AIRWAY MANAGEMENT

SMF Anestesi dan Reanimasi

Rumah Sakit Persahabatan
Jakarta
Elements of Basic Life
Support

A–B-C
 Basic Life Support:
Importance
 The respiratory system is important because it
is one of the primary systems that works to
supply oxygen to the body.
 If breathing is not resumed, brain damage will
result starting
after four
minutes.
RESUME OF Korban
BASIC LIFE Cek kesadaran
SUPPORT
Tidak sadar
Sadar
Open airway
Posisi mantap
Cek nafas = Look, feel and listen

Nafas Tidak nafas

Cek nadi 2-5 nafas buatan

Ada Tidak ada Kompresi

Ventilasi dan oksigenasi

ACLS ROSC Nilai irama dan cek pulse

George, 2004
 Indications for airway
protection
Decreased level of consciousness
GCS <9
Cerebral injury
Surgery
Medical problems
 Potential causes of airway
obstruction
Tongue
Dentures
Food stuffs
Vomit
Blood
Secretions
 Opening the Airway

Check the airway

Open the airway, place one hand on the
victims forehead and gently tilt head back
Remove any visible obstruction from the
victims mouth, including dislodged
dentures. Leave well fitting dentures in
place
DO NOT ATTEMPT ANY FINGER SWEEPS
Opening the airway
Jaw thrust technique may be
needed if C-spine injury
 Airway Devices
Oral Airways:
 are designed to keep the
tongue from falling back and
blocking the upper airway
 are easily available in six
sizes
 are only used in
unresponsive patients
without a gag reflex
 do not eliminate the need to
monitor the airway for
patency
 Oral Airways
Sizing
 To choose the
proper size, hold
the airway against
the side of the
patient’s face. It
should extend
from the corner of
the patient’s
mouth to the angle
of the jaw.
 Oral Airways
Insertion
 open mouth with cross-finger
technique. Insert airway with
tip pointing up to avoid
pushing tongue backward
 rotate airway tip slowly
downward until its curve
matches the curve of the tongue
 the flange of the airway should
rest against the patient’s lips
Nasopharyngeal Airways Sizing

