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AIRWAY MANAGEMENT

Yohanes Rudijanto, dr., SpAn.


KSM Anestesiologi
RS Immanuel - Bandung

ABC of Resuscitation

Airway: open the


airway

Breathing: provide
positive-pressure
ventilations

Circulation: give chest


compressions

Defibrillation: shock
VF/pulseless VT

Secondary Survey: ABCD

Airway :
airway

provide advanced
management

Breathing : confirm tube placement


check for adequate
oxygenation
and ventilation

Circulation :
obtain IV access
determine rhythm
give medications

Differential Diagnosis : search for, find


and
treat reversible causes

Airway Management

Ensure patent airway

Provide supplemental oxygen

Institute positive-pressure
ventilation when spontaneous
breathing is inadequate or
absent

Airway Obstruction
Most common cause:
loss of tonicity of submandibular
muscles
posterior displacement of tongue
and/or epiglottis

Basic Techniques to Open


Airway
1.
2.
3.

Head tilt
Chin Lift
Jaw Thrust

Trias
manouvers

Head Tilt- Chin Lift

Jaw Thrust

Airway devices
1. Oropharyngeal Airway
2. Nasopharyngeal Airway

Oropharyngeal Airway

Technique

Clear the mouth and


pharynx

Place the airway so


that it is turned
backward as it
enters the mouth

As airway
approaches the
posterior wall of the
pharynx rotate 180
degrees

Malposition of Oropharyngeal
Airway

Nasopharyngeal Airway

Technique

Airway is
lubricated with
anesthetic jelly

Resistance
slight rotation of
the tube

Provide supplemental oxygen

Without respiratory distress:

Mild respiratory distress:

2 L / min by nasal cannula


5-10 L / min by face mask

Severe respiratory distress or other


serious cases : advanced airway
devices, intubation and 100 %
oxygen

Devices Used to Administer


Supplemental Oxygen

Oxygen supply
Nasal cannula
Face mask
Face mask with oxygen
reservoir
Venturi mask

Nasal Cannula

Starting device

Provides up to
44% oxygen

Low flow system


in which the tidal
volume mixes
with room air

Nasal Cannula

Increasing the oxygen flow by 1 L /


min will increase the inspired oxygen
concentration by approximately 4%:
1 L/min: 24%

4 L/min: 36 %

2 L/min: 28%

5 L/min: 40%

3 L/min: 32%

6L/min: 44%

Face Mask

O2
concentration
up to 60 % can
be supplied
through face
mask at 6 to
10 L / min

Face Mask with reservoir

Provides up to 90 %100% O2

Each L/min increase


the inspired O2
concentration by
10%

6L/min: 60% O2
7L/min: 70% O2
8L/min: 80% O2
9L/min: 90% O2
10L/min: ~ 100% O2

Indications of Face Mask

Seriously ill patient who are


responsive with spontaneous
breathing but require high O2
concentration

Acute intervention producing a rapid


clinical effect

Venturi Mask

Patients with
chronic hypercarbia
(high CO2) and
moderate to severe
hypoxemia

Never withhold oxygen


from patients who have
respiratory distress simply
because you suspect
hypoxic ventilatory drive!

Ventilate the Patient


1. Mouth to Mouth / Mouth to
Nose
2. Mouth-to-Mask
3. Bag-Mask

Mouth to Mouth /
Mouth to Nose Ventilation

Mouth-to-Mask Ventilation

Pocket Mask
Device
1-way valve
Port to attach O2
source

Mouth-to-Mask Ventilation

Advantages
Provides effective ventilation and
oxygenation
Eliminates direct contact
Can administer O2
Eliminates exposure to exhaled
gases
Easy to teach and learn

Mouth-to-Mask Ventilation

1-rescuer
technique;
performed from
side
Rescuer slides over
for chest
compressions
Fingers: head tilt
chin lift

Mouth-to-Mask Ventilation

Fingers: jaw thrust


upward

Fingers: head tilt


chin lift

Bag-Mask Ventilation

1-Person:
difficult, less
effective

2-Person:
easier, more
effective

Bag-Mask Ventilation

Advantages

Provides immediate ventilation and


oxygenation
Operator gets sense of compliance and
airway resistance
May provide excellent short-term support of
ventilation
High oxygen concentrations are possible
Can be used to assist spontaneous
respirations

Advanced Ventilation
1.
2.
3.

