This document discusses difficult intubation and airways. It defines difficult airway as difficulty with facemask ventilation or tracheal intubation. The incidence is estimated between 3-18%. Optimal positioning for intubation is neck flexion with atlanto-axial extension. Several scales are used to evaluate difficulty, including LEMON, LM MAP, 4D, Wilson Risk Scale, and Magboul 4M. Preparations for difficult intubation include different sized laryngoscopes, ET tubes, introducers, airways, and LMAs. Special techniques discussed are awake intubation and awake tracheostomy under local anesthesia. The ASA algorithm provides guidance for recognized and unrecognized difficult airways.

1. Intubasi Sulit
NUR HAJRIYA BRAHMI

2. Definition
Difficult Airway :
 the clinical situation in which a conventionally
trained anesthesiologist experiences difficulty with
facemask ventilation of the upper airway, difficulty
with tracheal intubation, or both.
American Society of Anesthesiologist : Practice
Guidelines for Management of The Difficult
Airway, An update report, 2003

3. Incidens
 the incidence of difficult tracheal intubation has
been estimated at 3-18%.

4.  Tracheal intubation is best
achieved in the classic
"sniffing the morning
air" position in which the
neck is flexed and
there is extension at
the cranio-cervical
(atlanto-axial) junction
• the structures of the upper airway in the
optimum position for laryngoscopy and
permits the best view of the larynx

5. Evaluasi Kesulitan Intubasi
Kriteria :
- Skala LEMON atau MELON
- LM MAP
- 4D
- Wilson Risk Scale
- Magboul 4M

6. Skala LEMON atau MELON
Look externally
Evaluate 3-3-2-1 rule
Mallampati
Obstruction
Neck mobility

8. Tabel Skala LEMON

11. Grading the Airway (Cormack-Lehane)
Figure 2 – Cormack-Lehane
Grade I
- Full view of the glottic opening
Grade II
- Posterior portion of glottic opening visible
Grade III
- Only tip of epiglottis is visible
Grade IV
- Only soft palate is visible

12. LM-MAP
Look for external face deformities
Mallampati
Measure 3-3-2-1 fingers
Atlanto-occipital extension
Pathological obstructive conditions

13. 4D
Dentition(prominent upper incisor, receding chin)
Distortion(edema, blood, vomits, tumor, infection)
Disproportion(short chin, bull neck, large tongue,
small mouth)
Dysmobility(TMJ, cervical spine)

14. Wilson Risk Score
Weight (0=<90kg,1=90-110kg,2=>110kg)
Head and neck movement (0=>90 ,1=90 ,2=<90 )
Jaw movement (0=IG>5cm,SL>0, 1=IG<5cm,SL=0,
2=IG<5cm,SL<0)
Receding mandible (0=normal, 1=moderate, 2=severe)
Buck teeth (0=normal, 1=moderate, 2=severe)
Total max 10 points

15. Magboul 4 MS
Mallampati
Measurement
Movement
Malformation of STOP
(Skull,Teeth,Obstruction,Pathology)

17. Persiapan Dasar Intubasi Sulit
- Laringoskop berbagai ukuran
- ETT berbagai ukuran
- Introducer (stylet, elastic bougie)
- Oral dan nasal airway
- Set krikotirotomi
- Suction
- Assistant yang terlatih
- LMA berbagai ukuran

19. - Preoksigenisasi 100% O2
- Posisi pasien optimal untuk ventilasi dan intubasi
- Konfirmasi ETT setelah intubasi dilakukan

20. Special techniques for intubation
• Awake intubation under local anaesthesia
– The aim is to anaesthetise the upper airway using local
anaesthetic
– This avoids the need for general anaesthesia and muscle
relaxants to facilitate intubation
– This technique may be performed using either a fibreoptic
flexible bronchoscope or other fibrescope or using
direct laryngoscopy
– Atropine 500 mcg or glycopyrrolate 200 mcg should be given
intramuscularly half an hour before intubation to dry the
mucous membranes

21.  Awake tracheostomy performed under local
anaesthesia is the best solution when a patient is an
impossible intubation,
 sedation with ketamine has been used to facilitate
this approach

22. Failed intubation - Overview of failed
intubation drill

23. Alogaritma jalan nafas sulit
 Diciptakan oleh American Society of
Anesthesiologists(ASA) pada tahun 1993 dan
diperbaharui pada tahun2003
 Dimulai dengan menentukan apakah
“difficulty airway” bisa dikenali/diketahui
(reconigzed) atau tidak bisa dikenali/diketahui
(unrecognized)

24. The ASA Algorithm for Recognized and Unrecognized
Difficult Airways

26. REMEMBER.....
- Pada jalan nafas sulit (ventilasi dan intubasi),
intubasi awake adalah pilihan terbaik
- Pelumpuh otot diberikan apabila sudah pasti tidak
ada kesulitan ventilasi