DIFFICULT AIRWAY

Yonansah Abiyoga
16710037
Pembimbing
dr. Bambang Soekotjo, MSc., Sp.An

1 - 18% pasien memiliki anatomi

jalan nafas yang sulit
0,05 - 0,35% pasien tidak dapat
diintubasi dengan baik
1 10 pasien yang memiliki
anatomi jalan nafas yang sulit
untuk diintubasi
DIFFICULT
AIRWAY

Anatomi Jalan Nafas

Pars nasalis,

merupakan jalan nafas

dari hidung menuju
nasofaring,
Pars oralis, merupakan
jalan nafas dari mulut
menuju orofaring

Klasifikasi Difficult Airway

(ASA)
1. Kesulitan

2.
3.
4.
5.

ventilasi
dengan
sungkup atau supraglottic airway
(SGA)
Kesulitan penempatan SGA
Kesulitan dilakukan laringoskopi
Kesulitan intubasi trakea
Kegagalan intubasi

Etiologi Difficult Airway

Sumbatan di atas laring
Lidah jatuh ke hipofaring
Benda asing
Infeksi atau tumor
Trauma di muka
Sumbatan pada laring
Corpal
Tumor
Trauma laring
Sumbatan di bawah laring
Tumor mendesak trakea
Corpal bronkus
Spasme bronkus (tumor bronkus)

Diagnosis Difficut Airway

Metode 4MS
1. Mallampati

2. Measurements

3 - Jari. Bukaan mulut.

3 - Jari. Jarak hypomental = dari manthus
sampai leher
2 - Jari antara thypiod sampai dasar dari
mandibula
1 - Jari. Subluksasi mandibula

3. Movement of the neck

4. Malformation of the Skull (S), Teeth (T),

Obstruction (O), Pathology (P) STOP

Algoritma ASA
Menentukan gejala dan manifestasi klinik dari

penatalaksanaan masalah dasarnya:

Ventilasi

sulit.
Intubasi sulit.
Kesulitan dengan pasien yang tidak kooperatif.
Sulit untuk ditrakeostomi.

Secara aktif mencari kesempatan untuk menangani

kasus-kasus penatalaksanaan jalan nafas sulit.

Mempertimbangkan kegunaan dan hal-hal dasar yang
mungkin dilakukan sebagai pilihan penatalaksanaan :
Intubasi sadar Versus Intubasi setelah Induksi pada GA.
Pendekatan tehnik intubasi non invasif Versus Pendekatan tehnik

intubasi invasif.
Pemeliharaan ventilasi spontan Versus Ablasi ventilasi spontan.

Membuat strategi utama dan alternatifnya

Algoritma Difficult Airway

Sederhana menurut difficult
Airway Society

Algoritma Difficult Airway Pada

Intubasi Trakea Pasien Dewasa
Menurut Difficult Airway Society

Unanticipated difficult tracheal intubationduring routine induction of anaesthesia in an adult patient

Direct
laryngoscopy

Any
problems

Call
for help

Plan A: Initial tracheal intubation plan

Direct laryngoscopy - check:
Neck flexion and head extension
Laryngoscope technique and vector
External laryngeal manipulation by laryngoscopist
Vocal cords open and immobile
If poor view: Introducer (bougie) seek clicks or hold-up
and/or Alternative laryngoscope

Not more
than 4 attempts,
maintaining:
(1) oxygenation
with face mask and
(2) anaesthesia

failed intubation

succeed

Tracheal intubation
Verify tracheal intubation
(1) Visual, if possible
(2) Capnograph
(3) Oesophageal detector
"If in doubt, take it out"

Plan B: Secondary tracheal intubation plan

ILMA TM or LMATM
Not more than 2 insertions
Oxygenate and ventilate

succeed

failed oxygenation
(e.g. SpO2 < 90% with FiO 2 1.0)
via ILMA TM or LMATM

Confirm: ventilation, oxygenation,

anaesthesia, CVS stability and muscle
relaxation - then fibreoptic tracheal intubation
through IMLA TM or LMATM - 1 attempt
If LMATM, consider long flexometallic,nasal
RAE or microlaryngeal tube
Verify intubation and proceed with surgery
failed intubation via ILMA TM or LMA TM

Plan C: Maintenance of oxygenation, ventilation,

postponement of surgery and awakening

Revert to face mask

Oxygenate and ventilate
Reverse non-depolarising relaxant
1 or 2 person mask technique
(with oral nasal airway)

succeed

Postpone surgery

Awaken patient

failed ventilation and oxygenation

Plan D: Rescue techniques for

"can't intubate, can't ventilate" situation
Difficult Airway Society Guidelines Flow-chart 2004 (use wit h DAS guidelines paper)

