AIRWAY MANAGEMENT

SN Yanti Nor
SN Syaabaniah Yassin

Preoperative Assessment

Preoperative Assessment
SEJARAH untuk mengenal pasti pesakit
yang berisiko untuk difficult intubation.
PREGNANCY & LABOUR increased risk of
laryngeal edema in pre-eclampsia
KECACATAN FIZIKAL micrognathia,
macroglossia, congenital syndrome (ex:
Pierre Robin, Treacher Collins), burn
contracture involving head & neck

Preoperative Assessment
HALANGAN PADA UPPER AIRWAY
Tumor or edema involving upper airway, large
goitre, acute epiglottitis, maxillofascial trauma,
airway burns
MASALAH PADA TULANG BELAKANG
CERVICAL - #, Dislocation or subluxation of
cervical spine, rheumatoid arthritis, ankylosing
spondylitis

Preoperative Assessment
PEMERIKSAAN FIZIKAL
1.BERAT BADAN DAN STATUS AM
OBESITI BERAT > 90 kg
Kurang Berat: <18.5
BMI =
Berat (kg)
tinggi (m) x tinggi (m)

BMI Normal: 18.5 24.9

Lebih Berat: 25.0 29.9
Obesiti: >30.0

WANITA HAMIL peningkatan hormon senang

dapat laryngeal oedema

Preoperative Assessment
2.Pemeriksaan struktur muka dan leher:
Anterior ketidaknormalan tulang atau soft tissue,
small, receeding chin, maxillary #, tumor
Lateral bahagian leher bengkak, short neck,
goitre, parut, posisi thyroid cartillage, tracheal
deviation
Kenal pasti paten pernafasan stridor, tachypnoea,
respiratory distress

Menyebabkan kesukaran untuk memanipulasi

laryngoscope

Preoperative Assessment
3.Bukaan mulut
Darjah bukaan mulut pesakit inter-incisor gap = 3
jari sukar untuk masuk blade jika < 3 jari
Oral cavity jongang, gigi longgar, orthodontic work
cth: caps, crown, dentures, intra oral tumor
Kenal pasti kelas modified mallampati pesakit

Preoperative Assessment

Preoperative Assessment
Pengkelasan modified mallampati
Pesakit dalam keadaan duduk
Duduk searas dengan pesakit
Pesakit diminta membuka mulut seluasluasnya serta mengeluarkan lidah
Tidak perlu mengeluarkan bunyi cth: ahhh
- Class ||| dan |v diklasifikasikan sebagai difficult
intubation

PENGKELASAN MODIFIED
MALLAMPATI

UVULA
SOFT
PALATE

UVULA
TONSILLAR
PILLAR

SOFT
PALATE

SOFT
PALATE
HARD PALATE

Preoperative Assessment
4.Protrusion of mandible
Class A gigi bawah di hadapan, gigi atas di
belakang
Class B gigi atas = gigi bawah
Class C gigi atas di hadapan, gigi bawah di
belakang
Class B dan C = difficult intubation

Preoperative Assessment
5.Pergerakan kepalan dan leher
Flexion and extension > 90
Jika < 90 - kesukaran dalam posisi Sniffing
sukar untuk intubation
Flexion hujung dagu menyentuh xyphoid
sternum
Extension occipital menyentuh trapezius muscle

Preoperative Assessment

SNIFFING POSITION

Preoperative Assessment
6.Jarak thyroimental - tip of thyroid cartillage to tip of
mandible in full neck extension
> 6.5 cm jika < diklasifikasikan sebagai difficult
intubation

Preoperative Assessment
7. Jarak sternomental upper border of manubrium to the
tip of mandible > 12.5 cm

Preoperative Assessment
8. Wilson Risk Sum
. Dilihat daripada pergerakan kepala, leher dan
badan
. MARKAH 0-10
. markah > 4 - Dificult intubation

WILSON RISK SUM

Risk Factor

Level

Point

< 90 kg
90 110 kg
> 90 kg

0
1
2

> 90
About 90
< 90

0
1
2

IG 5 cm, Slux > 0

IG < 5 cm, Slux = 0
IG < 5 cm, Slux < 0

0
1
2

Receding mandible

Normal
Moderate
Severe

0
1
2

Buck teeth

Normal
Moderate
Severe

0
1
2

Weight

Head and neck movement

Jaw movement

Preoperative Assessment
9.PEMERIKSAAN RADIOLOGI
CERVICAL X-RAY - #, DISLOCATION OF CERVICAL
SPINE, SOFT TISSUE SHADOWS, TRACHEAL
COMPRESSION OR DEVIATION
PARTIALLY OBSTRUCTED AIRWAY PATIENT CT
SCAN, MRI MENENTUKAN TEMPAT, SAIZ DAN
TAHAP HALANGAN, DIMENSION OF TRACHEA,
BUKTI KOMPRESSI TRAKEA, INFILTRASI TUMOR
KE DINDING TRAKEA

