AIRWAY MANAGEMENT AIRWAY MANAGEMENT

SMF Anestesi dan ReanimasiSMF Anestesi dan Reanimasi

Rumah Sakit PersahabatanRumah Sakit Persahabatan

JakartaJakarta

Elements of Basic Life Elements of Basic Life SupportSupport

A – B - CA – B - C

Basic Life Support:Basic Life Support:ImportanceImportance

The respiratory system is important The respiratory system is important because it is one of the primary systems because it is one of the primary systems that works to supply oxygen to the body.that works to supply oxygen to the body.

If breathing is not resumed, brain If breathing is not resumed, brain damage will result starting damage will result starting

after four after four

minutes.minutes.

RESUME OF RESUME OF BASIC LIFE BASIC LIFE SUPPORTSUPPORT

Korban Korban

Cek kesadaranCek kesadaran

Sadar Sadar Tidak sadar Tidak sadar

Open airwayOpen airway

Cek nafas = Look, feel and listenCek nafas = Look, feel and listen

Posisi mantapPosisi mantap

Nafas Nafas Tidak nafasTidak nafas

2-5 nafas buatan2-5 nafas buatanCek nadiCek nadi

Ada Ada Tidak adaTidak ada Kompresi Kompresi

Ventilasi dan oksigenasiVentilasi dan oksigenasi

Nilai irama dan cek pulseNilai irama dan cek pulseROSCROSC

George, 2004George, 2004

ACLSACLS

Airway DevicesAirway DevicesOral Airways:Oral Airways:

are designed to keep the are designed to keep the tongue from falling back tongue from falling back and blocking the upper and blocking the upper airwayairway

are easily available in six are easily available in six sizessizes

are only used in are only used in unresponsive patients unresponsive patients without a gag reflexwithout a gag reflex

do not eliminate the do not eliminate the need to monitor the need to monitor the airway for patencyairway for patency

Oral AirwaysOral AirwaysSizingSizing

To choose the To choose the proper size, hold proper size, hold the airway the airway against the side against the side of the patient’s of the patient’s face. It should face. It should extend from the extend from the corner of the corner of the patient’s mouth patient’s mouth to the angle of to the angle of the jaw. the jaw.

Oral AirwaysOral AirwaysInsertionInsertion

open mouth with cross-finger open mouth with cross-finger technique. Insert airway technique. Insert airway with tip pointing up to avoid with tip pointing up to avoid pushing tongue backwardpushing tongue backward

rotate airway tip slowly rotate airway tip slowly downward until its curve downward until its curve matches the curve of the matches the curve of the tonguetongue

the flange of the airway the flange of the airway should rest against the should rest against the patient’s lipspatient’s lips

Nasopharyngeal Airways Nasopharyngeal Airways SizingSizing

curved, flexible curved, flexible rubber or plastic rubber or plastic tubes inserted tubes inserted into the patient’s into the patient’s nostrilnostril

use on responsive use on responsive patients who patients who need an airway need an airway assistassist

Nasopharyngeal Nasopharyngeal Airways Airways InsertionInsertion

lubricate with sterile, lubricate with sterile, water-soluble lubricant, water-soluble lubricant, and insert into nostril and insert into nostril that appears most that appears most open open

insert until flange is insert until flange is against the nostril against the nostril openingopening

check to ensure airflowcheck to ensure airflow

Breathing DevicesBreathing Devices

There are several devices designed There are several devices designed to make rescue breathing and to make rescue breathing and similar treatments easier and safer similar treatments easier and safer for the rescuer. for the rescuer.

Common breathing devices:Common breathing devices:– Resuscitation MaskResuscitation Mask– Bag Valve MaskBag Valve Mask

Breathing Devices:Breathing Devices:Resuscitation MaskResuscitation Mask

A resuscitation mask, also known A resuscitation mask, also known as a pocket mask, is a device as a pocket mask, is a device designed to separate the rescuers designed to separate the rescuers mouth from the victims.mouth from the victims.

This prevents disease transmissionThis prevents disease transmission

Breathing Devices:Breathing Devices:Resuscitation MaskResuscitation Mask

There are several criteria for a There are several criteria for a good mask:good mask:– Transparent, pliableTransparent, pliable– One way exhalation valveOne way exhalation valve– Inlet for supplementary oxygenInlet for supplementary oxygen– Resistant to extremes of heat or coldResistant to extremes of heat or cold– Easy to assemble and use.Easy to assemble and use.