Tracheal Intubation
Laryngeal Mask Airway
Combitube

Tracheal Intubation

Keeps Airway patent

Ensures delivery of high concentration of


oxygen

Ensures delivery of a selected tidal volume

Isolates and protects the airway from


aspiration of stomach contents

Permits effective suctioning

Provides route for administration of several


medications

Indications

Cardiac arrest with ongoing chest


compressions

Inability of conscious patient in


respiratory compromise to breathe
adequately

Inability of the patient to protect airway

Inability of the rescuer to ventilate the


unresponsive patient with conventional
methods

Equipment for Intubation

Laryngoscope with
several blades

Tracheal tubes

Malleable stylet

10-mL syringe

Magill forceps

Water-soluble lubricant

Suction unit, catheters,


and tubing

Curved vs Straight Blade

Macintosh
Miller

Curved vs Straight Blade

Visualization of Vocal Cords


Tongue
Vallecula
Epiglottis
Glottic
opening

Vocal
cord

Arytenoid
cartilage

Cricoid Pressure

Tracheal Intubation

Advantages

Protects airway from aspiration of foreign


material
Facilitates ventilation and oxygenation
Facilitates suctioning of trachea and bronchi
Provides route for drug administration
Prevents gastric inflation if used with cuff
Allows faster chest compressions

Tracheal Intubation
Indications

Inability to ventilate the unconscious


patient
After insertion of pharyngeal airway
Inability of patient to protect own airway
(coma, areflexia, or cardiac arrest)
Need for prolonged mechanical
ventilation

Tracheal Intubation

Recommendations

Intubate as soon as possible after ventilation


and oxygenation in cardiac arrest
Intubation should be done by most
experienced person
Do not take longer than 30 seconds per
attempt
Auscultate the thorax and epigastrium
after intubation

Tracheal Intubation
Complications

Traumateeth, lips, tongue,


mucosa,
vocal cords, trachea
Esophageal intubation
Vomiting and aspiration
Hypertension and arrhythmias

Esophageal-Tracheal
Combitube
E
Distal End
A
C

A = esophageal obturator; ventilation into trachea through


side openings = B
C = tracheal tube; ventilation through open end if proximal
end inserted in trachea
D = pharyngeal cuff; inflated through catheter = E
F = esophageal cuff; inflated through catheter = G
H = teeth marker; blindly insert Combitube until marker is at
level of teeth

Proximal End

H
D

Esophageal-Tracheal
Combitube

Laryngeal Mask Airway


(LMA)

Airway adjunct with a cuffed mask-like projection


at the distal end that is introduced to the pharynx

LMA Introduced Through Mouth


Into Pharynx

THANK
YOU

MATERI KULIAH PRA UTS


1.
2.
3.

4.
5.
6.
7.

PENGANTAR ANESTESIOLOGI
FARMAKOLOGI KLINIK OBAT-OBAT ANESTESIA
PERSIAPAN PRA ANESTESIA DAN PERAWATAN
PASKA ANESTESIA
ANASTESIA LOKAL DAN REGIONAL
PENATALAKSANAAN JALAN NAFAS
RESUSITASI JANTUNG PARU
TERAPI OKSIGEN

MATERI KULIAH PASKA UTS


1.
2.
3.
4.
5.
6.
7.

DASAR DASAR ICU / CRITICAL CARE


MEDICINE
TERAPI CAIRAN & TRANSFUSI DARAH
GANGGUAN ELEKTROLIT
KESEIMBANGAN ASAM BASA
PEMBERIAN ANESTESIA PADA
PEMBEDAHAN DARURAT
PEMBERIAN ANESTESI PADA KASUS
TERTENTU
PENATALAKSANAAN NYERI