Airway and Breathing

Management

Aris Sunaryo, dr., SpAn., M.Kes

Department of Anesthesiology & Intensive Therapy
Waled General Hospital
Cirebon
Objective:
Identification phases of resuscitation
Algorythm of CPR initiation
Airway management
Breathing support
Circulation Support
Drug s and fluids
Introduction
1961 : Safar devided CPR into 3 phases
Phase I :
Basic Life Support, goals of this phase action ( ABC)
Emergency Oxygenation
Phase II :
Advanced Life Support, goals of this phase action (DEF)
Restoration of spontaneous circulation and stabilization of the
cardiopulmonary system
Phase III :
Prolonged Life Support, goals ( GHI) Post resuscitative brain
oriented and intensive care
 Awake? / No
Breath ? / No

Airway management
Breath ?/No

Breathing Support 2x
Carotid Pulse / No

Circulation support
Case Scenario
What is your first priority?
34-year-old
motorcyclist lost
control and crashed
into a fence
Obvious facial trauma
No helmet
Smells of alcohol
Belligerent at scene;
now not communicating
Pulse oximeter 85%
Objectives
Identify the clinical
settings in which
airway compromise is
likely to occur.
Recognize the signs
and symptoms of
airway obstruction.
Describe the
techniques to establish
and maintain a patent
airway.
Discuss the importance
of adequate
oxygenation and
ventilation in all phases
 Airway Assessment
How do I know the airway is adequate?
Patient is alert and oriented.
Patient is talking normally.
There is no evidence of injury
to the head or neck.
You have assessed and
reassessed for deterioration.
 Airway Assessment
Signs and symptoms of airway compromise

High index of suspicion

Change in voice / sore throat
Noisy breathing (snoring and stridor)
Dyspnea and agitation
 Airway Assessment
Signs and symptoms of airway compromise (cont.)

Tachypnea
Abnormal breathing pattern
Low oxygen saturation (late sign)
Anatomi
Anatomi
Anatomi
Airway management:
The most common site of airway obstruction in comatouse
patients :
relaxed tongue , when patients head is in flexed or mid
position
Foreign matter : vomitus, blood
stimulation in stuporous or lightly comatose patients
Laryngospasm is usually caused by upper airway
could be complete or partial obstruction, in complete
obstrc (if not corrected) leads to apnea and cardiac arrest
within 5 10 minute , in partial obstrc must be corrected
promptly can result in brain damage or even cardiac
arrest
Airway Assessment
Impending Airway Obstruction
Recognition of Airway obtruction ;
Can not hear and feel of air flow at the mouth
and nose for complete airway obstruction
When patients still breathing inspiratory
retraction of intercostal and supraclavicular
Partial airway obstruction : snoring, crowing,
gurgling, wheezing
Hypercarbia : somnolence
Hypoxemia : sympathetic stimulation
Manual clearing of the airway:
The crossed finger maneuver
Finger behind teeth manuever
Tongue jaw lift manuever

Clearing the airway by suction

 Technique for foreign body clearing

If the victim is conscious ,

encourage to expel by coughing and spitting it
out
Apply abdominal thrust s or back blows

If the victim is unconscious

Apply back blows or abdominal thrust in
horizontal position
 Airway Assessment
When to intervene when the airway is patent

Inability to protect the airway

Impending airway compromise
Need for ventilation
Gambar. Face Mask Dewasa Gambar. Face Mask Anak
Gambar. cara satu tangan memegang face mask Gambar. jalan nafas yang sulit dapat
digunakan teknik dua tangan
 Airway Management
How do I manage the airway of a trauma
patient?
Supplemental oxygen
Basic techniques
Basic adjuncts
Definitive airway
Cuffed tube in the trachea
Difficult airway adjuncts
Unexpected difficult airway
Predicted difficult airway
Positioning to open the airway
Head tilt
Neck lift
Chin lift
Jaw thrust

Open the airway using equipment

Oropharyngeal airway
Nasopharyngeal airway
Endotracheal intubation
Cricothyroidotomy and Tracheostomy
 Airway Management

Caution
Protect the cervical spine during airway
management!
 Airway
Management

Basic Techniques
Chin-lift Maneuver
 H

Chin Lift
Neck Lift
 Airway Management

Basic Techniques
Jaw-thrust Maneuver
 Airway
Management

Basic Adjuncts
Oropharyngeal airway
Patients who can tolerate an oral airway will
usually need intubation.

Nasopharyngeal airway
Often well tolerated
Gambar A : Penempatan Oropharingeal Airway, B : Penempatan Nasopharingeal Airway
 Airway Management
How do I predict a potentially difficult airway?

Maxillofacial trauma and deformity

Mouth opening
Anatomy
Beard
Short, thick neck
Receding jaw
Protruding upper teeth
 Airway Management

Is this a difficult airway?