Breathing Devices:Breathing Devices:Resuscitation MaskResuscitation Mask

To use a mask, place it over the victims To use a mask, place it over the victims mouth and nose, starting on the bottom mouth and nose, starting on the bottom and rolling it over the rest of the face.and rolling it over the rest of the face.

Tilt the head back and breath into it.Tilt the head back and breath into it. A mask can also be used for the A mask can also be used for the

modified jaw thrust.modified jaw thrust.

Breathing Devices:Breathing Devices:Bag Valve MaskBag Valve Mask

A Bag Valve Mask (BVM), also called an A Bag Valve Mask (BVM), also called an AMBU bag, is a device that allows AMBU bag, is a device that allows artificial respiration without a rescuer to artificial respiration without a rescuer to give breaths.give breaths.

It is much less tiring and safer to use.It is much less tiring and safer to use. As the name implies a As the name implies a

BVM needs a squeezeable bag, a BVM needs a squeezeable bag, a one one way valve, and a mask.way valve, and a mask.

Breathing Devices:Breathing Devices:Bag Valve MaskBag Valve Mask

To use, place the mask over the victims To use, place the mask over the victims mouth and nose, and grip the mask in mouth and nose, and grip the mask in one hand using a C shaped grip, finger one hand using a C shaped grip, finger on the victim’s jaw.on the victim’s jaw.

Tilt the head back and squeeze the bag Tilt the head back and squeeze the bag to administer respirations.to administer respirations.

INTUBASI ENDOTRACHEALINTUBASI ENDOTRACHEAL

POLICPOLICYY

PROSEDUR PENTING NAMUN BERESIKO PROSEDUR PENTING NAMUN BERESIKO TINGGITINGGI– Darurat/waktu terbatasDarurat/waktu terbatas– Diindikasikan untuk gagal nafas akutDiindikasikan untuk gagal nafas akut– Ketidakstabilan hemodinamik Ketidakstabilan hemodinamik

(syok)/paska cardiac arrest(syok)/paska cardiac arrest– Trauma servikal (leher) atau orofaringTrauma servikal (leher) atau orofaring– Beresiko muntah dan aspirasiBeresiko muntah dan aspirasi– Posisi sulitPosisi sulit

Harus familiar dengan trolley emergency, Harus familiar dengan trolley emergency, peralatan dan obat2peralatan dan obat2

Asisten harus trampilAsisten harus trampil Jika sendiri, harus memanggil staf Jika sendiri, harus memanggil staf

anestesi, (penata atau dokter anestesi)anestesi, (penata atau dokter anestesi) Pada umumnya memakai teknik induksi Pada umumnya memakai teknik induksi

cepat cepat RAPID SEQUENCE INDUCTIONRAPID SEQUENCE INDUCTION

POLICYPOLICY

INDIKASIINDIKASI

Penggunaan ventilasi mekanikPenggunaan ventilasi mekanik Mempertahankan fungsi jalan Mempertahankan fungsi jalan

nafas (airway)nafas (airway)– Sumbatan jalan nafas atasSumbatan jalan nafas atas

Yang potensial – EARLY BURNSYang potensial – EARLY BURNS Real – EPIGLOTITIS, TRAUMAReal – EPIGLOTITIS, TRAUMA

– TRANSPORTATIONTRANSPORTATION Melindungi jalan nafas dari:Melindungi jalan nafas dari:

– Resiko aspirasiResiko aspirasi– Penurunan kesadaranPenurunan kesadaran– Kehilangan refleks glotisKehilangan refleks glotis– Trakeal “TOILET”Trakeal “TOILET”

TEKNIKTEKNIK

OROTRACHEAL – metode STANDARDOROTRACHEAL – metode STANDARD NASOTRACHEAL - jika;NASOTRACHEAL - jika;

– Pemakaian ventilator jangka pendek, trauma Pemakaian ventilator jangka pendek, trauma rongga mulutrongga mulut

