AIRWAY MANAGEMENT

AND
FBAO

dr. Prabowo Wicaksono Y.P., SpAn KMN., M. Bio Med.

BAGIAN ANESTESI FK UNISSULA

 2

AIRWAY MANAGEMENT
Apa ke-khusus-an penanganan pasien gawat darurat ? 3

Waktu untuk bertindak : terbatas

Data dasar untuk bertindak : terbatas

Konsep berfikir yang sederhana

Tindakan yang sistematik
Ketrampilan yang memadai
 4
PASIEN TRAUMA/ NON TRAUMA

A = airway
LIFE SUPPORT
B = breathing
Resusitasi
C = circulation
Stabilisasi
D = disability

TERAPI DEFINITIF/
SPESIALISTIK
 5
Life support
A ─B─ C─ D ─ E
Quick Diagnosis – Quick Treatment

A= Airway, bebaskan jalan nafas, Lindungi C-spine

B= Breathing, beri bantuan nafas, tambah oksigen
C= Circulation, hentikan perdarahan, beri infus
D= Disability/SSP, cegah TIK ↑
E= Exposure, buka semua baju, cegah hipotermi

Pasien obstruksi (A) atau apneu (B) akan mati dalam 3-5 menit
Pasien shock berat (C) akan mati dalam 1-2 jam
Pasien coma (D) akan mati dalam 1 minggu
 6
Bagaimana mengamankan jalan nafas?

Intubasi trakea = Gold standard

?
Bagaimana pendapat para ahli anestesiologi?
1.Intubasi oleh bukan ahli dapat timbulkan trauma
2.Resiko: hipoksia fatal/ secondary brain damage,
vagal reflex→ bradikardi berat, cardiac arrest
3.TIK naik hanya dapat dicegah dengan obat-obatan
4.Tidak semua fasilitas kesehatan dilengkapi peralatan untuk
intubasi trakea
 7

Trauma wajah berat, dengan potensi obstruksi airway

Intubasi trakea ? Setuju
 8

Obstruksi airway karena lidah terdorong ke

hipofaring, lebih sering terjadi.
Intubasi trakea ?
 9

Pasien mati karena hipoksia, bukan karena tidak

terpasang endotrakeal tube (ETT)

Tidak semua masalah airway harus

diselesaikan dengan intubasi trakea
 Banyak Cara Mengamankan Jalan Nafas
10

1. Basic/ Manual

A. Chin Lift

B.Jaw Thrust
 11

C. Head tilt – Chin lift

2. Airway (Alat Bantu Nafas) Dasar 12

A. Oropharyngeal Airway (OPA) / Guedel

B. Nasopharnygeal Airway (NPA)

3. Advanced Airway
13

A. Endotrakeal Tube (ETT)

B. Laryngeal Mask Airway (LMA)

 14

C. Combitube
 Airway 15

Menilai jalan nafas

Kesadaran (“ the talking patient”)

Look, Listen and Feel

Look
•Agitasi (hipoksia)/ tampak bodoh (hiperkarbia)
•Sianosis
•Retraksi
•Accessory respiratory muscle
 16
Listen
•Snoring
•Gurgling
•Stridor
•Hoarness

Feel
•Trachea location
Patients talks clearly ? 17

Airway is adequate
Management: observation and selective intubation
Special consideration in :
•Maxillofacial injury
•Soft-tissue injury of the neck
•Facial or neck burns
Patient is hoarse ? 18

Laryngeal injury
Larngeal/ tracheal burn
Management: Evaluate and perform (if necessary):
•Intubation
•Surgical airway

Patient cannot respond ?

•GCS ≤ 8
•Obstruction due to: Tongue
Aspiration
Foreign body
Maxillofacial injury
Neck Injury
•Cyanosis
•Rocking respirations
•Decreased or no air exchange 19

•Face or neck crepitus

•Neck hematoma or swelling

Management :
Simple management manuevers:
•Suction
•Chin lift
•Jaw thrust
Intubation

Caution !! Protect C-Spine During

Airway Management
 20

C-spine protection during airway management

 Airway Definitive 21

Pipa dalam trakea dengan balon (cuff) yang dikembangkan.

