AIRWAY ADJUNCT

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AIRWAY ADJUNCT

  1. 1. DISAMPAIKAN OLEH; GOODMAN BIN MOSITI PENOLONG PEGAWAI PERUBATAN U29 (BIUS) DEWAN BEDAH, HOSPITAL PITAS KURSUS “ BASIC LIFE SUPPORT” (BLS)
  2. 2. PENGENALAN <ul><li>Sebahagian peralatan tambahan / bantuan yang digunakan bagi pengendalian dan pengurusan salur pernafasan mangsa. </li></ul><ul><li>Membantu membuka saluran pernafasan pesakit / mangsa semasa tidak sedarkan diri dan memudahkan dalam pemberian oksigen (ventilasi) kepada. </li></ul>
  3. 3. Mekanisma Semasa Pesakit Tidak Sedar Diri <ul><li>Pesakit tidak dapat menjaga salur pernafasan sendiri. </li></ul><ul><li>Salur pernafasan akan tersumbat oleh; </li></ul><ul><li>-Lidah (Flacid tongue) </li></ul><ul><li>- ’Relaxed hypopharyngeal’ </li></ul><ul><li>-Epligotis </li></ul><ul><li>-Muntah </li></ul><ul><li>-Gigi palsu </li></ul><ul><li>-Dsb </li></ul>
  4. 4. ALGORITHM AIRWAY OPENING Unresponsive Patient Manual Maneuver Definitive Airway ABC (AIRWAY OPENING / CARE) Airway Adjunct <ul><li>Oropharyngeal </li></ul><ul><li>Nasophryngeal </li></ul><ul><li>LMA </li></ul><ul><li>Proceal </li></ul><ul><li>Intubating LMA </li></ul><ul><li>Combitube </li></ul><ul><li>Surgical Airway </li></ul><ul><li>Head Tilt Chin Lift </li></ul><ul><li>Jaw Trust </li></ul><ul><li>Modifed Jaw Trust </li></ul><ul><li>Endotracheal Tube (ETT) </li></ul>-Oral -Nasal -Jet Insufflation -Cricothyroidotomy -Tracheostomy
  5. 5. JENIS-JENIS OROL AIRWAY
  6. 6. OROPHARYNGEAL AIRWAY <ul><li>Oral Airway / OPA / Guedel Airway </li></ul><ul><li>Dicipta oleh Arthur E. Guedel (1883-1956) </li></ul><ul><li>Size: 000,00,0,1,2,3,4,5,6 / C o l o u r Code </li></ul><ul><li>Kebaikan:- Mudah didapati / dikendali </li></ul><ul><li>- Memudahkan “Suction” </li></ul><ul><li>-Bite Block (mengelak pesakit </li></ul><ul><li>menggigit tiub ETT ) </li></ul><ul><li>-Kurang Allergen </li></ul>
  7. 7. OROPHARYNGEAL AIRWAY <ul><li>INDIKASI; </li></ul><ul><li>-Pesakit yang tidak sedar diri </li></ul><ul><li>-Pesakit spontaneusly breathing </li></ul><ul><li>- Total hilang gag reflex </li></ul><ul><li>- Digunakan sebagai bite block </li></ul><ul><li>KONTRAINDIKASI; </li></ul><ul><li>-Pesakit sedar, ada gag reflex, susah buka mulut, masive oral trauma </li></ul><ul><li>-Mandibulo-maxillary wiring </li></ul><ul><li>KOMPLIKASI; </li></ul><ul><li>-Terlalu panjang: Menekan epligotis </li></ul><ul><li>-Terlalu pendek : Menolak lidah ke belakang </li></ul><ul><li>-Menyebabkan batuk, muntah dan laryngospasme </li></ul><ul><li>-Aspiration </li></ul>
  8. 8. OROPHARYNGEAL AIRWAY <ul><li>Menentukan Size OPA: </li></ul><ul><li>i) Coner of mouth to earlobe </li></ul><ul><li>ii) Against patient’s face to </li></ul><ul><li>angle of the mandible </li></ul>
  9. 9. OROPHARYNGEAL AIRWAY <ul><li>Tatacara memasukkan OPA </li></ul><ul><li>-Bersihkan oral pesakit (suctioning) </li></ul><ul><li>Teknik 1) Guna tongue blade untuk menekan lidah pesakit dan masukan OPA ke belakang (disarankan untuk infant).  </li></ul><ul><li>Teknik 2) Insert the oral airway upside down until the soft palate is reached.  Rotate the device 180 degrees and slip it over the tongue. </li></ul><ul><li>step 1 step 2 step 3 st ep 4 </li></ul>