– FIBREOPTICFIBREOPTIC Cedera kepala dan leher (servikal)Cedera kepala dan leher (servikal) Tidak mampu membuka mulut: fiksasi rahang, Tidak mampu membuka mulut: fiksasi rahang,

traumatrauma Obstruksi jalan nafas atas: tumor di rongga Obstruksi jalan nafas atas: tumor di rongga

mulutmulut METODEMETODE

– DIRECT VISUALISATION - laringoskopDIRECT VISUALISATION - laringoskop– FIBREOPTIC – intubasi sadar (AWAKE INTUBATION)FIBREOPTIC – intubasi sadar (AWAKE INTUBATION)– BLIND NASAL – AWAKE INTUBATIONBLIND NASAL – AWAKE INTUBATION

ENDOTRACHEAL TUBEENDOTRACHEAL TUBE

STANDARD TUBE: LOW PRESSURE HIGH VOLUME STANDARD TUBE: LOW PRESSURE HIGH VOLUME (PLAIN PVC)(PLAIN PVC)– Pria 8-9 MM: fiksasi pada 21-23 CM TO INCISORS Pria 8-9 MM: fiksasi pada 21-23 CM TO INCISORS

(gigi taring)(gigi taring)– Wanita 7-8 MM: fiksasi pada 19-21 CM TO Wanita 7-8 MM: fiksasi pada 19-21 CM TO

INCISORSINCISORS– Jangan memotong tube dibawah 26 cmJangan memotong tube dibawah 26 cm

DOUBLE LUMEN TUBES: jarang di ICU (kecuali DOUBLE LUMEN TUBES: jarang di ICU (kecuali CVVH)CVVH)

Tube dari OK/OT harus diganti jika diperkirakan Tube dari OK/OT harus diganti jika diperkirakan ekstubasi > 48 HOURSekstubasi > 48 HOURS

PROTOKOPROTOKOLL

A. PERSON: 4 orang, asisten trampil sangat perluA. PERSON: 4 orang, asisten trampil sangat perlu

– ““TOP END” INTUBATOR (yg melakukan intubasi) TOP END” INTUBATOR (yg melakukan intubasi) koordinator koordinator

– 1 orang 1 orang pemberi obat pemberi obat

– 1 orang menekan cricoid1 orang menekan cricoid

– 1 orang 1 orang menjaga agar kepala dan leher menjaga agar kepala dan leher segaris atau lurus (PROVIDE IN LINE CERVICAL segaris atau lurus (PROVIDE IN LINE CERVICAL SPINE IMMOBILISATION)SPINE IMMOBILISATION)

B. Jalur intravena harus dijamin lancarB. Jalur intravena harus dijamin lancar

C. Peralatan:C. Peralatan:– Lampu penerangan cukupLampu penerangan cukup– Guedel/mayoGuedel/mayo– Suction yg berfungsiSuction yg berfungsi– AMBU BAG dan MASKAMBU BAG dan MASK– 100% OXYGEN, 15 L/MIN100% OXYGEN, 15 L/MIN– 2 LARYNGOSCOPES yang berfungsi2 LARYNGOSCOPES yang berfungsi– MAGILL FORCEPSMAGILL FORCEPS– INTRODUCER (kawat mandrain) dan PLESTERINTRODUCER (kawat mandrain) dan PLESTER– 2 tube (ETT):2 tube (ETT):

NORMAL SIZE + 1 SIZE yang > kecilNORMAL SIZE + 1 SIZE yang > kecil CHECK CUFF COMPETENCCHECK CUFF COMPETENC

– Peralatan CRICOTHYROIDECTOMYPeralatan CRICOTHYROIDECTOMY:: SCAPEL 15SCAPEL 15 ETT NO 6.0ETT NO 6.0

PROTOKOPROTOKOLL

D. MONITORINGD. MONITORING– PULSE OXYMETRYPULSE OXYMETRY– KAPNOGRAFIKAPNOGRAFI– TEKANAN DARAHTEKANAN DARAH– EKGEKG

PROTOCOLPROTOCOL

E. OBAT-OBATANE. OBAT-OBATAN

– Obat induksi (pentotal, propofol, fentanil/sufentanil, Obat induksi (pentotal, propofol, fentanil/sufentanil,

ketalar,dormicun)ketalar,dormicun)