3 macam:
•Orotrakeal (Intubasi Oral)
•Nasotrakeal (Intubasi Nasal)
•Surgical airway (Krikotiroidotomi/ trakeostomi)
 Airway 22

DEFINITIVE
SURGICAL : Krikotiroidotomy
: Trakeostomy

NON SURGICAL : Oral Intubation

: Nasal Intubation

NON DEFINITIVE
OROPHARYNGEAL AIRWAY
NASOPHARNGEAL AIRWAY
23
 24

OBJECTIVE
 Clear and protected airway

 Oxygenation

 Positive pressure ventilation

 25
Basic Airway Manuever
1. Chin Lift
•Tidak boleh akibatkan hiperekstensi
leher.
•Aman untuk C-spine pada korban
trauma
2. Jaw Thrust 26

•Pegang pada angulus

mandibulae, dorong mandibula
ke depan (ventral ).
•Aman untuk C-spine pada
korban trauma
Jaw Thrust Technique 27
3. Head tilt – Chin lift 28

•Gabungan antara manuver Head tilt

dan Chin lift.
•Head tilt: meletakkan telapak tangan di
dahi, kepala diekstensikan.
•Pada pasien trauma: hati-hati cedera
pada C-spine.

•Pada pasien multipel trauma dengan suspek cedera cervical,

manuver yang paling aman : Jaw Thrust.
•Bila dengan Jaw Thrust tidak bisa buka airway: lakukan Head
Tilt – Chin Lift dengan ekstensi kepala minimal.
•Airway tetap merupakan prioritas, meski terdapat cedera C-
spine.
Head Tilt and Chin Lift 29
 30

Jangan Lakukan !!
 Airway Dasar 31

1. Oropharyngeal Airway (OPA)

•Menahan lidah tidak jatuh ke
belakang .
•Fasilitas suction.
•Mencegah lidah/ ETT tergigit

•Merangsang muntah pada pasien

sadar/ setengah sadar.

•Hati – hati pada anak dapat lukai

jaringan lunak.
 32
Oropharyngeal Airway/Guedel

NO: 0 1 2 3 4 5 6
How to measure the right size of 33

Oropharyngeal Airway

Komplikasi
 Obstruksi total
 Laringospasme
 Muntah
 Cara Pemasangan Oropharyngeal Airway
34
Dimasukkan mulut dg lengkungan menghadap palatum.
Setelah masuk separuh panjangnya, putar 180° hingga
lengkungan menempel pada lengkungan lidah.

1.
2.

3.
OPA INSERTION TECHNIQUE 35
2. Nasopharyngeal Airway (NPA) 36

Jalan nafas buatan dengan ujung di belakang lidah.

Hati hati pada fraktur basis cranii.
Indikasi:
Pasien setengah sadar dengan nafas spontan.
Lebih dapat ditoleransi pasien daripada OPA, kecil kemungkinan
rangsang muntah.
 37

Nasopharyngeal Airway
Komplikasi
Kerusakan mukosa nasal
Laryngospasme
Cara Pemasangan Nasopharyngeal Airway 38

Cara pemasangan: beri jelly pelicin, didorong memasuki

lubang hidung hingga ujung pipa terletak di orofaring. Arah ujungnya
datar menyusur dasar rongga hidung, arah menuju anak telinga
(tragus).

1.

2.

3.
 39
NPA INSERTION TECHNIQUE
 3. Advanced Airway 40

A.Endotrakeal Tube (ETT)

Keuntungan :
Menjaga jalan nafas terbuka
Mengurangi risiko aspirasi
Sebagai fasilitas ‘suction’ trakea
Sebagai fasilitas pemberian oksigen
konsentrasi tinggi
 41

Endotrakeal Tube Insertion (ETT)

Komplikasi
Hipoksia
Trauma
Muntah-aspirasi isi
lambung
Hipertensi
Disritmia jantung
Intubasi satu paru
Intubasi esofagus
Cardiac arrest akibat
vagal reflex
 42
Persiapan Intubasi Endotrakeal
1. Alat:
A. Laryngoscope
Terdiri dari : Blade (bilah) dan Handle (gagang).
Pilih ukuran blade yg sesuai.
Dewasa : no 3 atau 4
Anak : no 2
Bayi : no 1
Pasang blade dengan handle
Cek lampu harus menyala terang.
Laryngoscope 43
 Menyiapkan Laryngoscope
44
1. 2.