  10. 10. NASOPHARYNGEAL AIRWAY <ul><li>Dikenali juga sebagai NPA / nasal trumpet </li></ul><ul><li>Diperbuat daripada getah / plastik lembut </li></ul><ul><li>Mula diperkenalkan pada 1972. </li></ul><ul><li>INDIKASI; </li></ul><ul><li>-Pesakit spontaneously breathing </li></ul><ul><li>-Pesakit yang dikontraindikasi bagi Guedel airway </li></ul><ul><li>-Boleh digunakan walaupun pesakit ada gag reflex </li></ul><ul><li>-Pesakit tidak di intubasi. </li></ul><ul><li>KONTRAINDIKASI; </li></ul><ul><li>-Kakitangan tidak terlatih </li></ul><ul><li>-Kecederaan kepala / muka yang </li></ul><ul><li>teruk </li></ul><ul><li>-Basal Skull fracture </li></ul><ul><li>-Hidung tersumbat / jangkitan </li></ul><ul><li>-Struktur Kongenital, bleeding disorder </li></ul>
  11. 11. NASOPHARYNGEAL AIRWAY <ul><li>Size; </li></ul><ul><li>-12F, 14F, 16F, 18F 34F, 36F </li></ul><ul><li>-Guna ukuran Internal diammeter (I.D) </li></ul><ul><li>-Pilihan size; ? sama besar dengan jari klingking pesakit </li></ul><ul><li>-Penjang (mm); Tip of nose to tragus of </li></ul><ul><li>the ear </li></ul>
  12. 12. NASOPHARYNGEAL AIRWAY <ul><li>Tatacara; </li></ul><ul><li>-Pilih saiz yang sesuai </li></ul><ul><li>-Sapukan NPA dengan Lignocaine jel </li></ul><ul><li>-Pilih lubang hidung yang tidak tersumbat </li></ul><ul><li>-Masukkan dengan berhati-hati (elak kecederaan) </li></ul><ul><li>-Jika terdapat resistant, pusing sedikit NPA </li></ul><ul><li>-Kekalkan Head tilt </li></ul>
  13. 13. NASOPHARYNGEAL AIRWAY <ul><li>KOMPLIKASI; </li></ul><ul><li>-Terlalu Panjang:- Kecederaan pada epligotis / vocal cord / vagal stimulation </li></ul><ul><li>-Injured nasal mucosa; pendarahan </li></ul><ul><li>-Alahan </li></ul><ul><li>-Kurang Selesa </li></ul>
  14. 14. LARYNGEAL MASK AIRWAY <ul><li>Supraglottic airway management device. </li></ul><ul><li>Also called LMA </li></ul><ul><li>Designed between 1981 and 1988 by Dr. Archie I. J. Brain. </li></ul><ul><li>Cuff device that provides sufficient seal to allow for positive pressure ventilation to be delivered </li></ul><ul><li>Tiga komponen utama: airway tube, mask, and inflation line </li></ul><ul><li>Alternative airway device used for anesthesia and airway support in emergency (difficult intubation). </li></ul><ul><li>It is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle positive pressure ventilation. </li></ul><ul><li>All parts are latex-free. </li></ul>
  15. 15. LARYNGEAL MASK AIRWAY <ul><li>Indications: </li></ul><ul><li>-The Laryngeal Mask Airway is an appropriate airway </li></ul><ul><li>choice when mask ventilation can be used but </li></ul><ul><li>endotracheal intubation is not necessary. </li></ul><ul><li>-Guide for endotracheal intubation (Fastrach) </li></ul><ul><li>-Unanticipated difficult intubations </li></ul><ul><li>-Failed intubation </li></ul><ul><li>-Intubation of patients with limited head/neck </li></ul><ul><li>movement </li></ul>
