AIRWAY MANAGEMENT

AND

FBAO

BAGIAN ANESTESI FK UNISSULA

dr. Prabowo Wicaksono Y.P., SpAn KMN., M. Bio Med.

AIRWAY MANAGEMENT

2

3Apa ke-khusus-an penanganan pasien gawat darurat ?

Waktu untuk bertindak : terbatas

Data dasar untuk bertindak : terbatas

Konsep berfikir yang sederhana

Tindakan yang sistematik

Ketrampilan yang memadai

4PASIEN TRAUMA/ NON TRAUMA

LIFE SUPPORT

Resusitasi

Stabilisasi

A = airway

B = breathing

C = circulation

D = disability

TERAPI DEFINITIF/

SPESIALISTIK

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Life support

A ─B─ C─ D ─ EQuick Diagnosis – Quick Treatment

A= Airway, bebaskan jalan nafas, Lindungi C-spine

B= Breathing, beri bantuan nafas, tambah oksigen

C= Circulation, hentikan perdarahan, beri infus

D= Disability/SSP, cegah TIK ↑

E= Exposure, buka semua baju, cegah hipotermi

Pasien obstruksi (A) atau apneu (B) akan mati dalam 3-5 menit

Pasien shock berat (C) akan mati dalam 1-2 jam

Pasien coma (D) akan mati dalam 1 minggu

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Bagaimana mengamankan jalan nafas?

Intubasi trakea = Gold standard

?Bagaimana pendapat para ahli anestesiologi?

1.Intubasi oleh bukan ahli dapat timbulkan trauma

2.Resiko: hipoksia fatal/ secondary brain damage,

vagal reflex→ bradikardi berat, cardiac arrest

3.TIK naik hanya dapat dicegah dengan obat-obatan

4.Tidak semua fasilitas kesehatan dilengkapi peralatan untuk

intubasi trakea

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Trauma wajah berat, dengan potensi obstruksi airway

Intubasi trakea ? Setuju

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Obstruksi airway karena lidah terdorong ke

hipofaring, lebih sering terjadi.

Intubasi trakea ?

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Pasien mati karena hipoksia, bukan karena tidak

terpasang endotrakeal tube (ETT)

Tidak semua masalah airway harus

diselesaikan dengan intubasi trakea

10Banyak Cara Mengamankan Jalan Nafas

A. Chin Lift

B.Jaw Thrust

1. Basic/ Manual

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C. Head tilt – Chin lift

122. Airway (Alat Bantu Nafas) Dasar

A. Oropharyngeal Airway (OPA) / Guedel

B. Nasopharnygeal Airway (NPA)

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3. Advanced Airway

A. Endotrakeal Tube (ETT)

B. Laryngeal Mask Airway (LMA)

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C. Combitube

15AirwayMenilai jalan nafas

Kesadaran (“ the talking patient”)

Look, Listen and Feel

Look•Agitasi (hipoksia)/ tampak bodoh (hiperkarbia)

•Sianosis

•Retraksi

•Accessory respiratory muscle

16Listen•Snoring

•Gurgling

•Stridor

•Hoarness

Feel•Trachea location

17Patients talks clearly ?Airway is adequate

Management: observation and selective intubation

Special consideration in :

•Maxillofacial injury

•Soft-tissue injury of the neck

•Facial or neck burns

18Patient is hoarse ?Laryngeal injury

Larngeal/ tracheal burn

Management: Evaluate and perform (if necessary):

•Intubation

•Surgical airway

Patient cannot respond ?•GCS ≤ 8

•Obstruction due to: Tongue

Aspiration

Foreign body

Maxillofacial injury

Neck Injury

•Cyanosis

•Rocking respirations

19•Decreased or no air exchange

•Face or neck crepitus

•Neck hematoma or swelling

Management :

Simple management manuevers:

•Suction

•Chin lift

•Jaw thrust

Intubation

Caution !! Protect C-Spine During

Airway Management

C-spine protection during airway management

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21Airway Definitive

Pipa dalam trakea dengan balon (cuff) yang dikembangkan.

3 macam:

•Orotrakeal (Intubasi Oral)

•Nasotrakeal (Intubasi Nasal)

•Surgical airway (Krikotiroidotomi/ trakeostomi)

AirwayDEFINITIVE

SURGICAL : Krikotiroidotomy

: Trakeostomy

NON SURGICAL : Oral Intubation

: Nasal Intubation

NON DEFINITIVE

OROPHARYNGEAL AIRWAY

NASOPHARNGEAL AIRWAY

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23

OBJECTIVE Clear and protected airway

Oxygenation

Positive pressure ventilation

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Basic Airway Manuever25

1. Chin Lift

•Tidak boleh akibatkan hiperekstensi

leher.