– Obat pelumpuh otot; Suksinil kolin (1-2 MG/KGBB) Obat pelumpuh otot; Suksinil kolin (1-2 MG/KGBB)

merupakan obat pilihanmerupakan obat pilihan Kontraindikasi suksinil kolin:Kontraindikasi suksinil kolin:

– Luka bakar > 3 DAYSLuka bakar > 3 DAYS

– CHRONIC SPINAL INJURY (SPASTIC PLEGIA)CHRONIC SPINAL INJURY (SPASTIC PLEGIA)

– NEUROMUSCULAR DISEASE (Guillan Barre Syndrome)NEUROMUSCULAR DISEASE (Guillan Barre Syndrome)

– HYPERKALAEMIC STATE (K > 5.5)HYPERKALAEMIC STATE (K > 5.5)

Pertimbangkan Esmeron Pertimbangkan Esmeron ROCURONIUM (1-2 mg/kgBB) ROCURONIUM (1-2 mg/kgBB) Sulfas atropin (0.6 – 1.2 mg)Sulfas atropin (0.6 – 1.2 mg) ADRENALINE (10 ML 1:10.000)ADRENALINE (10 ML 1:10.000)

PROTOCOLPROTOCOL

PROCEDURE PROCEDURE Preoksigenasi 100% (NRM 15 l/m atau tempelkan Preoksigenasi 100% (NRM 15 l/m atau tempelkan

mask ke hidung/mulut selama 3-4 menit)mask ke hidung/mulut selama 3-4 menit) Loading cairan koloid 250-500 mlLoading cairan koloid 250-500 ml Obat induksi (dormicum + fentanil/petidin + Obat induksi (dormicum + fentanil/petidin +

S.kolin/esmeron/tracriumS.kolin/esmeron/tracrium Tekan CRICOIDTekan CRICOID Laringoskopi sampai melihat pita suara (VOCAL Laringoskopi sampai melihat pita suara (VOCAL

CORD) CORD) Intubasi Intubasi Inflasi CUFFInflasi CUFF Cek : ET CO2 AND stetoskopCek : ET CO2 AND stetoskop Lepas CRICOID PRESSURELepas CRICOID PRESSURE Plester tubePlester tube Hubungkan dgn VENTILATORHubungkan dgn VENTILATOR Pastikan sedasi dan pelumpuh ototPastikan sedasi dan pelumpuh otot CHEST X-RAYCHEST X-RAY Analisa gas darah 1 jam post intubasi dan sesuaikan Analisa gas darah 1 jam post intubasi dan sesuaikan

FiO2FiO2

Sedasi POST INTUBATION:Sedasi POST INTUBATION:

Tidak perlu jika pasien koma atau Tidak perlu jika pasien koma atau hemodinamik tidak stabilhemodinamik tidak stabil

MORPHINE+MIDAZOLAM, PROPOFOL, MORPHINE+MIDAZOLAM, PROPOFOL, FENTANYLFENTANYL

PROCEDURE PROCEDURE

PreoksigenasionPreoksigenasion

Pemberian O2 100% selama 2-5 menitPemberian O2 100% selama 2-5 menit Bagging mask selama 1-2 dgn 15 l/mBagging mask selama 1-2 dgn 15 l/m KALAU PS MASIH BERNAFAS SPONTAN DAN KALAU PS MASIH BERNAFAS SPONTAN DAN

SADAR, 3 kali tarik nafas dalam dgn baging SADAR, 3 kali tarik nafas dalam dgn baging maskmask

Gunanya untuk membuang gas nitrogen udara Gunanya untuk membuang gas nitrogen udara bebas dalam parubebas dalam paru

Memberikan cadangan O2 dalam paru jika Memberikan cadangan O2 dalam paru jika apne selama 3-5 minapne selama 3-5 min

Pretreatment Pretreatment

DefasiculationDefasiculation– Prevent increase ICPPrevent increase ICP– Pediatric patientsPediatric patients– 10% of neuromuscular 10% of neuromuscular

blockade doseblockade dose

ICP ConcernsICP Concerns

OxygenationOxygenation Prevent fasiculationsPrevent fasiculations Lidocaine- 1.0mg/ kgLidocaine- 1.0mg/ kg

BradycardiBradycardiaa

Atropine 0.01- 0.02mg/ kgAtropine 0.01- 0.02mg/ kg ALL ALL childrenchildren Dries secretionsDries secretions

SedationSedation

Prior to paralysisPrior to paralysis Immediately subsequentImmediately subsequent

You do not want a paralyzed You do not want a paralyzed awake patient!awake patient!

