AIRWAY MANAGEMENT
AIRWAY MANAGEMENTSN Yanti NorSN Syaabaniah YassinPreoperative
AssessmentPreoperative AssessmentSEJARAH untuk mengenal pasti
pesakit yang berisiko untuk difficult intubation.
PREGNANCY & LABOUR increased risk of laryngeal edema in
pre-eclampsiaKECACATAN FIZIKAL micrognathia, macroglossia,
congenital syndrome (ex: Pierre Robin, Treacher Collins), burn
contracture involving head & neckHALANGAN PADA UPPER AIRWAY
Tumor or edema involving upper airway, large goitre, acute
epiglottitis, maxillofascial trauma, airway burnsMASALAH PADA
TULANG BELAKANG CERVICAL - #, Dislocation or subluxation of
cervical spine, rheumatoid arthritis, ankylosing spondylitis
Preoperative AssessmentPreoperative AssessmentPEMERIKSAAN
FIZIKAL
1.BERAT BADAN DAN STATUS AMOBESITI BERAT > 90 kgBMI = Berat
(kg) tinggi (m) x tinggi (m)
WANITA HAMIL peningkatan hormon senang dapat laryngeal
oedemaKurang Berat: 30.02.Pemeriksaan struktur muka dan
leher:Anterior ketidaknormalan tulang atau soft tissue, small,
receeding chin, maxillary #, tumorLateral bahagian leher bengkak,
short neck, goitre, parut, posisi thyroid cartillage, tracheal
deviationKenal pasti paten pernafasan stridor, tachypnoea,
respiratory distressMenyebabkan kesukaran untuk memanipulasi
laryngoscopePreoperative Assessment3.Bukaan mulutDarjah bukaan
mulut pesakit inter-incisor gap = 3 jari sukar untuk masuk blade
jika < 3 jariOral cavity jongang, gigi longgar, orthodontic work
cth: caps, crown, dentures, intra oral tumorKenal pasti kelas
modified mallampati pesakit
Preoperative Assessment
Preoperative AssessmentPreoperative AssessmentPengkelasan
modified mallampatiPesakit dalam keadaan dudukDuduk searas dengan
pesakit Pesakit diminta membuka mulut seluas-luasnya serta
mengeluarkan lidahTidak perlu mengeluarkan bunyi cth: ahhh
- Class ||| dan |v diklasifikasikan sebagai difficult intubation
PENGKELASAN MODIFIED MALLAMPATI
SOFT PALATEUVULATONSILLAR PILLARHARD PALATEUVULASOFT PALATESOFT
PALATE4.Protrusion of mandibleClass A gigi bawah di hadapan, gigi
atas di belakangClass B gigi atas = gigi bawahClass C gigi atas di
hadapan, gigi bawah di belakangClass B dan C = difficult
intubationPreoperative Assessment5.Pergerakan kepalan dan leher
Flexion and extension > 90Jika < 90 - kesukaran dalam posisi
Sniffing sukar untuk intubationFlexion hujung dagu menyentuh
xyphoid sternumExtension occipital menyentuh trapezius
musclePreoperative AssessmentPreoperative Assessment
SNIFFING POSITION
Preoperative Assessment6.Jarak thyroimental - tip of thyroid
cartillage to tip of mandible in full neck extension > 6.5 cm
jika < diklasifikasikan sebagai difficult intubation
7.Jarak sternomental upper border of manubrium to the tip of
mandible > 12.5 cm
Preoperative Assessment
Preoperative AssessmentWilson Risk SumDilihat daripada
pergerakan kepala, leher dan badanMARKAH 0-10 markah > 4 -
Dificult intubation
WILSON RISK SUMRisk FactorLevelPointWeight< 90 kg90 110
kg> 90 kg012
Head and neck movement> 90About 90< 90012
Jaw movementIG 5 cm, Slux > 0IG < 5 cm, Slux = 0IG < 5
cm, Slux < 0012
Receding mandibleNormalModerateSevere012
Buck teethNormalModerateSevere012Preoperative
Assessment9.PEMERIKSAAN RADIOLOGICERVICAL X-RAY - #, DISLOCATION OF
CERVICAL SPINE, SOFT TISSUE SHADOWS, TRACHEAL COMPRESSION OR
DEVIATIONPARTIALLY OBSTRUCTED AIRWAY PATIENT CT SCAN, MRI
MENENTUKAN TEMPAT, SAIZ DAN TAHAP HALANGAN, DIMENSION OF TRACHEA,