•Aman untuk C-spine pada korban

trauma

262. Jaw Thrust•Pegang pada angulus

mandibulae, dorong mandibula

ke depan (ventral ).

•Aman untuk C-spine pada

korban trauma

27Jaw Thrust Technique

283. Head tilt – Chin lift

•Gabungan antara manuver Head tilt

dan Chin lift.

•Head tilt: meletakkan telapak tangan di

dahi, kepala diekstensikan.

•Pada pasien trauma: hati-hati cedera

pada C-spine.

•Pada pasien multipel trauma dengan suspek cedera cervical,

manuver yang paling aman : Jaw Thrust.

•Bila dengan Jaw Thrust tidak bisa buka airway: lakukan Head

Tilt – Chin Lift dengan ekstensi kepala minimal.

•Airway tetap merupakan prioritas, meski terdapat cedera C-

spine.

29Head Tilt and Chin Lift

Jangan Lakukan !!30

Airway Dasar 31

1. Oropharyngeal Airway (OPA)

•Menahan lidah tidak jatuh ke

belakang .

•Fasilitas suction.

•Mencegah lidah/ ETT tergigit

•Merangsang muntah pada pasien

sadar/ setengah sadar.

•Hati – hati pada anak dapat lukai

jaringan lunak.

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Oropharyngeal Airway/Guedel

NO: 0 1 2 3 4 5 6

How to measure the right size of

Oropharyngeal Airway

Komplikasi

Obstruksi total

Laringospasme

Muntah

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Cara Pemasangan Oropharyngeal Airway

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Dimasukkan mulut dg lengkungan menghadap palatum.

Setelah masuk separuh panjangnya, putar 180° hingga

lengkungan menempel pada lengkungan lidah.

1.

2.

3.

35OPA INSERTION TECHNIQUE

362. Nasopharyngeal Airway (NPA)

Jalan nafas buatan dengan ujung di belakang lidah.

Hati hati pada fraktur basis cranii.

Indikasi:

Pasien setengah sadar dengan nafas spontan.

Lebih dapat ditoleransi pasien daripada OPA, kecil kemungkinan

rangsang muntah.

Nasopharyngeal AirwayKomplikasi

Kerusakan mukosa nasal

Laryngospasme

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Cara Pemasangan Nasopharyngeal AirwayCara pemasangan: beri jelly pelicin, didorong memasuki

lubang hidung hingga ujung pipa terletak di orofaring. Arah ujungnya

datar menyusur dasar rongga hidung, arah menuju anak telinga

(tragus).

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1.

2.

3.

39NPA INSERTION TECHNIQUE

Keuntungan :

Menjaga jalan nafas terbuka

Mengurangi risiko aspirasi

Sebagai fasilitas ‘suction’ trakea

Sebagai fasilitas pemberian oksigen konsentrasi tinggi

403. Advanced Airway

A.Endotrakeal Tube (ETT)

Endotrakeal Tube Insertion (ETT)

Komplikasi

Hipoksia

Trauma

Muntah-aspirasi isi lambung

Hipertensi

Disritmia jantung

Intubasi satu paru

Intubasi esofagus

Cardiac arrest akibat vagal reflex

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Persiapan Intubasi Endotrakeal

1. Alat:

A. LaryngoscopeTerdiri dari : Blade (bilah) dan Handle (gagang).

Pilih ukuran blade yg sesuai.

Dewasa : no 3 atau 4

Anak : no 2

Bayi : no 1

Pasang blade dengan handle

Cek lampu harus menyala terang.

43Laryngoscope

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Menyiapkan Laryngoscope

1. 2.

3. 4.

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Memegang Laryngoscope

Memegang laryngoscope

selalu dengan tangan kiri

Posisi tangan yang betul

adalah memegang pada

handle, bukan pada

pertemuan blade dan handle

46Melepas Laryngoscope

Memasang dan melepas

laryngoscope selalu dengan

sudut 45°

47B. Endotrakeal Tube (ET)Pilih ukuran yang sesuai: (ID: Internal Diameter)

Dewasa : ID 6.5 , 7 atau 7.5 Atau ± sebesar

kelingking kiri pasien

Anak : ID = 4 + (Umur : 4)

Bayi : Prematur : ID 2.5

Aterm : 3.0 – 3.5

Selalu menyiapkan satu ukuran dibawah dan diatas.

