183 Difficult Airway Management (Gabungan)
-
Upload
lathifanur -
Category
Documents
-
view
248 -
download
0
Transcript of 183 Difficult Airway Management (Gabungan)
-
7/25/2019 183 Difficult Airway Management (Gabungan)
1/135
KPPIAKURSUS PENYEGAR DAN PENAMBAH ILMU ANESTESIA
5-9 AGUSTUS 2009
-
7/25/2019 183 Difficult Airway Management (Gabungan)
2/135
QUALITY OF CARE ANDPATIENT SAFETY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
3/135
THE AIMS OF ANESTHESIA IS SAFETY
THE SAFETYIS AN ACCIDENT PREVENTIONAN ACCIDENT PREVENTION BEGINS WITH
A GOOD PREOPERATIVE EVALUATION
-
7/25/2019 183 Difficult Airway Management (Gabungan)
4/135
GOOD JUDGMENTGOOD JUDGMENTcomescomes
fromfromEXPERIENCE.EXPERIENCE.
EXPERIENCEEXPERIENCEcomes fromcomes from
BAD JUDGMENT.BAD JUDGMENT.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
5/135
.AS SUCH, THE.AS SUCH, THE PRIMARY RESPONSIBILITYPRIMARY RESPONSIBILITYOF THEOF THEANESTHESIOLOGIST AS A CLINICAL ISANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THETO SAFEGUARD THEAIRWAYAIRWAY,, I.E. TO PRESERVE AND PROTECT IT DURINGI.E. TO PRESERVE AND PROTECT IT DURING
INDUCTION, MAINTENANCE, AND RECOVERY FROM THE STATEINDUCTION, MAINTENANCE, AND RECOVERY FROM THE STATEOF ANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITOF ANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLESURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLEINJURY FROM INADEQUATE OR COMPROMISEDINJURY FROM INADEQUATE OR COMPROMISEDOYGENATION.OYGENATION.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
6/135
SAFETY FIRSTSAFETY FIRST
THE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIST, PLAYS A UNIQUETHE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIST, PLAYS A UNIQUEROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAINROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAINEITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERALEITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERAL
ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.AS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLEAS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLERELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUSRELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUSPHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, ANDPHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, ANDHIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITHHIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITHEACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEXEACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEXBODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODYBODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODYTEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFEREDTEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFEREDWITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC ANDWITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC ANDMETABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATIONMETABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATIONSHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCESHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCEOF THE ANESTHETIZED STATEOF THE ANESTHETIZED STATE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
7/135
THESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFERTHESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFERIF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION ORIF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION ORMAINTENANCE OF THE ANESTHETIZED STATE.MAINTENANCE OF THE ANESTHETIZED STATE.
AS SUCH,AS SUCH, THE PRIMARY RESPONSIBILITYTHE PRIMARY RESPONSIBILITYOF THEOF THEANESTHESIOLOGIST AS A CLINICAL ISANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THETO SAFEGUARD THEAIRWAYAIRWAY,, I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,
MAINTENANCE, AND RECOVERY FROM THE STATE OFMAINTENANCE, AND RECOVERY FROM THE STATE OFANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLESURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLEINJURY FROM INADEQUATE OR COMPROMISED OYGENATION.INJURY FROM INADEQUATE OR COMPROMISED OYGENATION.
TECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) ARETECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) ARE
ERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELL-ERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELL-BEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELL-BEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELL-BEING IS UNSOUND OR TREATENED.BEING IS UNSOUND OR TREATENED.
BUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENTBUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENTAND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.AND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
8/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
9/135
CLINICAL ASSESSMENT OF THECLINICAL ASSESSMENT OF THE
AIRWAYAIRWAY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
10/135
INTRODUCTIONAIRWAY ANATOMY
THE SUPRAGLOTTIC AIRWAYSUBGLOTTIC AIRWAY
MANAGEMENT OF PATIENTS WITH NORMAL AIRWAYANATOMYMANAGEMENT OF PATIENT WITH THE DIFFICULT AIRWAY
PREDICTION
PREPARATIONPRACTICE
TOOLS FOR MANAGEMENT OF THE DIFFICULT AIRWAY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
11/135
INTRODUCTION
VARIOUS STUDIES REPORT THAT BETWEEN 1% AND 18% OFPATIENTS HAVE DIFFICULT AIRWAY ANATOMY. OF THESE, 0.05
0.!5% ARE NOT INTUBATED SUCCESSFULLY; AND ASIGNIFICANT PORTION MAY BE DIFFICULT TO VENTILATE BY
MAS. IT IS LIELY THAT THE PRACTITIONER WILL ENCOUNTERBETWEEN ONE AND !" PATIENTS PER YEAR IN WHOMINTUBATION OF THE TRACHEA WILL BE DIFFICULT ORIMPOSSIBLE.
WILL BE DISCUSS, THE BASICS OF AIRWAY ANATOMY ANDNORMAL AIRWAY MANAGEMENT, AND TO HIGHLIGHT SOME OFTHE FACTORS THAT CONTRIBUTE TO THE SAFE MANAGEMENT
OF THE PATIENT WITH A DIFFICULT AIRWAY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
12/135
AIRWAY ANATOMY
THE SUPRAGLOTTIC AIRWAY
SUBGLOTTIC AIRWAYMANAGEMENT OF PATIENTS WITH NORMAL AIRWAY ANATOMY
MANAGEMENT OF THE DIFFICULT AIRWAYPREDICTION
PREPARATION
PRACTICE
TAEN AS A SYSTEM, THE AIRWAY BEGINS AT THE E"TERNAL OPENINGS OF THE MOUTHAND NOSE AND ENDS IN THE ALVEOLAR UNITS.
AIRWAY ANATOMY WILL BE DISCUSSED IIN TERMS OF THE SUPRAGLOTTIC AIRWAY, THELARYN" AND THE SUBGLOTTIC AIRWAY.
THE SUPRAGLOTTIC AIRWAY
THE NOSE
THE NOSE SERVES TO WARM AND HUMIDITY AIR AS IT ENTERS THE BODY. THE NASALPASSAGE MAY BE LIMITED BY THE SIZE OF THE TURBINATES, WHICH ARE HIGHLYVASCULAR. PASSAGE OF ENDOTRACHEAL TUBES OR BRONCHOSCOPES THROUGH THE
NOSE MAY BE ASSOCIATED WITH PROFUSE BLEEDING. THE NASAL SEPTUM IS OFTENDEVIATED, GIVING A SMALLER PASSAGE ON ONE SIDE THAN THE OTHER. THENASOPHARYNX OPENS INTO THE OROPHARYNX BRANCHES OF THE FIFTH CRANIALNERVE PROVIDE SENSORY INNERVIATION TO THE NOSE
ANATOMY AIRWAY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
13/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
14/135
THE TONGUE MAY MOVE POSTERIORLY IN THE PHARYNX AND OBSTRUCT
THE AIRWAY BY CONTRACTING THE POSTERIOR WALL OF THEOROPHARYNX.
THIS CONDITION OCCURS IN ANESTHETIZED AND SEDATED PATIENTSBUT MAY ALSO OCCUR IN SLEEPING PATIENTS.
THE OBSTRUCTION OCCURS AS MUSCLE TONE DECREASES AND ADECREASE IN THE FUNCTIONAL LUMEN OF THE PHARYNX ENSUES.
WITH SPONTANEOUSLY BREATHING PATIENTS, A DECREASE INFUNCTIONAL AIRWAY LUMEN MAY BE ASSOCIATED WITH AN INCREASEDRESPIRATORY EFFORT AND RESULTANT GREATER NEGATIVE PRESSUREBELOW THE LEVEL OF OBSTRUCTION.
THIS CAN LEAD TO A WORSENING OF THE OBSTRUCTION AS THE
NEGATIVE PRESSURE PULLS MORE SOFT TISSUE INTO THE AREA OFCOLLAPSE.
A SIGNIFICANT FROM OF THIS PROBLEM IS OBSTRUCTIVE SLEEP APNEA
THE PHARYN
-
7/25/2019 183 Difficult Airway Management (Gabungan)
15/135
THE LARYN
THE LARYN" IS A COMPLICATED STRUCTURE THAT SERVES TO PROTECT THELOWER AIRWAYS, AS THE ORGAN OF PHONATION AND AS THE CONDUIT FORRESPIRATION.
THESE FUNCTIONS DEPEND ON THE INTERATCTION OF THE CARTILAGINOUS,BONY AND SOFT TISSUE COMPONENTS OF THE LARYNX AND PHARYNX.
THERE ARE # CARTILAGES OF THE LARYNX. THE MUSCLES OF THE LARYNX AREBOTH EXTRINSIC AND EXTRINSIC.
CARTILAGES OF THE LARYN"
THYROID CARTILAGECRICOID CARTILAGEARYTENOID CARTILAGESEPIGLOTTIS
SUBGLOTTIC AIRWAYTRACHEALOBAR BRONCHI
-
7/25/2019 183 Difficult Airway Management (Gabungan)
16/135
MANAGEMENT OF PATIENTS WITH NORMAL AIRWAY ANATOMY
MASTERING VENTILATION BY BAG AND MAS# IS CRITICAL FOR SAFE PRACTICE.THE BASIC MANEUVERS USED TO FACILITATE AIR E"CHANGE IN SPONTANEOUSLYBREATHING OR PARALY$ED PATIENTS ARE DIRECTED TO OPENING THE AIRWAY
ABOVE THE GLOTTIS.MOTIONS THAT MOVE THE TONGUE AND OTHER SOFT TISSUES OF THESUPRAGLOTTIC AIRWAY ANTERIORLY WILL GENERALLY IMPROVE AIR EXCHANGE.
THESE MANEUVERS INCLUDE CHIN LIFT, $AW THRUST, HEAD TILT ANDINTRODUCTION OF ORAL OR NASAL AIRWAYS.
DIFFICULT WITH MAS# VENTILATION MAY BE PREDICTED IN SOME PATIENTS.FACTORS REPORTED TO CORRELATE TO DIFFICULT MAS# VENTILATION INCLUDEDPRESENSE OF A BEARDBODY MASS INDEX GREATER THAN %&LAC OF TEETHAGE OVER '' YEARSHISTORY OF SNORING
-
7/25/2019 183 Difficult Airway Management (Gabungan)
17/135
MOTIONS REQUIRED FOR INTUBATION IN THE NORMAL PATIENT ARE PERFORMED TOALLOW VISUALIZATION OF THE LARYNX FROM THE OPENING OF THE MOUTH.
IN PATIENTS WITH NORMAL AIRWAY ANATOMY, THE MA$OR COMPONENTS OF THISPOSITIONING ARE FLEXION OF THE NEC, PARTICULARLY IN THE LOWER CERVICAL SPINEAND EXTENSION OF THE AT THE ATLANTOOCCIPITAL $OINT.
THIS POSITION IS REFERRED TO AS THE SNIFFING POSITION
-
7/25/2019 183 Difficult Airway Management (Gabungan)
18/135
MANAGEMENT OF THE DIFFICULT AIRWAY
IDEALLY ALL PATIENTS WOULD HAVE NORMAL AIRWAYANATOMY.
ANY PATIENT REQUIRING A CONTROLLED AIRWAY WOULDHAVE NO ADDITIONAL RIS.
THE ANESTHESIOLOGIST MUST HAVE A WAY TO IDENTIFY ANDCARE FOR PATIENTS WITH ABDNORMAL AIRWAY ANATOMY.
