INFORMASI UMUM

• Presentasi ini disampaikan pada kegiatan WORKSHOP

DIFTERI
• Hari / Tanggal : Minggu / 07 Januari 2017
• Tempat : Aula Pertemuan RSUD Kabupaten Tangerang
• Narasumber : UKK Infeksi & ERIA IDAI
• Semua isi dan materi presentasi adalah hak cipta dari
narasumber, digunakan untuk kalangan terbatas dalam
kepentingan edukasi kesehatan di bidang terkait.
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 CURRICULUM VITAE

Nama : Dr. Dzulfikar DLH, dr., SpA(K), MKes, MMRS

(e-mail: dzulfikar_dlh@yahoo.com)
Pekerjaan: Divisi Emergensi/Rawat Intensif Anak
Departemen Ilmu Kesehatan Anak FKUP/RSHS Bandung
Pendidikan : - Dokter umum, FK Unpad, tahun 1991
- Spesialis anak, FK Unpad , tahun 2002
- Magister Kesehatan, FK Unpad , tahun 2003
- Konsultan Gawat Darurat Pediatri, IDAI, tahun 2006
- Doktor, Unpad, 2013
- Magister Manajemen Rumah Sakit, STIE Gotong Royong, Jakarta, 2014
Kegiatan : - Instruktur Advanced Trauma Life Support (ATLS)
- Instruktur Pediatric Fundamental Critical Care Support (PFCCS)
- Instruktur General Emergency Life Support (GELS)
- Instruktur Pengelolaan Penderita Gawat Darurat (PPGD)
- Instruktur Advanced Pediatric Resuscitation Course (APRC)
Organisasi : - Ketua Perhimpunan Kedokteran Gawat Darurat Indonesia (PKGDI)
Cabang Jawa Barat
- Pengurus Ikatan Dokter Indonesia (IDI) Wilayah Jawa Barat
- Pengurus Ikatan Dokter Anak Indonesia (IDAI) Cabang Jawa Barat
- Ketua Program Studi Pendidikan Dokter Spesialis Anak Fakultas
Kedokteran Universitas Padjadjaran /RS. Dr. Hasan Sadikin Bandung
- Anggota Senat FakultasDIFTERI
WORKSHOP Kedokteran
- © IDAI Universitas Padjadjaran Bandung
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 Emergensi dan
Rawat Intensif Anak

UPPER AIRWAY OBSTRUCTION

Dr. dr. Dzulfikar DLH, SpA(K), M.Kes, MMRS

UKK Emergensi dan Rawat Intensif Anak
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 DEFINITION

Upper airway obstruction is defined as

blockage of any portion of the airway
above the thoracic inlet

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07/01/2018 Pediatric Emergency Medicine Practice. 2013
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• Most of the common causes among
children presenting to emergency
department are of acute infectious
etiology
• Among these, croup is the commonest
while diphteria remains the serious life
threatening cause

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 SIGNS OF UPPER AIRWAY
OBSTRUCTION

• Stridor
• Suprasternal retraction
• Change of voice

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 STRIDOR
Definition

• Stridor is a harsh,
• vibratory sound produced when
the airway becomes partially
obstructed
• resulting in turbulent flow.
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 Correlation between phase of stridor and
probable level of airway obstruction

Stridor Level of obstruction

Inspiratory Above the cords (extrathoracic); e.g. croup,
epiglottitis

Expiratory Below the cords (intrathoracic); e.g. foreign

body

Biphasic At or below the cords (intra or extrathoracic);

e.g. foreign body, bacterial tracheitis

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The “Difficult Airway” Definitions

 Difficult Mask Ventilation

 Difficult intubation

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UpToDate 2016
 Etiology of Difficult Airway In Children

Congenital Infections of the Sudden obstruction of without known

abnormalities airway the airway congenital or acquired
abnormalities who are
• Laryngomalacia • Epiglotitis • Foreign body unexpectedly difficult
aspiration to visualize for
• Glottic Webs • Croup intubation.
• Trauma
• syndrome
• Hemangiomas • Diphtheria

• Vascular Rings

• Hypoplastic
Mandible

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Predicting the difficult laryngoscopic intubation:
are we on the right track?
Editorial ; M. Murphy et al. CAN J ANESTH 2005,52:3;231-35

1. able to oxygenate via bag mask ventilation

2. able to ventilate via Supraglottic device
3. able to intubate
4. able to secure a surgical airway

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 Findings that predict the presence of a
difficult airway in children

Limited mouth opening

small mouth
Large tongue
lingual tonsils
Prominent central incisor
Mandibular hypoplasia