BUKTI KOMPRESSI TRAKEA, INFILTRASI TUMOR KE DINDING TRAKEA
Normal CXRMRI imagePreoperative AssessmentCormack and Lehanne
classificationDilihat sewaktu direct laryngoscopy ke epiglottis
pesakitMenunjukkan view of epiglottic structureInitially for
obstetric patient, but now is widely usedClass ||| dan |v difficult
intubation
CORMACK & LEHANE CLASSIFICATION
Features of Potential Difficult IntubationFeatures of Potential
Difficult IntubationCiri-ciri pesakit yg berpotensi untuk difficult
intubationObesePregnantBurn contracture pd bahagian kepala dan
leherAnatomical anomaly in upper airwayCervical spine problem C2 C3
subclavian kena buat fiberoptik minimize cervical
movementMallampati class ||| and |vWilson Risk Sum > 4Hx of
radiotherapy - head and neck region oral cavityHx of difficult
intubation previous anaestheticAirway ManagementAirway
ManagementEvery caseEvery placeLaryngoscopes
Macintosh Blade Miller Blade
LaryngoscopesMC COY BLADECurved Blade (Macintosh)Insert from
right to leftVisualize anatomy Blade in valleculaLift up and away
DO NOT PRY ON TEETHLift epiglottis indirectly
From AHA ACLSStraight Blade (Miller)Insert from right to
leftVisualize anatomyBlade past vallecula and over epiglottisLift
up and away DO NOT PRY ON TEETH Lift epiglottis directly
From AHA ACLSLaryngoscopy Technique
Inserting Laryngoscope
Macintosh Blade in ValleculaMiller Blade Under EpiglottisTip
position (not force) is the main determinant of glottic
exposure.
33
Gum Elastic Bougie
35DESCRIPTIONthe original Eschmann tracheal tube introducer is a
flexible device that is 60cm (24in) in length, 15 French (5mm
diameter) with a small hockey-stick angle at the far end (the coude
tip usually at 35-40 degrees)some types have external distance
markingssome types have a central lumen and port for
ventilationSizes of different types range 10 or 15 F (600700
mm)
USESBougie-assisted tracheal intubation especially in difficult
airways or during CPRtracheal intubation via supraglottic airway
devicesurgical airway (cricothyrotomy)selective endobronchial
intubationblind digital intubationconfirmation of endotracheal tube
positionendotracheal tube exchange (a device with a central lumen
allowing oxygenation is better for this)
Bougie
39 Lightwand (Trachlight)Lighted StyletteNot yet widely
usedExpensiveAnother method of visual feedback about placement in
trachea40 Lightwand (Trachlight)DisadvantagesBlind techniqueMay
damage airwayUsually requires darkened roomExpertise requires
practice
STYLETFLEXIBLE WANDREUSABLE HANDLE Lightwand (Trachlight)Source:
Laerdal
43 Lightwand (Trachlight)
Source: Laerdal44
Flexible Fiberoptic ScopeAdvantagesAllows direct airway
visualizationCauses little hemodynamic stressNasotracheal or
orotracheal routeCan be done in all age groupsRequires minimal neck
movement Flexible Fiberoptic ScopeDisadvantagesExpensiveExpertise
requires practice Delicate equipment needs careful
maintenanceVisual field easily impaired by blood and secretions
C-MAC FIVEFLEXIBLE FIBEROPTIC SCOPE Rigid Fiberoptic
ScopeBullard Wu Scope
Rigid Fiberoptic ScopeUpsher GlideScope
Levitan Scope Rigid Fiberoptic Scope
Rigid Fiberoptic ScopeC-MAC Rigid Fiberoptic
ScopeAdvantagesDirect airway visualizationMinimal neck movementMay
overcome difficult viewUseful in disrupted airwayDurable, sturdy
instruments Rigid Fiberoptic ScopeDisadvantagesExpensiveExpertise