SAFE MANAGEMENT OF PATIENTS WITH A DIFFICULT AIRWAY.PREDICTION
PREPARATIONPRACTICE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
19/135
MANAGEMENT OF THE DIFFICULT AIRWAY
PREDICTION
THERE ARE SEVERAL POPULAR METHODS OF PREDICTING EASE ORDIFFICULTY OF INTUBATION USING A PHYSICAL EXAMINATION.
DIFFICULT IN INTUBATING THE TRACHEA CAN BE SAID TO OCCURWHEN AN E"PERIENCED PRACTITIONER IS UNABLE TO PASS ANENDOTRACHEAL TUBE IN THE NORMAL TIME AND FASHION, IT MAYBE DEFINED AS AN INTUBATION THAT REUIRES MORE THAN ONEATTEMPT.
HOWEVER, MORE DIFFICULT INTUBATIONS CAN BE RELATED TO THEGRADE OF LARYNGOSCOPIC.
DIFFICULTY DURING INTUBATION IS LIELY WITH A GRADE III OR IVVIEW.GRADE I * VOCAL CORDS ARE VISIBLE
GRADE II * VOCAL CORDS ARE ONLY PARTLY VISIBLEGRADE III * ONLY THE EPIGLOTTIS IS SEENGRADE IV * NOT EVEN THE EPIGLOTTIS IS SEEN
-
7/25/2019 183 Difficult Airway Management (Gabungan)
20/135
A B
DC
-
7/25/2019 183 Difficult Airway Management (Gabungan)
21/135
MANAGEMENT OF THE DIFFICULT AIRWAY
THERE ARE VARIOUS FACTORS TO EVALUATE WHEN ASSESSING A PATIENTS
FOR ENDOTRACHEAL INTUBATION
HISTORY;HOWEVER, PATIENTS WHO GIVE A HISTORY OF PRIORDIFFICULT INTUBATION HAVE A VERY HIGH INCIDENCE OF DIFFICULTINTUBATION. THE PRESENCE OF CONDITIONS ASSOCIATED WITHDIFFICULT INTUBATION SHOULD BE ASCERTAINED
THESE CONDITIONS INCLUDE * CONGENITAL SYNDROMES, INCLUDING DOWN, GOLDNHAR, TREACHER
COLLINS, PIERRE ROBIN AND MUCOPOLYSACCHARIDOSES, AMONG OTHERS
- BONY DISEASES, INCLUDING RHEUMATOID ARTHRITIS,ANYLOSING
SPONDYLLITIS, MANDIBULAR FRACTURE OR FIXATION, ANYLOSISOF
THE TEMPOROMANDIBULAR $OINT.- SOFT TISSUES ABNORMALITIES, INCLUDING OBESITY, TUMORS,
HEMANGIOMAS, ABSCESSES, AIRWAY INFECTIONS SUCH AS
EPIGLOTTITIS, BLEEDING.
- TRAUMA TO FAE OR NEC, BURNS, POSTOPERATIVE CHANGES
INCLUDING SCARRING, RADIATION-INDUCED CHANGES
-
7/25/2019 183 Difficult Airway Management (Gabungan)
22/135
MANAGEMENT OF THE DIFFICULT AIRWAY
DENTITION
TEMPOROMANDIBULAR JOINT MOBILITY
OROPHARYNGEAL CLASS. THIS IS COMMONLY CALLED MALLAMPATICLASS
THE OPENING IN THE PHARYNX IS EVALUATED. SCORES OF + OR ARE
ASSOCIATED WITH A GREATER CHANGE OF DIFFICULT INTUBATION.
WIDTH OF THE PALATE
THE TYROMENTAL DISTANCE
COMPLIANCE OF THE MANDIBULAR SPACE
BODY HABITUS
NEC! MOBILITY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
23/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
24/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
25/135
MANAGEMENT OF THE DIFFICULT AIRWAY
ONE SET OF MANEUVERS WITH SEEMS TO WOR WELL AND ALLOWS,
EVALUATION OF THE SIGNIFICANT FACTORS IS OUTLINED BELOW.WITH
THE PATIENT IN A SITTING OR SEMISITTING POSITION EVALUATE & BODY HABITUS, ESPECIALLY THE DISTRIBUTION OF BODY FAT
AROUND THE HEAD AND NEC# THYROMENTAL DISTANCE, MANDIBULAR COMPLIANCE; IM GOING
TO PUT MY HAND UNDER YOUR CHIN TEETH, MOUTH OPENING AND ORALPHARYNGEAL SPACE; OPENYOUR MOUTH AS WIDE AS YOU CAN; IF THE MALLAMPATI SCORE ISNOT ! OR % AS, FOR PLHONATION.
TEMPOROMANDIBULAR 'OINT MOBILITY; RELAX. NOW STIC YOURCHIN OUT TO PUT YOUR LOWER TEETH IN FRONT OF YOUR UPPERTEETH.
NEC# FLE"ION;PIC YOUR HEAD UP AND GTRY TO TOUCH YOURCHIN TO YOUR CHEST
HEAD E"TENSION; IM GOING TO HOLD MY HAND BEHIND YOURNEC . TIP YOUR HEAD BAC AS FAR AS YOU CAN, LIE YOU ARETRYING TO LOO AT THE CEILLING.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
26/135
PREPARATION
ADEQUATE PREPARATION TO CARE FOR PATIENTS WITH DIFFICULTAIRWAY ANATOMY REQUIRES ASQUISITION OF NOWLEDGE AND
EQUIPMENT.THE NOWLEDGE NECESSARY FOR SAFE MANAGEMENT OF THESEPATIENTS IS AN EXTENSION OF THE NOWLEDGE NEEDED TOPROVIDE CARE FOR ANY PATIENT BUT WITH ADDITIONAL POINTS.
THE ALGORITHM SUGGESTS THE FOLLOWING STEPS *
-
7/25/2019 183 Difficult Airway Management (Gabungan)
27/135
A B
-
7/25/2019 183 Difficult Airway Management (Gabungan)
28/135
TOOLS FOR MANAGEMENT OF THE DIFFICULT AIRWAY
AIRWAYS
STYLETS, INTUBATION GUIDES AND BOUGIES
AIRWAY EXCHANGE CATHETER
SPECIALIZED FORCEPS
LARYNGOSCOPY
RIGID DIRECTVISION LARYNGOSCOPESARE AVAILABLE IN A WIDE ASSORTMENT OFBLADE SHAPES AND SIZES.
PATIENTS WITH A LONG, FLOPPY EPIGLOTTIS ARE OFTEN EASIER TO INTUBATEUSING A STRAIGHT BLADE THAN A MACHINTOSH BLADE.
RIGID, SEMIDIRECT LARYNGOSCOPESHAVE A PRISM ON THE BALDE TO ALLOW VISIONOF THE LARYNGEAL STRUCTURES WHEN THE PATIENTS ANATOMY DOESNT ALLOWDIRECT VISION.
RIGID FIBEROPTIC LARYNGOSCOPESSUCH AS THE BULLARD AND UPSHER SCOPESALLOW VISUALIZATION OF LARYNGEAL STRUCTURES VIA FIBEROPTICS.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
29/135
LARYNGOSCOPY
THESE SCOPES MAY BE VERY USEFUL IN PATIENTS WITH ANANTERIOR
LARYNX.
ADVANTAGESOF THE RIGID FIBEROPTIC INTUBATING SCOPESINCLUDE *
RIGID SCOPE MORE SIMILAR TO USUAL LARYNGOSCOPES POSSIBLY SHORTER LEARNING CURVE
POSSIBLY MORE DURABLE THAN FLEXIBLE FIBEROPTIC SCOPES
DISADVANTAGESOF THE RIGID FIBEROPTIC INTUBATING SCOPESINCLUDE *
THE ENDOTRACHEAL TUBE IS PASSED INTO THE LARYNX WHILEWATCHING THROUGH THE FIBEROPTIC EYEPIECE, NOT DIRECTLY
OVER THE SCOPE. TECHNIQUE MAY BE DIFFICULT OR AWWARD PATIENT SIZE LIMITS RELATED TO THE RELATIVELY LARGE BLADE
SIZE
FIBEROPTIC BRONCHOSCOPIC INTUBATION
-
7/25/2019 183 Difficult Airway Management (Gabungan)
30/135
FIBEROPTIC BRONCHOSCOPIC INTUBATION (FBI) USES FLEXIBLE BRONCHOSCOPES TOINTUBATE THE TRACHEA.
MANY MANUFACTURERS HAVE DEVELOPED SCOPES SPECIFICALLY FOR INTUBATION THAT ARETYPICALL LONGER AND OF SMALLER DIAMETER THAN STANDARD DIAGNOSTICBRONCHOSCOPES.
THE ADVANTAGES OF FBI INCLUDE :
THE ENDOTRACHEAL TUBE IS PASSED INTO THE TRACHEA DIRECTLY OVERTHE SCOPE
ACCEPTABLE RANGE OF PATIENT SIZES, SINCE DIFFERENT-SIZED SCOPESARE AVAILABLE.
THERAPEUTIC USES INCLUDE PLACEMENT OF BRONCHIAL BLOCERS ANDDOUBLE-LUMEN ENDOTGRACHEAL TUBES. ADDITIONALLY, THEBRONCHOSCOPE MAY BE USEFUL IN REMOVING SECRETIONS FROM THEBRONCHI.
DISADVANTAGES OF FBI INCLUDETHE TECHNIQUE CAN BE DIFFICULT TO LEARNTHE COST AND FRAGILITY OF THE EQUIPMENT ARE OF CONCERN
PITFALLS OF FBI INCLUDEBLOOD SECRETIONS MAY OBSCURE VIEWDISTORTED ANATOMYSPECIAL PROBLEMS WITH FBI *
ENDOTRACHEAL TUBE MAY HANG UP ON LARYNGEAL STRUCTURES
SCOPE MAY LOOP IN PHARYNX LENS MAY FOG
-
7/25/2019 183 Difficult Airway Management (Gabungan)
31/135
ROLE OF THE LARYNGEAL MAS! AIRWAY IN DIFFICULT AIRWAY MANAGEMENT
THE LMA CAN BE USED TO CHANGE A CAN"T VENTILATE TO A CAN VENTILATE SITUATION.
THIS ALLOWS YOU TO CONTINUE THE ANESTHETIC WITH THE LMA AS YOUR AIRWAY DEVICE OR AWAEN THE PATIENT TO ALLOW A SAFE ALTERNATIVEINTUBATION OR TRACHEOSTOMY.
HOWEVER, ONCE VENTILATION IS ASSURED THROUGH THE LMA, OTHER TECHNIQUES MAY BE USED TO SECURE THE AIRWAY.
THE INTUBATING LMA #ILMA$ ADDS ANOTHER TOOL FOR MANAGEMENT OF PATIENTS WITH DIFFICULT AIRWAY ANATOMY.
THE ILMA SHOULD BE CONSIDERED EARLY IN MANAGEMENT OF PATIENTS WITH UNSUSPECTED DIFFICULT AIRWAY ANATOMY AS IT MAY ALLOWRAPID CONVERSION OF A DIFFICULT AIRWAY TO A CONTROLLED AIRWAY.
IF AN ILMA IS NOT AVAILABLE, THE LMA MAY STILL BE USED AS A CONDUIT TO INTUBATION, AS A BLIND TECHNIQUE OR WITH AIRWAYECHANGE CATHETERS OR FIBEROPTIC BRONCHOSCOPES.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
32/135
BLINDENDOTRACHEAL TUBE INTUBATION VIA LARYNGEALMAS!