  16. 16. LARYNGEAL MASK AIRWAY Type of LMA Description <ul><li>LMA Classic (CLMA) </li></ul><ul><li>LMA (ambu) </li></ul><ul><li>he original LMA airway with the basic features and components </li></ul><ul><li>Designed base an oral structure </li></ul><ul><li>LMA Unique </li></ul><ul><li>A disposable version of the CLMA </li></ul><ul><li>LMA ProSeal (PLMA) </li></ul><ul><li>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 </li></ul><ul><li>LMA Flexible </li></ul><ul><li>Single Use LMA Flexible </li></ul><ul><li>Both of these feature a wire-reinforced, flexible airway tube that allows it to be positioned away from the surgical field </li></ul><ul><li>LMA Fastrach </li></ul><ul><li>An intubating LMA that is designed to facilitate intubation with a special flexible cuffed endotracheal tube (ETT) </li></ul><ul><li>LMA Ctrach </li></ul><ul><li>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 </li></ul>
  17. 17. LARYNGEAL MASK AIRWAY Proceal LMA LMA Classic LMA Fastrach LMA Unique ETT for LMA Fastrach Handle of Proceal
  18. 18. LMA Classic
  19. 19. LMA Ambu
  20. 20. LARYNGEAL MASK AIRWAY Proceal LMA Fastrach LMA
  21. 21. PANDUAN SAIZ LMA
  22. 22. LARYNGEAL MASK AIRWAY Advantages Disadvantages <ul><li>Increased speed and ease of placement by inexperienced personnel </li></ul>Lower seal pressure <ul><li>Increased speed of placement by anesthetists </li></ul>Higher frequency of gastric insufflation <ul><li>Improved hemodynamic stability at induction and during emergence </li></ul><ul><li>Minimal increase in intraocular pressure following insertion </li></ul><ul><li>Reduced anesthetic requirements for airway tolerance </li></ul><ul><li>Lower frequency of coughing during emergence </li></ul><ul><li>Improved oxygen saturation during emergence </li></ul><ul><li>Lower incidence of sore throats in adults </li></ul>
  23. 23. Contraindications to LMA Use <ul><li>Non-fasted including patients whose fasting cannot be confirmed </li></ul><ul><li>Grossly or morbidly obese </li></ul><ul><li>>14 weeks pregnant </li></ul><ul><li>Multiple or massive injury </li></ul><ul><li>Acute abdominal or thoracic injury </li></ul><ul><li>Any condition associated with delayed gastric emptying </li></ul><ul><li>Patients with a fixed decreased pulmonary compliance </li></ul><ul><li>Patients where the peak inspiratory pressures are anticipated to exceed 20-30 cm H 2 O </li></ul><ul><li>Adult patients who are unable to understand instructions or cannot adequately answer questions regarding their medical history </li></ul>
  24. 24. TATACARA MEMASUKKAN LMA
  25. 25. LANGKAH-LANGKAH MEMASUKAN LMA 1. Press the mask up against the hard palate. Note the flexed wrist. 2. Slide the mask inward, extending the index finger 3. Press the finger towards the other hand, which exerts counter-pressure 4. Advance the LMA cuff into the hypopharynx until resistance is felt 5. Hold the outer end of the airway tube while removing the index finger Correct position of LMA
  26. 26. COMPLICATION USE LMA <ul><li>Oral trauma </li></ul><ul><li>Laryngo-spasm </li></ul><ul><li>Aspiration </li></ul><ul><li>Incorrect position; hypoxia </li></ul><ul><li>Dislodge </li></ul>
  27. 27. COBRA LMA TERBARU….!!!!
