Airway Management

Dr.Erniody, Sp.An.,KIC.,M.Kes
26 Februari 2016
 Tanda2 Sumbatan Jalan
1. Parsial:
Nafas
• Gelisah

• Cuping hidung

• Menggunakan otot2 bantuan nafas

• Retraksi dada

• Suara nafas tambahan

2. Total:

• suara nafas atau aliran udara (-)

• Dada tidak bergerak

• Retraksi supraklavikula dan sela iga (+)

 Sumbatan Jalan Nafas
• Atas:

- Snoring

- Gargling

- Choking

- Edema larinks

• Bawah: bronkhospasme
Sumbatan Jalan Nafas Atas

Tanpa Alat
Tanpa Alat
Dengan Alat
Suctioning
Benda asing
The conscious patient will usually make clutching motions toward
the neck, even when the obstruction dews not prevent speech.

For the conscious patient with an apparent partial obstruction, en-

courage him or her to cough.

NOTE: patient has an apparent partial obstruction but cannot

cough, begin to treat the patient as if this were a complete
obstruction. This alsoapplies to patients who are cyanotic.

The unconscious patient with a complete airway obstruction

exhibits none of the usual signs of breathing:
- rise and fall ofthe chest
- air exchange through the nose and/or mouth.
Choking
 Edema larinks pascaekstubasi
(30%)

e is caused by pressure and ischemia resulting in an inflammator

Risk factor:
- Female mucous membrane being less resistant to trauma
and thinner than that in men
- Tube size
- Duration of intubation
 Edema larinks pascaekstubasi
- Cuff leak volume >110 ml none developed
post extubation stridor
- specificity 99% and the negative predictive
value for absence of PES was 98%

Parenteral administration:
- corticosteroids
- epinephrine nebulization
- inhalation of a helium/oxygen mixture

Reintubation should be considered early after onset of

laryngeal edema to adequately secure an airway --> increased
cost, morbidity and mortality.
Crit Care. 2009; 13(6): 233.
Published online 2009 Dec 1. doi: 10.1186/cc8142
PMCID: PMC2811912
 Croup
• dexamethasone is the recommended corticosteroid for
treatment of croup because of its longer half-life (a single
dose provides anti-inflammatory effects over the usual
symptom duration of 72 hours).

• Benefit has generally been demonstrated at doses of 0.15

to 0.60 mg per kg.

• A systematic review found that the higher dose of 0.60 mg

per kg (maximal dose: 10 mg) was more effective in
patients with severe croup.
 Croup
Epinephrine inhalation

The term racemic epinephrine refers to a mixture of 50 % each

of the dextro-rotatory and levo-rotatory isomers.

Mechanism of action

Racemic epinephrine works by:

- stimulation of the α-adrenergic receptors in the airway with
resultant tightening of the mucosa (mucosal vasoconstriction)
and decreased fluid in the airway (subglottic edema)
- by stimulation of the β-adrenergic receptors causing
relaxation of the bronchial smooth muscle.
 Croup
The recommended dose:
- 0.05 mL per kg (maximal dose: 0.5 mL) of racemic epinephrine
- 0.5 mL per kg (maximal dose: 5 mL) of L-epinephrine 1:1,000 v

With either form of epinephrine, therapeutic benefit usually occur

Croup: An Overview

ROGER ZOOROB, MD, MPH; MOHAMAD SIDANI, MD, MS; and JOHN MURRAY, MD, PhD, Meharry Medical
College, Nashville, Tennessee

Am Fam Physician. 2011 May 1;83(9):1067-1073.

 Croup
bulization with 3 to 5 ml of adrenaline (1:1000) in children: an evid
Linjie Zhang1, Lucas Soares Sanguebsche2

Jornal de Pediatria - Vol. 81, No.3, 2005

Sumbatan Jalan Nafas Bawah: bronkhospasme

Steroid Aminofilin
 Gagal Nafas

• Hipoksemia ( tipe1 ): PaO2 < 60mmHg

• Hiperkarbia ( tipe 2): PCO2 > 50mmHg

• Mixed ( tipe 3)
Pierre Robin
Treacher Collins
 Bag Mask Ventilation
One-handed technique Two-handed techniques

Three facial landmarks that must be covered by mask: Small tidal volumes
1. Bridge of the nose Squeeze steadily – don’t force air too
2. Two malar eminences quickly
3. Mandibular alveolar ridge 10-12 breaths/minute
Assess for rise and of fall chest
 Laryngoscopes

Macintosh Blade Miller Blade

 Inserting Laryngoscope

Macintosh Blade in Vallecula Miller Blade Under Epiglottis

Laryngoscopy Technique
Laryngoscopy is a predictable sequence of progressively
visualized structures
The difficult airway (DA) has been defined as 'the clinical
situation in which a conventionally trained anesthesiologist
experiences difficulty with face mask ventilation of the upper
airway, difficulty with tracheal intubation, or both'.
Difficult Airway:

• Inadequate ventilation not reversed by mask ventilation

• Oxygen saturation not maintained above 90%
• More than 3 attempts or more than 10 minutes required to
complete tracheal intubation

American Society of Anesthesiologist (ASA)

Before anaesthesia, the anaesthetist should be able to answer k
• Will I be able to mask ventilate?
• Will I be able to perform laryngoscopy, directly or indirectly?
• Will I be able to intubate this patient?
• Is there a significant aspiration risk?
• If I predict difficulty, should I secure the airway awake?
• Can I access the cricothyroid membrane if needed?
• How will the airway behave at extubation?

66
Chances of Difficult Airway

Difficult mask ventilation Probability Uncertain

Difficult intubation 1 - 4%
Failed intubation 0,05 - 0,35%
Difficult ventilation & Difficult intubation 1,5%
Cannot Ventilate & Cannot Intubate 0,0001 - 0,02%

Rose DK, Cohen MM: The airway: Problems and predictions in

18,500 patients. Can J Anaesth 1994; 41:372-383
DIRECT CAUSES

Operator:
1. Inadequate assessment
2. Inadequate equipment
3. Lack of experience
4. Poor technique
5. Malfunctioning equipment
6. Inexperience assistance

Patient:
1. Congenital causes
2. Acquired causes
 Cricothyrotomy

Transtracheal cath with jet ventilation Retrograde intubation

diac output that returns to the left heart without the benefit of expo

Dead space: that part of inspired air that is exhaled without the
benefit of exposure to perfused alveoli.

QS/QT = (CcO2 - CaO2) / (CcO2 - CvO2)

Normal shunt fraction (QS/QT) is less than 0.05 (<5%).

Thank Qiu