AIRWAY MANAGEMENT

AND
FBAO

Dr. Prabowo Wicaksono Y.P., SpAn

Dr. Wignyo Santosa, SpAn

BAGIAN/ SMF ANESTESI FK UNISSULA/ RSI

SULTAN AGUNG
2008
AIRWAY MANAGEMENT

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Apa ke-khusus-an penanganan pasien gawat darurat ?

Waktu untuk bertindak : terbatas

Data dasar untuk bertindak : terbatas

Konsep berfikir yang sederhana

Tindakan yang sistematik
Ketrampilan yang memadai

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PASIEN TRAUMA/ NON TRAUMA

LIFE SUPPORT A = airway

Resusitasi B = breathing
Stabilisasi C = circulation
D = disability

TERAPI DEFINITIF/
SPESIALISTIK

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 Life support
A ─B─ C─ D
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 ↑

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

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 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
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Trauma wajah berat, dengan potensi obstruksi airway
Intubasi trakea ? Setuju
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Obstruksi airway karena lidah terdorong ke
hipofaring, lebih sering terjadi.
Intubasi trakea ?
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Pasien mati karena hipoksia, bukan karena tidak
terpasang endotrakeal tube (ETT)

Tidak semua masalah airway harus

diselesaikan dengan intubasi trakea

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 Banyak Cara Mengamankan Jalan Nafas
1. Basic/ Manual

A. Chin Lift

B.Jaw Thrust 10
C. Head tilt – Chin lift

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2. Airway (Alat Bantu Nafas) Dasar

A. Oropharyngeal Airway (OPA) / Guedel

B. Nasopharnygeal Airway (NPA) 12

3. Advanced Airway

A. Endotrakeal Tube (ETT)

B. Laryngeal Mask Airway (LMA) 13

C. Combitube

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 Airway
Menilai jalan nafas

Kesadaran (“ the talking patient”)

Look, Listen and Feel

Look
•Agitasi (hipoksia)/ tampak bodoh (hiperkarbia)
•Sianosis
•Retraksi
•Accessory respiratory muscle

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Listen
•Snoring
•Gurgling
•Stridor
•Hoarness

Feel
•Trachea location

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 Airway Definitive
Pipa dalam trakea dengan balon (cuff) yang dikembangkan.
3 macam:
•Orotrakeal (Intubasi Oral)
•Nasotrakeal (Intubasi Nasal)
•Surgical airway (Krikotiroidotomi/ trakeostomi)

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21
 OBJECTIVE
 Clear and protected airway

 Oxygenation

 Positive pressure ventilation

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

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2. Jaw Thrust
•Pegang pada angulus
mandibulae, dorong mandibula
ke depan (ventral ).
•Aman untuk C-spine pada
korban trauma

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3. Head tilt – Chin lift
•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.
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Jangan Lakukan !!

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 Airway Dasar
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.

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 Oropharyngeal Airway/Guedel

NO: 0 1 2 3 4 5 6

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How to measure the right size of
Oropharyngeal Airway

Komplikasi
– Obstruksi total
– Laringospasme
– Muntah

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 Cara Pemasangan Oropharyngeal Airway
Dimasukkan mulut dg lengkungan menghadap palatum.
Setelah masuk separuh panjangnya, putar 180° hingga lengkungan
menempel pada lengkungan lidah.

1.
2.

3.

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2. Nasopharyngeal Airway (NPA)

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.

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 Nasopharyngeal Airway
Komplikasi
 Kerusakan mukosa nasal
 Laryngospasme

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Cara Pemasangan Nasopharyngeal Airway
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.

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 3. Advanced Airway

A.Endotrakeal Tube (ETT)

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

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Endotrakeal Tube (ETT)
Komplikasi
 Hipoksia
 Trauma
 Muntah-aspirasi isi
lambung
 Hipertensi
 Disritmia jantung
 Intubasi satu paru
 Intubasi esofagus
 Cardiac arrest akibat
vagal reflex
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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.

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Laryngoscope

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 Menyiapkan Laryngoscope
1. 2.

3. 4.

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 Memegang Laryngoscope
Memegang laryngoscope
selalu dengan tangan kiri

Posisi tangan yang betul

adalah memegang pada
handle, bukan pada
pertemuan blade dan handle

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Melepas Laryngoscope
Memasang dan melepas
laryngoscope selalu dengan
sudut 45°

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B. Endotrakeal Tube (ET)
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.