3. 4.
 Memegang Laryngoscope
45
Memegang laryngoscope
selalu dengan tangan kiri

Posisi tangan yang betul

adalah memegang pada
handle, bukan pada
pertemuan blade dan handle
Melepas Laryngoscope 46

Memasang dan melepas

laryngoscope selalu dengan
sudut 45°
B. Endotrakeal Tube (ET) 47

Pilih ukuran yang sesuai: (ID: Internal Diameter)

Dewasa : ID 6.5 , 7 atau 7.5 Atau ± sebesar
kelingking kiri pasien
Anak : ID = 4 + (Umur : 4)

Bayi : Prematur : ID 2.5

Aterm : 3.0 – 3.5
Selalu menyiapkan satu ukuran dibawah dan diatas.
Pilih ET yang High Volume Low Pressure (ETT putih/ fortex)
Bila memakai yg re-useable, cek cuff dan patensi lubang ET.
 48
ETT dissposible (Low
Pressure High Volume)

ETT re-usable (High

Pressure Low Volume)
Tidak dianjurkan.
C. Spuit 20 cc. 49

D. Stylet (bila perlu).

E. Handsgloves steril.
F. KY jelly.
G. Forcep Magill (bila perlu).
H. AMBU Bag dg kantung reservoir dihubungkan dengan
sumber oksigen.

I. Plester untuk fiksasi ETT.

J. Oropharngeal Airway.
H. Alat suction dg suction catheter .
K. Stetoscope.
2. Obat Emergency 50

- Sulfas Atropin (SA) dalam spuit

- Adrenaline dalam spuit.

3. Pasien
Informed consent mengenai tujuan dan resiko tindakan.

Ingat resiko/komplikasi intubasi bisa berakibat

fatal !!!
Persiapan Intubasi Endotrakeal 51
Langkah – langkah Intubasi Endotrakeal52
Ventilasi tekanan positif dan Oksigenasi
Harus dilakukan sebelum intubasi.
Dada harus mengembang selama ventilasi diberikan.
Oksigenasi dengan oksigen 100% (10 L/menit).
Bila intubasi gagal (waktu >30 detik), lakukan ventilasi dan
oksigenasi ulang, bahaya hipoksia !!!
 Posisi Tangan Saat Ventilasi Tekanan Positif
53

Ibu jari dan jari telunjuk

menekan face mask ke bawah
sambil mempertahankan sekat
yg tidak bocor antara face
mask dan penderita.

Jari tengah, jari manis dan

kelingking pada ramus
mandibula, mendorong ke atas
sambil membuka airway.
INTUBASI TRAKEA
54

Singkirkan lidah ke kiri

Cari Epiglotis
POSITION OF THE TIP OF LARYNGOSCOPE BLADE
55

LIDAH
VALEKULA
EPIGLOTIS

Trakea

Esofagus !!!

Sniffing Position
Mambantu Visualisasi laring
 ELEVASI LARINGOSKOP 56

Gunakan kekuatan tangan untuk mengangkat. Jangan diungkit dg

menggunakan gigi seri atas sebagai titik tumpu (awas patah!!).

Arah elevasi laringoskop Jangan diungkit !!!

INTUBASI TRAKEA 57
INTUBASI TRAKEA 58

Plica Vocalis Epiglotis Trakea

 59

BURP MANUEVER
 Menekan kartilago krikoid ke bawah, atas, kanan
(Back, Up, Right Pressure= BURP)
 Membantu visualisasi plika vokalis
 Dilakukan oleh asisten yg membantu intubator
ADAM’S APPLE

BURP

THYROID

CRICOID
 INTUBASI TRAKEA 60

G. H.Intubasi endobronkhial

Ujung distal cuff

Cara cegah intubasi endobronkhial:
Masukkan ETT hanya sampai ujung distal cuff lewati plica
vocalis
TEKNIK INTUBASI TRAKEA 61
Buka mulut dengan tangan kanan, gerakan jari menyilang (ibu jari menekan
mandibula, jari telunjuk menekan maksila)
Pegang laringoskop dg tangan kiri, masukkan melalui sisi sebelah kanan
mulut, singkirkan lidah ke samping kiri
Cari epiglotis. Tempatkan ujung bilah laringoskop di valekula (pertemuan
epiglotis dan pangkal lidah)
Angkat epiglotis dg elevasi laringoskop ke atas (jangan menggunakan gigi
seri atas sbg tumpuan !!!) untuk melihat plika vokalis
Bila tidak terlihat, minta bantuan asisten utk lakukan BURP manuver (Back,
Up, Right Pressure) pada kartilago krikoid sampai terlihat plika vokalis
Masukkan ETT, bimbing ujungnya masuk trakea sampai cuff ETT melewati
plika vokalis
Kembangkan cuff ETT secukupnya (sampai tidak ada kebocoran udara)
Pasang OPA
Sambungkan konektor ETT dg ambu bag. Beri ventilasi buatan. Cek suara
paru kanan = kiri, Awas intubasi endobronkial !!
Fiksasi ETT dengan plester
 Teknik Oral
62