Normal CXR

MRI image

Preoperative Assessment
Cormack and Lehanne classification
Dilihat sewaktu direct laryngoscopy ke
epiglottis pesakit
Menunjukkan view of epiglottic structure
Initially for obstetric patient, but now is widely
used
Class ||| dan |v difficult intubation

CORMACK & LEHANE CLASSIFICATION

Features of Potential Difficult

Intubation

Features of Potential Difficult Intubation

Ciri-ciri pesakit yg berpotensi untuk difficult intubation
1. Obese
2. Pregnant
3. Burn contracture pd bahagian kepala dan leher
4. Anatomical anomaly in upper airway
5. Cervical spine problem C2 C3 subclavian kena buat
fiberoptik minimize cervical movement
6. Mallampati class ||| and |v
7. Wilson Risk Sum > 4
8. Hx of radiotherapy - head and neck region oral cavity
9. Hx of difficult intubation previous anaesthetic

Airway Management

Airway Management
Assess
(recognize)

Plan (prepare)

Back-up

Every case

Manage (act)

Every place

Laryngoscopes

Macintosh Blade

Miller Blade

Laryngoscopes

MC COY BLADE

Curved Blade (Macintosh)

Insert from right to left
Visualize anatomy
Blade in vallecula
Lift up and away
DO NOT PRY ON
TEETH
Lift epiglottis indirectly

From AHA ACLS

Straight Blade (Miller)

Insert from right to left
Visualize anatomy
Blade past vallecula
and over epiglottis
Lift up and away
DO NOT PRY ON
TEETH
Lift epiglottis directly
From AHA ACLS

Laryngoscopy Technique

Inserting Laryngoscope

Macintosh Blade in Vallecula

Miller Blade Under Epiglottis

Gum Elastic Bougie

DESCRIPTION
the original Eschmann tracheal tube introducer
is a flexible device that is 60 cm (24 in) in length,
15 French (5 mm diameter) with a small
hockey-stick angle at the far end (the coude tip
usually at 35-40 degrees)
some types have external distance markings
some types have a central lumen and port for
ventilation
Sizes of different types range 10 or 15 F (600
700 mm)

USES
Bougie-assisted tracheal intubation especially
in difficult airways or during CPR
tracheal intubation via supraglottic airway device
surgical airway (cricothyrotomy)
selective endobronchial intubation
blind digital intubation
confirmation of endotracheal tube position
endotracheal tube exchange (a device with a
central lumen allowing oxygenation is better for
this)

Bougie

Lightwand (Trachlight)
Lighted Stylette
Not yet widely used
Expensive
Another method of visual feedback about
placement in trachea

Lightwand (Trachlight)
Disadvantages

Blind technique
May damage airway
Usually requires darkened room
Expertise requires practice

STYLET

FLEXIBLE WAND

REUSABLE HANDLE

Lightwand (Trachlight)

Source: Laerdal

Lightwand (Trachlight)

Source: Laerdal

Flexible Fiberoptic Scope

Advantages

Allows direct airway visualization

Causes little hemodynamic stress
Nasotracheal or orotracheal route
Can be done in all age groups
Requires minimal neck movement

Flexible Fiberoptic Scope

Disadvantages
Expensive
Expertise requires practice
Delicate equipment needs careful
maintenance
Visual field easily impaired by blood and
secretions

C-MAC FIVE
FLEXIBLE FIBEROPTIC SCOPE

Rigid Fiberoptic Scope

Bullard

Wu Scope

Rigid Fiberoptic Scope

Upsher

GlideScope

Rigid Fiberoptic Scope

Levitan Scope

Rigid Fiberoptic Scope

C-MAC

Rigid Fiberoptic Scope

Advantages

Direct airway visualization

Minimal neck movement
May overcome difficult view
Useful in disrupted airway
Durable, sturdy instruments

Rigid Fiberoptic Scope

Disadvantages
Expensive
Expertise requires practice
Visual field easily impaired by blood and
secretions
Not readily available