Pilih ET yang High Volume Low Pressure (ETT putih/ fortex)

Bila memakai yg re-useable, cek cuff dan patensi lubang ET.

48ETT dissposible (Low

Pressure High Volume)

ETT re-usable (High

Pressure Low Volume)

Tidak dianjurkan.

49C. Spuit 20 cc.

D. Stylet (bila perlu).

E. Handsgloves steril.

F. KY jelly.

G. Forcep Magill (bila perlu).

H. AMBU Bag dg kantung reservoir dihubungkan dengan

sumber oksigen.

I. Plester untuk fiksasi ETT.

J. Oropharngeal Airway.

H. Alat suction dg suction catheter .

K. Stetoscope.

502. Obat Emergency- Sulfas Atropin (SA) dalam spuit

- Adrenaline dalam spuit.

3. Pasien

Informed consent mengenai tujuan dan resiko tindakan.

Ingat resiko/komplikasi intubasi bisa berakibat

fatal !!!

51Persiapan Intubasi Endotrakeal

52Langkah – langkah Intubasi Endotrakeal

Ventilasi tekanan positif dan Oksigenasi

Harus dilakukan sebelum intubasi.

Dada harus mengembang selama ventilasi diberikan.

Oksigenasi dengan oksigen 100% (10 L/menit).

Bila intubasi gagal (waktu >30 detik), lakukan ventilasi dan

oksigenasi ulang, bahaya hipoksia !!!

53Posisi Tangan Saat Ventilasi Tekanan Positif

Ibu jari dan jari telunjuk

menekan face mask ke bawah

sambil mempertahankan sekat

yg tidak bocor antara face

mask dan penderita.

Jari tengah, jari manis dan

kelingking pada ramus

mandibula, mendorong ke atas

sambil membuka airway.

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INTUBASI TRAKEA

Singkirkan lidah ke kiri

Cari Epiglotis

55POSITION OF THE TIP OF LARYNGOSCOPE BLADE

VALEKULAEPIGLOTIS

LIDAH

Sniffing Position

Mambantu Visualisasi laring

Trakea

Esofagus !!!

56ELEVASI LARINGOSKOP

Gunakan kekuatan tangan untuk mengangkat. Jangan diungkit dg

menggunakan gigi seri atas sebagai titik tumpu (awas patah!!).

Arah elevasi laringoskop Jangan diungkit !!!

57INTUBASI TRAKEA

INTUBASI TRAKEA 58

Plica Vocalis TrakeaEpiglotis

BURP MANUEVERMenekan kartilago krikoid ke bawah, atas, kanan

(Back, Up, Right Pressure= BURP)

Membantu visualisasi plika vokalis

Dilakukan oleh asisten yg membantu intubator

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BURP

THYROID

CRICOID

ADAM’S APPLE

60INTUBASI TRAKEAG. H.

Cara cegah intubasi endobronkhial:

Masukkan ETT hanya sampai ujung distal cuff lewati plica

vocalis

Ujung distal cuff

Intubasi endobronkhial

TEKNIK INTUBASI TRAKEA

Buka mulut dengan tangan kanan, gerakan jari menyilang (ibu jari menekan mandibula, jari telunjuk menekan maksila)

Pegang laringoskop dg tangan kiri, masukkan melalui sisi sebelah kanan mulut, singkirkan lidah ke samping kiri

Cari epiglotis. Tempatkan ujung bilah laringoskop di valekula (pertemuan epiglotis dan pangkal lidah)

Angkat epiglotis dg elevasi laringoskop ke atas (jangan menggunakan gigi seri atas sbg tumpuan !!!) untuk melihat plika vokalis

Bila tidak terlihat, minta bantuan asisten utk lakukan BURP manuver (Back, Up, Right Pressure) pada kartilago krikoid sampai terlihat plika vokalis

Masukkan ETT, bimbing ujungnya masuk trakea sampai cuff ETT melewati plika vokalis

Kembangkan cuff ETT secukupnya (sampai tidak ada kebocoran udara)

Pasang OPA

Sambungkan konektor ETT dg ambu bag. Beri ventilasi buatan. Cek suara paru kanan = kiri, Awas intubasi endobronkial !!