  28. 28. COMBETUBE <ul><li>The Combitube is a twin lumen device designed for use in emergency situations and difficult airways. It can be inserted without the need for visualization into the oropharynx, and usually enters the esophagus. It has a low volume inflatable distal cuff and a much larger proximal cuff designed to occlude the oro- and nasopharynx </li></ul><ul><li>If the tube has entered the trachea, ventilation is achieved through the distal lumen as with a standard ETT. More commonly the device enters the esophagus and ventilation is achieved through multiple proximal apertures situated above the distal cuff. In the latter case the proximal and distal cuffs have to be inflated to prevent air from escaping through the esophagus or back out of the oro- and nasopharynx. </li></ul>
  29. 29. COMBITUBE
  30. 30. COMBITUBE <ul><li>Used effectively in cardiopulmonary resuscitation and patient with difficult airways secondary to severe facial burns, trauma, upper airway bleeding and vomiting where there was an inability to visualize the vocal cords. </li></ul><ul><li>It can be used in patients whose cervical spine has been immobilized with a rigid cervical collar. </li></ul><ul><li>The Combitube can only be used in the adult population as no pediatric sizes are available. </li></ul><ul><li>Complications of the Combitube include an increased incidence of sore throat, dysphagia and upper airway hematoma when compared to endotracheal intubation and LMA. </li></ul><ul><li>Esophageal rupture is a rare complication but has been described. </li></ul>
  31. 31. ENDOTRACHEAL TUBE <ul><li>Called ETT / ET Tube </li></ul><ul><li>Used in GA, ICU, EM, </li></ul><ul><li>Invasive Airway management </li></ul><ul><li>Mechanical Ventilation </li></ul><ul><li>Sir Ivan Whiteside Magill (1888-1986) </li></ul>
  32. 32. TRACHEAL INTUBATION <ul><li>Oral </li></ul><ul><li>Nasal </li></ul><ul><li>Fiberoptic endoscopy </li></ul>
  33. 33. INDICATIONS <ul><li>Provide patent airway </li></ul><ul><li>Prevent aspiration </li></ul><ul><li>Facilitate IPPV </li></ul><ul><li>Operative positions </li></ul><ul><li>Difficult airway maintenance </li></ul><ul><li>Suction of respiratory tract </li></ul><ul><li>Thoracic operations </li></ul><ul><li>Disease involving upper airway </li></ul>
  34. 34. <ul><li>PERALATAN UNTUK INTUBASI </li></ul><ul><li>Laryngoscope and spare </li></ul><ul><li>ET tubes/ connector </li></ul><ul><li>Stilette </li></ul><ul><li>Magill forceps </li></ul><ul><li>20 ml syringe </li></ul><ul><li>Securing tapes / bandage </li></ul><ul><li>LA 4 % lignocane spray </li></ul><ul><li>Cocaine gel - nasal </li></ul><ul><li>Lubricant </li></ul><ul><li>Throat packs </li></ul><ul><li>GA machine, face mask, airways </li></ul>
  35. 35. PREPARATION <ul><li>Assess patients </li></ul><ul><li>Oral versus nasal intubation? </li></ul><ul><li>Check equipment </li></ul><ul><li>Assistant required </li></ul><ul><li>Check Ventilator / BVM </li></ul><ul><li>check suction pump </li></ul><ul><li>Correct sizes of scopes and blades </li></ul><ul><li>Correct sizes of ET tubes </li></ul>
  36. 36. Equipment Required for Successful Intubation (F.E / M.A.L.E.S)
  37. 37. <ul><li>TYPE OF INDUCTION </li></ul><ul><li>Rapid sequence induction </li></ul><ul><li>2. Normal sequence induction </li></ul>