AIRWAY
PLACE LMA AND VERIFY VENTILATION VIA LMA PASS A WELL-LUBRICATED ENDOTRACHEAL TUBE DOWN THE LMA, ROTATED
#""FROM NORMAL TO EASE PASSAGE THROUGH BARS ON LMA; AT %" CM,ROTATE ENDOTRACHEAL TUBE INTO NORMAL POSITION
PASS THE ENDOTRACHEAL TUBE INTO TRACHEA, INFLATE CUFF, VERIFYVENTILATION
SECURE THE ENDOTRACHEAL TUBE AND LMA IN PLACE OR CUT AND SPLIT
LMA TO ALLOW FOR SECURING OF THE ENDOTRACHEAL TUBE ALONE
SIZE
!!.'%%.'+
'
WEIGHT
/'G'-!"G!"-%"G%"-+"G+"G TO SMALL ADULTADULT
LARGE ADULTPOOR SEAL WITH
MAXIMUMAIR IN CUFF
ML0 ML
!" ML! ML%" ML+" ML
" ML
ETT SIZE THAT WILL PASS
+." UNCUFFED
.' UNCUFFED
&." UNCUFFED&." CUFFED
0.' CUFFED
LARYNGEAL MAS! AIRWAY SI%ES ANDCORRESPONDING ENDOTRACHEAL TUBE #ETT$
-
7/25/2019 183 Difficult Airway Management (Gabungan)
33/135
FIBEROPTIC INTUBATION VIA LARYNGEAL MAS! AIRWAY PLACE LMA AND VERIFY VENTILATION VIA LMA LUBRICATE ENDOTRACHEAL TUBE WELL, POSITION ON BRONCHOSCOPE PASS BRONCHOSCOPE DOWN LMA, INTO TRACHEA, ADVANCE ENDOTRACHEAL TUBE ALONG BRONCHOSCOPE. VERIFY POSITION OF ENDOTRACHEAL TUBE VISUALLY, WITHDRAW BRONCHOSCOPE SECURE ENDOTRACHEAL TUBE AND LMA IN PLACE OR CUT AND SPLIT LMA TO ALLOW FOR SECURING OF THE ENDOTRACHEAL TUBE ALONE.
PASSAGE OF INTUBATING GUIDE VIA LARYNGEAL MAS! AIRWAY PLACE LMA AND VERIFY VENTILATION VIA LMA PASS VENTILATING OR NONVENTILATING INTUBATION GUIDE VIA LMA 1 VENTILATING GUIDE ALLOWS VERIFICATION OF POSITION OF GUIDE BY CAPNOMETRY BEFORE ENDOTRACHEAL TUBE
PASSAGE. REMOVE LMA, PASS APPROPRIATE-SIZED ENDOTRACHEAL TUBE OVER GUIDE, REMOVE INTUBATING GUIDE VERIFY POSITION OF ENDOTRACHEAL TUBE IN TRACHEA BY BRONCHOSCOPY, CAPNOMETRY AND VENTIL ATION SECURE ENDOTRACHEAL TUBE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
34/135
LARYNGEAL MAS! AIRWAYS ALLOW VENTILATION OF PATIENT DURING
OTHER AIRWAY MANAGEMENT TECHNIQUESTRACHEOSTOMY RETROGRADE WIRE-GUIDED INTUBATION
PITFALLS OF LARYNGEAL MAS! AIRWAY IN DIFFICULT AIRWAY
MANAGEMENT EPIGLOTTIS MAY FOLD DOWN DURING INSERTION OF THE AIRWAY AND LIMIT THE ABILITY TO PASS OTHER DEVICES INTO THE TRACHEA-THIS MAY HAPPEN EVEN THROUH SOME
VENTILATION IS POSSIBLE. BARS ON LMA MAY LIMIT PASSAGE OF OTHER DEVICESTHE ENDOTRACHEAL TUBE MAY BE TOO SHORT TO COMPLETELY ENTER THE TRACHEA VIA LMA.THE LMA ENDOTRACHEAL TUBE COMBINATION MAY BE DIFFICULT TO SECURE AND MAY SLIP OUT OF TRACHEA. RIS OF ASPIRATION OF GASTRIC CONTENTS 1 PROSEAL MAY DECREASE THIS RIS
-
7/25/2019 183 Difficult Airway Management (Gabungan)
35/135
ADVANCED AIRWAY TECHNIQUES
RETROGRADE INTUBATION
TRANSTRACHEAL $ET VENTILATION
CRICOTHYROIDOTOMY
TRACHEOSTOMY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
36/135
SIZE
!!.'%%.'+
'
WEIGHT
/'G'-!"G!"-%"G%"-+"G+"G TO SMALL ADULTADULT
LARGE ADULTPOOR SEAL WITH
MAXIMUMAIR IN CUFF
ML0 ML
!" ML! ML%" ML+" ML
" ML
ETT SIZE THAT WILL PASS
+." UNCUFFED
.' UNCUFFED
&." UNCUFFED&." CUFFED
0.' CUFFED
LARYNGEAL MAS! AIRWAY SI%ES ANDCORRESPONDING ENDOTRACHEAL TUBE #ETT$
-
7/25/2019 183 Difficult Airway Management (Gabungan)
37/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
38/135
INTRODUCTION
BEDSIDE ASSESSMENT
MANDIBLE MEASURE MENTAL-TYROID DISTANCE
O PENING OF THE MOUTHSU VULA VISIBILITY
TEETH PRESENTATION
H EAD MOVEMENT
S ILLOUETTE THE PROFILE OF THE HEAD, NEC AND CHEST
-
7/25/2019 183 Difficult Airway Management (Gabungan)
39/135
INTRODUCTION
AN INADEQUATE AIRWAY LEADS RAPIDLY TO HYPOXAEMIA ANDUNCORRECTED HYPOXAEMIA WILL RESULT IN BRAIN DAMAGE ANDULTIMATELY DEATH.
THE GOLD STANDARD FOR A SECURE AIRWAY IS TRACHEAL
INTUBATION.
EVERY AIRWAY ASSESSMENT SHOULD INCLUDE TESTS THAT AIM TOPREDICT DIFFICULTY WITH TRACHEAL INTUBATION.
NO SINGLE TEST CAN PREDICT AIRWAY OR INTUBATION DIFFICULTY
RELIABLY.
NO SINGLE TEST, OR A COMBINATION OF TESTS, CAN DETECTDIFFITULTY WITH AIRWAY MANAGEMENT WITH !""2 CERTAINTY.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
40/135
BEDSIDE ASSESSMENT
MOUTHS
THE LETTERS STAND FOR * MANDIBLE, OPENING, UVULA, TEETH, HEAD ANNEC, SILHOUETTE
MANDIBLE MEASURE MENTAL-TYROID DISTANCE,
$AW THRUST PROTRUSION
- MENTO-TYROID DISTANCE LESS THAN & CM A SMALL RECEDINGMANDIBLE
- $AW THRUST PROTRUSION
FULL PROTRUSION *LOWER INCISORS, ANTERIOR TO UPPER INCISORS IS
CLASSED AS CLASS A,PART PROTRUSION
UPPER AND LOWER, INCISORS IN LINE AS CLASS B,NO PROTRUSION
LOWER INCISORS, BEHIND UPPER AS CLASS C
-
7/25/2019 183 Difficult Airway Management (Gabungan)
41/135
O PENING BE AT LEAST + CM
U VULA (INCLUDING THE PALATE AND THE PHARYNGEALSTRUCTURES)MALLAMPATI AND MODIFIED BY SAMSOON AN YOUNG. THE TERMMALLAMPATI GRADE I TO IV.EVEN WITH BEST STANDARDISATION (PATIENT SITTING, HEAD IN
NEUTRAL POSITION, MAXIMUM MOUTH OPENING AND TONGUEPROTRUSION THERE IS INTER-OBSERVER VARIABILITY AND ARELATIVELY HIGH INCIDENCE OF FALSE NEGATIVES
-
7/25/2019 183 Difficult Airway Management (Gabungan)
42/135
TEETHA COMPLETELY EDENTULOUS PATIENT HAS A WIDER GAPE AND THEREFORE ISRELATIVELY EASY TO INTUBATE
H EAD ALL
ASSESS RANGES OF MOVEMENT OF THE HEAD (ATLANTO-OCCIPITAL $OINT) ANDCERVICAL SPINE. AT LEAST A #""DIFFRENCE BETWEEN FULL FLEXION (CHIN ONCHEST) AND EXTENSION (AS THE PATIENT TO LOO AT THE CEILING WHILESITTING UPRIGHT. THE ABSENCE OF MOVEMENT PARTICULARLY IN THE ATLATO-OCCIPITAL $OINT MAY MAE IT PHYSICALLY IMPOSSIBLE TO OBTAIN A LINE OFVISION AT ATTEMPTED DIRECT LARYNGOSCOPY.
S ILLOUETTE THE PROFILE OF THE HEAD, NEC AND CHEST
THE COMBINATION OF MALLAMPATI, 'AW PROTRUSION AND CRANIOCERVICALE"TENSION HAS A SPECIFICITY OF ((% AND POSITIVE PREDICTIVE VALUE OF (!%.
A THROUGH BEDSIDE ASSESSMENT OF THE AIRWAY WILL ALERT THEANAESTHETIST TO MOST CASES OF DIFFICULTIES WITH LARYNGOSCOPY ANDINTUBATION. HOWEVER, SOME CASES WILL ONLY DISCOVERED AT INTUBATION
-
7/25/2019 183 Difficult Airway Management (Gabungan)
43/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
44/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
45/135
EASY OR HARD?
-
7/25/2019 183 Difficult Airway Management (Gabungan)
46/135
CLINICALCLINICAL
ASSESSMENTASSESSMENTOF THE AIRWAYOF THE AIRWAY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
47/135
INTRODUCTIONINTRODUCTION
GLOBAL ASSESSMENTGLOBAL ASSESSMENT
AIRWAY-COMPROMISING CONDITIONSAIRWAY-COMPROMISING CONDITIONS
OBJECTIVE ASSESSMENTOBJECTIVE ASSESSMENT
-
7/25/2019 183 Difficult Airway Management (Gabungan)
48/135
INTRODUCTIONINTRODUCTION
SAFETY FIRSTSAFETY FIRST
THE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIS, PLAYS A UNIQUETHE CLINICAL ANESTHESIOLOGIST, AS A SPECIALIS, PLAYS A UNIQUEROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAINROLE IN HEALTH CARE, RENDERING PATIENTS FREE FROM PAIN
EITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERALEITHER IN THE FORM OF REGIONAL ANESTHESIA OR GENERALANESTHESIA TO FACILITATE SURGICAL OPERATIONS.ANESTHESIA TO FACILITATE SURGICAL OPERATIONS.
AS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLEAS A RESULT OF RAPID-ACTING NEURODEPRESSANTS AND MUSCLERELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUSRELAXANTS CURRENTLY USED IN CLINICAL PRACTICE, THE VARIOUSPHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, ANDPHYSIOLOGIC FORCES, MULTITUDE OF PROTECTIVE REFLEXES, ANDHIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITHHIGHLY INTRICATE NEUROGENIC MECHANISMS THAT INTERACT WITH
EACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEXEACH OTHER TO SUPPORT AND MAINTAIN THE VASTLY COMPLEXBODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODYBODILY FUNCTIONS (ACID-BASE STATUS, MAINTENANCE OF BODYTEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFEREDTEMPERATURE AND HEMODYNAMIC) ARE SUBDUED OR INTERFEREDWITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC ANDWITH FROM MOMENT TO MOMENT. THESE HEMODYNAMIC ANDMETABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATIONMETABOLIC FUNCTIONS ARE APT TO SUFFER IF OXYGENATIONSHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCESHOULD BE COMPROMISED DURING INDUCTION OR MAINTENANCEOF THE ANESTHETIZED STATEOF THE ANESTHETIZED STATE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
49/135
THESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFERTHESE HEMODYNAMIC AND METABOLIC FUNCTIONS ARE APT TO SUFFERIF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION ORIF OXYGENATION SHOULD BE COMPROMISED DURING INDUCTION ORMAINTENANCE OF THE ANESTHETIZED STATE.MAINTENANCE OF THE ANESTHETIZED STATE.