requires practiceVisual field easily impaired by blood and
secretionsNot readily availableArtificial AirwayArtificial
AirwayAnaesthetic face mask
The Anaesthetic Face MaskUsed to deliver oxygen to pt - pre
oxygenateCara ukur di ukur daripada bridge of nose to end of
chinMeliputi bridge of nose dan chin patient create a seal tidak
leaking semasa ventilate ptCara pegang C E techniqueArtificial
Airway
2. OROPHARYNGEAL AIRWAY
OROPHARYNGEAL AIRWAY
Oral Airway / OPA / Guedel AirwayDicipta oleh Arthur E. Guedel
(1883-1956)Size: 000,00,0,1,2,3,4,5,6 / Colour CodeKebaikan:- Mudah
didapati / dikendali- Memudahkan Suction-Bite Block (mengelak
pesakit menggigit tiub ETT)OROPHARYNGEAL AIRWAYINDIKASI;-Pesakit
yang tidak sedar diri-Pesakit spontaneusly breathing-Total hilang
gag reflex-Digunakan sebagai bite block-Elakkan lidah pt terbalik
ke belakang semasa pre ox-Mengekalkan airway patency
KONTRAINDIKASI;-Pesakit sedar, ada gag reflex, susah buka mulut,
masive oral trauma-Mandibulo-maxillary wiring
KOMPLIKASI;-Terlalu panjang: Menekan epligotis-Terlalu pendek :
Menolak lidah ke belakang-Menyebabkan batuk, muntah dan
laryngospasme-Aspiration
OROPHARYNGEAL AIRWAYSizesLength
(mm)00030004005016027038049051006110Menentukan Size OPA: i) Coner
of mouth to earlobe ii) Against patients face to angle of the
mandible
Tatacara memasukkan OPAMeasure correct size.
Open mouth and insert airway upside down.When airway is in
mouthas far as it will go, turn itright-side up.
You can also insert an oral airway right side up, IF you use a
tongue depressor to press the tongue down and forward.Artificial
Airway3.NASOPHARYNGEAL AIRWAYDikenali juga sebagai NPA / nasal
trumpetDiperbuat daripada getah / plastik lembut Mula diperkenalkan
pada 1972.
Nasopharyngeal Airway72INDIKASI;-Pesakit spontaneously
breathing-Pesakit yang dikontraindikasi bagi Guedel airway-Boleh
digunakan walaupun pesakit ada gag reflex-Pesakit tidak di
intubasi.
KONTRAINDIKASI;-Kakitangan tidak terlatih-Kecederaan kepala /
muka yang teruk-Basal Skull fracture-Hidung tersumbat /
jangkitan-Struktur Kongenital, bleeding disorder
Size;-12F, 14F, 16F, 18F, 34F, 36F-Guna ukuran Internal
diammeter (I.D) -Pilihan size; ? sama besar dengan jari klingking
pesakit-Penjang (mm); Tip of nose to tragus of the ear
NASOPHARYNGEAL AIRWAYKOMPLIKASI;-Terlalu Panjang:- Kecederaan
pada epligotis / vocal cord / vagal stimulation-Injured nasal
mucosa; pendarahan-Alahan-Kurang Selesa
Tatacara memasukkan NPA-Pilih saiz yang sesuai-Sapukan NPA
dengan Lignocaine jel-Pilih lubang hidung yang tidak
tersumbat-Masukkan dengan berhati-hati (elak kecederaan)-Jika
terdapat resistant, pusing sedikit NPA-Kekalkan Head tilt
NPA insertion: Choose correct size.
Lubricate airway.
Insert the airway posteriorly. If it doesnot advance, try the
other nostril.Artificial Airway4.LARYNGEAL MASK AIRWAYSupraglottic
airway management device. Also called LMADesigned between 1981 and
1988 by Dr. Archie I. J. Brain.Cuff device that provides sufficient
seal to allow for positive pressure ventilation to be delivered
LARYNGEAL MASK AIRWAYTiga komponen utama: airway tube, mask, and
inflation lineAlternative airway device used for anesthesia and
airway support in emergency (difficult intubation). It is inserted
blindly into the pharynx, forming a low-pressure seal around the
laryngeal inlet and permitting gentle positive pressure
ventilation. All parts are latex-free.
