AIRWAY MANAGEMENT

RISTIAWAN MUJI LAKSONO

SMF/BAG ANESTESIOLOGI DAN TERAPI INTENSI
FKUB-RSSA
INTRODUCTION
 Difficulty in breathing 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 reaction
 Anaphylaxis
 Epilepsy
DIAGNOSIS OF AIRWAY
OBSTRUCTION
 LOOK : Respiratory movements, gasping , suprasternal
retraction
 LISTEN: Breath sounds

 FEEL : Expired air

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

 The lower airway

THE UPPER AIRWAY
A Epiglottis
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 Bronchi
D Tracheal Ligament
E Trachea
F Larynx
G Esophagus
H Left Lung
I
Trachea
J
DIFFERENCE BETWEEN ADULT AND
INFANT AIRWAY
TECHNIQUES OF COMMON AIRWAY
INDEXES MEASUREMENT
 Thyromental distance: measured along a straight line
from tip of mentum to thyroid notch in neck-extended
position
 Mouth opening: interincisor distance (or inter-alveolus
distance when edentulous) with the mouth fully opened
 Mallampati score

 Head and neck movement: the range of motion from full

extension to full flexion
 Ability to prognath: capacity to bring the lower incisors
in front of the upper incisors7
MALLAMPATI GRADES
MALLAMPATI GRADES
 Class I: Uvula/tonsillar pillars 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 (also commonly termed
“denitrogenation”) should be practiced in all cases when
time permits.
 This procedure entails the replacement of the 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
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, leaving the right hand free for other uses
UKURAN PERNAFASAN
 Tidal Volume = volume 1 x nafas = VT
 VT = 8 – 10 cc / kg
 Pasien 60 kg  500 – 600 cc
 Minute Volume = volume 1 menit = VT x RR
 Pasien tsb bernafas 500 cc x 12 = 6000 cc = 6 lpm
 Minute Volume berkurang = hipoventilasi
 mungkin karena VT turun
 mungkin karena RR turun
HIPOVENTILASI
 Menyebabkan :
 Diatasi dengan :
 Hipoksia
 Memberi oksigen
 Hiperkarbia
 Memberi nafas bantuan
 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%

 mask
 mask + reservoir
 bag + mask / Jackson Reese

 Mungkin perlu segera nafas buatan

 bag
+ mask / Jackson Reese
 AMBU bag (+ reservoir)
RESCUE BREATHING (MOUTH TO
MOUTH / MASK)

 Diberikan pada
 apnea = pasien tidak bernafas
 hipoventilasi = pasien masih bernafas tetapi MV kurang
Cara memberi nafas buatan (1)
Cara memberi nafas buatan (2)
OROPHARYNGEAL AIRWAY
 Indications :
 Unconscious but spontaneously breathing patients
due to tongue positions
 Advantages :
 Seperates tongue from posterior pharyngeal wall
 Disadvantages :
 Activates gag reflex in conscious patients
OROPHARYNGEAL AIRWAY
 Size :
 Adult : 100 mm
 Small adult : 80 – 90 mm

 Technique :
 Position
 Use tongue blade
 Insert inverted and later rotate
OROPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAY
 Indications:
 Tongue obstruction
 Inadequate oral opening
 Oral Surgery

 Advantages :
 Well tolerated even in conscious patient
 Sizes : (Internal Diameter)
 Large adult :8-9 mm
 Small adult : 6-8 mm
NASOPHARYNGEAL AIRWAY
NASOPHARYNGEAL AIRWAY
 Position
 Determine the size of tubes

 Local Anesthesia

 Lubricate
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
after insertion
BENEFITS
RISKS
PATIENTSELECTION
APPROPRIATE INSERTION
 General purpose
LMA™ airway for
routine anaesthesia
 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 the airway from
nasopharyngeal bleeding
LMA-FASTRACH™
 Designed for the
anatomically difficult
airway and emergency
airway
 Facilitates rapid intubation