  38. 38. <ul><li>OROTRACHEAL INTUBATION </li></ul><ul><li>1. Position of the patient </li></ul><ul><li>-Height of table </li></ul><ul><li>-Elevate patient’s head </li></ul><ul><li>-Use of head ring/ pad under occiput </li></ul>
  39. 39. Technique of Endotracheal Intubation
  40. 40. <ul><li>-Sniffing position </li></ul><ul><li>-Align oral, pharyngeal and laryngeal axis </li></ul><ul><li>-Lips to glottic opening - straight line </li></ul><ul><li>-Open patient’s mouth with right thumb </li></ul><ul><li>2.Direct laryngoscope </li></ul><ul><li>-Hold laryngoscope in Lt hand </li></ul><ul><li>-Insert blade into Rt side of mouth </li></ul><ul><li>-Deflect the tongue to the left </li></ul>
  41. 41. <ul><li>3. VISUALIZE THE EPIGLOTTIS </li></ul><ul><li>-Advance blade in the midline </li></ul><ul><li>-Until epiglottis visualized </li></ul><ul><li>-Advance tip of blade into vallecula </li></ul><ul><li>-Or beneath epiglottis - straight blade </li></ul><ul><li>-Forward & upward movement </li></ul><ul><li>-Elevate epiglottis </li></ul><ul><li>-Expose glottic opening </li></ul><ul><li>-Depression of thyroid cartilage </li></ul><ul><li>-Exposure of glottic opening </li></ul>
  42. 42. <ul><li>4. PLACEMENT OF ET TUBE </li></ul><ul><li>-Introduce tube with Rt hand </li></ul><ul><li>-Through Rt side of mouth </li></ul><ul><li>-Advance tube through glottic opening </li></ul><ul><li>-Until calf just passes vocal cord </li></ul><ul><li>-Remove scope blade </li></ul><ul><li>-Inflate the cuff </li></ul><ul><li>-IPPV – absence of air leak </li></ul>
  43. 43. <ul><li>5.CONFIRMATION OF ET TUBE PLACEMENT </li></ul><ul><li>-Co2 in exhaled gases </li></ul><ul><li>-Bilateral breath sounds </li></ul><ul><li>-Epigastric auscultation </li></ul><ul><li>-Fogging of water vapour in tube </li></ul><ul><li>-Maintenance of O2 saturation </li></ul>
  44. 44. <ul><li>6. Secure tube with tape/ bandage </li></ul><ul><li>7.Continue IPPPV </li></ul><ul><li>NASAL INTUBATION </li></ul><ul><li>-Dental / ENT operations </li></ul><ul><li>-Long term intubation </li></ul><ul><li>-Pre- formed nasal tube </li></ul><ul><li>-Smaller in size </li></ul>
  45. 45. <ul><li>-Choose nostril that breath more easily </li></ul><ul><li>-Lubricate tube </li></ul><ul><li>-Insert tube through nostril </li></ul><ul><li>-Advance tube until tip visualized in the orophargynx </li></ul><ul><li>-Advance distil end of ET tube into tracheal through visualizes glottic opening </li></ul>
  46. 46. <ul><li>-Used of magill forceps </li></ul><ul><li>-Avoid damage to cuff </li></ul><ul><li>-Confirm tube placement </li></ul><ul><li>-Cuff tube </li></ul><ul><li>-Insertion of moist gauze pack </li></ul><ul><li>-Secure tube </li></ul>
  47. 47. <ul><li>FIBREOPTIC INTUBATION </li></ul><ul><li>Difficult airway/ intubation </li></ul><ul><li>Glottic opening cannot be visualised </li></ul><ul><li>Awake intubation </li></ul><ul><li>Oral or nasal </li></ul>
  48. 48. <ul><li>ORAL ET TUBE SITE GUIDELINE </li></ul>AGE INTERNAL DIAMETER(mm) LENGTH(cm) Premature 2.5 10 neonate 3.0-3.5 10-11 6-12mth 11-12 3.5-4.0 2 years 4.5 13 4 years 5.0 14 6 years 5.5 15 8 years 6.0 16 10 years 6.5 17 12 years 7.0 18
  49. 49. <ul><li>ORAL ET TUBE SIZE GUIDELINES </li></ul>AGE ADULT INTERNAL DIAMETER (mm) LENGTH ( CM ) Female 7.0-7.5 18-20 Male 7.5-9.0 22-24
  50. 50. <ul><li>FORMULA : For paediatric : </li></ul><ul><li>Internal diameter : 4+ age mm </li></ul><ul><li>length : 12 + age mm ( oral ) </li></ul><ul><li> </li></ul><ul><li>nasal : 15 + age mm </li></ul><ul><li> </li></ul>4 2 2