Fiksasi ETT dengan plester

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62Teknik Oral

1

2

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3

4

64

5

65Teknik Nasal

1 2

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3

4

67

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MENCEGAH KOMPLIKASI

INTUBASI TRAKEA

Dilakukan oleh tenaga terlatih

Alat-alat intubasi lengkap : laryngoskop & pipa trakea berbagai ukuran

Intubasi dilakukan < 30 detik

Dilakukan penekanan pada kartilago krikoid (BURP Manuever)

Pilih pipa trakea ‘high volume low pressure cuff’

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RJP DENGAN PASIEN

TERPASANG ETT

Pasien dengan

intubasi trakhea,

bantuan ventilasi

tidak perlu sinkron

dengan kompresi

dada pada saat RJP

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Airway Management 70

Intubation71

723. Advanced AirwayB. Laryngeal Mask Airway

Keuntungan :

•Teknik pemasangan lebih mudah

•Trauma lebih sedikit

•Tidak membutuhkan laringoskop

Kerugian :Tidak melindungi terhadap aspirasi

73Laryngeal Mask Airway

Foreign Body Airway

Obstruction

(FBAO)

Conscious Adult Choking 75

1. To confirm that the victim is choking, ask: “Are you choking?”

If the victim is choking, he will not be able to Speak, Breathe or Cough.

If “YES”, say “I am trained, can I help?”

2. If the victim is upright, the rescuer stands behind the victim.

If the victim is sitting, the rescuer kneels down and positions himself

behind the victim.

3. Put your arms around the victim’s abdomen.

Place fist with thumb side against victim’s abdomen in the mid line about

2 fingers’ breadth above the navel and well below the tip of the xiphoid.

Give quick inward and upward thrusts in one motion into the victim’s

abdomen until the foreign body is expelled or the victim becomes

unconscious.

Steps Involved in Relief of FBAO ( Conscious)

ADULT HEIMLICH MANEUVER

Look for the Universal Sign of the victim's hand across their throat . . . . . . .

•if the victim is making sound or moving air, encourage them to cough.

•If the victim is not making sound, or is turning color, intervene.

•Announce to the victim that you know the Heimlich Manuver and can help!

•Have someone activate emergency medical system - CALL 911.

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•Stand behind the victim with your arms wrapped around the

victims chest.

•Feel for the victim's xiphoid process with your right hand.

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Make a fist with your left hand and place it (THUMB IN) below the right hand.

•Wrap the right hand over the left hand.

•Give inward and upward thrusts towards the shoulder blades.

•Repeat this until either the obstruction is removed, or the victim becomes

unconscious.

•If the victim becomes unconscious, assist them to the ground and perform

•C.P.R. CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE

SUPPORT IS AVAILABLE.

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Subdiaphragmatic abdominal thrust

(the Heimlich maneuver) administered to a conscious

(standing) victim of foreign body airway obstruction.

79

Subdiaphragmatic abdominal thrust (the Heimlich

maneuver) administered to a conscious (standing)

victim of foreign body airway obstruction.

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ADULT CHOKING MOVIE81

CHILD HEIMLICH MANUVER

Look for the Universal Sign of the victim's hand across their throat.

•If the victim is making sound or moving air, encourage them to cough.

•If the victim is not making sound, or is turning color, intervene.

•Announce to the victim that you know the Heimlich Manuver and can help!

•Have someone activate emergency medical system - CALL 911.

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•If you are alone, perform Heimlich Manuver first, then call 911, because children

need air !!!

•Stand behind the victim with your arms wrapped around the victims chest.

•Feel for the victim's xiphoid process with your left hand.

•Make a fist with your right hand and place it (THUMB IN)below the left hand.

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Wrap the left hand over the right hand.

Give inward and upward thrusts towards the shoulder blades.

Repeat this until either the obstruction is removed, or the victim becomes

unconscious.

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•If the victim becomes unconscious, assist them to the ground and

perform C.P.R.

CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE SUPPORT IS

AVAILABLE.

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CHILD CHOKING MOVIE86

INFANT HEIMLICH MANUVER

Intervene if the infant is turning color, or is not making sound !!!

•Place victim flat on his/her back with their head to your right, on

a hard surface.

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With your left hand cupped in a "C" shape, grab the infant by the jaw

and rest the remainder of your arm across the infant's body.

•Lift the infant with your left hand and invert the victim so their body is resting across

the rescuer's left arm with the legs straddling your arm.