AS SUCH, THE PRIMARY RESPONSIBILITY OF THEAS SUCH, THE PRIMARY RESPONSIBILITY OF THEANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THEANESTHESIOLOGIST AS A CLINICAL IS TO SAFEGUARD THEAIRWAYAIRWAY,, I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,I.E. TO PRESERVE AND PROTECT IT DURING INDUCTION,
MAINTENANCE, AND RECOVERY FROM THE STATE OFMAINTENANCE, AND RECOVERY FROM THE STATE OFANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITANESTHESIA; AND IN THE EVENT OF LOS OF THE AIRWAY, ITSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSHOULD BE PROMPTLY RE-ESTABLLISH BY INTRUMENTATION ORSURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLESURGERY BEFORE THE INDIVIDUAL SUFFERS IRREVERSIBLEINJURY FROM INADEQUATE OR COMPROMISED OYGENATION.INJURY FROM INADEQUATE OR COMPROMISED OYGENATION.
TECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) ARETECHNOLOGIC INNOVATIONS (PULSE OXIMETRY, CAPNOGRAPHY) AREERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELL-ERTAINLY HELPFUL AS MONITORS TO INDICATE THE STATE OF WELL-
BEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELL-BEING OF THE PATIENT AND ALERT THE CLINICIAN WHEN THE WELL-BEING IS UNSOUND OR TREATENED.BEING IS UNSOUND OR TREATENED.
BUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENTBUT THEY ARE BY NO MEANS A SUBSTITUTE FOR CLINICAL ASSESSMENTAND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.AND ANTICIPATION OF ANY PROBLEM, INCLUDING THE DIFFICULT AIRWAY.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
50/135
GLOBAL ASSESSMENTGLOBAL ASSESSMENT
ALTHOUGH AIRWAY ASSESSMENT IS ESSENTIALLY A REGIONALALTHOUGH AIRWAY ASSESSMENT IS ESSENTIALLY A REGIONALANATOMIC ASSESSMENT A GENERAL ASSESSMENT OF THEANATOMIC ASSESSMENT A GENERAL ASSESSMENT OF THEBODY BUILD AND OF THE HEAD AND NEC.BODY BUILD AND OF THE HEAD AND NEC. TO VIEW THETO VIEW THE
HEAD AND NEC! FRONTALLY AS WELL AS N PROFILE ANDHEAD AND NEC! FRONTALLY AS WELL AS N PROFILE ANDTA!E INTO CONSIDERATION THE BODY BUILD AS WELL.TA!E INTO CONSIDERATION THE BODY BUILD AS WELL.
THE SHORT, THIC NEC THAT IS OFTEN ASSOCIATED WITHTHE SHORT, THIC NEC THAT IS OFTEN ASSOCIATED WITHDIFFICULT INTUBATION IS WELL NOWN AS IS THE CASE WITHDIFFICULT INTUBATION IS WELL NOWN AS IS THE CASE WITHMORBID OBESITY.MORBID OBESITY.
AIRWAYS DIFFICULTIES TEND TO BE ASSOCIATED WITHAIRWAYS DIFFICULTIES TEND TO BE ASSOCIATED WITHSHORT AND STUMPY INDIVIDUALS MORE OFTEN THANSHORT AND STUMPY INDIVIDUALS MORE OFTEN THANTALL AND THIN INDIVIDUALSTALL AND THIN INDIVIDUALS; THIS IS ESPECIALLY TRUE; THIS IS ESPECIALLY TRUEWITH PREGNANT WOMEN, PERHAPS ALSO AS A REFLECTION OFWITH PREGNANT WOMEN, PERHAPS ALSO AS A REFLECTION OFFLUID RETENTION DURING PREGNANCY.FLUID RETENTION DURING PREGNANCY.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
51/135
ANATOMICALLY, THE AIRWAY MAY BE COMPROMISED BY AANATOMICALLY, THE AIRWAY MAY BE COMPROMISED BY A
BROADBROAD
ARRAY OF FACTORS THAT MAY BE CLASSIFIED ON THE BASISARRAY OF FACTORS THAT MAY BE CLASSIFIED ON THE BASIS
OFOF
CAUSE.CAUSE.!.!. DISPROPORTION, PARTICULARLY BETWEEN THE BASE OFDISPROPORTION, PARTICULARLY BETWEEN THE BASE OF
TONGUE AND OROPHARYNGEAL SPACE.TONGUE AND OROPHARYNGEAL SPACE.
%.%. DISTORTIONDISTORTION
+.+. DECREASED MOBILITY OF $OINTS (ATLANTO-OCCIPICALDECREASED MOBILITY OF $OINTS (ATLANTO-OCCIPICAL
AND TEMPOROMANDIBULAR $OINTS)AND TEMPOROMANDIBULAR $OINTS).. DENTAL OVERBITEDENTAL OVERBITE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
52/135
CONGENITALCONGENITAL PIERRE ROBIN SYNDROMEPIERRE ROBIN SYNDROME
TEACHER COLLINSTEACHER COLLINSSYNDROMESYNDROME
GOLDENHARS SYNDROMEGOLDENHARS SYNDROME
DOWNS SYNDROMEDOWNS SYNDROME
LIPPEL-FEIL SYNDROMELIPPEL-FEIL SYNDROME
GOITERGOITER
MICROGNETHIA, MACROGLOSSIA, CLEFT SOFMICROGNETHIA, MACROGLOSSIA, CLEFT SOFPALATEPALATE
AURICULAR AND OCULAR DEFECTS; MALARAURICULAR AND OCULAR DEFECTS; MALAR
AND MANDIBULAR HYPOPLASIAAND MANDIBULAR HYPOPLASIA
AURICULAR AND OCULAR DEFECTS; MALARAURICULAR AND OCULAR DEFECTS; MALARAND MANDIBULAR HYPOPLASIA;AND MANDIBULAR HYPOPLASIA;
OCCIPITALIZATION OF ATLASOCCIPITALIZATION OF ATLAS
POORLY DEVELOPED OR ABSENT BRIDGE OFPOORLY DEVELOPED OR ABSENT BRIDGE OFTHE NOSE; MACROGLOSSIA.THE NOSE; MACROGLOSSIA.
CONGENITAL FUSION OF A VARIABLECONGENITAL FUSION OF A VARIABLE
NUMBER OF CERVICAL VERTEBRAE;NUMBER OF CERVICAL VERTEBRAE;
RESTRICTION OF NEC MOVEMENTRESTRICTION OF NEC MOVEMENT
COMPRESSION OF TRACHEA, DEVIATION OFCOMPRESSION OF TRACHEA, DEVIATION OF
LARYNXTRACHEALARYNXTRACHEA
AIRWAY-COMPROMISING CONDITIONS
AIRWAY-COMPROMISING CONDITIONS
-
7/25/2019 183 Difficult Airway Management (Gabungan)
53/135
ACQUIREDACQUIRED INFECTIONSINFECTIONS
SUPRAGLOTTITISSUPRAGLOTTITIS
CROUPCROUP
ABSCESS (INTRAORAL,ABSCESS (INTRAORAL,RETROPHARNGEAL)RETROPHARNGEAL)
LUDWIGS ANGINALUDWIGS ANGINAARTHRITISARTHRITIS
RHEUMATOID ARTHRITISRHEUMATOID ARTHRITIS
ANYLOSING SPONDYLITISANYLOSING SPONDYLITIS
BENIGN TUMORSBENIGN TUMORS
EXAPLES; CYSTIC HYGROMA,EXAPLES; CYSTIC HYGROMA,LIPOMA, ADENOMA, GOITERLIPOMA, ADENOMA, GOITER
MALIGNANT TUMORSMALIGNANT TUMORS
EXAMPLES; CARCINOMA OFEXAMPLES; CARCINOMA OFTONGUE, CARCIONAMA OFTONGUE, CARCIONAMA OFLARYNX, CARCINOMA OFLARYNX, CARCINOMA OF
THYROID.THYROID.
TRAUMATRAUMA
EXAMLES; FACIAL IN$URY,EXAMLES; FACIAL IN$URY,CERVICAL SPINE IN$URY,CERVICAL SPINE IN$URY,
LARYNGEALTRACHEAL TRAUMALARYNGEALTRACHEAL TRAUMA
OBESITYOBESITY
ACROMEGALYACROMEGALY
ACUTE BURNSACUTE BURNS
LARYNGEAL EDEMALARYNGEAL EDEMA
LARYNGEAL EDEMALARYNGEAL EDEMA
DISTORTION OF THE AIRWAY AND TRISMUSDISTORTION OF THE AIRWAY AND TRISMUS
DISTORTION OF THE AIRWAY AND TRISMUSDISTORTION OF THE AIRWAY AND TRISMUS
TEMPOROMANDIBULAR $OINT ANYLOSIS,TEMPOROMANDIBULAR $OINT ANYLOSIS,CRICOARYTENOID ARTHRITIS, DEVIATION OFCRICOARYTENOID ARTHRITIS, DEVIATION OFLARYNX, RESTRICTED MOBILITY OF CERVICALLARYNX, RESTRICTED MOBILITY OF CERVICALSPINESPINE
ANYLOSIS OF CERVICAL SPINE; LESS COMMONLYANYLOSIS OF CERVICAL SPINE; LESS COMMONLYANYLOSIS OF TEMPOROMANDIBULAR OOINTS;ANYLOSIS OF TEMPOROMANDIBULAR OOINTS;LAC OF MOBILITY OF CERVICAL SPINE.LAC OF MOBILITY OF CERVICAL SPINE.
STENOSIS OR DISTORTION OF THE AIRWAYSTENOSIS OR DISTORTION OF THE AIRWAY
STENOSIS OR DISTORTION OF THE AIRWAY;STENOSIS OR DISTORTION OF THE AIRWAY;
FIXATION OF LARYNX OR AD$ACENT TISSUESFIXATION OF LARYNX OR AD$ACENT TISSUESSECONDARY TO INFILTRATION OR FIBROSIS FROMSECONDARY TO INFILTRATION OR FIBROSIS FROM
IRRADIATION.IRRADIATION.
EDEMA OF THE AIRWAY, HEMATOMA, UNSTABLEEDEMA OF THE AIRWAY, HEMATOMA, UNSTABLEFRACTURES(S) OF THE MAXILLAE, MANDIBLE ANDFRACTURES(S) OF THE MAXILLAE, MANDIBLE ANDCERVICAL VERTEBRAECERVICAL VERTEBRAE
SHORT, THIC NEC; REDUNDANT TISSUE IN THESHORT, THIC NEC; REDUNDANT TISSUE IN THEOROPHARYNX; SLEEP APNEAOROPHARYNX; SLEEP APNEA
MACROGLOSSIA; PROGNATHISMMACROGLOSSIA; PROGNATHISMEDEMA OF AIRWAYEDEMA OF AIRWAY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
54/135
OBJECTIVE ASSESSMENTOBJECTIVE ASSESSMENT
DIFFICULT LARYNGOSCOPY CAN STILL BE ENCOUNTEREDDIFFICULT LARYNGOSCOPY CAN STILL BE ENCOUNTERED
DURING INDUCTION IN INDIVIDUALS WITH NO OBVIOUSDURING INDUCTION IN INDIVIDUALS WITH NO OBVIOUS
ANATOMIC VARIATIONS, UNRESTRICTED MOVEMENT OF HEADANATOMIC VARIATIONS, UNRESTRICTED MOVEMENT OF HEAD
AND NEC, ADEQUATE RELAXATION, OPTIMAL POSITIONING,AND NEC, ADEQUATE RELAXATION, OPTIMAL POSITIONING,
AND SOUND TECHNIQUE.AND SOUND TECHNIQUE.