Unanticipated difficult tracheal intubation - during rapid s equence

induction of anaestheia in non-obstetric adult patient

Algoritma Difficult Airway

Menurut Difficult Airway Society

Direct
laryngoscopy

Any
problems

Call
for help

Plan A: Initial tracheal intubation plan

Pre-oxygenate

Cricoid force: 10N awake 30N anaesthetised

Direct laryngoscopy - check:
=
Neck flexion and head extension
=Laryngoscopy technique and vector
=External laryngeal manipulation =by laryngoscopist
=Vocal cords open and immobile
If poor view:
=Reduce cricoid force
=Introducer (bougie) - seek clicks or hold-up
=and/or Alternative laryngoscope

succeed

Not more than 3

attempts, maintaining:
(1) oxygenation with
face mask
(2) cricoid pressure and
(3) anaesthesia

Tracheal intubation
Verify tracheal intubation
(1) Visual, if possible
(2) Capnograph
(3) Oesophageal detector
"If in doubt, take it out"

failed intubation
Plan C: Maintenance of
oxygenation, ventilation,
postponement of
surgery and awakening

Maintain
30N cricoid
force

Plan B not appropriate for this scenario

Use face mask, oxygenate and ventilate

1 or 2 person mask technique
(with oral nasal airway)
Consider reducing cricoid force if
ventilation difficult

succeed

failed oxygenation
(e.g. SpO2 < 90% with FiO 2 1.0) via face mask

Postpone surgery
LMATM
Reduce cricoid force during insertion
Oxygenate and ventilate
failed ventilation and oxygenation

succeed

and awaken patient if possible

or continue anaesthesia with
LMATM or ProSeal LMA TM if condition immediately
life-threatening

Plan D: Rescue techniques for

"can't intubate, can't ventilate" situation
Difficult Airway Society Guidelines Flow-chart 2004 (use wit h DAS guidelines paper)

Failed intubation, increasing hypoxaemia and difficult venti lation in the paralysed
anaesthetised patient: Rescue techniques for the "can't intu bate, can't ventilate" situation

Algoritma Difficult Airway

Menurut Difficult Airway Society

failed intubation and difficult ventilation (other than lary ngospasm)

Face mask
Oxygenate and Ventilate patient
Maximum head extension
Maximum jaw thrust
Assistance with mask seal
Oral 6mm nasal airway
Reduce cricoid force - if necessary

failed oxygenation with face mask (e.g. SpO 2 < 90% with FiO 2 1.0)

call for help

LMATM Oxygenate and ventilate patient

Maximum 2 attempts at insertion
Reduce any cricoid force during insertion

succeed

Oxygenation satisfactory
and stable: Maintain
oxygenation and
awaken patient

"can't intubate, can't ventilate" situation with increasing hypoxaemia

Plan D: Rescue techniques for
"can't intubate, can't ventilate" situation
or

Cannula cricothyroidotomy

Surgical cricothyroidotomy

Equipment: Kink-resistant cannula, e.g.

Patil (Cook) or Ravussin (VBM)
High-pressure ventilation system, e.g. Manujet III (VBM)

Equipment: Scalpel - short and rounded

(no. 20 or Minitrach scalpel)
Small (e.g. 6 or 7 mm) cuffed tracheal
or tracheostomy tube

Technique:
1.=
Insert cannula through cricothyroid membrane
2.=
Maintain position of cannula - assistant's hand
3.=
Confirm tracheal position by air aspiration = 20ml syringe
4.=
Attach ventilation system to cannula
5.=
Commence cautious ventilation
6.=
Confirm ventilation of lungs, and exhalation
= through upper airway
7.=
If ventilation fails, or surgical emphysema or any
= other complication develops - convert immediately
= to surgical cricothyroidotomy

fail

4-step Technique:
1.=
Identify cricothyroid membrane
2.=
Stab incision through skin and membrane
= Enlarge incision with blunt dissection
= (e.g. scalpel handle, forceps or dilator)
3.=
Caudal traction on cricoid cartilage with
= tracheal hook
4.=
Insert tube and inflate cuff
Ventilate with low-pressure source
Verify tube position and pulmonary ventilation

Notes:
1. These techniques can have serious complications - use onl y in life-threatening situations
2. Convert to definitive airway as soon as possible
3. Postoperative management - see other difficult airway gui delines and flow-charts
4. 4mm cannula with low-pressure ventilation may be successf ul in patient breathing spontaneously
Difficult Airway Society guidelines Flow-chart 2004 (use wit h DAS guidelines paper)

TERIMA KASIH