  51. 51. <ul><li>COMPLICATIONS OF ENDOTRACHEAL INTUBATION </li></ul><ul><li>1.During intubation </li></ul><ul><li>Aspiration </li></ul><ul><li>Malpositioning </li></ul><ul><li>Esophageal intubation </li></ul><ul><li>Endobronchial intubation </li></ul><ul><li>Aspiration </li></ul><ul><li>Dental damage </li></ul><ul><li>Injury to lips and gums </li></ul>
  52. 52. <ul><li>Activation of sympathetic nervous system </li></ul><ul><li>Bronchospasm </li></ul><ul><li>Sore throat </li></ul><ul><li>Dislocated mandible </li></ul><ul><li>2. AFTER EXTUBATION </li></ul><ul><li>Aspiration </li></ul><ul><li>Laryngospasm </li></ul><ul><li>Transient vocal cord incompetence </li></ul><ul><li>Glottic or subglottic oedema </li></ul><ul><li>Pharyngitis or tracheitis </li></ul>
  53. 53. <ul><li>DIFFICULT INTUBATION </li></ul><ul><li>1 in 65 patients </li></ul><ul><li>Difficulty with laryngoscopy </li></ul><ul><li>Cause of mobidity & mortality </li></ul><ul><li>sequelae </li></ul><ul><li>- dental & airway trauma </li></ul><ul><li>- pulmonary aspiration </li></ul><ul><li>-hypoxaemia </li></ul>
  54. 54. <ul><li>CAUSES OF DIFFICULT INTUBATION </li></ul><ul><li>Inadequate assessment </li></ul><ul><li>Inadequate equipment preparation </li></ul><ul><li>Inexperience </li></ul><ul><li>Poor technique </li></ul><ul><li>Equipment </li></ul><ul><li>-Malfunction </li></ul><ul><li>-Unavailability </li></ul><ul><li>-No trained assistant </li></ul>
  55. 55. <ul><li>PATIENT </li></ul><ul><li>Congenital </li></ul><ul><li>-syndromes ( Down’s, Pierre – Robin) </li></ul><ul><li>Achondroplasia </li></ul><ul><li>Cystic hygroma </li></ul><ul><li>Encephalocele </li></ul><ul><li>Acquired </li></ul><ul><li>-Reduced jaw movement </li></ul><ul><li>i) Trismus </li></ul><ul><li>ii) Fibrosis </li></ul>
  56. 56. <ul><li>- tumours </li></ul><ul><li>- Jaw wiring </li></ul><ul><li>Reduced neck movement </li></ul><ul><li>- Rheumatoid / osteoarthritis </li></ul><ul><li>- ankylosing spondylitis </li></ul><ul><li>- cervical # / fusion </li></ul><ul><li>Airway </li></ul><ul><li>- oedema </li></ul><ul><li>- compression </li></ul><ul><li>- scarring </li></ul>
  57. 57. <ul><li>- tumours/ polyps </li></ul><ul><li>- Foreign body </li></ul><ul><li>- Nerve palsy </li></ul><ul><li>Others </li></ul><ul><li>- mobid obesity </li></ul><ul><li>- pregnancy </li></ul><ul><li>- acromegaly </li></ul>
  58. 58. <ul><li>ANATOMICAL FACTOR : DIFFICULT LARYNGOSCOPY </li></ul><ul><li>Short neck </li></ul><ul><li>Protuding incisions </li></ul><ul><li>Long high arched palate </li></ul><ul><li>Receding lower jaw </li></ul><ul><li>Poor mobility of mandible </li></ul><ul><li> anterior depth of mandible </li></ul><ul><li>Reduced jaw opening </li></ul><ul><li>Reduced neck extension </li></ul>
  59. 59. <ul><li>DIFFICULT INTUBATION KIT </li></ul><ul><li>Airway adjuncts </li></ul><ul><li>Gum elastic bougies/ ET tubes </li></ul><ul><li>Cricothyrotomy needle </li></ul><ul><li>Jet ventilation </li></ul><ul><li>Maccoy Blade </li></ul>
  60. 60. Extreme Clinical Situations <ul><li>Tracheostomy </li></ul><ul><li>LA </li></ul>
  61. 61. CLASSIFICATION OF MALLAMPATI TEST
  62. 62. FAIL INTUBATION PROTOCOL Kong Thau Chin
  63. 64. THANK YOU

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