A TOTALLY UNEPECTED DIFFICULT LARYNGOSCOPYA TOTALLY UNEPECTED DIFFICULT LARYNGOSCOPY
MIGHT CONTRIBUTE TO SIGNIFICANT MORBIDITY ANDMIGHT CONTRIBUTE TO SIGNIFICANT MORBIDITY AND
MORTALITY.MORTALITY.
THE BASIS OF AIRWAY CLASSIFICATION *THE BASIS OF AIRWAY CLASSIFICATION *
CLASS ! * UVULA, FAUCIAL PILLARS, SOFT PALATE VISIBELCLASS ! * UVULA, FAUCIAL PILLARS, SOFT PALATE VISIBEL
CLASS % * FAUCIAL PILLARS, SOFT PALATE VISIBLECLASS % * FAUCIAL PILLARS, SOFT PALATE VISIBLE
CLASS + * SOFT PALATE VISIBLECLASS + * SOFT PALATE VISIBLE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
55/135
A B C
-
7/25/2019 183 Difficult Airway Management (Gabungan)
56/135
CORRELATION BETWEEN VISIBILITY OF FAUCIAL PILLARS,CORRELATION BETWEEN VISIBILITY OF FAUCIAL PILLARS,
SOFT PALATE AND UVULA AND EPOSURE OF GLOTTIS BYSOFT PALATE AND UVULA AND EPOSURE OF GLOTTIS BY
DIRECT LARYNGOSCOPYDIRECT LARYNGOSCOPY
LARYNGOSCOPY GRADELARYNGOSCOPY GRADE
VISIBILITY OFVISIBILITY OF
STRUCTURESSTRUCTURES
NO.OF PTS.NO.OF PTS.
(2)(2)
GRADE !GRADE !
NO.OF PTSNO.OF PTS
(2)(2)
GRADE %GRADE %
NO OF PTSNO OF PTS
(2)(2)
GRADE +GRADE +
NO.OF PTSNO.OF PTS
(2)(2)
GRADE GRADE
NO. OF PTSNO. OF PTS
(2)(2)
CLSS !CLSS !
!'' (0+.32)!'' (0+.32) !%' ('#.'2)!%' ('#.'2) +" (!.+2)+" (!.+2) -- --
CLASS %CLASS %
" (!#2)" (!#2) !% ('.02)!% ('.02) ! (&.02)! (&.02) !" (.02)!" (.02) (!.#2) (!.#2)
CLASS +CLASS +
!' (0.!2)!' (0.!2) -- ! (".'2)! (".'2) # (.+2)# (.+2) ' (%.2)' (%.2)
-
7/25/2019 183 Difficult Airway Management (Gabungan)
57/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
58/135
LARYNGOSCOPELARYNGOSCOPE
CLINICAL PROBLEM-BASED ASSESSMENT OFCLINICAL PROBLEM-BASED ASSESSMENT OFTRADITIONAL LARYNGOSCOPE DESIGNTRADITIONAL LARYNGOSCOPE DESIGN
ANTESTERNAL SPACE RESTRICTIONANTESTERNAL SPACE RESTRICTION
LIMITED MOUTH OPENINGLIMITED MOUTH OPENING
REDUCED INTRAORAL CAVITYREDUCED INTRAORAL CAVITY
THE ANTERIOR LARYNTHE ANTERIOR LARYN
MANDIBULAR SPACEMANDIBULAR SPACEUNUSUALLY WIDE, SUCH AS THEUNUSUALLY WIDE, SUCH AS THE
BI%ARRI-GUFFRIDBI%ARRI-GUFFRID
NOVEL LARYNGOSCOPE TECHNIQUESNOVEL LARYNGOSCOPE TECHNIQUES
INDIRECT VISUALI$ATION OF THE VOCAL CORDSINDIRECT VISUALI$ATION OF THE VOCAL CORDS
DIRECT VISUALI$ATION OF THE VOCAL CORDSDIRECT VISUALI$ATION OF THE VOCAL CORDS
EPIGLOTTIS POSITIONINGEPIGLOTTIS POSITIONING
INFANT AND PEDIATRIC REQUIREMENTSINFANT AND PEDIATRIC REQUIREMENTS
-
7/25/2019 183 Difficult Airway Management (Gabungan)
59/135
VARIOUS LARYNGOSCOPES HAVE BEEN DESIGNED SINCE WILLIAM MACEWAN
USED HIS FINGERS TO GUIDE TUBE FROM THE MOUTH INTO THE TRACHEA.
A LARYNGOSCOPE CONSISTS OF A HANDLE JOINED TO A BLADE.
THIS $UNCTION USUALLY IS REFERRED TO AS THE FITTING.
THE BLADE CONSISTS OF FIVE PARTS.
!. THE SPATULA IS THE MAIN SHAFT OF THE BLADE. THE BOTTOM CONTACTSTHE TONGUE AND THE TOP FACES THE ROOF OF THE MOUTH.
%. THE WEB OR STEP PRO$ECT UPWARD FROM THE BLADE TOWARD THE
ROFF OF THE MOUTH.+. THE FLANGE PRO$ECTS LATERALLY FROM THE WEB. THE DIRECTION MAY
BE OVER THE BLADE SO THAT A CROSS SECTIONAL AREA IS OPENPARTIALLY, OR COMPLETELY ENCLOSED TO FORM A TUBE. ALTERNATIVELY
THE FLANGE BENDS AWAY FROM THE BLADE AND IS REFERRED TO AS AREVERSED FLANGE.
. THE BEA IS THE TIP OF THE BLADE, PLACED IN THE VALLECULA OR
BEYOND THE EPIGLOTTIS TO ELEVATE IT DIRECTLY.'. APPROXIMATING THE BEA IS A LIGHT SOURCE. THERE MAY BE
ADDITIONAL FEATURES, SUCH AS OXYGEN DELIVERY AND SUCTION
-
7/25/2019 183 Difficult Airway Management (Gabungan)
60/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
61/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
62/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
63/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
64/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
65/135
CLINICAL PROBLEM-BASED ASSESSMENT OFCLINICAL PROBLEM-BASED ASSESSMENT OF
TRADITIONAL LARYNGOSCOPE DESIGNTRADITIONAL LARYNGOSCOPE DESIGN
ANTESTERNAL SPACE RESTRICTIONANTESTERNAL SPACE RESTRICTION
LIMITED MOUTH OPENINGLIMITED MOUTH OPENING
REDUCED INTRAORAL CAVITYREDUCED INTRAORAL CAVITY
THE ANTERIOR LARYNXTHE ANTERIOR LARYNX
MANDIBULAR SPACE * TONGUE SIZE DISPROPORTIONMANDIBULAR SPACE * TONGUE SIZE DISPROPORTION
ANY BLADE WITH A REVERSED FLANGE, PARTICULARLY IFANY BLADE WITH A REVERSED FLANGE, PARTICULARLY IF
UNUSUALLY WIDE, SUCH AS THE BIZARRI-GUFFRIDA.UNUSUALLY WIDE, SUCH AS THE BIZARRI-GUFFRIDA.
EPIGLOTTIS POSITIONINGEPIGLOTTIS POSITIONING
-
7/25/2019 183 Difficult Airway Management (Gabungan)
66/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
67/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
68/135
NOVEL LARYNGOSCOPE TECHNIQUESNOVEL LARYNGOSCOPE TECHNIQUES
-
7/25/2019 183 Difficult Airway Management (Gabungan)
69/135
INDIRECT VISUALIZATION OF THE VOCAL CORDSINDIRECT VISUALIZATION OF THE VOCAL CORDS
THE BELLHOUSE BLADE INCORPORATES A PRISM WHENTHE BELLHOUSE BLADE INCORPORATES A PRISM WHEN
NECESSARYNECESSARY
NOVEL LARYNGOSCOPE TECHNIQUESNOVEL LARYNGOSCOPE TECHNIQUES
-
7/25/2019 183 Difficult Airway Management (Gabungan)
70/135
DIRECT VISUALIZATION OF THE VOCAL CORDSDIRECT VISUALIZATION OF THE VOCAL CORDS
THE BILLARD LARYNGOSCOPE HAS A BROAD BLADETHE BILLARD LARYNGOSCOPE HAS A BROAD BLADE
TERMINATING INTUBATION BROAD CURVE. IT IS THIN ANDTERMINATING INTUBATION BROAD CURVE. IT IS THIN AND
LACS A STEPLACS A STEP
-
7/25/2019 183 Difficult Airway Management (Gabungan)
71/135
INFANT AND PEDIATRIC REQUIREMENTSINFANT AND PEDIATRIC REQUIREMENTS
PREANAESTHESIA ASSESSMENT OF INFANT ANDPREANAESTHESIA ASSESSMENT OF INFANT ANDPEDIATRIC PATIENTS IS SIMILAR TO THAT FOR ADULT.PEDIATRIC PATIENTS IS SIMILAR TO THAT FOR ADULT.