 Single handed insertion

INDICATIONS
 As an alternative to the face mask during 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
patient
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 field
 Protected lower airway from contamination with blood

 In children, recovery less eventful

 Less airway obstruction

 Better airway acceptance

LMA-FASTRACH™
WHAT ELSE DOES IT OFFER
 The head can be kept in a neutral 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
time to think the Fastrach™ is a life saver
 LMA CTRACH
 The LMA CTrach™ system is a
fiber-optic, connected to a
colour LCD monitor ctrachtestbambang.avi

 direct visualisation of the

larynx and vocal cords during
intubation.
 capable of “visualising and
ventilating” the patient’s airway
at the same time.
 allows the retrieval and
maintenance of the patient’s
airway and the supply of
oxygen without interruption
during the visualisation process
LMA™ AIRWAY V TT

 The LMA is a useful alternative to the 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 over both the
facemask and tracheal tube

Brimacombe J. The advantages of the LMA over the

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

Advantages over ETT

 Increased speed and ease of
placement
 Improved haemodynamic
stability at induction and
during emergence
 Minimal rise in intraocular
pressure
 Reduced anaesthetic (no
muscle relaxant)
 Less coughing
 Improved SpO2 during
emergence
 Less sore throats
META-ANALYSIS

Advantages over facemask

 Easierplacement by  Placement independent
inexperienced personnel of facial anatomy
 Improved SpO2 during  Better access to head and
emergence neck
 Less hand fatigue  Suitable for low flow
LMA ClassicTM compared with LMA ProSealTM

•Insertion of nasogastric tube easy with LMA

ProSealTM
•Leak pressure higher with LMA ProSealTM
•Risk of regurgitation insufflation,
regurgitation and aspiration lower
Can the LMA ProSealTM be used in
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
•Protection against regurgitation
•Protection against secretions
•Prevention of gastric insufflation during positive
pressure ventilation
 The LMA ProSealTM
Higher leak pressure
•Prevention of gastric insufflation
•Better protection against risk of aspiration
Prevention of regurgitation
•Drainage tube allowing gastric emptying
•Lower risk of gastric insufflation
Advantages of the LMA ProSealTM over
tracheal intubation
Insertion is easier and faster
Fewer respiratory incidents
•Laryngospasm (absence of laryngeal stimulation)
•Bronchospasm (child with a runny nose)
•Desaturation during induction
•Absence of reflex bronchostriction

Inspiratory pressure is lower

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

 LMA can prevent

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 LMA in CPR
 At least as effective as other methods of airway management
 LMA failure and complication
 May not offer total protection from gastric content, but offer total
protection from aspiration of material above the device
 Conclusion
The LMA ProSealTM is an alternative to the ET
tube in the OR except
•In oropharygeal surgery
•In major surgery (cardiac, abdominal
surgery, neurosurgery)
Patient with a full stomach is still a
contraindication except in a cannot-intubate-
cannot ventilate situation
Lateral 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,”
SUPRAGLOTTIC DEVICES - EVIDENCE
 Combitube
 A rescue airway device for failed airway in the US and Canada
 Success rate of insertion 98 – 100%
 Cuffed Oropharyngeal Airway
 Disappeared from clinical use
 Laryngeal Tube Airway
 Simple handling , available in various sizes
 Mucosal compression by the balloon may lead to mucosal
ischemic injury
 Pharyngeal Airway Xpress
 Suggest substantial incidence of superficial pharyngeal mucosal
injury
 Glottic Aperture Seal Airway
 No literature to support recommendation for emergency airway
management
LARYNGEAL MASK AIRWAY (LMA)
LARYNGEAL MASK AIRWAY
 Procedure:
 Identify correct size
 Lubricate
 Anesthetize
 Extend neck
 Insert, follow the curvatures of oropharynx and rest
over pyriform fossa
 Inflate cuff
 Check position using sthethoscope
 Attach to ventilator apparatus
LMA PLACEMENT
LMA PLACEMENT
 THE END

THANK YOU

November 2012