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ETT dissposible (Low
Pressure High Volume)

ETT re-usable (High

Pressure Low Volume)
Tidak dianjurkan.

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C. Spuit 20 cc.
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.

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2. Obat Emergency
- Sulfas Atropin (SA) dalam spuit
- Adrenaline dalam spuit.

3. Pasien
Informed consent mengenai tujuan dan resiko tindakan.

Ingat resiko/komplikasi intubasi bisa berakibat

fatal !!!

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Persiapan Intubasi Endotrakeal

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Langkah – langkah Intubasi Endotrakeal
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 !!!

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 Posisi Tangan Saat Ventilasi Tekanan Positif
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.

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INTUBASI TRAKEA

Singkirkan lidah ke kiri

Cari Epiglotis

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POSITION OF THE TIP OF LARYNGOSCOPE BLADE

LIDAH
VALEKULA
EPIGLOTIS

Trakea

Esofagus !!!

Sniffing Position
Mambantu Visualisasi laring

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 ELEVASI LARINGOSKOP
Gunakan kekuatan tangan untuk mengangkat. Jangan diungkit
dg menggunakan gigi seri atas sebagai titik tumpu (awas
patah!!).

Arah elevasi laringoskop Jangan diungkit !!!

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INTUBASI TRAKEA

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 INTUBASI TRAKEA
Plica Vocalis Epiglotis Trakea

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 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

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 INTUBASI TRAKEA
G. H.Intubasi endobronkhial

Ujung distal cuff

Cara cegah intubasi endobronkhial:
Masukkan ETT hanya sampai ujung distal cuff lewati plica
vocalis

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 TEKNIK INTUBASI TRAKEA
 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.
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

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 Teknik Oral

2
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3
4
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5
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Teknik Nasal

1 2
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3

4
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5 61
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’
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RJP DENGAN PASIEN
TERPASANG ETT
Pasien dengan
intubasi trakhea,
bantuan ventilasi
tidak perlu sinkron
dengan kompresi
dada pada saat
RJP

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 3. Advanced Airway
B. Laryngeal Mask Airway

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

Kerugian :Tidak melindungi terhadap aspirasi

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Laryngeal Mask Airway

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AIRWAY MANAGEMENT MOVIE
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AIRWAY ANATOMY BRONCHOSCOPY MOVIE
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Foreign Body Airway
Obstruction
(FBAO)
 Conscious Adult Choking
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.
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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.

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•Stand behind the victim with your arms wrapped around the
victims chest.
•Feel for the victim's xiphoid process with your right hand.

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Make a fist with your left hand and place it (THUMB IN) below the right hand.

•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. 72
 Subdiaphragmatic abdominal thrust
(the Heimlich maneuver) administered to a conscious
(standing) victim of foreign body airway obstruction.
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Subdiaphragmatic abdominal thrust (the Heimlich
maneuver) administered to a conscious (standing)
victim of foreign body airway obstruction.
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ADULT CHOKING MOVIE 75
 CHILD HEIMLICH MANUVER
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.

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•If you are alone, perform Heimlich Manuver first, then call 911, because children
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.

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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.

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•If the victim becomes unconscious, assist them to the ground and
perform C.P.R.

CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS

AVAILABLE.
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CHILD CHOKING MOVIE
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 INFANT HEIMLICH MANUVER
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.

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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.

•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.

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•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 hand.

Back blow in an infant.

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•Sandwich the infant between both arms, supporting the head with your
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.

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•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 the
nipple-line.
•Raise the index finger and depress sternum 1 inch using the remaining 2
fingers.
•Perform 5 compresions (Chest Thrust)

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•Look in the infant's mouth to see if the foreign body has been
displaced.

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•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. 87
INFANT CHOKING MOVIE
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 Steps Involved in Relief of FBAO ( Conscious to Unconscious)
. Ask: “Are you choking?”

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

very obese victims, perform chest thrusts.

f the victim becomes Unconscious,

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

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

. Push chin down and check mouth for foreign body object

. 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. 89
 Finger Sweep
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.
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 Steps Involved in Relief of FBAO ( Conscious to Unconscious)

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.

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 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.

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 Chest Thrust
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.

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3. Place your arms under the victim’s armpits to encircle the chest.
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.

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Chest thrust administered to a conscious victim (standing) of
foreign body airway obstruction.

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Chest thrust administered to an unconscious victim (lying) of
foreign body airway obstruction.
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Thank you.....

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