THE NORMAL ANATOMY DIFFERS FROM THE ADULT IN THETHE NORMAL ANATOMY DIFFERS FROM THE ADULT IN THEFOLLOWING DETAILS *FOLLOWING DETAILS *THE TONGUE IS LONGERTHE TONGUE IS LONGER
THE EPIGLOTTIS IS MORE CEPHALAD AND MORETHE EPIGLOTTIS IS MORE CEPHALAD AND MOREANTERIORANTERIOR
THE EPIGLOTTIS IS V SHAPED AND NARROWERTHE EPIGLOTTIS IS V SHAPED AND NARROWER
THE HYOID CARTILAGE IS MORE RESISTANT TO PRESSURETHE HYOID CARTILAGE IS MORE RESISTANT TO PRESSURETHE LARYNX IS AT A HIGHER VERVICAL LEVEL (C+-)THE LARYNX IS AT A HIGHER VERVICAL LEVEL (C+-)
THE VOCAL CORDS SLOPE UPWARD AND BACWARDSTHE VOCAL CORDS SLOPE UPWARD AND BACWARDS
-
7/25/2019 183 Difficult Airway Management (Gabungan)
72/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
73/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
74/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
75/135
SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND UESTIONS TO GUIDE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
76/135
PROBLEMS PRESENTED BY PATIENT
UPPER CHEST WALL
ANTESTERNAL SPACE RESTRICTION
NEC
CHIN-TYROID NOTCH DISTANCE REDUCED
SCARRING, OTHER SPACE-OCCUPYINGPATHOLOGY
TYROID CARTILAGE IMMOBILITY
SUBMENTAL MASS OR SCARRING
ATLANTO-OCCIPITAL $OINT MOBILITYREDUCED
CERVICAL SPINE TRAUMATIZED OR REDUCEDMOBILITY
FACE
MICROGNATHIA
MACROGNATHIA
SPLIT LIP
MANDIBULAR MAXILLARY FRACTURENASAL PATHOLOGY OR TRAUMA
ORAL ORIFICE NARROW
LARYNGOSCOPE DESIGN CHARACTERISTICS
BEA TIPWILL THIS ATRAUMATICALLY AND SECURELY TILT ORLIFT THE EPIGLOTTIS EFFECTIVELY4
BEA
WILL A TILT FROM AXIS OF THE SPATULA AIDVISUALIZATIONACCESS FOR VOCAL CORDAPERTURE4
WILL AN EXPOSED CROSS-SECTIONAL AREA BEPROTECTED FROM PATHOLOGIC ORANATOMICALLY ABNORMAL TISSUES4
WILL THE SIZE OCCUPY SPACE NEEDED TOMANIPULATE TIP OF ETT4
SPATULA WITH REFERENCE TO THE LENGTH THAT WILLBE IN THE ORAL CAVITY
APPROACHING BETWEEN THE INCISOR, TEETH WILL ITSCURVATURE STRAIGHTNESS AID VISUALIZATION AIDACCESS TO THE VOCAL CORDS4
USING A MOLAR OR RETROMOLAR APPROACH, WILL ITSCURVATURE STRAIGHTNESS AID VISUALIZATION AIDACCESS TO THE VOCAL CORDS4
WILL ITS WIDTH COMPRESS TH E TONGUEADWQUATELY4
WILL ITS SIZE HINDER ETT MANIPULATION4
SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND UESTIONS TO GUIDESELCTION OF THE MOST SUITABLE LARYNGOSCOPE BLADE
SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND UESTIONS TO GUIDESELCTION OF THE MOST SUITABLE LARYNGOSCOPE BLADE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
77/135
PROBLEMS PRESENTED BY PATIENT
MOUTH
RESTRICTED OPENING
DENTAL MISALIGNMENT
TONGUE LARGE
INTRAORAL VOLUME SMALL
PHARYNGEAL SPACE-OCCUPYING PATHOLOGY
MALLAMPATI SIGN II-IVMOLAR TEETH PRESENT
LARYNGOSCOPE DESIGN CHARACTERISTICS
WITH REFERENCE TO THE LENGTH THAT WILL BEOUTSIDE THE ORAL CAVITY
WILL ITS SHAPE PROVIDE THE WIDEST FIELD OFVIEW NECESSARY
WILL ITS SHAPE HINDER MANIPULATION OF THEETT AND USE OF OTHER AIDS
FLANGE !MODIFIED " REVERSED#
WILL IT AID TONGUE COMPRESSIONWILL IT CROSS-SECTIONAL AREA$ RELATIVE TOTHAT OF ENTRY TO MOUTH$ HINDERMANIPULATION OF THE ETT OUTSIDE THE
LUMEN OF SPATULA AND FLANGE
SUMMARY OF PROBLEMS PRESENTED BY PAITENTS AND UESTIONS TO GUIDESELCTION OF THE MOST SUITABLE LARYNGOSCOPE BLADE )CONTINUED*
-
7/25/2019 183 Difficult Airway Management (Gabungan)
78/135
PROBLEMS PRESENTED BY PATIENT
UPPER CHEST WALL
ANTESTERNAL SPACE RESTRICTION
NEC
CHIN-THYROID NOTCH DISTANCE REDUCED
SCARRING, OTHER SPACE-OCCUPYING PATHOLOGYTYROID CARTILAGE IMMOBILITY
SUBMENTAL MASS OR SCARRING
ATLANTO-OCCIPITAL $OINT MOBILITY REDUCED
CERVICAL SPINE TRAUMATIZED OR REDUCED MOBILITY
FACE
MICROGNATHIA
MACROGNATHIA
SPLIT LIP
MANDIBULAR MAXILLARY FRACTURE
NASAL PATHOLOGY OR TRAUMA
ORAL ORIFICE NARROW
MOUTH
RESTRICTED OPENING
DENTAL MISALIGNMENT
TONGUE LARGE
INTRAORAL VOLUME SMALL
PHARYNGEAL SPACE-OCCUPYING PATHOLOGY
MALLAMPATI SIGN II-IV
MOLAR TEETH PRESENT
LARYNGOSCOPE DESIGN CHARACTERISTICS
STEPWILL THE HEIGHT PREVENT ENTRY TO THE PATIENTS
MOUTH 4WILL ANGULATION OF SPATULA TO THE AXIS OF THE
TRACHEA BE HINDERED4WILL SHALLOWNESS OR ABSENCE ABOLISH ITS PROP
CAPABILITY IN THAT PATIENT4
FITTINGWILL THE ANGLE BETWEEN HANDLE AND BLADEPREVENT THE BLADE ENTERING THE MOUTH AND ITS
MANIPULOATION4
WILL VISUALIZATION AND MANIPULATION BE
COMPROMISED UNLESS BLADE IS OFFSET4
HANDLE
IS THE HANDLE TOO LONG TO PERMIT BLADE ENTRYINTO THE MOUTH4
DO THE PROBLEMS PRESENTED DEMAND VISUAL AND ACCESS AIDS SUCH AS PRISMS OR VISUALIMAGE TRANSMISSION VIA RIGID OR FLEXIBLE ROUTE4
THE USER WHO DETERMINES THE USEFULNESS OF AN INSTRUMENT. EXAMINE YOUR PATIENT, UNDERSTANDLARYNGOSCOPES, LEARN HOW TO USE THEM
-
7/25/2019 183 Difficult Airway Management (Gabungan)
79/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
80/135
THE TRIPLE MANOEUVREHEAD TILT
CHIN LIFT'AW THRUST
FACEMAS#SONE HAND TECHNIUE
TWO HAND METHOD
THE OROPHARYNGEAL AIRWAYNASOPHARYNGEAL AIRWAYTHE LARYNGEAL MAS# AIRWAY )LMA*OTHER SUPRAGLOTTIC DEVICES
AIRWAY MANAGEMENT DEVICE, AMD TM.COMBITUBETM,CUFFED OROPHARYNGEAL AIRWAY, COPATM,LARYNGEAL TUBE,LT,PAX
TMOROPHARYNGEAL AIRWAY. PAXPREESSTM
-
7/25/2019 183 Difficult Airway Management (Gabungan)
81/135
THE FIRST PART OF FOLLOW, DESCRIBES HOW THE AIRWAY ISMAINTAINED WITHOUT AIRWAY AD'UNCTSAND WITH THE AID OFSUPRAGLOTTIC DEVICES.
AIRWAY MANAGEMENT WITHOUT INTUBATION )AMWI* IS ANIMPORTANT S#ILL THAT MUST BE MASTERED BY THE MEDICAL
STAFF.
IT MAY BE CARRIED OUT & AS A PART OF PRIMARY AIRWAY MANAGEMENT PRIOR TO
EMERGENCY OR ELECTIVE INTUBATION. WHEN INTUBATION EEQUIPMENT OR INTUBATION SILLS ARE
UNAVAILABLE, E.G. ON THE WARDS OR OUT OF HOSPITALSCENARIOS. WHEN INTUBATION IS DIFFICULT WHEN THE PATIENT HAS A PARTIALLY OBSTRUCTED AIRWAY AS A PART OF A GENERAL ANAESTHETIC
-
7/25/2019 183 Difficult Airway Management (Gabungan)
82/135
THE UPPER AIRWAY HAS
A RIGID WALL SUPPORTED BY THE VERTEBRA POSTERIORLY
COLLAPSIBLE ANTERIOR WALL FORMED BY THE TONGUE AND THEEPIGLOTTIS ANTERIORLY.
THE ANTERIOR WALL OBSTRUCTS THE AIRWAY IFTHERE IS A LOSS OF MUSCLE TONE (UNCONSCIOUSNESS, PARALYSIS)
THE BUL OF THE SOFT TISSUE IS INCREASED (OEDEMA, ABSCESS, TUMOUR)
AMWI MAY CONSIST OF THE USE OF ONE OR MORE OF THE FOLLOWING &TRIPLE MANOEUVREFACEMASSOROPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAYLARYNGEAL MAS OESOPHAGOTGRACEHAL COMBITUBE AIRWAYMANAGEMENT DEVICES
-
7/25/2019 183 Difficult Airway Management (Gabungan)
83/135
!I#!II#
!III#
-
7/25/2019 183 Difficult Airway Management (Gabungan)
84/135
THE TRIPLE MANOEUVRE,CLASSICALLY CONSISTS OF *HEAD TILTCHIN LIFT$AW THRUST
THE HEAD TILT AND CHIN LIFT IS AVOIDED IN PATIENTS WITHSUSPECTED HEAD OR CERVICAL SPINE IN'URY
FACEMAS#S
FACEMASS ARE DESIGNED SO AS TO FIT SNUGLY OVER THE PATIENTSMOUTH AND NOSE.
THE PURPOSE OF THE FACEMAS IS TO DELIVER OXYGEN, PLUS MINUSANAESTHETIC GASES FROM THE BREATHING SYSTEMS TO THE PATIENT.
THE OROPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAY
THE LARYNGEAL MAS# AIRWAY )LMA*
-
7/25/2019 183 Difficult Airway Management (Gabungan)
85/135
LARYNGEAL MAS# AIRWAY )LMA*
INDICATIONS
THESE CAN BE CLASSIFIED AS EMERGENCY OR ELECTIVE
CONTRAINDICATIONS
WHERE THERE IS A RIS# OF ASPIRATION, SUCH AS PATIENTS WITH FULL STOMACH HISTORY OF ACTIVE REFLUX OR A HIATUS HERNIA MA$OR SURGERY MORBIDLY OBESE PATIENTS PREGNANCY (ELECTIVE SURGERY FROM !& WEES UP TO 3 H
POSTDELIVERY)
-
7/25/2019 183 Difficult Airway Management (Gabungan)
86/135
METHOD OF INSERTION
THERE ARE SEVERAL TECHNIQUES THAT HAVE BEEN DESCRIBED FORINSERTION OF THE LMA. THE STANDARD TECHNIQUE ID DESCRIBEDBELOW*
!. INFLATE THE CUFF UP TO '"2 OF ITS MAXIMUM VOLUME AND CHECFOR CUFF LEAS
%. DEFLATE THE CUFF FULLY OR PARTLY AND APPLY A LUBRICANT $ELLY
TO LUBRICATE THE BAC OF THE CUFF (I.E. THE PHARYNGEAL SIDE)+. ENSURE THAT THE PATIENT IS ADEQUATELY ANAESTHETISED. EXTENT THE PATIENTS NEC AND STABILISE THE OCCIPUT SO THAT
THE $AW FALLS OPEN. THE ASSISTANT MAY HELP BY HOLDING THEPATIENTS MOUTH OPEN.
'. GRASP THE LMA LIE A PEN IN THE DOMINANT HAND AND PRESS THEDISTALTIP OF THE DFLATED LMA CUFF AGAINST HE HARD PALATE
USING THE INDEX FINGER OF THE NON-DOMINANT HAND TO GUIDETHE TUBE OVER THE BAC OF THE TONGUE AND INTO THEOROPHARYNX
METHOD OF INSERTION
-
7/25/2019 183 Difficult Airway Management (Gabungan)
87/135
&. ADVANCE THE LMA GENTLY UNTIL CHARACTERISTIC RESISTANCE ISFELT AS IT ENGAGES THE UPPER OESOPHAGEAL SPHINCTER
0. THE CUFF IS THEN GENTLY INFLATED WITH AIR NOT EXCEEDINGTHE MAXIMUM RECOMMENDED VOLUME
3. THE LMA MAY FLOAT OUT SLIGHTLY THIS MANOEUVRE AS ITTRIES TO FIT ITSELF IN THE CORRECT POSITION.
#. THE LMA IS THEN CONNECTED TO THE BREATHING SYSTEM
!". CORRECT POSITION IS CHECED WITH GANTLE POSITIVEPRESSURE BREATHS SHOWING CHEST EXPANSION, NOTICING THEMOVEMENTS OF THE RESERVOIR BAG IN A SPONTANEOUSLYBREATHING PATIENT, AUSCULTATION AND WATCHING THE END-TIDAL CARBON DIOXIDE TRACE. THE BLAC LINE ON THE TUBE OFTHE LMA LIES DORSALLY IN THE MIDLINE.