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BANTEN PW Sheeran - 17
2014
 Findings that predict the presence of
a difficult airway in children

Laryngeal edema (infection, inhalation injury)

Hemangioma of the lip
Facial or hemi-facial anomalies
Malformation of the ear

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PW Sheeran - 2014
 Findings that predict the presence of
a difficult airway in children

 Mandibular, mid-face, and facial trauma

 Cervical spine immobility (immobilization,

trauma, congenital malformation)

 Short neck

 obesity

 Obstructive sleep apnea

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PW Sheeran - 2014
 Findings that predict the presence of
a difficult airway in children

Congenital hydrocephalus Abscess

Tracheal stenosis
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Tumor/ Foreign body
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PW Sheeran - 2014
Assessment in the emergency situation

Need to be fast

No time to come back another day

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 Assessment in the emergency
situation
• Appearance of child
• Work of breathing
• Agitation
• Noisy breathing/stridor/voice/cry
• Body position
• Normal facies
• Neck mobility
• Drooling

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 Approach to difficult airway assessment

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Emergency Medicine’s Top Clinical
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Pr
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 Recognising the Difficult Airway in Children

Difficult Difficult for Difficult

Difficult
Ventilation LMA Cricothyroido
Intubation
Insertion tomy

Manual Emergency Airway, 2007

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 Sumbatan saluran napas
berdasarkan kriteria Jackson
• Jackson I: sesak, stridor inspirasi ringan, retraksi
suprasternal, tanpa sianosis.
• Jackson II: gejala sesuai Jackson I tetapi lebih berat
yaitu disertai retraksi supra dan infraklavikula, sianosis
ringan, dan pasien tampak mulai gelisah.
• Jackson III: Jackson II yang bertambah berat disertai
retraksi interkostal, epigastrium, dan sianosis lebih
jelas.
• Jackson IV: ditandai dengan gejala Jackson III disertai
wajah yang tampak tegang, dan terkadang gagal napas.

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 Tatalaksana

• Stadium 1:
Oksigen, antiinflamasi, antialergi dan
antibotika
• Stadium 2 dan 3:
tindakan untuk membebaskan
saluran napas, misalnya intubasi endotrakea,
trakeostomi
• Stadium 4: Krikotirotomi
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 The Principles of
managing a child with
potentially difficult airway

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 Airway Management Protocol
• Begin airway assesment
• Asses the airway and give oxygen
• If evidence •ofPerform
obstruction or altered
airway opening manouvere
consciousness• Consider suction , foreign body removal
Consider oro or nasopharyngeal airway or
• If obstruction• persist
LMA Allow self-ventilation whenever possible
Consider intubation, and if carried out
• If obstruction• still persist
Encourage oxygen but not force to wear
check position of tracheal tube
mask
• If intubation•is imposible
Consider orlieunsuccessful
cricothyroidotomy
Do not force to down
• If stridor but• relatively alertthe airway (except as
Do not inspect
definitive procedure under controlled
conditions )
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Advanced Pediatric Life Support. 2011
 Oropharyngeal Airway

UKURAN dan POSISI

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 Pemasangan
Oropharyngeal Airway

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 Nasopharyngeal Airway

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 Opening the airway
Chin Lift

Jaw Thrust

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Tracheal Intubation

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 Portable
Videolaryngoscope

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 LMA

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Pediatric
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 Laryngeal Mask Airways

LMA cuff
Patient size LMA size
vol (ml)

babies up to 7 kg 1 2-5

1.5

small child to 20 kg 2 7-10

child 20-30 kg 2.5 15

child > 30 kg 3.0 15-20

normal to large adult 4.0 25-30

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07/01/2018 British Journal of Hospital
WORKSHOPMedicine, December 2009, Vol 70, No45 12
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British Journal of Hospital
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 Plan A: succeed
Initial tracheal Direct laryngoscopy Tracheal intubation
intubation plan
failed intubation

Plan B: Confirm - then

Secondary tracheal succeed fibreoptic tracheal
intubation plan ILMATM or LMATM intubation through
ILMATM or LMATM
failed oxygenation
failed intubation

Plan C:
Maintenance of
oxygenation, ventilation,
postponement of
surgery and awakening
succeed
Revert to face mask Postpone surgery
Oxygenate & ventilate Awaken patient
failed oxygenation

Plan D: improved
Rescue techniques oxygenation
for "can't intubate, LMATM Awaken patient
can't ventilate" situation
increasing hypoxaemia
or

Cannula Surgical
cricothyroidotomy cricothyroidotomy
fail

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