Difficult

airway
management
Sunaryo
Bagian Anesthesiologi dan Reanimasi
Fakultas Kedokteran UNDIP/RS dr.
Kariadi
Semarang

Difficult airway
Definition :
Usually related solely to
tracheal intubation or
problems with mask
ventilation.

In approaching the difficult airway, consider the

following broad categories:

1.Previous history

access to the patient`s airway

of difficulty or failure in establishing control and

2.Presence of anatomical or physiological pathology

which might predictably be associated with difficulty in airway management.

3.Limited

experience in evaluating,planning and managing the

difficult airway.

Premedication
Ideally,the patient should be brought
to the operating room without any
premedication that can suppress
ventilation.
Even small doses of narcotic,tranquillizer
or barbiturate can turn a partial
obstruction into a complete
obstruction with alarming rapidity.
Antisialogogues (glycopyrollate,hyoscine
(scopolamine) ) is controversial.

Monitoring
Require systemic
monitoring
Pulse oxymeter (most useful)

Continuous electrocardiogram
(particularly with history of cardiac disease or arrhythmias)

End-tidal PCO2 monitor

(assists in
confirming correct intubation and is concidered mandatory
in patients with a history of bronchospastic disease )

Iatrogenic
Problem

Opening the mouth (cause by

bony pathology)

Extending the head

Blade placement
Sellick manoeuvre (lingual nerve
damagehyperaesthesia of the tongue)

Unexpected Airway
Problems in the
operating
room
Induction
Readily available the equipment that
might be needed if a problems arises.
Include :intubation guides,light wand and
a prepared airway trolley for specialized
techniques (fibreopic,Bullard).
The simplest approaches are often
the best.

Intraoperative.

The Difficult
Airway

Instrumentation

Intubation with radiographic C-arm

assistance

Jet ventilation

Retrograde intubation

The Bullard laryngoscope

The laryngeal mask
Endobronchial intubation
The rigid bronchoscope

Complication and
constraints

Technique

Complications and
constraints

Jet (Venturi)

Pneumolarynx and trachea,

pneumomediastinum, pneumothorax,also
infection
Trauma to vocal folds,infection,other laryngeal
and tracheal trauma,etc.
Tissue burn from heat of bulb
Haemorrhage ,nasal diameter
(Access via intubation airway)
(Access via oral route only)

Retrograde
Light wand
Fibreoptic (nasal)
Fibreoptic (oral)
Intubation guide
(Norton Teflon or
EschmannR woven
or Sheridan TXXr
tubular)
Bullardr
laryngoscope with
intubation guide
Tracheostosis

(Access via oral route only)

Tracheal infection,stenosis,loss of Valsalva
mechanism,communication
problems,cicatrix,haemorrhage
Haemorrhage

ANATOMI JALAN NAFAS

Elemen paling vital dalam memberikan
respirasi fungsional adalah jalan nafas
Jalan nafas manusia
- hidung : nasofaring
- mulut : orofaring
Dipisahkan palatum, bergabung di
belakang dalam faring

Faring
Struktur
fibromuskuler
berbentuk U yg
berjalan dari basis
cranii sampai
kartilago krikoid.

Epiglotis
Memisahkan orofaring
dari laringofaring
Mencegah terjadinya
aspirasi
Nervus rekuren
laringeus menginervasi
laring antara plika
vokalis dan trakea
Laring
Rangka kartilago yang
disokong oleh ligamen
dan otot.
Terdiri dari sembilan
kartilago: tiroid, krikoid,
epiglottis, dan
(pasangan) aritenoid,
kornikulata ,
kuneiformis.

N. glossofaringeus

Superior laringeal

Internal laringeal
N. vagus

Recuren laringeal

Suplai sensorik untuk jalan

nafas bagian atas
V1 : nervus ethmoidalis
anterior
V2 : nervus spenopalatinus
V3 : nervus ervus lingualis

Masih dapat dikerjakan

Hydrocephalus ,sering kita

hadapi

Terlalu kecil untuk diintubasi

Bagaimana kita
menghadapi ini?

Tidak mudah

Tumor lidah

Dapat dibayangkan
bagaimana sulitnya
intubasi.

SUMBATAN JALAN
NAFAS
KOMA
ASPIRASI

TRAUMA
MAXILOFACIA
L
TRAUMA
LEHER

ROBOTICS can NOT do this

HOW can you apply the Airway Workshop
on this case ? Use Glidescope ? FOB ?

