AIRWAY MANAGEMENT

RISTIAWAN MUJI LAKSONO

SMF/BAG ANESTESIOLOGI DAN TERAPI
INTENSIF FKUB
FKUB-RSSA
RSSA
INTRODUCTION
| Difficulty
y in breathing
g is one of the most
disconcerting problems for the patient who is
conscious yet unable to breath properly. One
needs to be aware of the psychological aspect of
the patient while management of airway
obstruction.
INDICATIONS OF AIRWAY MANAGEMENT
| Maxillofacial trauma
| Aspiration of foreign body
| Vasodepressor syncope
| Asthma
| Heart failure
| Hypoglycemia
| Overdose
O d reaction
ti
| Anaphylaxis
| Epilepsy
DIAGNOSIS OF AIRWAY OBSTRUCTION
| LOOK : Respiratory
p y movements,, g
gasping
p g,
suprasternal retraction
| LISTEN: Breath sounds

| FEEL : Expired air

DIAGNOSIS OF AIRWAY OBSTRUCTION
| Abnormal sounds in airway
y obstruction
y Snoring - due to obstruction of upper
airway by the tongue
y Gurgling - due to obstruction of upper
airway by liquids (blood, vomit)
y Wheezing - due to narrowing off the lower
airways
y Complete airway obstruction is silent.
silent
PURPOSE
| Deprived of oxygen; brain death will occur
within
i hi minutes.
i
| To provide an artificial airway that is as close to
the patient's natural airway as possible along
with
ith a continuous
ti source off oxygen.
ANATOMY OF RESPIRATORY SYSTEM
y can be divided in to p
The airways parts namely:
y
¾ The upper airway.

¾ The lower airway

THE UPPER AIRWAY
A Epiglottis
pg
B Mandible
C Frontal Sinus
D Soft Palate
E Trachea
F Glottis
G Esophagus
H Vocal Cords
THE UPPER AIRWAY
THE LOWER AIRWAY
Primary Bronchi
A Hyoid Bone
B Right Lung
C Secondary
D Bronchi
E Tracheal
Ligament
F
Trachea
G
Larynx
H
Esophagus
I
Left Lung
J
T achea
Trachea
DIFFERENCE BETWEEN ADULT AND
INFANT AIRWAY
TECHNIQUES OF COMMON AIRWAY
INDEXES MEASUREMENT
| Thyromental
y distance: measured along g a straight
g
line from tip of mentum to thyroid notch in neck-
extended position
| Mouth
M th opening:i i t i i
interincisor di t
distance (or
( inter-
i t
alveolus distance when edentulous) with the
mouth fully opened
| Mallampati score

| Head and neck movement: the range of motion

f
from full
f ll extension
i to ffull
ll fl
flexion
i
| Ability to prognath: capacity to bring the lower
incisors in front of the upper incisors7
MALLAMPATI GRADES
MALLAMPATI GRADES
| Class I: Uvula/tonsillar ppillars visible
| Class II: Tip of uvula/pillars hidden by tongue

| Class III: Only soft palate visible

| Class IV: Only hard palate visible

CLINICAL MANAGEMENT OF THE AIRWAY
PREOXYGENATION
| Preoxygenation
yg ((also commonlyy termed
“denitrogenation”) should be practiced in all
cases when time permits.
| This
Thi procedure
d entails
t il the
th replacement
l t off the
th
nitrogen volume of the lung (upwards of 69% of
the FRC) with oxygen to provide a reservoir for
diffusion into the alveolar capillary blood after
the onset of apnea.
| Preoxygenation with 100% O2 via a tight-fitting
tight fitting
facemask for 5 minutes in a spontaneously
breathing patient can furnish up to 10 minutes of
oxygen reserve following apnea
ASSESSMENT AND PREDICTABILITY OF
DIFFICULT MASK VENTILATION
Criteria for difficult mask ventilation
| Inability for one anesthesiologist to maintain
oxygen saturation >92%
| Significant gas leak around face mask

| Need for ≥IS 4 min gas flow (or use of fresh gas
flow button more than twice)
| No chest movement

| Two-handed mask ventilation needed

| Change of operator required

THE ANESTHESIA FACEMASK
| The anesthesia facemask is the device most
commonly used to deliver anesthetic gases and
oxygen, as well as to ventilate the patient who
has been made apneic
| The skillful use of a facemask remains a
mainstay in the delivery of anesthesia and
resuscitation
| The mask is gently held over the patient's face
with the left hand,
hand leaving the right hand free for
other uses
UKURAN PERNAFASAN