AgentAgentss

BarbituatesBarbituates BenzodiazepinesBenzodiazepines DissociativesDissociatives OpiatesOpiates OtherOther

BenzodiazepineBenzodiazepiness

Midazolam (Dormicum)Midazolam (Dormicum)

0.1-0.2 mg/kg0.1-0.2 mg/kg Diazepam (Valium)Diazepam (Valium)

0.25-0.4 mg/kg0.25-0.4 mg/kg

Amnestic, anticonvulsant,Amnestic, anticonvulsant, Dose related hypotensionDose related hypotension

DissociativDissociativeses

Ketamine (Ketalar)0.5-2mg/kg

Analgesic, amnestic, bronchodilator,

Increased ICP, hypersecretion

OpiodsOpiods

Morphine SulfateMorphine Sulfate

0.1-0.2 mg/kg0.1-0.2 mg/kg Fentanyl (Sublimaze)Fentanyl (Sublimaze)

2-10mcg/kg2-10mcg/kg

Analgesic Analgesic

OthersOthers

Etomidate (Amidate)Etomidate (Amidate)

0.2-0.4 mg/kg0.2-0.4 mg/kg– Decreases ICP, Decreases ICP, little BP effectlittle BP effect

Propofol (Diprivan)Propofol (Diprivan)– 1-2mg/kg1-2mg/kg– Decreases ICP, Decreases ICP, anticonvulsantanticonvulsant, ,

antiemeticantiemetic– HypotensionHypotension

NMBNMB

Depolarizing Depolarizing – Succinylcholine (Anectine) Succinylcholine (Anectine)

1-1.5mg/kg1-1.5mg/kg NondepolarizingNondepolarizing

– Rocuronium (Esmeron) - 0.6-1.2mg/kgRocuronium (Esmeron) - 0.6-1.2mg/kg– Vecuronium (Norcuron) - 0.1mg/kgVecuronium (Norcuron) - 0.1mg/kg– Pancuronium Pavulon) - 0.1mg/kgPancuronium Pavulon) - 0.1mg/kg

Selleck’s Selleck’s ManueverManuever

Prevents Prevents PASSIVEPASSIVE regurgitatioon regurgitatioon VisualizationVisualization

SuctionSuction

If you couldn’t get it done before, If you couldn’t get it done before, you can nowyou can now

Patient Patient PositioningPositioning– GoalGoal

Align the 3 planes Align the 3 planes of view, so thatof view, so that

The vocal cords The vocal cords are most visibleare most visible

– T - tracheaT - trachea– P - PharynxP - Pharynx– O - OropharynxO - Oropharynx

ComplicationsComplications

Inability to intubateInability to intubate Inability to ventilateInability to ventilate Associated complicationsAssociated complications

Always have a back up plan and Always have a back up plan and be prepared to use it!be prepared to use it!– CombitubeCombitube– LMA (Laringeal Mask Airway)LMA (Laringeal Mask Airway)– CricothyroidotomyCricothyroidotomy

COMBITUBECOMBITUBE

No. 1

100 ml

No. 1100 ml

Combitube®Combitube®

LARINGEAL MASK LARINGEAL MASK AIRWAYAIRWAY

POSITIONING OF THE AIRWAY FOR LMAPOSITIONING OF THE AIRWAY FOR LMA

DEFLATION & INFLATION OF THE LMADEFLATION & INFLATION OF THE LMA

LMA Insertion

Step 1

LMA Insertion

Step 2

LMA Insertion

Step 3

LMA Insertion

Step 4

LMA Insertion

Step 5

Fast-trach LMAFast-trach LMA

The Difficult or Failed AirwayThe Difficult or Failed Airway

Difficult to ventilate or oxygenateDifficult to ventilate or oxygenate Difficult to intubateDifficult to intubate Difficult cricothyroidotomy candidateDifficult cricothyroidotomy candidate

Comprise 1- 3% patientsComprise 1- 3% patients Unpredictably difficult to intubate or Unpredictably difficult to intubate or

ventilate with BVM 1:10,000ventilate with BVM 1:10,000