Artificial Airway

Artificial Airway
1. Anaesthetic face mask

The Anaesthetic Face Mask

 Used to deliver oxygen to pt - pre

oxygenate
Cara ukur di ukur daripada bridge of
nose to end of chin
Meliputi bridge of nose dan chin patient
create a seal tidak leaking semasa
ventilate pt
Cara pegang C E technique

Artificial Airway
2. OROPHARYNGEAL AIRWAY

OROPHARYNGEAL AIRWAY

OROPHARYNGEAL AIRWAY
Oral Airway / OPA / Guedel Airway
Dicipta oleh Arthur E. Guedel (1883-1956)
Size: 000,00,0,1,2,3,4,5,6 / Colour Code
Kebaikan:
- Mudah didapati / dikendali
- Memudahkan Suction
-Bite Block (mengelak pesakit menggigit tiub ETT)

 INDIKASI;
-Pesakit yang tidak sedar diri
-Pesakit spontaneusly breathing
-Total hilang gag reflex
-Digunakan sebagai bite block
-Elakkan lidah pt terbalik ke belakang semasa pre ox
-Mengekalkan airway patency
KONTRAINDIKASI;
-Pesakit sedar, ada gag reflex, susah buka mulut, masive
oral trauma
-Mandibulo-maxillary wiring

 KOMPLIKASI;
-Terlalu panjang: Menekan epligotis
-Terlalu pendek : Menolak lidah ke belakang
-Menyebabkan batuk, muntah dan
laryngospasme
-Aspiration

OROPHARYNGEAL AIRWAY
Sizes

Length (mm)

000

30

00

40

50

60

70

80

90

100

110

 Menentukan Size OPA:

i) Coner of mouth to earlobe
ii) Against patients face to angle of the mandible

Tatacara memasukkan OPA

Measure correct size.

Open mouth and insert

airway upside down.

When airway is in mouth

as far as it will go, turn it
right-side up.

You can also

insert an oral
airway right side
up, IF you use a
tongue depressor
to press the
tongue down and
forward.

Artificial Airway
3.NASOPHARYNGEAL AIRWAY
Dikenali juga sebagai NPA / nasal
trumpet
Diperbuat daripada getah / plastik
lembut
Mula diperkenalkan pada 1972.

Nasopharyngeal Airway

 INDIKASI;
-Pesakit spontaneously breathing
-Pesakit yang dikontraindikasi bagi Guedel airway
-Boleh digunakan walaupun pesakit ada gag reflex
-Pesakit tidak di intubasi.
KONTRAINDIKASI;
-Kakitangan tidak terlatih
-Kecederaan kepala / muka yang
teruk
-Basal Skull fracture
-Hidung tersumbat / jangkitan
-Struktur Kongenital, bleeding disorder

 Size;
-12F, 14F, 16F, 18F, 34F, 36F
-Guna ukuran Internal diammeter (I.D)
-Pilihan size; ? sama besar dengan jari
klingking pesakit
-Penjang (mm); Tip of nose to tragus of
the ear

NASOPHARYNGEAL AIRWAY
KOMPLIKASI;
-Terlalu Panjang:- Kecederaan pada
epligotis / vocal cord / vagal stimulation
-Injured nasal mucosa; pendarahan
-Alahan
-Kurang Selesa

Tatacara memasukkan NPA

-Pilih saiz yang sesuai

-Sapukan NPA dengan Lignocaine jel
-Pilih lubang hidung yang tidak tersumbat
-Masukkan dengan berhati-hati (elak kecederaan)
-Jika terdapat resistant, pusing sedikit NPA
-Kekalkan Head tilt

NPA insertion:
Choose correct size.

Lubricate airway.

Insert the airway posteriorly. If it does

not advance, try the other nostril.

Artificial Airway
4. LARYNGEAL MASK AIRWAY
Supraglottic airway management device.
Also called LMA
Designed between 1981 and 1988 by Dr.
Archie I. J. Brain.
Cuff device that provides sufficient seal to
allow for positive pressure ventilation to be
delivered

LARYNGEAL MASK AIRWAY

Tiga komponen utama: airway tube, mask, and
inflation line
Alternative airway device used for anesthesia
and airway support in emergency (difficult
intubation).
It is inserted blindly into the pharynx, forming a
low-pressure seal around the laryngeal inlet and
permitting gentle positive pressure ventilation.
All parts are latex-free.