| Tidal Volume = volume

olume 1 x nafas = VT
y VT = 8 – 10 cc / kg
y Pasien 60 kg ≈ 500 – 600 cc

| Minute Volume = volume 1 menit = VT x RR

y Pasien tsb bernafas 500 cc x 12 = 6000 cc = 6 lpm
| Mi
Minute V
Volume
l b
berkurang
k = hi
hipoventilasi
il i
y mungkin karena VT turun
y mungkin karena RR turun
HIPOVENTILASI
| Menyebabkan
y :
| Diatasi dengan :
| Hipoksia
| Memberi oksigen
| Hiperkarbia
| M b i nafas
Memberi f bantuan
b t
 CARA MEMBERIKAN OKSIGEN

nasal prong 2-3 lpm

mask w/ reservoir 6-8 lpm
→ 30%
→ 80%

bag-mask / Jacksoon Reese 10 lpm

mask 6-8 lpm
→ 100%
→ 60%
PASIEN GAWAT

| Perlu oksigen 60-100%

y mask
y mask + reservoir
y bag + mask / Jackson Reese

| M
Mungkin
ki perlu
l segera nafas
f buatan
b t
y bag + mask / Jackson Reese
y AMBU bag (+ reservoir)
RESCUE BREATHING (MOUTH TO MOUTH / MASK)

| Diberikan pada
y apnea = pasien
i tidak
tid k bernafas
b f
y hipoventilasi = pasien masih bernafas tetapi MV
kurang
Cara memberi nafas buatan (1)
Cara memberi nafas buatan (2)
OROPHARYNGEAL AIRWAY
| Indications :
y Unconscious but spontaneously breathing
patients due to tongue
p g p positions
| Advantages :
y Sepe a es tongue
Seperates o g e from
o posterior
pos e o
pharyngeal wall
| Disadvantages
g :
y Activates gag reflex in conscious patients
OROPHARYNGEAL AIRWAY
| Size :
y Adult : 100 mm
y Small adult : 80 – 90 mm

| Technique :
y Position
y Use tongue blade
y Insert inverted and later rotate
OROPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAY
| Indications:
y Tongue obstruction
y Inadequate oral opening
y Oral
O l Surgery
S
| Advantages :
y Well tolerated even in conscious patient
| Sizes : (Internal Diameter)
y Large adult :8-9 mm
y Small adult : 6-8 mm
NASOPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAY
| Position
| Determine the size of tubes

| Local Anesthesia

| Lubricate
ENDOTRACHEAL INTUBATION
| Definition :
y Endotracheal intubation is the placement of a
tube into the trachea (windpipe) in order to
maintain an open airway in patients who are
unconscious or unable to breathe on their own.
Oxygen,
yg , anesthetics,, or other gaseous
g
medications can be delivered through the tube.
ENDOTRACHEAL INTUBATION
y Indications:
◦ Treatment of symptomatic hypercapnia.
◦ Treatment of symptomatic hypoxemia.
◦ Airwayypprotection against
g aspiration.
p
◦ Pulmonary toilet
◦ Present or impending respiratory failure
◦ Apnea
◦ Unable to protect own airway
y Contraindications:
◦ Awake patient.
patient
◦ Airway can be managed less invasivel
ENDOTRACHEAL INTUBATION
| Advantages
g
y Secures airway
y Route for a few medications
y O ti i
Optimizes ventilation,
til ti oxygenation
ti
y Allows suctioning of lower airway
| Hazards:
y Esophageal intubation
y Damage to vocal cords
y Damage to teeth (Laryngoscope)
y Endobroncheal intubation
ENDOTRACHEAL INTUBATION
y Equipment:
q p
1. Endotracheal tube
Adult female= 7- 8 mm
Adult Male = 8 – 9 mm
child = diameter of little finger
ENDOTRACHEAL INTUBATION
1. Laryngoscope
y g p blade
1. Stright
1. Adult : size 3 to 4
2. Child : Size 2-3
3. Baby : size 1- 2
2. Curved
1. Adult : size 3 to 4
2. Child : Size 2-3
3. Baby : size 1- 2
CURVED BLADE
| Insert from right
g to left
| Visualize anatomy