WHEN THE LMA IS USED FOR CONTROLLED VENTILATION, IT IS IMPORTANT#EEP INFLATION PRESSURES NOT GREATHER THAN +0CM OF WATER,OTHERWISE IT MAY RESULT IN GASTRIC INSUFFLATION
-
7/25/2019 183 Difficult Airway Management (Gabungan)
88/135
OTHER SUPRATLOTTIS DEVICES
AIRWAY MANAGEMENT DEVICE, AMD TM. NAGOR LTD, DOUGLAS,ISLE OF MAN.
COMBITUBETM, TYCO HEALTCARE LTD, GOSPORT, U CUFFED OROPHARYNGEAL AIRWAY, COPATM, TYCO HEALTCARE LTD,
GOSPORT, U LARYNGEAL TUBE,LT, VBM GMBH, SULZ GERMANY PAXTMOROPHARYNGEAL AIRWAY. PAXPREESSTMVITAL SIGNS LTD,
BARNHAM U
-
7/25/2019 183 Difficult Airway Management (Gabungan)
89/135
56789:8O% WAS =#"2 BEFORE ANAESTHETIC INTERVENTION
IT IS NOT POSSIBLE FOR THE UNASSISTED ANAESTHESIOLOGIST TOPREVENT OR REVERSE SIGNS OF INADEQUATE VENTILATIONDURING POSITIVE PRESSURE MAS VENTILATION
DIFFICULT TRACHEAL INTUBATION IS SAID TO OCCUR IF
PROPER PLACEMENT OF THE TRACHEAL TUBE WITH CONVENTIONAL
LARYNGOSCOPY REQUIRES MORE THAN THERE ATTEMPTS
PROPER INSERTION OF THE TRACHEAL TUBE WITH CONVENTIONALLARYNGOSCOPY REQUIRES MORE THAN (MIN
-
7/25/2019 183 Difficult Airway Management (Gabungan)
106/135
THIS WOULD BE MOSTLY IN CASES OF DIFFICULT LARYNGOSCOPY, WHENIT IS NOT POSSIBLE TO VISUALISE ANY PORTION OF THE VOCAL CORDSWITH CONVENTIONAL LARYNGOSCOPY.
THIS CORRESPONDS TO GRADES III AND IV OF THE CORMAC ANDLEHANE CLASISIFICATION.
THE TRAINEE MUST BE BEAR IN MIND THAT THE TIME SPENT DURINGINTUBATION ALSO INCLUDES PERIODS OF OXYGENATION BY ALTERNATIVEMEANS I.E. HAND VENTILATION WITH BAG, MAS AND AIRWAY.
THE INCIDENCE OF FAILED TRACHEAL INTUBATION IS "."'-".++2(DEPENDING ON PATIENT POPULATION, ANAESTHETIC SILL ANDEQUIPMENT.
THE HIGHER FIGURE REFERS TO DATA FROM OBSTETRIC PATIENTS. THE
INCIDENCE OF FAILED MAS VENTILATION AND TRACHEAL INTUBATION IS"."! 1 %."2.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
107/135
THE REPORTED INCIDENCE OF DIFFICULT LARYNGOSCOPY IS +-
!+2 A DIFFICULT LARYNGOSCOPY DOES NOT ALWAYS EQUATEWITH DIFFICULT INTUBATION.
A GRADE III LARYNGOSCOPIC VIEW MAY ENABLE RELATIVELYEASY INTUBATION WITH A BOUGIE, WHILE A GRADE II WITH ANANTERIOR AND DEEP LYING LARYNX MAY BE DIFFICULT TO
INTUBATE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
108/135
PREVENTION AND PORPER PREPARATION ENABLES THEANAESTHETIST TO DEAL WITH THESE SITUATIONS.
ADEQUATE AIRWAY ASSESSMENT IS IMPORTANT BUT BY NOMEANS GUARANTES AN EASY TIME.
ALWAYS HAVE A PRIMARY AND A SECONDARY PLAN FOR AIRWAYMANAGEMENT.
THE FIRST PLAN MUST INCLUDE PLANNING FOR THE ALTERNATIVE.
ADMINISTER A H% BLOCER TO PATIENTS AT RIS ASPIRATION,SUCH AS THE MORBIDLY OBESE (BMI=+'GM%) OR THOSE WITHHERNIA.
REMEMBER NOT TO DO ANYTHING BEYOND YOUR COMPETENCE,HENCE CALL FOR HELP SOONER RATHER THAN LATER.
INITIAL ATTEMPS AT INTUBATION SHOULD BE INTERPRETED BYTHE $UNIOR TRAINEE AS CALL FOR HELP.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
109/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
110/135
ASA TAS FORCEDIFFICULT AIRWAY ALGORITHM
DIFFICULTY WITH MAS# VENTILATION
A $UNIOR TRAINEE SHOULD NOT ADMINISTER A LONG ACTING
-
7/25/2019 183 Difficult Airway Management (Gabungan)
111/135
MUSCLE RELAXANT TO A PATIENT BAFORE ACHIEVING SEVERAL
SATISFACTORY TEST INFLATIONS VIA THE MAS AND AIRWAY.
IF VENTILATION IS POSSIBLE WITHOUT MUSCLE PARALYSIS, IT WILL
BE EASIER AFTER THE ADMINISTRATION OF THE MUSCLE RELAXANT.
TRY THE FOLLOWING IF THERE IS A PROBLEM WITH MAS#
VENTILATION AT THIS STAGE.!. USE THE CORRECT MAS FIT. TRY A DIFFERENT SIZE MAS
%. TRY AD$USTING THE TRIPLE MANOEUVER; HEAD TILT, CHIN LIFT AND $AWTHRUST.
+. INSERT THE CORRECT SIZE OROPHARYNGEAL OR A NASOPHARYNGEAL AIRWAY.
. TRY TWO-HAND TECHNIQUE, I.E. THE ASSISTANT SQUEENZES THE BAG WHILETHE PRACTITIONER HOLDS THE MAS WITH BOTH HANDS (OFTEN NEEDED INEDENTULOUS PATIENTS OR PATIENTS OF A LARGE BODY MASS INDEX)
'. USE SOME FORM OF SUPRAGLOTTIS DEVICE SUCH AS THE LARYNGEAL MASAIRWAY (LMA)
-
7/25/2019 183 Difficult Airway Management (Gabungan)
112/135
DIFFICULTY WITH INTUBATION
VARIOUS ANAESTHETIC ORGANISATIONS HAVE DEVISED THEIROWN
ALGORITHMS FOR THE MANAGEMENT OF THE DIFFICULT AIRWAY.ONE SUCH IS THE ASA ALGORITHM AS DESCRIBED ABOVE.PREVENTION OF DIFFICULT IS PREFERABLE
ANTICIPATE BEFORE THE PROCEDURE 1 MAE AN ASSESSMENT BE PREPARED 1 MAE SURE YOU HAVE GOT ALL THE EQUIPMENT SPOT THE PROBLEM EARLY CALL FOR HELP EARLY DO NOT PANIC 1 MAINTAIN OXYGENATION WITH !""2 OXYGEN HAVE A BAC-UP PLAN
MA#E SURE THE SURGEON IS AWARE OF THE PROBLEM
-
7/25/2019 183 Difficult Airway Management (Gabungan)
113/135
IF THE PATIENT IS ANAESTHETISED AND PARALYSED AND THE
INTUBATION IS DIFFICULT (UNABLE TO INTUBATE WITH ACONVENTIONAL LARYNGOSCOPE IN THE FIRST INSTANCE )
THEN *
!. CONTINUE WITH EFFECTIVE MAS VENTILATION ASDECRIBED ABOVE
%. IDENTIFY THE PROBLEM, E.G. BUCED TEETH, SMALLMOUTH, POSITION OF NEC, LARGE BREASTS
+. TAE THE NECESSARY ACTION
. CALL FOR HELP IF MORE THAN TWO ATTEMPTS ATINTUBATION ARE REQUIRED.
REMEMBER, THE PATIENT IS SAFE AS LONG AS EFFECTIVE
VENTILATION CAN BE CONTINUED WITH 100% O"YGEN
PROBLEM ACTION
-
7/25/2019 183 Difficult Airway Management (Gabungan)
114/135
POOR VIEW (GRADE III-IV)
SMALL MOUTH, BUCEDETEETH
LARGE OBESE PATIENT, BIGBREASTS
ANTERIOR LARYNX, POOR
VIES
ACTION
APPLY OR RELAX PRESSURE
ON THE LARYNX, ALTERNATIVEBLADE (CURVEDSTRAIGHT)
SMALL BLADE
SHORT-HANDLE OR POLIOBLADE
USE A BOUGIELARGE BLADE,LARYNGEAL PRESSURE,ALTERNATIVE BLADE
VARIOUS LARYNGOSCOPIC BLADES ARE AVAILABLE FOR USE IN DIFFESITUATIONS. FOR A DEEP LYING ANTERIOR LARYN" SELECT A LONG AOR STRAIGHT BLADE& FOR A LARGE FLOPPY EPIGLOTTIS TRY THEM-COY LARYNGOSCOPE WITH A TILTING TIP.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
115/135
IS IN AN EMERGENCY OR LIFE-SAQVING SURGERY/
IN AN EMERGENCY OR LIFE-SAVING SURGERY, ONE HAS NOOPTION
OTHER THEN EEPING THE PATIENT ANAESTHETISED, WHILE
MAINTAINING SPONTANEOUS BREATHING OR CONTINUINGEFFECTIVE MAS# VENTILATION UNTIL HELP ARRIVES.
IF IT IS A NONEMERGENCY SURGERY, THE SAFEST OPTION ISTO
WA#E THE PATIENTS UP AND TA#E STOC#.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
116/135
TECHNIQUES FOR DIFFICULT INTUBATION
ALTERNATIVE LARYNGOSCOPE 1 LARGE, M5COY OR POLIOBLADE, SHORT HANDLE
INTUBATING STLET GUM ELASTIC BOUGIE BLIND NASAL INTUBATING THROUGH A LMA FIBEROPTIC INTUBATION (AWAE OR UNDER GENERAL
ANAESTHESIA) RETROGRADE INBTUBATION SURGICAL AIRWAY 1 CRICOTHROIDOTOMY, TRACHEOSTOMY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
117/135
DIFFICULTY WITH INTUBATION AND VENTILATION
THIS SITUATION MAY ARISE DURING RAPID SEQUENCEINDUCTION WITH CRICOID PRESSURE, FOLLOWING FAILURE TOINTUBATE.
OFTEN THE CRICOID PRESSURE APPLIED BY ANINEXPERIENCED ASSISTANT CONTRIBUTES TO THE DIFFICULTY.
IF LARYNGOSCOPY AND INTUBATION HAVE FAILED USING
STRATEGIES AVAILABLE, MAS VENTILATION OR LMAVENTILATION IS THE NEXT STEP.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
118/135
IF ALL POSSIBLE MANEUVRES TO ACHIEVE EFFECTIVEVENTILATION HAVE FAILED INTUBATION IS UNSUCCESSFULAND THE PATIENT IS DESATURATING, THEN IMMEDIATEOXYGEN DELIVERY TO THE PATIENT IS ABSOLUTELYNECESSARY. THIS IS A CANNOT INTUBATE, CANNOTVENTILATE.
