Airway

management
 Why do we breathe?
To support life

Disruption of airway
and breathing
is the most common
cause of death
 Airway
management
 Airway management consists of clearing
the upper airway, maintaining an open air
passage with a mechanical device, and/or
assisting respirations.
 Prevent hypoxic damage to the brain and
other vital organs.
Respiratory
System
 The Airways are Protected by
Reflexes
 Cough Reflex “Batuk”
 Gag Reflex
 Swallowing Reflex “Telan”

These reflexes are lost in patients with

HEAD / SPINAL INJURY or
who are UNCONSCIOUS
 Disruptions to the airway
Tongue
Bleeding
from
Blood mouth
and nose

Vomitu
s

Secreti
Vomitus
ons blocking
airways

Foreign
Supine Position
Posisi Baring
Bodies
Upright
Position
Swellin
Posisi Tegak g
 Oxygen therapy
The prime goal of airway management is to prevent hypoxic damage to the
brain and other vital organs. Therefore if available, oxygen should be
administered
Below is a graph which reflects the % oxygen administered with various
methods of airway management.
FUNDAMENTAL AIM:
To restore the tissue oxygen tension
towards normal.
Increase [O2] in inspired air (FiO2)
Improve gaseous exchange
Increase O2 carriage to the tissues
Improve tissue oxygenation.
 Who needs O2? All of us !!! 21%
Who needs more O2?
 Patients with any sign of breathing difficulty
 Unconscious / unresponsive patients
 During CPR*
 All major trauma victims
 Risk of impaired airway
 Heart attacks, strokes, seizures
 History suggestive of drug overdoses**
 Provide oxygen if considered, even if unsure
 Any patient who may benefit from it
 Oxygen Delivery
Devices
Nasal Cannulae
 Most comfortable for patients
 Max 2 – 4 L/min providing 28 – 35 % O2

 Higher flow rate uncomfortable / useless

Simple Face Mask

5 – 10 L/min providing 40 – 60
% O2

< 5 L/min: re-breathing occurs

10 L/min: irritation to eyes,

nose
 Venturi masks

50% FR 12L
35% FR 6L
31% FL 6L

28% FR 4L

Color % of O2 O2 flow Rate

Blue 24% 2L
Yellow 28% 4L
White 31% 6L
Red 40% 8-10 L
Orange 50% 12 L
 Oxygen Delivery
Devices

 Non re-breather mask (“High Flow Mask”)

 High oxygen concentration delivered (80% O2 with 15 L/min)
 Flow rate at least 10 L/min (** very dangerous if less than 10
L/min)
 One-way valves prevent re-breathing
 Used for critically-ill patients
(who need high oxygen levels)
 Initial Assessment

Look,
Listen,
Feel
Check for at least five
seconds before
deciding whether it is
absent.
 OPEN AIRWAY

Place your right hand

on the victim's
forehead, displacing it
downwards, and with
your left hand hold the
victim's chin; tilting it
up.
a) Head tilt chin lift
b) Jaw Thrust
 Maintaining the Open Airway
 Oropharyngeal airway
(Guedal’s airway)
 Size
 Insertion
 Indications
 Contra-indications
 Oropharyngeal airway
The oropharyngeal airway is a specially curved, rigid, hollow
plastic tube. It is available in various sizes (i.e. from neonate
- adult sizes). They should only be used in unconscious
patients
 Oropharyngeal airway
Estimate the correct size required by selecting the airway
that approximates most closely to the vertical distance
between the patients incisor teeth and mandibular angle.
 Nasopharyngeal airway
Never attempt to insert a nasopharyngeal airway in a
patient who you suspect of having a basal skull
fracture
 Nasopharyngeal airway
Lubricate the airway
Carefully with a slight twisting action, insert the nasopharygeal airway,
bevelled edge first. Try to point the curve of the airway to the patient's feet.

Nasal airways
Will cause bleeding from the nose in a large number of cases.
This will result in worsening airway problems so use only as a last resort.
 Facial mask and self inflating
bag
By connecting a reservoir system to the self-inflating bag - can
increase the inspired oxygen concentration to approx 85%.
 Mouth to mask
Blow through the inspiratory valve.

Remember to observe the patient to see if this has caused a chest rise.
Facial mask and self inflating bag
Place the face mask to the patients face making a tight seal.
The other person can then compress the bag sufficiently enough to allow a
chest rise. If in an arrest situation 2 ventilations per 30 chest compressions. If
the patient has a circulation try to achieve a rate of 12 ventilations per
minute.
 Initial Assessment
 Breathing adequacy or inadequacy:
 This determination is probably the most
important one you will make for this
patient.
 Assess rate and quality
 An inadequate rate (too fast or too slow),
OR an inadequate depth (minimal air
exchange) means you must provide PPV
immediately.
Endo-tracheal Intubation
Tracheal intubation is the
placement of a flexible plastic tube
into the trachea to protect the
patient's airway and provide a
means of mechanical ventilation.
 Tracheal intubation is the "gold
standard" of advanced airway
maintenance was downplayed (in
favour of more basic techniques
like bag-valve-mask ventilation)
by the American Heart
Association's Guidelines for
Cardiopulmonary Resuscitation
in 2000 and again in 2005.

Tracheal intubation is a potentially very dangerous invasive

procedure that requires a lot of clinical experience to master.
the associated complications may rapidly lead to the patient's
death.
Indications
Inability to oxygenate patient
(SpO2 < 90%, PaO2 < 55)
Inability to ventilate patient
(rising PaCO2, respiratory acidosis, mental
status change or other symptoms)
Patient unable to protect the airway
PREPARATION:
1. Laryngoscope with blades and bright light source.
2. Bag-valve-mask connected to functioning oxygen delivery system.
3. Working suction with Yankauer / catheters
4. Endotracheal tube(s)
5. Oral pharyngeal airway
6. Syringe to inflate ETT cuff.
7. Introducer Bougie / Flexiguide Stylet.
8. Magill forceps
9. K-Y Jelly
10. Plaster
11. Stethoscope
12. Alternative airway (example: LMA ,Proseal, Combitube),
13. Manpower
14. Vital signs monitor ( Capnometer).
15. IV is in place
16. Anticipated pharmacological agents
Observational methods to confirm correct tube
placement
1. Direct visualization of the tube passing through the vocal cords
2. Clear and equal bilateral breath sounds on auscultation of the chest
3. Absent sounds on auscultation of the epigastrium
4. Equal bilateral chest rise with ventilation
5. Fogging of the tube
6. An absence of stomach contents in the tube

Instruments to confirm correct tube placement

1. Calorimetric end tidal CO2 detector
2. Waveform capnography
3. Pulse oximetry (patients with a pulse)
Complications
1. Can't intubate,
2. Esophageal intubation
3. Aspiration
4. Trauma from laryngoscope -Teeth, lips, soft
tissues
5. Edema
6. Equipment failure
7. Cardiac arrest.