| Blade in vallecula

| Lift up and away DO NOT

PRY ON TEETH
| Lift epiglottis
i l tti indirectly
i di tl
ENDOTRACHEAL INTUBATION
y Procedure:
y Assess
◦ airway – note landmarks, swelling, deformities.
◦ Remove dentures. – Assess tongue size, dental
obstruction, visibility of oropharynx,
◦ degree
g of neck mobility.
y - Maintain cervical spine
p
stability as necessary.
y Open airway: suction or manually extract
foreign material.
material – Chin lift,
lift jaw thrust.
thrust
y Heimlich maneuver as needed.
ENDOTRACHEAL INTUBATION
| Position p patient into “sniffing
gpposition” if
possible; restrain as necessary.
| Standing at the supine patient’s head, gentle
i
insert
t laryngoscope
l blade
bl d withith left
l ft hand.
h d
| Patient Positioning
y Goal
| Align 3 planes of view, so
| Vocal cords are most visible

y T - trachea
y P - Pharynx
y O - Oropharynx
TUBE PLACEMENT
| Inflate ETT cuff with 5 – 10 cc air via syringe.
y g
| Ventilate with bag and oxygen.

| Confirm tube placement

y chest auscultation,
y CO2 monitor
y chest x-ray.
x ray
OPTIONS WHEN
YOU CAN’T
INTUBATE 1
LMA, LMA-Fastrach,
LMA-Proseal, Combitube
THE LMA™ RANGE
| Secure and reliable
airway management
| For routine and
difficult airways
| Hands free
performance
f after
ft
insertion
|BENEFITS
|RISKS
|PATIENTSELECTION
S C O
|APPROPRIATE INSERTION
„ General purpose
LMA™ airway for
routine
ti anaesthesia
th i
„ Does not require
muscle relaxants
„ Secure reliable airway
„ With a proven track
record
LMA-FLEXIBLE™
| For head, neck and
dental surgery
| Flexibility of tube
reduces risk of losing
the cuff seal
| Protects
P t t th the airway
i
from nasopharyngeal
bleeding
LMA-FASTRACH™
| Designed for the
anatomically difficult
airway and emergency
airway
i
| Facilitates rapid
intubation
| Single handed
insertion
INDICATIONS
| As an alternative to the face mask during
g routine
and emergency anaesthesia
| Elective surgical procedures where the ETT is
not necessary
| Difficult airway situations known or unknown
| During resuscitation in the profoundly
unconscious
i patient
i
CONTRAINDICATIONS
As there is a potential risk of aspiration and
regurgitation the following are contraindications:
| Patients that have not fasted, including those that can not
be confirmed
| Symptomatic hiatus hernia, Pregnancy past 14 weeks
| Morbid obesity
| Multiple or massive injury, Acute abdominal or thoracic
injury,
| Conditions associated with delayed gastric emptying
| Patients where peak inspiratory airway pressures are
anticipated to be higher than 20cm H2O
LMA-FLEXIBLE™
| LMA did not interfere with the surgical
g field
| Protected lower airway from contamination with
blood
| In
I children,
hild recovery less
l eventful
f l
| Less airway obstruction

| Better airway acceptance

LMA-FASTRACH™
WHAT ELSE DOES IT OFFER
| The head can be kept p in a neutral p
position
therefore for head and neck injuries it can be a
life safer
| Be placed from any position
| Doctor can ventilate while he is intubating
| When you need to get O2 into the patient and you
need d time
i to think
hi k the
h Fastrach™
F h™ is
i a life
lif saver
 LMA CTRACH
| The LMA CTrach™ system
i a fiber-optic,
is fib ti connectedt d
to a colour LCD monitor ctrachtestbambang.avi

| direct visualisation of the

larynx and vocal cords
during intubation.
| capable of “visualising and
ventilating”
g the ppatient’s
airway at the same time.
| allows the retrieval and
maintenance of the
patient’s
ti t’ airway
i and
d the
th
supply of oxygen without
interruption during the
visualisation process
p
Movie
LMA™ AIRWAY V TT

| The LMA is a useful alternative

alternati e to the TT
TT. In
particular the LMA reduces the incidence of post
operative sore throats
LMA™ AIRWAY V ETT

| LMA showed good airway protection from

oropharyngeal contamination and low haemodynamic
responses
WHY USE THE LMA™ AIRWAY?
| LMA™ has real,, measurable advantages
g over
both the facemask and tracheal tube

Brimacombe J. The advantages

g off the LMA over the
Tracheal tube or face mask: a meta-analysis. Can J Anaesth
1995; 42:1017-1023
META-ANALYSIS