Use no FOB
Use no glidescope

USE common sense

insert ETT
into the cut
portion of
trachea,
give oxygen,
give ventilation

PERALATAN
1. Alat Jalan Nafas Oral dan Nasal
Mencegah lidah jatuh ke
dinding posterior faring.
Alat jalan nafas artifisial
yang dimasukkan ke
dalam mulut atau hidung
memberikan jalan untuk
udara masuk di antara
lidah dan dinding faring
posterior.
Nasal resiko: epistaksis
KI: antikoagulan atau
anak dengan adenoid
prominen serta fraktur
basis kranii.

orotrakheal

nasotrakheal

3. Laringeal Mask Airway (LMA)

LMA sering digunakan
untuk menggantikan
sungkup wajah atau ET
Digunakan pada pasien
yang jalan nafasnya sulit

Dimasukkan secara blind

sampai hipofaring.
Kerugian: distensi gaster
regurgitasi.
KI:abses faring, obstruksi faring,
lambung penuh(wanita hamil,
hernia),komplain paru yang
rendah (obesitas).

4. Esofageal-Trakeal Combitube
Combitube memberikan
seal dan perlindungan
yang lebih baik terhadap
regurgitasi gaster &
aspirasi
Hanya tersedia dalam satu
ukuran dewasa
Penggunaannya sebaiknya
dihindari pd pasien dengan
gag refleks yang intak,
patologi esofagus / riwayat
konsumsi bahan korosif.

Pemasangan nasotracheal

Nasotracheal tube

Orotracheal tube

Panjang jalan nafas

hidung diperkirakan
dari jarak antara nares
sampai meatus
akustikus,biasanya 24 cm lebih panjang dari
jalan nafas mulut.
Memasukkan tube ke
dalam hidung
sebaiknya diberi
lubrikan dan
dimasukkan dengan
sudut tegak lurus
terhadap wajah untuk
mencegah trauma pada
konka dan atap hidup.

7. Bronkoskop Fiberoptik Fleksibel

Untuk pasien dengan
kelainan servikal
yang tidak stabil,
susah membuka
mulut atau kelainan
kongenital jalan
napas atas.

Intubasi Nasal Fiberoptik Fleksibel

ENDOSKOP FLEKSIBEL

PEMASANGAN ENDOSKOP
FLEKSIBEL
BERSAMA TUBE NON KINKING

PEMASANGAN ENDOSKOP
BERSAMA
DENGAN GUIDE WIRE

PEMASANGAN GUIDE WIRE

DISERTAI PEMASANGAN SUCTION
CATHETER

TUBE NON KINKING DIMASUKKAN

DENGAN PANDUAN GUIDE WIRE &
SUCTION CATHETER

Difficult Airway
Algorithm
1. Assess the likelihood and clinical
impact of basic management problems:
A. Difficult intubation
B. Difficult ventilation
C. Difficulty with patient cooperation or consent

2. Consider the relative merits and

feasibility of basic management choices:
A.,B.,C.

2. Consider the relative merits

and feasibility of basic
management choices:
Non-surgical
Surgical

A.

B.

C.
.

technique for
initial approach
to intubation

Awake
intubation
Presentation of
spontaneous

vs

vs

vs

technique for
initial approach
to intubation
Intubation
attempts after
induction of
general
anesthesia

Ablation of
spontaneous
ventilation

3.Develop primary and alternative

Intubation attempts
strategies
Awake
A Airway
intubation
approached by

Airway

Nonsurgical

secured by

intubation

Succ
ed

Cancel
case

Fai
l
Consid

Surgical
access

er
feasibil
ity of
other
options

NonEmergency
Pathway

Surgi
cal
airwa
y

after

Induction of
general anesthesia

Initial
intubation
Attempts
successful

Initial
intubation
Attempts
unsuccessful
From this point

onwards
Repeatedly
consider
The advisability
of:
1.Returning to spontaneous
ventilation
2.Awakening the patient
3.Calling for help

Emergency
Pathway

Non-Emergency Pathway
Patient anesthetized,intubation unsuccessful
Mask ventilation adequate

Alternative
approaches
To intubation

Succeed

Surgical
airway

Fail
after
Multiple
attemps

Surgery
under
Mask
anesthe
sia

Emergency Pathway
Patient anesthetized,intubation unsuccessful
Mask ventilation Inadequate

If mask
Ventilatio
n
Becomes
Inadequat
e

Awak
en
patie
nt

Call for
help

One
Emergen
more
cy nonIntubat
surgical
ion
Airway
ventilatio
attemp
n
t
Succe
Succ Fai
Fail
d
ed
l
Emerge
Definiti
ncy
ve
Surgical
airway
airway

Finally
The skilled clinician must be
familiar with all approaches
to the difficult airway and
must,therefore, develop
skills that do not only
depend on the most
advanced technology.

Terima Kasih

Difficult Airway Manajement