AIRWAY MANAGEMENT

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

JALAN NAFAS ATAS

1. 2. 3. 4.

HIDUNG FARING LARING TRAKEA

LARYNG (VOICE BOX)

- separates pharyng and trachea - cartilages, membrane, ligaments

45 mm long, 35 mm - 35 mm long, 25 mm
-

FUNCTION
- Patent airway

To act as a switching

mechanism to route air and

9 Pieces of cartilages form the larynx 1. Thyroid cartilage (Adams 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 epithelium Functions 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 ligament Landmark for making an emergency or long term airway (tracheotomy) 4&5. Arytenoid Cartilage 6&7. Corniculate Cartilage 8&9. Cuneiform Cartilage

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

SELLICKS MANEUVRE Used to prevent gastric distention Technique Apply slight pressure anteriorly over cricoid cartilage Closes off esophagus

SELLICKS MANUEVER

MOVEMENTS OF VOCAL CORDS

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

Glottis & Epiglottis

epiglottis glottis

Respiratory Physiology
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 !!

BRAIN

AIRWAY & RESPIRATION

CARDIO VASCULAR
Fig. Three main organs influenced by anesthetic agents.

SUATU SEBAB PENDERITA TAK SADAR

RELAKSASI OTOT

HILANG REFLEKS PERLINDUNGAN

LIDAH

KLEP

SUMBATAN JALAN NAFAS

MUNTAH REGURGITASI

ASPIRASI

SUMBATAN SUMBATAN JALAN JALAN NAFAS NAFAS Look / Lihat Perubahan Status Mental Agitasi / gelisah Hipoksemia Obtundasi / teler Hiperkarbia Gerak Nafas Normal See saw / rocking Retraksi Deformitas Debris Darah / sekret Muntahan Gigi Sianosis

PEMBEBASAN PEMBEBASAN JALAN JALAN NAFAS NAFAS

PENYEBAB LIDAH Manual : - Non trauma : Head tilt Neck lift Chin lift Jaw thrust - Trauma : Chin lift Jaw thrust Dengan in-line manual immobilization atau pasang cervical collar Bantuan Alat - Oropharyngeal airway - Nasopharyngeal airway

PEMBEBASAN PEMBEBASAN JALAN JALAN NAFAS 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: OBESE 1. Obese (BMI>26 kg/m2) 2. Bearded 3. Elderly (>55 th) 4. Snorers 5. Edentulous

EVALUASI KESULITAN INTUBASI

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

SKALA LEMON ATAU MELON

Look externally Evaluate 3-2-1 rule Mallampati Obstruction Neck 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 deformities Mallampati Measure 3-3-2-1 fingers Atlanto-occipital extension Pathological obstructive conditions

4D
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
Mallampati Measurement Movement Malformation 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. B. Awake intubation vs Intubation attempts after induction of general anesthesia. Noninvasive technique for initial approach to intubation vs Invasive technique for initial approach to intubation. Preservation of spontaneous ventilation vs Ablation of spontaneous ventilation.

C.

DIFFICULT AIRWAY ALGORITHM (CONT)

Develop primary & alternative strategies:

A
Succeed Cancel case

Awake Intubation Airway approached by noninvasive intubation Fail Consider feasibility of other options Invasive airway access Airway secured by invasive access

 Intubation attempts after induction of General Anesthesia:

Intubation successful Intubation unsuccessfu l point onward consider: From this

DIFFICULT AIRWAY ALGORITHM (CONT)

1. Call for help. 2. Returning to spontaneous ventilation. 3. Awakening the patient. Face mask ventilation Adequate Face mask ventilation not Adequate LMA not LMA adequate adequate

DIFFICULT AIRWAY ALGORITHM (CONT)

Nonemergency pathway:
Ventilation adequate, intubation unsuccessful Alternative approaches to intubation Intubation successful Fail after multiple attempts

Invasive airway ventilation

Consider other options

Awaken patient

DIFFICULT AIRWAY ALGORITHM (CONT)

Emergency pathway:
Ventilation Inadequate, intubation unsuccessful Call for help airway Emergency noninvasive ventilation Ventilation successful

Fail Emergency invasive airway access.

Invasive airway ventilation

Consider other options

Awaken patient

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 (CONT)
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