2
 63

3
4
 64

5
Teknik Nasal 65

1 2
 66

4
 67

5
 68

MENCEGAH KOMPLIKASI
INTUBASI TRAKEA
Dilakukan oleh tenaga terlatih
Alat-alat intubasi lengkap : laryngoskop & pipa
trakea berbagai ukuran
Intubasi dilakukan < 30 detik
Dilakukan penekanan pada kartilago krikoid
(BURP Manuever)
Pilih pipa trakea ‘high volume low pressure
cuff’
RJP DENGAN PASIEN 69

TERPASANG ETT

Pasien dengan
intubasi trakhea,
bantuan ventilasi
tidak perlu sinkron
dengan kompresi
dada pada saat RJP
Airway Management 70
Intubation 71
 3. Advanced Airway 72

B. Laryngeal Mask Airway

Keuntungan :
•Teknik pemasangan lebih mudah
•Trauma lebih sedikit
•Tidak membutuhkan laringoskop

Kerugian :Tidak melindungi terhadap aspirasi

Laryngeal Mask Airway 73
Foreign Body Airway
Obstruction
(FBAO)
 Conscious Adult Choking 75

Steps Involved in Relief of FBAO ( Conscious)

1. To confirm that the victim is choking, ask: “Are you choking?”
If the victim is choking, he will not be able to Speak, Breathe or Cough.

If “YES”, say “I am trained, can I help?”

2. If the victim is upright, the rescuer stands behind the victim.

If the victim is sitting, the rescuer kneels down and positions himself
behind the victim.

3. Put your arms around the victim’s abdomen.

Place fist with thumb side against victim’s abdomen in the mid line about
2 fingers’ breadth above the navel and well below the tip of the xiphoid.
Give quick inward and upward thrusts in one motion into the victim’s
abdomen until the foreign body is expelled or the victim becomes
unconscious.
 ADULT HEIMLICH MANEUVER 76

Look for the Universal Sign of the victim's hand across their throat . . . . . . .

•if the victim is making sound or moving air, encourage them to cough.
•If the victim is not making sound, or is turning color, intervene.
•Announce to the victim that you know the Heimlich Manuver and can help!
•Have someone activate emergency medical system - CALL 911.
•Stand behind the victim with your arms wrapped around the 77
victims chest.
•Feel for the victim's xiphoid process with your right hand.
Make a fist with your left hand and place it (THUMB IN) below the right hand.
78

•Wrap the right hand over the left hand.

•Give inward and upward thrusts towards the shoulder blades.
•Repeat this until either the obstruction is removed, or the victim becomes
unconscious.
•If the victim becomes unconscious, assist them to the ground and perform
•C.P.R. CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE
SUPPORT IS AVAILABLE.
 79

Subdiaphragmatic abdominal thrust

(the Heimlich maneuver) administered to a conscious
(standing) victim of foreign body airway obstruction.
 80

Subdiaphragmatic abdominal thrust (the Heimlich

maneuver) administered to a conscious (standing)
victim of foreign body airway obstruction.
ADULT CHOKING MOVIE
81
 CHILD HEIMLICH MANUVER 82

Look for the Universal Sign of the victim's hand across their throat.

•If the victim is making sound or moving air, encourage them to cough.
•If the victim is not making sound, or is turning color, intervene.
•Announce to the victim that you know the Heimlich Manuver and can help!
•Have someone activate emergency medical system - CALL 911.
•If you are alone, perform Heimlich Manuver first, then call 911, because 83children
need air !!!

•Stand behind the victim with your arms wrapped around the victims chest.
•Feel for the victim's xiphoid process with your left hand.
•Make a fist with your right hand and place it (THUMB IN)below the left hand.
 84

Wrap the left hand over the right hand.

Give inward and upward thrusts towards the shoulder blades.
Repeat this until either the obstruction is removed, or the victim becomes
unconscious.
 85
•If the victim becomes unconscious, assist them to the ground and
perform C.P.R.

CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS

AVAILABLE.
CHILD CHOKING MOVIE 86
 INFANT HEIMLICH MANUVER 87
Intervene if the infant is turning color, or is not making sound !!!