How would you manage this
patient?
 Airway Management
Definitive Airway Easy
Oral intubation (medication assisted)
Cricoid pressure, suction, back-up
Maintain c-spine immobilization
Plan for failure:
Gum elastic bougie
LMA / LTA
Needle cricothyroidotomy
Surgical airway
 Airway Management
Definitive Airway Easy
Preoxygenate
Cricoid pressure
Sedate (midazolam)
Paralytic (succinylcholine)
Intubate
Confirm (Auscultate, CO2)
Release cricoid pressure and ventilate
Gambar: A: LMA yang siap digunakan, B: cara pemasangan LMA, C: dengan
menggunakan jari yang lain untuk mendorong sehingga LMA tepat pada tempatnya, D:
LMA didorong oleh tangan yang lain dan jari telunjuk mendorong masuk.
Tabel. Variasi LMA dengan Perbedaan Volume Cuff yang Disediakan untuk
Pasien yang Berbeda Ukuran
Tabel. Keuntungan Dan Kerugian Dari LMA Dibandingkan Dengan Face Mask Dan ETT
 usia Diameter internal Panjang (cm)
(mm)
Bayi cukup bulan 3,5 12
Anak anak 4 + usia/4 14 + usia/2
Dewasa
Wanita 7.0-7,5 24
Laki-laki 7,5-9,0 24

Tabel. patokan ukuran ETT.

Gambar. posisi aman dan intubasi dengan blade macinthos
Gambar. gambaran glotiss selama laringoscopi dengan blade yang melengkung.
Gambar. sisi yang diauskultasi untuk suara nafas pada dada dan lambung.
Selama laringoskopi dan intubasi
Malposisi
Intubasi esophagus
Intubasi bronchial
Posisi cuff laryng
Trauma jalan nafas
Gigi rusak
Lacerelasi lidah, bibir dan mucosa
Dislokasi mandibula
Retropharingeal diseksi
Reflek fisoilogi
Hipoksia, hiperkarbi
Hipertensi, takikardi
Hipertensi intracranial
Hipertensi intraokuler
Laringospasme
Malfingsi pipa
Perporasi cuff
Bergesernya pipa
Malposisi
Unitentional ekstubasion
Intubasi bronkhial
Posisi cuff laringeal
Trauma jalan nafas
Inflamasi mucosa dan ulcerasi
Exkoreasi di hidung
Malfungsi pipa
Terbakar
Obstruksi
Menyertai ekstubasi
 Tabel. Kondisi yang Dihubungkan dengan Kesulitan
Intubasi.
Tumor
Higroma kistik
Hemangioma
Hematoma
Infeksi
Abses mandibula
Abses peritonsiler
Epiglotitis
Kelainan kongenital
Sindroma pierre robin
Sindroma treacher collin
Atresia laring
Sindrom goldenhar
Distosia craniofacial
Benda asing
Trauma
Fraktur laring
Fraktur mandibula atau maxilla
Inhalasi burn
Cedera servikal
Gemuk
Extensi leher yang tidak adekuat
Rhematoid artritis
Spondilitis
Halo traksi
Variasi anatomi
Gambar. klaifikasi mallampati.
 Airway Management
Is this a difficult airway?
How would you manage this
patient?
 Airway Management
Definitive Airway Difficult
Get help
Be prepared
Consider rapid sequence intubation vs. awake
intubation
Maintain c-spine immobilization
Consider use of:
Gum elastic bougie
LMA / LTA
Surgical airway
Other advanced airway techniques, eg, fiberoptic
intubation
 Airway Management
Definitive Airway
Surgical airway
Cricothyroidotomy
Needle
Surgical
Airway Decision Scheme
 Airway Confirmation
How do I know the tube is in the right
place?

Visualize it going
through the cords
Watch the chest
Auscultation
Pulse oximeter
CO2 detector
Radiology
 Summary
Suspect airway compromise in all injured patients.
Adjuncts for establishing a patent airway include:
Chin-lift and jaw-thrust maneuvers
Oropharyngeal and nasopharyngeal airways
Laryngeal mask airway
Multilumen esophageal airway
Gum elastic bougie device
 Summary
With all airway maneuvers, the cervical spine must be
protected by inline immobilization.
A surgical airway is indicated when an airway is
needed and intubation is unsuccessful.
The assessment of airway patency and adequacy of
ventilation must be performed quickly and accurately.
Pulse oximetry and end-tidal CO2 measurement are essential.
 Summary

A definitive airway requires a tube placed in the

trachea (inflated cuff, oxygen, assisted ventilation,
airway secure).
Oxygenated inspired air is best provided via a tight-
fitting oxygen reservoir face mask with a flow rate of
greater than 11 L/min.
Thank you