DIFFICULT AIRWAY

MANAGEMENT
Desi Ayu (41201396100004)
Pembimbing: dr. Zeta, Sp.An
Anatomi Saluran Napas Atas
DIFFICULT AIRWAY
DEFINISI
Situasi klinis di mana anestesi konvensional terlatih mengalami kesulitan dengan
ventilasi masker di saluran napas bagian atas, kesulitan intubasi trakea, atau
keduanya.
KLASIFIKASI
• Kesulitan ventilasi dengan sungkup atau supraglottic airway (SGA)
• Kesulitan melakukan laringoskopi
• Kesulitan intubasi
• Kesulitan Tracheostomy
Difficult Mask Ventilation
◦ Ketidakmampuan untuk mempertahankan ◦ Faktor-faktor yang menyebabkan kesulitan
SaO2 >90% dengan Oksigen 100% pada pasien Ventilasi:
yang sebelum Tindakan anestesi memiliki - Beard
saturasi oksigen >90%.
- Obesity (IMT > 26)
◦ Tanda Ventilasi tidak adekuat:
- No Teeth
- Pergerakan dinding dada yang tidak adekuat
- Elderly (> 55 thn.)
- Tidak ada suara napas
- Snores
- Sianosis
- Perubahan Hemodinamik
- Saturasi oksigen turun
Derajat Kesulitan Ventilasi
- Mudah dilakukan (hanya dengan chin-lift)  Derajat 0
- Harus dilakukan Jaw thrust/mask seal  Derajat 1
- Harus menggunakan OPA/NPA  Derajat 2
- Memerlukan 2 orang untuk melakukan Jaw Thrust 
Derajat 3
- Derajat 3 + OPA/NPA  Derajat 4
- Tidak dapat dilakukan Ventilasi  Derajat 5
Difficult Laryngoscopy and Intubation
ASSESSMENT OF DIFFICULT AIRWAY
- ANAMNESIS
Riwayat Kelainan kongenital pada saluran napas atas, Riwayat
operasi sebelumnya, gejala infeksi saluran napas atas.

- TANDA DAN GEJALA

Snoring atau mengorok, gigi terkikis, perubahan suara, disfagia, atau
stridor.
Pemeriksaan Fisik
DIFFICULT AIRWAY
MANAGEMENT
Persiapan Standar pada Managemen Kesulitan Jalan Napas
1. Tersedianya peralatan untuk pengelolaan kesulitan jalan napas
2. Menginformasikan kepada pasien atau keluarga tentang adanya atau
dugaan kesulitan jalan nafas, prosedur yang berkaitan dengan
pengelolaan kesulitan jalan nafas, dan risiko khusus yang kemungkinan
dapat terjadi
3. Memastikan bahwa setidaknya ada satu orang tambahan sebagai asisten
dalam manajemen kesulitan jalan nafas,
4. Melakukan preoksigenasi preanestesi dengan sungkup wajah sebelum
memulai manajemen kesulitan jalan nafas, kurang lebih selama 3 menit
untuk mencapai hasil saturasi oksigen yang baik
ALGORITM OF
DIFFICULT
AIRWAY
ALGORITM OF
DIFFICULT
AIRWAY
 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
failed int ubat ion a n d difficult ventilat ion (other t ha n l a r y n g o s p a s m )

Face mask
O x yg ena te a nd Ventilate patient
M a x i mu m head
extension Ma x im um jaw
thrust
Assistance with
ma s k seal
Oral ± 6 m m nasal
airway
R ed uc e cricoid force
- if necessary

Oxygenation satisfactory

ALGORITM OF
L M Afailed
T M O xox y genteatand
ygena ion wit h f a c e patient
ventilate m a s k (e.g. S p O 2 < 9 0 % w ith F i O 2 1.0)
succeed and stable: Maintain
M a x i mu m 2 attempts at insertion
R edu ce any cricoid force during
call for help oxygenation and
awa ke n patient
insertion

DIFFICULT "can't intubat e, can't ventilate" situation with incr easing h y p o x a e m i a

P l a n D : R e s c u e t e c hniq ue s for

AIRWAY
"can't intubate, can't ventilate" situation

or

Cannula cricothyroidotomy Surgical cricothyroidotomy

Equipment: Kink-resistant cannula, e.g. Equipment: Scalpel - short and rounded
Patil (Cook) or Ravussin (VBM) (no. 20 or Minitrach scalpel)
High-pressure ventilation system, e.g. Small (e.g. 6 or 7 mm) cuffed tracheal
Manujet III (V BM)
Technique: or tracheostomy tube
fail
1. Insert cannula through cricothyroid m em bra ne 4-step Technique:
2. Maintain position of cannula - assistant's hand 1. Identify cricothyroid membrane
3. Confirm tracheal position by air aspiration - 2. Stab incision through skin and membrane
20ml syringe
Enlarge incision with blunt dissection
4. Attach ventilation system to cannula
(e.g. scalpel handle, forceps or dilator)
5. Com me nce cautious ventilation
6. Confirm ventilation of lungs, and exhalation
3. Caudal traction on cricoid cartilage with
through upper airway tracheal hook
7. If ventilation fails, or surgical em ph ysem a or any 4.Insert tube and inflate cuff
other complication develops - convert immediately Ventilate with low-pressure source
to surgical cricothyroidotomy Verify tube position and pulmonary
ventilation

Notes:
1. These techniques can have serious complications - use only in life-threatening situations
2. Convert to definitive airway as soon as possible
3. Postoperative management - see other difficult airway guidelines and flow-charts
4. 4 m m cannula with low-pressure ventilation may be successf ul in patient breathing spontaneously

Difficult Airway Society guidelines Flow-chart 2 00 4 (use wit h D A S guidelines paper)

 Prosedur Tracheostomy

Cricothyroidotomy
device
REFERENSI
1. Bergesio, L, dkk. 2016. International Jurnal of Anesthetics and Anesthesiology Edisi 3: Manajemen
Difficult Airway pada Pasien dengan General Anestesi. Milan : Department of Anesthesia and Intensive
Care, Humanity Research Hospital.
2. Bicalho, G. P. et. al. 2016. A Prospective Evaluation of Tree Multivariate Model for Prediction of
Difficult Tracheal Intubation. Belo Horionte: The American Society of Anesthesiologist (ASA): The
Anesthesiologist Annual Meeting Butterworth, J. F. et. al. 2018.
3. Morgan & Mikail’s Clinical Anesthesiology : 6th Edition. United States of America. McGraw Hill
Company, Inc.
4. Rosenblatt, W. H. & Carlos A et. al. 2019. Management of The Difficult Airway for General Anesthesia
in Adult. Philadelphia : Wolters Kluwer.
5. Latief, S. A., 2010. Buku Petunjuk Praktis Anestesiologi Edisi Kedua. Jakarta : Bagian Anestesiologi
dan Terapi Intensif FK-UI.
THANK YOU