LARYNGEAL MASK AIRWAY

Indications:
-The Laryngeal Mask Airway is an appropriate
airway choice when mask ventilation can be
used but endotracheal intubation is not
necessary kes kurang 2 jam
-Guide for endotracheal intubation (Fastrach LMA)
-Unanticipated difficult intubations
-Failed intubation
-Intubation of patients with limited head/neck
movement

Advantages
Increased speed and ease of placement by inexperienced

Disadvantages
Lower seal pressure

personnel
Increased speed of placement by anesthetists

Higher frequency of gastric

insufflation

Improved hemodynamic stability at induction and during

emergence
Minimal increase in intraocular pressure following insertion

Reduced anesthetic requirements for airway tolerance

Lower frequency of coughing during emergence
Improved oxygen saturation during emergence
Lower incidence of sore throats in adults

Contraindications to LMA Use

Non-fasted including patients whose fasting cannot be confirmed
Grossly or morbidly obese
>14 weeks pregnant
Multiple or massive injury
Acute abdominal or thoracic injury
Any condition associated with delayed gastric emptying
Patients with a fixed decreased pulmonary compliance
Patients where the peak inspiratory pressures are anticipated to exceed 2030 cm H2O
Adult patients who are unable to understand instructions or cannot
adequately answer questions regarding their medical history

PANDUAN SAIZ LMA

COMPLICATION USE LMA

Oral trauma
Laryngo-spasm
Aspiration
Incorrect position; hypoxia
Dislodge

LMA Take-Home Points

Test cuff before use

Lubricate before insertion to pt
Insert only in unconscious patient
Keep cuff inflated until patient awake
Dont throw out!! Used 40 50 times

Type of LMA

Description

LMA Classic (CLMA)

he original LMA airway with the basic features and components

LMA (ambu)

Designed base an oral structure

LMA Unique

A disposable version of the CLMA

LMA ProSeal (PLMA)

An advanced form of LMA that has been specifically designed for

use with positive pressure ventilation (PPV) with and without
muscle relaxants at higher airway pressures

LMA Flexible

Both of these feature a wire-reinforced, flexible airway tube that

allows it to be positioned away from the surgical field

Single Use LMA

Flexible
LMA Fastrach

An intubating LMA that is designed to facilitate intubation with a

special flexible cuffed endotracheal tube (ETT)

LMA Ctrach

A variant of the LMA Fastrach with an integrated fiberoptic system

that allows visualization of the anatomical structures immediately
in front of the aperture of the mask via a detachable, portable
color display screen

LARYNGEAL MASK AIRWAY

Proceal LMA

LMA Classic

Handle of Proceal

ETT for
LMA
Fastrach

LMA Fastrach

LMA Unique

LMA Classic
trakea

esofagus

LMA Ambu

LMA Flexible

LMA PROSeal

LMA PROSeal
Proseal bersaiz 1.5, 2, 2.5, 3, 4, 5
Mempunyai saluran untuk Ryles tube
Indikasi 4-5 H of surgery
- Failed intubation
- NBM not complete pt
Komplikasi airway obstruction
- Laryngospasm
- Accidental dislodgement

LMA-ProSeal
LMA Size

Weight (kg)

Max Cuff
Inflation
Volume
(mL)

Max.
Fiberoptic
Scope Size
(mm)

Max.
gastric
Tube
Size (Fr)

Length
of Drain
Tube
(cm)

Largest
Tracheal
Tube (ID in
mm)

1.5

5 to 10

10

18.2

4.0
uncuffed

10 to 20

10

10

19.0

4.0
uncuffed

2.5

20 to 30

14

14

23.0

4.5
uncuffed

30 to 50

20

16

26.5

5.0
uncuffed

50 to 70

30

16

27.5

5.0
uncuffed

70 to 100

40

18

28.5

6.0 cuffed

LMA-FASTRACH
The LMA-Fastrach
(intubating LMA, ILMA, ILM,
intubating laryngeal mask
airway) designed for
tracheal intubation.
Parts
1) A short, curved stainless
steel shaft with a standard
15-mm connector.
2) Single, movable epiglottic
elevator bar
3) A V-shaped guiding ramp
built into the floor of the
mask.

LARYNGEAL MASK AIRWAY

Proseal LMA

Fastrach LMA

LANGKAH-LANGKAH MEMASUKAN LMA

1. Press the mask

up against the hard
palate. Note the
flexed wrist.

