menekan epiglottis
 menembus glotis.
 Intubasi
Endotrakeal
 Untuk mendukung ventilasi pada pasien dengan beberapa penyakit
patologis.
•Obstruksi jalan nafas atas
•Gagal respiratori
•Penurunan kesadaran

Indikasi Untuk mendukung ventilasi selama anestesi umum.

intubasi •Jenis pembedahan

•Operasi di aderah jalan nafas atas
endotrakeal •Operasi di abodominal dan torak
•Posisi prone dan lateral
•Operasi yang berlangsung lama

Pasien memiliki risiko aspirasi

Sulit dengan menggunakan sungkup

Laryngoscope :
Handle and Blade
 LARYNGOSCOPIC BLADE
 Macintosh (curved) and Miller (straight) blade
Dewasa : Macintosh blade, anak kecil : Miller
blade

Miller blade Macintosh blade

Sniffing position
DIFFICULT AIRWAY
 Metode “LEMON”
Menilai kemungkinan kesulitan tatalaksana jalan nafas
 L : Look externally (trauma wajah, gigi seri besar, janggut
atau kumis, dan lidah besar)

Airway  E : Evaluate the 3-3-2 rule (3 jari pasien membuka mulut,

jarak hyoid/mental < 3 ujung jari, jarak tiroid-mulut < 2
assesment ujung jari)
 M : Mallampati score

 O : Obstruction (adanya kondisi apapun yg bisa

menyebabkan hambatan jalan nafas)
 N : Neck Mobility (mobilitas leher terbatas)
Skor Mallampati

 Class I: visualisasi pallatum molle, fauce, uvula, pilar anterior dan posterior.
 Class II: visualisasi pallatum molle, fauce, dan uvula.
 Class III: visualisasi pallatum molle, fauce, dan dasar uvula.
 Class IV: pallatum molle tidak tampak.
  Darah di saluran nafas atas

 Benda asing

 Hematoma
Obstruksi
 Abses

 Pembengkakan intraoral

 Edema laring
Flexion and extension of neck
HOW TO VENTILATE
(DELIVER POSITIVE
PRESSURE
VENTILATION)
Bag-Valve-Mask (BVM) Ventilation
Bag-Valve-Mask (BVM) Ventilation

 administration of high flow O2

 provision of PEEP (positive end-expiratory pressure)
 provision of controlled ventilation
 provision of augmentation of spontaneous ventilation
 failed intubation and difficult ventilation (other than laryngospasm)

Face mask
Oxygenate and Ventilate patient
Maximum head extension 1
Maximum jaw thrust
Assistance with mask seal

Can’t Oral +/- 6mm nasal airway

Reduce cricoid force - if necessary

Intubate, failed oxygenation with face mask (e.g. SpO2 with FO2 1,0
Can’t Call for help 3
Ventilate 2
Succeed Oxygenation satisfactory
LMA Oxygenate and ventilate patient
and stable. Maintain
Maximum 2 attempts at insertion
oxygenation and awaken
Reduce any cricoid force during insertion
patient

Difficult Airway Society Guidelines Flowchart 2004 “can’t intubate, can’t ventilate” situation with increasing hypoxaemia

Plan D: Rescue techniques for “can’t

intubate, can’t ventilate” situation
 Cannula cricothyroidotomy Surgical cricothyroidotomy
Equipment: kink-resistant cannula, Equipment: Scapel - short and
e.g. Patil (Cook) or Ravussin (VBM) rounded (no. 20 or Minitech
High pressure ventilation system, scalpel)

Can’t e.g. Manujet III (VBM)

Technique
Small (e.g. 6 or 7mm) cuffed
tracheal or tracheostomy tube

Intubate, 1. Insert cannula through cricothyroid

membrane
4-step technique:
1. Identify cricothyroid membrane

Can’t
2. Maintain position of cannula - 2. Stab incision through skin and
assistant’s hand membrane Enlarge incision
3. Confirm tracheal position by air
Ventilate 4.
aspiration - 20ml syringe
Attach ventilation system to
with blunt dissection (e.g.
scalpel handle, forceps or
cannula dilator)
5. Commence cautious ventilation 3. Caudal traction on cricoid
6. Confirm ventilation of lungs and cartilage with tracheal hook
exhalation through upper airway 4. Insert tube and inflate cuff
7. If ventilation fails, or surgical Ventilate with low pressure source
emphysema or any other
complication develops - convert
Verify tube position and pulmonary
Difficult Airway Society Guidelines Flowchart 2004 ventilation
immediately to surgical
cricothyroidotomy
 merci 고마워
danke schön tack
고마워 ขอบคุณ
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