IN THIS SITUATION THE ONLY WAY TO ACHIEVE OXYGENATIONQUICLY IS EITHER A TRANS-TRACHEAL VENTILATION USING
A TRANS-TRACHEAL CANNULA,
NEEDLE CRICOTHYROIDOTOMY.
SURGICAL CRICOTHYROIDOTOMY.
PRECUTANEOUS NEEDLE CRICOTHYROIDOTOMY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
119/135
PRECUTANEOUS NEEDLE CRICOTHYROIDOTOMY
THE CRICOTHYROID MEMBRANE IS PUNCTURED VERTICALLY IN THE
MIDLINE USING A LARGE-BORE INTRAVENOUS CANNULA ATTACHED
TO A SYRINGE
!. THE PATIENTS HEAD IS EXTENDED
%. THE CANNULA IS ADVANCED IN THE MIDLINE VERTICALLYDOWN UNTIL AIR IS ASPIRATED AND IT IS THEN DIRECTED
CAUDALLY SO THAT THE CANNULA SLIDES INTO THE TRACHEAAND THE NEEDLE IS REMOVED.
+. ASPIRATION OF AIR CONFIRMS CORRECT PLACEMENT
. THE CANNULA IS THEN CONNECTED TO A HIGH PRESSUREOXYGEN SOURCE ( BAR) DELIVERING OXYGEN AT !%-!'LMINVIA A SANDARS $ET IN$ECTOR (NEWER DEVICES ALLOW
PRESURE REGULATION), OR USING SOME OTHER DEVICE.
-
7/25/2019 183 Difficult Airway Management (Gabungan)
120/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
121/135
ADVANTAGES
!. RAPID ACCESS TO THE AIRWAY IN ACUTE UPPER AIRWAYOBSTRUCTION OR THE CANNOT INTUBATE, CANNOTVENTILATE SITUATION.
%. BUYS TIME TO PREPARE FOR A MORE DEFINITIVE FORM OFAIRWAY USING ADVANCED TECHNIQUES.
DISADVANTAGES
!. TRAUMA TO SURROUNDING STRUCTURES, ESPECIALLY THEOESOPHAGUS
%. HAEMORRHAGE
+. SURGICAL EMPHYSEMA
. PULMONARY BAROTRAUMA
SURGICAL CRICOTHYROIDOTOMY #LARYNGOTOMY$
-
7/25/2019 183 Difficult Airway Management (Gabungan)
122/135
SURGICAL CRICOTHYROIDOTOMY #LARYNGOTOMY$
A SCALPEL US USED TO PIERCE THE CRICOTHYROIDMEMBRANE. IT IS POSSIBLE TO INSERT A SMALL-CUFFED
TRACHEAL TUBE OR A SPECIFICALLY DESIGNED MMCANNULA.
TRANS-TRACHEAL JET VENTILATION
IT USES THE VENTURI PRINCIPLE WHEREBY A $ET OF OXYGEN
UNDER HIGH PRESSURE (BAR) ENTRAINS A LARGER VOLUMEOF AIR, RESULTING IN CHEST INFLATION.
IT IS A POTENTIALLY DANGEROUS TECHNIQUES THAT CANEASILY RESULT IN BAROTRAUMA.
OTHERWISE USE A SURGICAL CRICOTHYRODOTOMY AND AMINIMUM MM INTERNAL DIAMETER EMERGENCY AIRWAY.
STRIDOR
-
7/25/2019 183 Difficult Airway Management (Gabungan)
123/135
IF STRIDOR IS PRESENT, IT MEANS A MA'OR UPPER AIRWAYOBSTRUCTION COMPRESSION.
STRIDOR IS A CLEAR WARNING OF EXPECTED DIFFICULTY WITHMAS VENTILATION AND QUITE LIELY DIFFICULTY WITHLARYNGOSCOPY AND INTUBATION.
PARTIAL AIRWAY OBSTRUCTION WHEN THE PATIENT IS CONSCIOUSMAY RAPIDLY PROGRESS TO COMPLETE AIRWAY OBSTRUCTION
WHEN CONSCIOUSNESS IS LOSTTHE FAILED MAS VENTILATION AND FAILED INTUBATIONALGORITHM IS OF LITTLE USE IN THIS SITUATION.
DO PRE-OPERATIVE ASSESSMENT
OPTIMISING BREATHING
-
7/25/2019 183 Difficult Airway Management (Gabungan)
124/135
STRATEGIES FOR INTUBATION
THIS CAN BE ACHIEVED IN EXPERT HANDS WITH AWAE FIBEROPTICINTUBATION.
MANY THEREFORE PREFER INHALATIONAL INDUCTION OF ANAESTHESIAWITH OXYGEN AND A VOLATILE AGENT, MAINTAINING SPONTANEOUSRESPIRATION UNTIL A SUFFICIENTLY DEEP LEVEL OF ANAESTHESIA IS
ACHIEVED TO ALLOW LARYNGOSCOPY
THE TRAINEE ANAESTHETIST SHOULD AVOIDE ANAESTHETISING PATIENTSWITH STIDOR
-
7/25/2019 183 Difficult Airway Management (Gabungan)
125/135
SUMMARY
AVOID DIFFICULTY 1 BE PREPAREDOPTIMISE YOUR CONDITIONS (STAFF, EQUIPMENT, PATIENT
PREPARATION)USE ALTERNATIVE MEANS IF PRIMARY STRATEGY FAILSOXYGENATE
-
7/25/2019 183 Difficult Airway Management (Gabungan)
126/135
-
7/25/2019 183 Difficult Airway Management (Gabungan)
127/135
THE DIFFICULT AIRWAYDIFFICULT BMV MOANS DIFFICULT LARYNGOSCOPY AND INTUBATION LEMONS DIFFICULT EGD RODS DIFFICULT CRICOTHYROTOMY SHORT
AIRWAY ALGORITHMTHE UNIVERSAL EMERGENCY AIRWAY ALGORITHMMAIN EMERGENCY AIRWAY MANAGEMENT ALRORITHMTHE CRASH AIRWAY ALGORITHMTHE DIFFICULT AIRWAY ALGORITHM
THE FAILED AIRWAY ALGORITHM
-
7/25/2019 183 Difficult Airway Management (Gabungan)
128/135
THE DIFFICULT AIRWAY
IN CLINICAL PACTICE, THE DIFFICULT AIRWAY HAS FIVE DIMENSIONS&
!.DIFFICULT BMV%.DIFFICULT LARYNGOSCOPY
+.DIFFICULT INTUBATION.DIFFICULT EGD
'.DIFFICULT CRICOTHYROTOMY
THESE FIVE DIMENSIONS CAN BE REDUCED TO FOUR TECHNICALOPEATIONS &
!.DIFFICULT BMV%.DIFFICULT LARYNGOSCOPY AND INTUBATION
+.DIFFICULT EGD.DIFFICULT CRICOTHYROTOMY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
129/135
DIFFICULT BAG 0 MAS! VENTILATION & MOANS
MAS SEAL
OBESITY OBSTRUCTIONAGENO TEETH
STIFF
DIFFICULT LARYNGOSCOPY AND INTUBATION & LEMON
LOO EXTERNALLYEVALUATE THE +-+-% RULE
MALLAMPATI SCORE
OBSTRUCTION OBESITYNEC MOBILITY
-
7/25/2019 183 Difficult Airway Management (Gabungan)
130/135
DIFFICULT ETRAGLOTTIC DEVICES & RODS
RESTRICTED MOUTH OPENING
OBSTRUCTIONDISRUPTED OR DISTORTED AIRWAYSTIFF LUNGS OR CERVICAL SPINE
DIFFICULT CRICOTHYROTOMNY & SHORT
SURGERY (OR OTHER AIRWAY DISRUPTION)HERMATOMA (INCLUDES INFECTION ABSCESS)OBESITY (INCLUDES ANY ACCESS PROBLEM)RADIATION DISTORTION (AND OTHER DEFORMITY)
TUMOR
THE UNIVERSAL EMERGENCY AIRWAY ALGORITHM
-
7/25/2019 183 Difficult Airway Management (Gabungan)
131/135
UNCONSCIOUSUNREACTIVENEAR DEATH
DIFFICUTAIRWAY 4
RSI
CRASHAIRWAY
ALGORITHM
DIFFICUT
AIRWAY 4ALGORITHM
FAILED
AIRWAYALGORITHM
YES
YES
NO
NO
FAILS
FAILS
FAILS
NEEDSINTUBATION
CRASHYES
MAIN EMERGENCY AIRWAYMANAGEMENT ALRORITHM
-
7/25/2019 183 Difficult Airway Management (Gabungan)
132/135
UNRESPONSIVENEAR DEATH
PREDICT DIFFICULTAIRWAY
RSI
ATTEMPTINTUBATION
SUCCESSFUL
FAILURE TO MAINTAINO%YGENATION
2-' ATTEMPTS AT OTI BYE%PERIENCED OPERATOR
FROM DIFFICULTAIRWAY
CRASHAIRWAY
DIFFICULTAIRWAY
POST INTUBATIONMANAGEMENT
FAILEDAIRWAY
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES
CRASHAIRWAY
MAINTAIN O%YGENATION
THE CRASH AIRWAYALGORITHM
-
7/25/2019 183 Difficult Airway Management (Gabungan)
133/135
MAINTAIN O%YGENATION
INTUBATION ATTEMPT
SUCCESSFUL
UNABLE TO BAG VENTILATE
SUCCINYCHOLINE 2 MG"KG IVP
ATTEMPT INTUBATION
SUCCESSFUL
FAILURE TO MAINTAINO%YGENATION
POST INTUBATION
MANAGEMENT
FAILEDAIRWAY
POST INTUBATIONMANAGEMENT
FAILEDAIRWAY
NO
NO
NO
NO
NO
YES
YES
YES
YES
YES( ' ATTEPTS BYE%PERIENCED OPERATOR
DIFFICULT AIRWAYPREDICTED
CALL FOR ASSISTANCE
THE DIFFICULT AIRWAYALGORITHM
-
7/25/2019 183 Difficult Airway Management (Gabungan)
134/135
PREDICTED
FAILURE TO MAINTAINO%YGENATION
BMV OR EGDPREDICTED TO BE
SUCCESSFUL
AWAKE DL$ FO$ ORVL SUCCESSFUL
ILMAFO OR VL)
CRICOTHYROTOMYBNTI LIGHTED STYLET
INTUBATION PREDICTEDTO BE SUCCESSCUL
RSI
FAILEDAIRWAY
FAILEDAIRWAY
FAILEDAIRWAY
YES
YES
YES
NO
YES
NO
NO
NO
CALL FOR ASSISTANCEFAILEDAIRWAY CRITERI
A
THE FAILED AIRWAYALGORITHM
-
7/25/2019 183 Difficult Airway Management (Gabungan)
135/135
FAILURE TO MAINTAINO%YGENATION
CHOOSE ONE AT
-FIBEROPTIC METHOD-VIDEO LARYNGOSCOPY-E%TRA GLOTTIC DEVICE-LIGHTED STYLET-CRICOTYROTOMY
CUFFED ETT PLACED
CRITOTHYROTOMYYES
NO
NO
POST INTUBATIONMANAGEMENT
YES
E%TRA-GLOTTIC DEVICE
MAY BE ATTEMPTED