4. Advance the
LMA cuff into the
hypopharynx until
resistance is felt

2. Slide the mask

inward, extending
the index finger

5. Hold the outer end

of the airway tube
while removing the
index finger

3. Press the finger

towards the other
hand, which exerts
counter-pressure

Correct position of LMA

Tracheal Intubation

Tracheal Intubation
A. Orotracheal intubation intubation
through oral
B. Nasotracheal intubation intubation
through nasal
ENT/Dental operation
Cant be performed on pt with
suspected/basilar skull #
Can be performed on pt with intact gag reflex
awake intubation

Endotracheal Intubation
Tube into trachea to provide ventilations
using BVM or ventilator
Sized based upon inside diameter (ID)
in mm
Lengths increase with increased ID (cm
markings along length)
Cuffed vs. Uncuffed

Endotracheal Intubation
Advantages
Secures airway
Route for a few medications (LANE)
Optimizes ventilation, oxygenation
Allows suctioning of lower airway

Endotracheal Intubation
Indications
Present or impending respiratory failure
Apnea
Unable to protect own airway

Endotracheal Intubation
Complications
Soft tissue trauma/bleeding
Dental injury
Laryngeal edema
Laryngospasm
Vocal cord injury
Hypoxia
Aspiration
Esophageal intubation

Endotracheal Intubation
M
A
L
E
S

Basic Equipment
M A L E S
Mask, Magill
Airway
Laryngoscope, lubricant, LMA
ETT
Suction, stylet, secure tape, stethoscope

Endotracheal tube

ENDOTRACHEAL TUBE

Called ETT / ET Tube

Used in GA, ICU, A&E
Invasive Airway management
Mechanical Ventilation
Sir Ivan Whiteside Magill (1888-1986)

 Indikasi untuk endotracheal intubation:

C C C AR
Cardiorespiratory arrest
Critically ill pt
Cerebral protection
Airway patency
Respiratory distress

ENDOTRACHEAL TUBE
The tracheal tube (endotracheal tube,
intratracheal tube, tracheal catheter) is a device
that is inserted through the larynx into the trachea
to convey gases and vapors to and from the
lungs.
Parts
1) The machine (proximal) end
2) The patient (tracheal or distal) end
3) Bevel.

ENDOTRACHEAL TUBE
4) Murphy eye
5) A radiopaque marker
6) Cuff Systems - consists of the cuff plus an
inflation system, which includes an inflation
tube, a pilot balloon, and an inflation valve.

Angled tip

Pilot balloon with one Pilot tube

way valve

Connector

Murphys eye

Cuff

Indicator marker
Radio opaque
Intubation depth marking
Size marking

ENDOTRACHEAL TUBE
Uncuffed dan cuffed
Saiz : 2 8.5 mm
Jenis-jenis: Murphys ETT, oral rae,
nasal rae, flexometalic, microlaryngeal
tube, double lumen tube

Double Lumen Tube

Marking level
2 airway
Radiopaque line
http://www.combitube.org/

Proximal cuff
2 one way cuff
Distal cuff
Murphy eye

Double Lumen Tube

Putih masuk ke trakea
Biru masuk ke bronkiol
2 adapter disambung ke circuit untuk
collapse one side of lung intraoperatively
Saiz 28mm 40mm right and left
Kegunaan thoracic surgery; thoracotomy,
labectomy
Bila dah insert, inflate bronchiole dahulu (warna
biru) untuk maintenance
Setelah confirm in, baru inflate trache cuff (warna
putih) sehingga tiada leaking

Double Lumen Tube

Advantage
Potential use by relatively inexperienced
personnel
Rapid control of airway
Protection against aspiration
No head movement req.

Disadvantage
- Possible easophangeal trauma
- Inability to suction trachea in easophangeal
position

Double Lumen Tube

 Microlaryngeal
tube

Flexometallic tube

 Oral rae

Nasal Rae

ENDOTRACHEAL TUBE
Oral intubation
1. Direct Laryngoscopy
2. Blind Oral Intubation
3. Digital Technique
4. Fiberoptic guided
5. Retrograde intubation
Nasal intubation
6. Direct Laryngoscopy
7. Flexible Fiberoptic Laryngoscopy
8. Blind Nasal Intubation

ENDOTRACHEAL TUBE
Latex coated red rubber tubes

PVC tubes

Reused multiple times

Disposable

Not transparent

Transparent

Harden and become sticky with

age, poor resistance to kinking,
become clogged by dried
secretions

Less likely to kink than rubber

tubes. They are stiff enough for
intubation at room temperature but
soften at body temperature, so
they tend to conform to the
patient's upper airway.

Latex allergy in susceptible

patients

No latex allergy

Technique of Endotracheal
Intubation

THANK YOU
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