LARYNGEAL MASK AIRWAYIndications:-The Laryngeal Mask Airway is
an appropriate airway choice when mask ventilation can be used but
endotracheal intubation is not necessary kes kurang 2 jam-Guide for
endotracheal intubation (Fastrach LMA)-Unanticipated difficult
intubations -Failed intubation -Intubation of patients with limited
head/neck movement
AdvantagesDisadvantagesIncreased speed and ease of placement by
inexperienced personnelLower seal pressureIncreased speed of
placement by anesthetistsHigher frequency of gastric
insufflationImproved hemodynamic stability at induction and during
emergenceMinimal increase in intraocular pressure following
insertionReduced anesthetic requirements for airway toleranceLower
frequency of coughing during emergenceImproved oxygen saturation
during emergenceLower incidence of sore throats in
adultsContraindications to LMA Use Non-fasted including patients
whose fasting cannot be confirmed Grossly or morbidly obese >14
weeks pregnant Multiple or massive injury Acute abdominal or
thoracic injury Any condition associated with delayed gastric
emptying Patients with a fixed decreased pulmonary compliance
Patients where the peak inspiratory pressures are anticipated to
exceed 20-30 cm H2O Adult patients who are unable to understand
instructions or cannot adequately answer questions regarding their
medical historyPANDUAN SAIZ LMA
COMPLICATION USE LMAOral traumaLaryngo-spasmAspiration Incorrect
position; hypoxiaDislodgeLMA Take-Home PointsTest cuff before
useLubricate before insertion to ptInsert only in unconscious
patientKeep cuff inflated until patient awakeDont throw out!! Used
40 50 timesType of LMADescriptionLMA Classic (CLMA)LMA (ambu)he
original LMA airway with the basic features and components Designed
base an oral structureLMA UniqueA disposable version of the CLMALMA
ProSeal (PLMA)An advanced form of LMA that has been specifically
designed for use with positive pressure ventilation (PPV) with and
without muscle relaxants at higher airway pressures LMA
FlexibleSingle Use LMA FlexibleBoth of these feature a
wire-reinforced, flexible airway tube that allows it to be
positioned away from the surgical fieldLMA FastrachAn intubating
LMA that is designed to facilitate intubation with a special
flexible cuffed endotracheal tube (ETT) LMA CtrachA variant of the
LMA Fastrach with an integrated fiberoptic system that allows
visualization of the anatomical structures immediately in front of
the aperture of the mask via a detachable, portable color display
screenLARYNGEAL MASK AIRWAY
Proceal LMALMA ClassicLMA FastrachLMA UniqueETT for LMA
FastrachHandle of ProcealLMA Classic
esofagustrakeaLMA Ambu
LMA Flexible
LMA PROSeal
LMA PROSealProseal bersaiz 1.5, 2, 2.5, 3, 4, 5Mempunyai saluran
untuk Ryles tubeIndikasi 4-5 H of surgeryFailed intubationNBM not
complete ptKomplikasi airway obstructionLaryngospasmAccidental
dislodgement
LMA-ProSeal
LMA Size Weight (kg) Max Cuff Inflation Volume (mL) Max.
Fiberoptic Scope Size (mm) Max. gastric Tube Size (Fr)Length of
Drain Tube (cm)Largest Tracheal Tube (ID in mm) 1.55 to 10 7-1018.2
4.0 uncuffed 210 to 20 10-1019.0 4.0 uncuffed2.520 to 30 14-1423.0
4.5 uncuffed330 to 50 20-1626.5 5.0 uncuffed450 to 70 3041627.5 5.0
uncuffed570 to 100 4051828.5 6.0 cuffedLMA-FASTRACH
The LMA-Fastrach (intubating LMA, ILMA, ILM, intubating
laryngeal mask airway) designed for tracheal intubation.Parts 1) A
short, curved stainless steel shaft with a standard 15-mm
connector. 2) Single, movable epiglottic elevator bar3) A V-shaped
guiding ramp built into the floor of the mask.
LARYNGEAL MASK AIRWAY
Proseal LMAFastrach LMALANGKAH-LANGKAH MEMASUKAN LMA
1. Press the mask up against the hard palate. Note the flexed
wrist.