 curved, flexible
rubber or plastic
tubes inserted
into the patient’s
nostril
 use on responsive
patients who need
an airway assist
 Nasopharyngeal
Airways Insertion
 lubricate with sterile,
water-soluble lubricant,
and insert into nostril
that appears most open
 insert until flange is
against the nostril
opening
 check to ensure airflow
 Breathing Devices
 There are several devices designed to
make rescue breathing and similar
treatments easier and safer for the
rescuer.
 Common breathing devices:
– Resuscitation Mask
– Bag Valve Mask
 Breathing Devices:
Resuscitation Mask
 A resuscitation mask, also known as a
pocket mask, is a device designed to
separate the rescuers mouth from the
victims.
 This prevents disease transmission
 Breathing Devices:
Resuscitation Mask
 There are several criteria for a good
mask:
– Transparent, pliable
– One way exhalation valve
– Inlet for supplementary oxygen
– Resistant to extremes of heat or cold
– Easy to assemble and use.
 Breathing Devices:
Resuscitation Mask
 To use a mask, place it over the victims
mouth and nose, starting on the bottom and
rolling it over the rest of the face.
 Tilt the head back and breath into it.
 A mask can also be used for the modified jaw
thrust.
 Breathing Devices:
Bag Valve Mask
 A Bag Valve Mask (BVM), also called an
AMBU bag, is a device that allows artificial
respiration without a rescuer to give breaths.
 It is much less tiring and safer to use.
 As the name implies a BVM needs a
squeezeable bag, a one way valve, and a
mask.
 Breathing Devices:
Bag Valve Mask
 To use, place the mask over the victims
mouth and nose, and grip the mask in one
hand using a C shaped grip, finger on the
victim’s jaw.
 Tilt the head back and squeeze the bag to
administer respirations.
INTUBASI ENDOTRACHEAL
 POLICY
 PROSEDUR PENTING NAMUN BERESIKO
TINGGI
– Darurat/waktu terbatas
– Diindikasikan untuk gagal nafas akut
– Ketidakstabilan hemodinamik (syok)/paska
cardiac arrest
– Trauma servikal (leher) atau orofaring
– Beresiko muntah dan aspirasi
– Posisi sulit
 POLICY
 Harus familiar dengan trolley emergency, peralatan
dan obat2
 Asisten harus trampil
 Jika sendiri, harus memanggil staf anestesi, (penata
atau dokter anestesi)
 Pada umumnya memakai teknik induksi cepat 
RAPID SEQUENCE INDUCTION
 INDIKASI
 Penggunaan ventilasi mekanik
 Mempertahankan fungsi jalan
nafas (airway)
– Sumbatan jalan nafas atas
 Yang potensial – EARLY BURNS
 Real – EPIGLOTITIS, TRAUMA
– TRANSPORTATION
 Melindungi jalan nafas dari:
– Resiko aspirasi
– Penurunan kesadaran
– Kehilangan refleks glotis
– Trakeal “TOILET”
 TEKNIK
 OROTRACHEAL – metode STANDARD
 NASOTRACHEAL - jika;
– Pemakaian ventilator jangka pendek, trauma rongga
mulut
– FIBREOPTIC
 Cedera kepala dan leher (servikal)
 Tidak mampu membuka mulut: fiksasi rahang, trauma
 Obstruksi jalan nafas atas: tumor di rongga mulut
 METODE
– DIRECT VISUALISATION - laringoskop
– FIBREOPTIC – intubasi sadar (AWAKE INTUBATION)
– BLIND NASAL – AWAKE INTUBATION
ENDOTRACHEAL TUBE
 STANDARD TUBE: LOW PRESSURE HIGH VOLUME
(PLAIN PVC)
– Pria 8-9 MM: fiksasi pada 21-23 CM TO INCISORS (gigi
taring)
– Wanita 7-8 MM: fiksasi pada 19-21 CM TO INCISORS
– Jangan memotong tube dibawah 26 cm
 DOUBLE LUMEN TUBES: jarang di ICU (kecuali CVVH)
 Tube dari OK/OT harus diganti jika diperkirakan ekstubasi
> 48 HOURS
 PROTOKOL
A. PERSON: 4 orang, asisten trampil sangat perlu
– “TOP END” INTUBATOR (yg melakukan intubasi) 
koordinator
– 1 orang  pemberi obat
– 1 orang menekan cricoid
– 1 orang  menjaga agar kepala dan leher segaris atau lurus
(PROVIDE IN LINE CERVICAL SPINE
IMMOBILISATION)
B. Jalur intravena harus dijamin lancar
 PROTOKOL
C. Peralatan:
– Lampu penerangan cukup
– Guedel/mayo
– Suction yg berfungsi
– AMBU BAG dan MASK
– 100% OXYGEN, 15 L/MIN
– 2 LARYNGOSCOPES yang berfungsi
– MAGILL FORCEPS
– INTRODUCER (kawat mandrain) dan PLESTER
– 2 tube (ETT):
 NORMAL SIZE + 1 SIZE yang > kecil
 CHECK CUFF COMPETENC
– Peralatan CRICOTHYROIDECTOMY:
 SCAPEL 15
 ETT NO 6.0
 PROTOCOL

D. MONITORING
– PULSE OXYMETRY
– KAPNOGRAFI
– TEKANAN DARAH
– EKG
 PROTOCOL
E. OBAT-OBATAN
– Obat induksi (pentotal, propofol, fentanil/sufentanil,
ketalar,dormicun)
– Obat pelumpuh otot; Suksinil kolin (1-2 MG/KGBB)
merupakan obat pilihan
 Kontraindikasi suksinil kolin:
– Luka bakar > 3 DAYS
– CHRONIC SPINAL INJURY (SPASTIC PLEGIA)
– NEUROMUSCULAR DISEASE (Guillan Barre Syndrome)
– HYPERKALAEMIC STATE (K > 5.5)
 Pertimbangkan Esmeron  ROCURONIUM (1-2 mg/kgBB)
 Sulfas atropin (0.6 – 1.2 mg)
 ADRENALINE (10 ML 1:10.000)
 PROCEDURE
 Preoksigenasi 100% (NRM 15 l/m atau tempelkan mask ke
hidung/mulut selama 3-4 menit)
 Loading cairan koloid 250-500 ml
 Obat induksi (dormicum + fentanil/petidin +
S.kolin/esmeron/tracrium
 Tekan CRICOID
 Laringoskopi sampai melihat pita suara (VOCAL CORD) 
Intubasi
 Inflasi CUFF
 Cek : ET CO2 AND stetoskop
 Lepas CRICOID PRESSURE
 Plester tube
 Hubungkan dgn VENTILATOR
 Pastikan sedasi dan pelumpuh otot
 CHEST X-RAY
 Analisa gas darah 1 jam post intubasi dan sesuaikan FiO2
 PROCEDURE

