Airway Management

Antonius Freddy 19
Dept /SMF Emergency Medicine
FKUB - RSSA
 Contoh kasus
• Seorang wanita 26 tahun,dibawa ke IGD
dengan keluhan utama sesak. Terjadi
mendadak.
• TTV : RR 26/1 retraksi iga, nadi 123/1
bounding, tekanan darah 160/100 mmHg.
Saturasi oksigen 96%, akral dingin , auskultasi
paru ronchi seluruh lapang paru.
• 6 hari lalu post partum.
 Indikasi Intubasi
• Gagal oksigenasi .
• Gagal ventilasi.
• Perburukan klinis.
• Antisipasi pasien dengan resiko perburukan .
• Penilaian awal terhadap kesulitan intubasi .
• Pada kasus Gagal Nafas Akut ,ventilasi Bag
Valve Mask atau dengan noninvasive positive
pressure ventilation (NiPPV) berfungsi sebagai
jembatan , tidak menggantikan Intubasi.
 Pemilihan Alat Intubasi

• Video Laryngoscope : pilihan utama, karena 1st

pass success rate melebihi Direct Laryngoscope(DL)
• DL: paling sering dipakai (Mac or Miller blade).
• Awake sedated airway
(when difficult laryngoscopy is anticipated):
Inhalasi topical local anesthetic,
when airway established  sedate/paralyze,
intubate via VL or fiber optic, → requires
cooperative patient.
Cormack–Lehane laryngoscopic view
 Pearls
• Siapkan rescue devices : Extra Glottic Devices,
Cricothyrotomy kit.
• Pertimbangkan glycopyrrolate 0.2 mg IV
untuk mengurangi sekresi bila ketamine
diberikan.
• Good BVM technique saves lives.
 RAPID SEQUENCE INTUBATION
The “7 Ps”
• Preparation,
• Preoxygenation,
• Pretreatment,
• Positioning,
• Paralysis w/ induction,
• Placement w/proof,
• Postintubation management
 Preparation/ Persiapan
• Alat Monitor tanda tanda vital, ≥1 IV line.
• BVM, suction, ET CO2 detector, oral airway, Bougie
• Intubation equipment (eg, laryngoscope): Blade,
backup blade, check video monitor/light.
• ETT:7.5–8 (male), 7–7.5 (female); check cuff, load
stylet/10-cc syringe; pediatrics tube size: = 4 + (age in
y/4) → or use Broselow tape.
• Obat obatan RSI .
• Nilai kesulitan BVM, intubation, & cricothyrotomy →
prepare appropriately.
• Preoxygenation: BVM (provides ∼100% FiO2) × 3 min
atau 8 vital capacity breaths.
Pertimbangkan passive/apneic oksigenasi :
beri oksigen aliran tinggi dengan Nasal cannule selama
prosedur intubasi  memperpanjang waktu desaturasi.
• Pretreatment: 3 menit sebelum intubasi—
lidocaine 1.5 mg/kg IV (↓ ICP, in pts w/ ↑ ICP, ↓
bronchospasm in pts w/ reactive airway dz);
fentanyl 3 μg/kg IV (↓ ICP in pts w/ ↑ ICP, ↓ HTN
response in pts w/ cardiac ischemia, aortic dissection,
head bleed)
Paralysis with induction: Selalu Induksi sebelum dilumpuhkan.
• Induksi: Etomidate (0.3 mg/kg IV), midazolam (0.3 mg/kg
IV),ketamine (1–3 mg/kg IV), thiopental (3 mg/kg IV)
• Paralysis: Succinylcholine (1.5 mg/kg IV, if no CI),
rocuronium (1–1.2mg/kg IV) .

 Succinylcholine kontrindikasi: Large burns, paralysis, crush

injury (w/ in 3 d–6mo), abd sepsis (>3 d), elevated ICP or
intraocular pressure, hx of MH, neurologic d/o (muscular
dystrophy, MS, Amyotrophic Lateral Sclerosis)
 Rocuronium : longer half-life often leads to delayed
sedation.
• Positioning: ± Cricoid pressure (prevents gastric
regurgitation but may worsen DL view) before/during
intubation until tube placement confirmed
• Placement with proof: Insert ETT via direct
visualization of vocal cords,inflate cuff .
• Confirm placement: ET CO2 detector, auscultate lungs
(assess for R side intubation),Secure ETT, release
cricoid pressure
• Post intubation management: Oral gastric tube, CXR,
sedation (benzos, propofol) ± paralytics (vecuronium
0.1 mg/kg IV), analgesia (fentanyl),initiate mechanical
ventilation
Terima kasih