2. Slide the mask inward, extending the index finger
3. Press the finger towards the other hand, which exerts
counter-pressure
4. Advance the LMA cuff into the hypopharynx until resistance is
felt5. Hold the outer end of the airway tube while removing the
index finger
Correct position of LMA
Tracheal IntubationTracheal IntubationOrotracheal intubation
intubation through oralNasotracheal intubation intubation through
nasalENT/Dental operationCant be performed on pt with
suspected/basilar skull #Can be performed on pt with intact gag
reflex awake intubationEndotracheal IntubationTube into trachea to
provide ventilations using BVM or ventilatorSized based upon inside
diameter (ID) in mmLengths increase with increased ID (cm markings
along length)Cuffed vs. UncuffedEndotracheal
IntubationAdvantagesSecures airwayRoute for a few medications
(LANE)Optimizes ventilation, oxygenationAllows suctioning of lower
airwayEndotracheal IntubationIndicationsPresent or impending
respiratory failureApneaUnable to protect own airwayEndotracheal
IntubationComplicationsSoft tissue trauma/bleedingDental
injuryLaryngeal edemaLaryngospasmVocal cord
injuryHypoxiaAspirationEsophageal intubationEndotracheal
Intubation
MALESBasic EquipmentM A L E SMask, MagillAirwayLaryngoscope,
lubricant, LMAETTSuction, stylet, secure tape,
stethoscopeEndotracheal tube
ENDOTRACHEAL TUBE Called ETT / ET TubeUsed in GA, ICU, A&E
Invasive Airway managementMechanical VentilationSir Ivan Whiteside
Magill (1888-1986) Indikasi untuk endotracheal intubation:C C C A
RCardiorespiratory arrestCritically ill ptCerebral protectionAirway
patencyRespiratory distressENDOTRACHEAL TUBE The tracheal tube
(endotracheal tube, intratracheal tube, tracheal catheter) is a
device that is inserted through the larynx into the trachea to
convey gases and vapors to and from the lungs.Parts The machine
(proximal) end The patient (tracheal or distal) end Bevel.
ENDOTRACHEAL TUBE4) Murphy eye5) A radiopaque marker 6) Cuff
Systems - consists of the cuff plus an inflation system, which
includes an inflation tube, a pilot balloon, and an inflation
valve.
Angled tipMurphys eyeCuff Radio opaque Size markingIntubation
depth markingPilot balloon with one way valvePilot tubeConnector
Indicator markerENDOTRACHEAL TUBEUncuffed dan cuffedSaiz : 2 8.5
mmJenis-jenis: Murphys ETT, oral rae, nasal rae, flexometalic,
microlaryngeal tube, double lumen tube Double Lumen
Tubehttp://www.combitube.org/
Distal cuffProximal cuffMurphy eye2 airwayRadiopaque lineMarking
level2 one way cuff118Double Lumen TubePutih masuk ke trakeaBiru
masuk ke bronkiol2 adapter disambung ke circuit untuk collapse one
side of lung intraoperativelySaiz 28mm 40mm right and leftKegunaan
thoracic surgery; thoracotomy, labectomyBila dah insert, inflate
bronchiole dahulu (warna biru) untuk maintenanceSetelah confirm in,
baru inflate trache cuff (warna putih) sehingga tiada leaking
119Double Lumen TubeAdvantage Potential use by relatively
inexperienced personnelRapid control of airwayProtection against
aspirationNo head movement req.Disadvantage Possible easophangeal
traumaInability to suction trachea in easophangeal positionDouble
Lumen Tube
Microlaryngeal tubeFlexometallic tube
Oral raeNasal Rae
ENDOTRACHEAL TUBEOral intubation Direct LaryngoscopyBlind Oral
IntubationDigital TechniqueFiberoptic guidedRetrograde
intubation
Nasal intubation Direct LaryngoscopyFlexible Fiberoptic
LaryngoscopyBlind Nasal IntubationENDOTRACHEAL TUBE Latex coated
red rubber tubesPVC tubesReused multiple times DisposableNot
transparentTransparentHarden and become sticky with age, poor
resistance to kinking, become clogged by dried secretionsLess
likely to kink than rubber tubes. They are stiff enough for
intubation at room temperature but soften at body temperature, so
they tend to conform to the patient's upper airway. Latex allergy
in susceptible patientsNo latex allergy
Technique of Endotracheal Intubation
THANK YOU(^_^)*~