Ad
Advantages over ETT

| Increased speed and | Reduced anaesthetic

ease of placement (no muscle relaxant)
| Improved
p | Less coughing
g g
haemodynamic stability | Improved SpO2 during
at induction and during emergence
emergence | Less sore throats
| Minimal rise in
intraocular pressure
META-ANALYSIS

Ad
Advantages over ffacemask
k
| Easier placement by | Placement
inexperienced independent of facial
personnel anatomy
| Improved
I dSSpO
O2 | Better
B tt access tto hheadd
during emergence and neck
| Less hand fatigue | Suitable for low flow
LMA ClassicTM compared with LMA ProSealTM

•Insertion of nasogastric tube easy with LMA

ProSealTM
•Leak
Leak pressure higher with LMA ProSealTM
•Risk of regurgitation insufflation,
regurgitation
g g and aspiration
p lower
Can the
C h LMA P ProSeal
S lTM be
b used
d in
i
place of ET tube?

Has the LMA ProSealTM changed

airway management in
paediatrics ?
The LMA ProSealTM must meet the following
criteria to be an alternative to the ET tube

•Airtight
Airtight
•Protection against regurgitation
•Protection against secretions
•Prevention of gastric insufflation during positive
pressure ventilation
 The LMA ProSealTM
¾Higher leak pressure
•Prevention of gastric insufflation
•Better protection against risk of aspiration
¾Prevention of regurgitation
•Drainage tube allowing gastric emptying
•Lower risk of g
gastric insufflation
 Advantages of the LMA ProSealTM
over tracheal intubation
¾Insertion is easier and faster
¾Fewer respiratory incidents
•Laryngospasm (absence of laryngeal stimulation)
•Bronchospasm (child with a runny nose)
•Desaturation during induction
•Absence
Ab off reflex
fl bronchostriction
b h t i ti

¾Inspiratory pressure is lower

PAEDIATRIC
| Uncuffed tubes used in paediatric
p
y Blood can easily pass the throat pack and enter the
larynx
y Blood can easily enter the stomach very stimulating
y Result post op nausea and vomiting

| LMA can prevent

p
LMA - EVIDENCE
| Difficult and Failed Airway Management
| Usefull in emergency airway, both of it
| Intubating through the Fastrack LMA
| Blind intubation success rate 70 – 95%
| Trachlight success rate 100%

| LMAs and pediatrics

| Appropriate and widely accepted as a rescue device
| Ease of insertion for basic rescuer non medic, paramedic, nurse
etc
| Training is key to successful use of the device
| The
h LMA
A in
i CPR
C
| At least as effective as other methods of airway
management
| LMA ffailure
il and
d complication
li ti
| May not offer total protection from gastric content, but offer
total protection from aspiration of material above the device
 Conclusion
¾The LMA ProSealTM is an alternative to the ET
tube in the OR except
•In oropharygeal surgery
•In major surgery (cardiac, abdominal
surgery, neurosurgery)
¾Patient with a full stomach is still a
p in a cannot-intubate-
contraindication except
cannot ventilate situation
¾Lateral or ventral positions surgery are
indications to be discussed
DR BRAIN
| “The LMA™ is less traumatic than the ET tube,,
even in quite unskilled hands, as it is simply put
in a less traumatic place, or a place which is used
to receiving foreign bodies,
bodies ”
SUPRAGLOTTIC DEVICES - EVIDENCE
| Combitube
y A rescue airway device for failed airway in the US and
Canada
y Success rate of insertion 98 – 100%
| Cuffed Oropharyngeal Airway
y Disappeared from clinical use
| Laryngeal Tube Airway
y Simple handling , available in various sizes
y Mucosal compression by the balloon may lead to
mucosal ischemic injury
| Pharyngeal
y g Airway y Xpress
p
y Suggest substantial incidence of superficial pharyngeal
mucosal injury
| Glottic Aperture Seal Airway
y No
N literature
li to support recommendation
d i for
f emergency
airway management
LARYNGEAL MASK AIRWAY (LMA)
LARYNGEAL MASK AIRWAY
| Procedure:
y Identify correct size
y Lubricate
y Anesthetize
y Extend neck
y Insert, follow the curvatures of oropharynx
and rest over pyriform fossa
y Inflate cuff
y Check position using sthethoscope
y Attach to ventilator apparatus
LMA PLACEMENT
LMA PLACEMENT
 THE END

THANK YOU

November 2012