Sedasi POST INTUBATION:

Tidak perlu jika pasien koma atau hemodinamik
tidak stabil
MORPHINE+MIDAZOLAM, PROPOFOL,
FENTANYL
 Preoksigenasion
 Pemberian O2 100% selama 2-5 menit
 Bagging mask selama 1-2 dgn 15 l/m
 KALAU PS MASIH BERNAFAS SPONTAN DAN
SADAR, 3 kali tarik nafas dalam dgn baging mask
 Gunanya untuk membuang gas nitrogen udara bebas
dalam paru
 Memberikan cadangan O2 dalam paru jika apne
selama 3-5 min
 Pretreatment

 Defasiculation
– Prevent increase ICP
– Pediatric patients
– 10% of neuromuscular
blockade dose
 ICP Concerns

 Oxygenation
 Prevent fasiculations
 Lidocaine- 1.0mg/ kg
 Bradycardia

 Atropine 0.01- 0.02mg/ kg

 ALL children
 Dries secretions
 Sedation

 Prior to paralysis
 Immediately subsequent

 You do not want a paralyzed awake

patient!
 Agents
 Barbituates
 Benzodiazepines
 Dissociatives
 Opiates
 Other
 Benzodiazepines

 Midazolam (Dormicum)
0.1-0.2 mg/kg
 Diazepam (Valium)
0.25-0.4 mg/kg

 Amnestic, anticonvulsant,
 Dose related hypotension
 Dissociatives

 Ketamine (Ketalar)
0.5-2mg/kg

 Analgesic, amnestic, bronchodilator,

 Increased ICP, hypersecretion
 Opiods
 Morphine Sulfate
0.1-0.2 mg/kg
 Fentanyl (Sublimaze)
2-10mcg/kg

Analgesic
 Others
 Etomidate (Amidate)
0.2-0.4 mg/kg
– Decreases ICP, little BP effect

 Propofol (Diprivan)
– 1-2mg/kg
– Decreases ICP, anticonvulsant, antiemetic
– Hypotension
 NMB
 Depolarizing
– Succinylcholine (Anectine) 1-1.5mg/kg
 Nondepolarizing
– Rocuronium (Esmeron) - 0.6-1.2mg/kg
– Vecuronium (Norcuron) - 0.1mg/kg
– Pancuronium Pavulon) - 0.1mg/kg
 Selleck’s Manuever

 Prevents PASSIVE regurgitatioon

 Visualization
 Suction

 If you couldn’t get it done before, you

can now
 Patient Positioning
– Goal
 Align the 3 planes of
view, so that
 The vocal cords are
most visible
– T - trachea
– P - Pharynx
– O - Oropharynx
Nasotracheal intubation
 Complications

 Inability to intubate
 Inability to ventilate
 Associated complications
 Always have a back up plan and be
prepared to use it!
– Combitube
– LMA (Laringeal Mask Airway)
– Cricothyroidotomy
COMBITUBE
 N o. 1
10 0 m l N o. 1

Combitube®
1 00 m l
LARINGEAL MASK
AIRWAY
POSITIONING OF THE AIRWAY FOR LMA
DEFLATION & INFLATION OF THE LMA
LMA Insertion
Step 1
LMA Insertion

Step 2
LMA Insertion
Step 3
LMA Insertion
Step 4
LMA Insertion
Step 5
Fast-trach LMA
 The Difficult or Failed Airway

 Difficult to ventilate or oxygenate

 Difficult to intubate
 Difficult cricothyroidotomy candidate

 Comprise 1- 3% patients
 Unpredictably difficult to intubate or
ventilate with BVM 1:10,000
Questions