•Lower the victim's head.

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Back blow in an infant.

•With the infant's back towards you, perform 5 back blows at the

level of the infant's shoulder blades with the heel of your right

hand. 89

•Sandwich the infant between both arms, supporting the head with your

right hand.

•Invert the victim to the right arm, facing upwards with the legs

straddling your right arm and move the victim to the level of your chest.

90

•Take the left hand,and extend the middle 3 fingers. Place them on the

infant's chest with the index finger in the center of the chest at the nipple-

line.

•Raise the index finger and depress sternum 1 inch using the remaining 2

fingers.

•Perform 5 compresions (Chest Thrust)

91

92•Look in the infant's mouth to see if the foreign body has been

displaced.

•If no air goes in, reposition the head and try again.

•If no response after 1 minute, call emergency medical system dial-911

•Return to victim and continue the Heimlich Manuver.

CONTINUE UNINTERRUPTED UNTIL ADVANCED LIFE

SUPPORT IS AVAILABLE.

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INFANT CHOKING MOVIE94

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1. Ask: “Are you choking?”

2. Perform abdominal thrusts (Heimlich maneuver) / For pregnant and

very obese victims, perform chest thrusts.

If the victim becomes Unconscious,

3. Position the victim on his back and call “Help! Call 995”

4. Open the airway – Perform Head-Tilt-Chin Lift

5. Push chin down and check mouth for foreign body object

6. If foreign body is seen, If foreign body is seen, insert the index finger of

the other hand down along the inside of the cheek and deeply into the throat.

Use a hooking action to dislodge the foreign body and maneuver it out of

the mouth./ Take precaution not to force the foreign body deeper into the

throat. This maneuver is known as the finger sweep.

Steps Involved in Relief of FBAO ( Conscious to Unconscious)

96Finger Sweep

Use a hooking action to dislodge the foreign body and

maneuver it out of the mouth./ Take precaution not to

force the foreign body deeper into the throat. This man

oeuvre is known as the finger sweep.

Check for Foreign Body – use Push chin

down

If foreign body is seen, insert the index

finger of the other hand down along the

inside of the cheek and deeply into the

throat.

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7. Check breathing – Look, Listen and See

8. If there is no breathing, attempt to ventilate (1st ventilation). If the chest

does not rise, reposition victim’s head and reattempt to ventilate

(2nd ventilation)

9. If the chest does not rise again, give 30 chest thrusts. The hand position

for chest thrusts is the same as chest compression performed in CPR.

10. Repeat S/N 4 to 8 until there are 2 successful ventilations, and check the

breathing.

Steps Involved in Relief of FBAO ( Conscious to Unconscious)

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1. To treat one’s own complete FBAO, make a fist with one hand, place

the thumb side on the abdomen above the navel (2 fingers breadth) and

below the xiphoid process, grasp the fist with the other hand, and then

press inward and upward toward the diaphragm with a quick motion.

2. If unsuccessful, the victim can also press the upper abdomen over any

firm surface such as the back of a chair, side of table, or porch railing.

Several thrusts may be needed to clear the airway.

The Self-Administered Heimlich Maneuver

99

May be used as an alternative to Heimlich Maneuver. It is performed on

obese or pregnant victim.

1. To confirm that the victim is choking, ask: “Are you choking?”

If the victim is choking, he will not be able to Speak, Breathe or Cough.

If “YES”, say “I am trained, can I help?”

2. If the victim is upright, the rescuer stands behind the victim.

If the victim is sitting, the rescuer kneels down and positions himself

behind the victim.

Chest Thrust

1003. Place your arms under the victim’s armpits to encircle the chest.

Place one fist with thumb side on the middle of the breastbone.

Grasp fist with the other hand and give successive quick backward

thrusts..

Deliver each thrust firmly and distinctly with the intent of relieving

the obstruction until the foreign body is expelled or the victim

becomes unconscious.

When the victim becomes unconscious, the rescuer should activate

emergency medical services by dialing 995 for an ambulance and

begin CPR.

Chest thrust administered to a conscious victim (standing) of

foreign body airway obstruction.

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Chest thrust administered to an unconscious victim (lying) of

foreign body airway obstruction.

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ATLS AIRWAY ALGORITHM

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105NEEDLE CRICOTHYROIDOTOMY

106SURGICAL CRICOTHYROIDOTOMY

Thank you.....

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