Documenti di Didattica
Documenti di Professioni
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Tjahya Aryasa,SpAn
Bagian/SMF Ilmu Anestesi dan Terapi
Intensif FK UNUD/RSUP Sanglah
Review of airway anatomy
Airway evaluation
Mask ventilation
Endotracheal intubation
The difficult airway
The Airway Problems:
• 3 mechanisms of injury:
1. Esophageal intubation
2. Failure to ventilate
3. Difficult Intubation
Anaesthesiology & Emergency
Patent nares
Ability to open mouth widely
with TMJ rotation and
subluxation (3 – 4 cm or two
finger breaths)
Mallampati Class I
Patient sitting straight up,
opening mouth as wide as
possible, with protruding
tongue; the uvula, posterior
pharyngeal wall, entire
tonsillar pillars, and fauces can
be seen
At least 6 cm (3 finger
breaths) from tip of mandible
to thyroid notch with neck
extension
At least 9 cm from symphysis
of mandible to mandible angle
Upper Airway Lower Airway
Pharynx Trachea
Epiglottis Bronchi
Glottis Alveoli
Vocal cords Lung tissue,
Larynx consisting of lobes
and lobules (3 on
the right and 2 on
the left)
Pleura
Ab-ductor
Posterior
cricoarytenoid
Tensor
Cricothyroid
Ad-ductors
All the rest
Innervation
Vagus n.
Superior laryngeal n.
External branch – motor to
cricothyroid m.
Internal branch – sensory
larynx above TVC’s
Recurrent laryngeal n.
Right – subclavian
Left – Aortic arch (board
question)
Motor to all other muscles,
Sensory to TVC’s and
trachea
Innervation of
oropharynx
Glossopharyngeal n.
innervates tongue base
and oropharynx
Membranes
Thyrohyoid
Cricothryoid
Cartilages
Hyoid
Thyroid
Cricoid
Take very seriously
history of prior difficulty
Head and neck movement
(extension)
Alignment of oral,
pharyngeal, laryngeal axes
Cervical spine arthritis or
trauma, burn, radiation,
tumor, infection,
scleroderma, short and thick
neck
Jaw Movement
Both inter-incisor gap and
anterior subluxation
<3.5cm inter-incisor gap
concerning
Inability to sublux lower
incisors beyond upper
incisors
Receding mandible
Protruding Maxillary
Incisors (buck teeth)
Obesity
Distribution, i. e. short,
thick neck more
concerning
Neck circumference
Thyromental
distance: bony point
on mentum
(mandible) to thyroid
notch
If short (<3FB’s or
6cm), pharyngeal and
laryngeal axis off
Oropharyngeal visualization
Mallampati Score
Sitting position, protrude tongue, don’t say
“AHH”
Class I: soft palate, tonsillar fauces,
tonsillar pillars, and uvuala visualized
spine
2 Infants/children between 10
and 20 kg
Additionally:
Dentition
Pathology - Acquired and
Congenital
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.
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.
Oral intubation –
1. Direct Laryngoscopy
2. Blind Oral Intubation
3. Digital Technique
4. Fiberoptic guided
5. Retrograde intubation
Nasal intubation –
1. Direct Laryngoscopy
2. Flexible Fiberoptic Laryngoscopy
3. Blind Nasal Intubation
Preparation:
Equipment Check
100% oxygen at high flows (> 10 Lpm) during bask/mask
ventilation
Suction apparatus
Intubation tray
Two laryngoscopic handles and blades
Airways
ET tubes
Needles and syringes
Stylet
KY Jelly
Suction Yankauer
Magill Forceps
LMA’s
Traditional:
3 minutes of tidal volume breathing at 5 ml/kg
100% O2
Rapid
8 deep breaths within 60 seconds at 10 L/min
www.int-med.uiowa.edu/Research/TLIRP/Bronchos
Look for vocal cords or arytenoid
cartilages and try to optimize
view
(i.e. lift head, apply more
traction at 45 degree angle if
necessary)
Do not move once view is
optimized!
Assistant will hand you ETT
Insert ETT into far right aspect
of mouth
Traction of laryngoscope
slightly to left may assist
Traction of laryngoscope at 45
degrees will also help keep
mouth open
Poor positioning of the head
Tongue in the way
Pivoting laryngoscope against upper teeth
Rushing
Being overly cautious
Inadequate sedation
Inappropriate equipment
Unskilled laryngoscopist
El-Canouriet al. - prospective study of
10, 507 patients demonstrating difficult
intubation with objective airway risk
criteria
Mouth opening < 4 cm
Thyromental distance < 6 cm
Mallampati grade 3 or greater
Neck movement < 80%
Inability to advance mandible (prognathism)
Body weight > 110 kg
Positive history of difficult intubation
Trauma, deformity: burns, radiation therapy, infection,
swelling, hematoma of face, mouth, larynx, neck
Stridor or air hunger
Intolerance in the supine position
Hoarseness or abnormal voice
Mandibular abnormality
Decreased mobility or inability to open the mouth at least 3
finger breaths
Micrognathia, receding chin
Treacher Collins, Peirre Robin, other syndromes
Less than 6 cm (3 finger breaths) from tip of the mandible to
thyroid notch with neck in full extension
< 9 cm from the angle of the jaw to symphysis
Increased anterior or posterior mandibular length
Laryngeal Abnormalities
Fixation of larynx to other structures of neck,
hyoid, or floor of mouth.
Macroglossia
Deep, narrow, high arched oropharynx
Protruding teeth
Mallampati Class 3 and 4
Neck Abnormalities
Short and thick
Decreased range of motion (arthritis, spondylitis, disk
disease)
Fracture (subluxation)
Trauma
Thoracoabdominal abnormalities
Kyphoscoliosis
Prominent chest or large breasts
Morbid obesity
Term or near term pregnancy
Age 50 – 59
Male gender
Previous Intubations
Dental problems (bridges, caps, dentures, loose
teeth)
Respiratory Disease (sleep apnea, smoking,
sputum, wheeze)
Arthritis (TMJ disease, ankylosing spondylitis,
rheumatoid arthritis)
Clotting abnormalities (before nasal intubation)
Congenital abnormalities
Type I DM
NPO status
Difficultintubation 10 x higher in long term
diabetics
Limited joint mobility in 30 – 40 %
Prayer sign
Unable to straighten the interpharyngeal joints
of the fourth and fifth fingers
Palm Print
100% sensitive of difficult airway
General:
LOC, facies and body habitus, presence or absence of cyanosis,
posture, pregnancy
Facies:
Abnormal facial features
Pierre Robin
Treacher Collins
Klippel – Feil
Apert’s syndrome
Fetal Alcohol syndrome
Acromegaly
Nose:
For nasal intubation
Patency
Oral Cavity
Foreign bodies
Teeth:
Long protruding teeth can restrict access
Dental damage 25% of all anesthesia litigations
Loose teeth can aspirate
Edentulous state
Rarely associated with difficulty visualizing airway
Tongue:
Size and mobility
TMJ Joint – articulation and movement
between the mandible and cranium
Diseases:
Rheumatoid arthritis
Ankylosing spondylitis
Psoriatic arthritis
Degenerative join disease
Movements: rotational and advancement
of condylar head
Normal opening of mouth 5 – 6 cm
TERIMA KASIH