•Place victim flat on his/her back with their head to your right, on
a hard surface.
With your left hand cupped in a "C" shape, grab the infant by the jaw
and rest the remainder of your arm across the infant's body. 88

•Lift the infant with your left hand and invert the victim so their body is resting across
the rescuer's left arm with the legs straddling your arm.
•Lower the victim's head.
•With the infant's back towards you, perform 5 back blows at the
level of the infant's shoulder blades with the heel of your right 89
hand.

Back blow in an infant.

•Sandwich the infant between both arms, supporting the head with your
90
right hand.
•Invert the victim to the right arm, facing upwards with the legs
straddling your right arm and move the victim to the level of your chest.
•Take the left hand,and extend the middle 3 fingers. Place them on the
infant's chest with the index finger in the center of the chest at the91 nipple-
line.
•Raise the index finger and depress sternum 1 inch using the remaining 2
fingers.
•Perform 5 compresions (Chest Thrust)
•Look in the infant's mouth to see if the foreign body has been
92
displaced.
 93

•If no air goes in, reposition the head and try again.
•If no response after 1 minute, call emergency medical system dial-911
•Return to victim and continue the Heimlich Manuver.

CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE

SUPPORT IS AVAILABLE.
INFANT CHOKING MOVIE
94
 Steps Involved in Relief of FBAO ( Conscious to Unconscious)
95

1. Ask: “Are you choking?”

2. Perform abdominal thrusts (Heimlich maneuver) / For pregnant and

very obese victims, perform chest thrusts.

If the victim becomes Unconscious,

3. Position the victim on his back and call “Help! Call 995”

4. Open the airway – Perform Head-Tilt-Chin Lift

5. Push chin down and check mouth for foreign body object

6. If foreign body is seen, If foreign body is seen, insert the index finger of
the other hand down along the inside of the cheek and deeply into the throat.
Use a hooking action to dislodge the foreign body and maneuver it out of
the mouth./ Take precaution not to force the foreign body deeper into the
throat. This maneuver is known as the finger sweep.
 Finger Sweep 96

Check for Foreign Body – use Push chin

down
If foreign body is seen, insert the index
finger of the other hand down along the
inside of the cheek and deeply into the
throat.

Use a hooking action to dislodge the foreign body and

maneuver it out of the mouth./ Take precaution not to
force the foreign body deeper into the throat. This man
oeuvre is known as the finger sweep.
 Steps Involved in Relief of FBAO ( Conscious to Unconscious)
97

7. Check breathing – Look, Listen and See

8. If there is no breathing, attempt to ventilate (1st ventilation). If the chest

does not rise, reposition victim’s head and reattempt to ventilate
(2nd ventilation)

9. If the chest does not rise again, give 30 chest thrusts. The hand position
for chest thrusts is the same as chest compression performed in CPR.

10. Repeat S/N 4 to 8 until there are 2 successful ventilations, and check the
breathing.
 98

The Self-Administered Heimlich Maneuver

1. To treat one’s own complete FBAO, make a fist with one hand, place
the thumb side on the abdomen above the navel (2 fingers breadth) and
below the xiphoid process, grasp the fist with the other hand, and then
press inward and upward toward the diaphragm with a quick motion.

2. If unsuccessful, the victim can also press the upper abdomen over any
firm surface such as the back of a chair, side of table, or porch railing.
Several thrusts may be needed to clear the airway.
 Chest Thrust 99

May be used as an alternative to Heimlich Maneuver. It is performed on

obese or pregnant victim.

1. To confirm that the victim is choking, ask: “Are you choking?”

If the victim is choking, he will not be able to Speak, Breathe or Cough.

If “YES”, say “I am trained, can I help?”

2. If the victim is upright, the rescuer stands behind the victim.

If the victim is sitting, the rescuer kneels down and positions himself
behind the victim.
3. Place your arms under the victim’s armpits to encircle the chest. 100
Place one fist with thumb side on the middle of the breastbone.
Grasp fist with the other hand and give successive quick backward
thrusts..
Deliver each thrust firmly and distinctly with the intent of relieving
the obstruction until the foreign body is expelled or the victim
becomes unconscious.
When the victim becomes unconscious, the rescuer should activate
emergency medical services by dialing 995 for an ambulance and
begin CPR.
 101

Chest thrust administered to a conscious victim (standing) of

foreign body airway obstruction.
 102

Chest thrust administered to an unconscious victim (lying) of

foreign body airway obstruction.
ATLS AIRWAY ALGORITHM
103
104
NEEDLE CRICOTHYROIDOTOMY 105
SURGICAL CRICOTHYROIDOTOMY 106
 107

Thank you.....