The document discusses various airway management devices and techniques used in basic life support. It describes oropharyngeal airways, nasopharyngeal airways, laryngeal mask airways, endotracheal tubes, and difficult airway management devices like the Combitube. Guidelines for sizing and inserting these devices are provided, along with their indications, contraindications, and potential complications. Factors that can make intubation difficult are also outlined.

1. DISAMPAIKAN OLEH; GOODMAN BIN MOSITI PENOLONG PEGAWAI PERUBATAN U29 (BIUS) DEWAN BEDAH, HOSPITAL PITAS KURSUS “ BASIC LIFE SUPPORT” (BLS)

2. PENGENALAN Sebahagian peralatan tambahan / bantuan yang digunakan bagi pengendalian dan pengurusan salur pernafasan mangsa. Membantu membuka saluran pernafasan pesakit / mangsa semasa tidak sedarkan diri dan memudahkan dalam pemberian oksigen (ventilasi) kepada.

3. Mekanisma Semasa Pesakit Tidak Sedar Diri Pesakit tidak dapat menjaga salur pernafasan sendiri. Salur pernafasan akan tersumbat oleh; -Lidah (Flacid tongue) - ’Relaxed hypopharyngeal’ -Epligotis -Muntah -Gigi palsu -Dsb

4. ALGORITHM AIRWAY OPENING Unresponsive Patient Manual Maneuver Definitive Airway ABC (AIRWAY OPENING / CARE) Airway Adjunct Oropharyngeal Nasophryngeal LMA Proceal Intubating LMA Combitube Surgical Airway Head Tilt Chin Lift Jaw Trust Modifed Jaw Trust Endotracheal Tube (ETT) -Oral -Nasal -Jet Insufflation -Cricothyroidotomy -Tracheostomy

5. JENIS-JENIS OROL AIRWAY

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

7. OROPHARYNGEAL AIRWAY INDIKASI; -Pesakit yang tidak sedar diri -Pesakit spontaneusly breathing - Total hilang gag reflex - Digunakan sebagai bite block 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

8. OROPHARYNGEAL AIRWAY Menentukan Size OPA: i) Coner of mouth to earlobe ii) Against patient’s face to angle of the mandible

9. OROPHARYNGEAL AIRWAY Tatacara memasukkan OPA -Bersihkan oral pesakit (suctioning) Teknik 1) Guna tongue blade untuk menekan lidah pesakit dan masukan OPA ke belakang (disarankan untuk infant). 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. step 1 step 2 step 3 st ep 4

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

11. NASOPHARYNGEAL AIRWAY 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

12. NASOPHARYNGEAL AIRWAY Tatacara; -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

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

14. 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 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.

15. 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. -Guide for endotracheal intubation (Fastrach) -Unanticipated difficult intubations -Failed intubation -Intubation of patients with limited head/neck movement

16. LARYNGEAL MASK AIRWAY Type of LMA Description LMA Classic (CLMA) LMA (ambu) he original LMA airway with the basic features and components 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 Single Use LMA Flexible Both of these feature a wire-reinforced, flexible airway tube that allows it to be positioned away from the surgical field 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

17. LARYNGEAL MASK AIRWAY Proceal LMA LMA Classic LMA Fastrach LMA Unique ETT for LMA Fastrach Handle of Proceal

18. LMA Classic

19. LMA Ambu

20. LARYNGEAL MASK AIRWAY Proceal LMA Fastrach LMA

21. PANDUAN SAIZ LMA

22. LARYNGEAL MASK AIRWAY Advantages Disadvantages Increased speed and ease of placement by inexperienced personnel Lower seal pressure 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

23. 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 20-30 cm H 2 O Adult patients who are unable to understand instructions or cannot adequately answer questions regarding their medical history

24. TATACARA MEMASUKKAN LMA

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. COMPLICATION USE LMA Oral trauma Laryngo-spasm Aspiration Incorrect position; hypoxia Dislodge

27. COBRA LMA TERBARU….!!!!

28. COMBETUBE 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 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.

29. COMBITUBE

30. COMBITUBE 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. It can be used in patients whose cervical spine has been immobilized with a rigid cervical collar. The Combitube can only be used in the adult population as no pediatric sizes are available. Complications of the Combitube include an increased incidence of sore throat, dysphagia and upper airway hematoma when compared to endotracheal intubation and LMA. Esophageal rupture is a rare complication but has been described.

31. ENDOTRACHEAL TUBE Called ETT / ET Tube Used in GA, ICU, EM, Invasive Airway management Mechanical Ventilation Sir Ivan Whiteside Magill (1888-1986)

32. TRACHEAL INTUBATION Oral Nasal Fiberoptic endoscopy

33. INDICATIONS Provide patent airway Prevent aspiration Facilitate IPPV Operative positions Difficult airway maintenance Suction of respiratory tract Thoracic operations Disease involving upper airway

34. PERALATAN UNTUK INTUBASI Laryngoscope and spare ET tubes/ connector Stilette Magill forceps 20 ml syringe Securing tapes / bandage LA 4 % lignocane spray Cocaine gel - nasal Lubricant Throat packs GA machine, face mask, airways

35. PREPARATION Assess patients Oral versus nasal intubation? Check equipment Assistant required Check Ventilator / BVM check suction pump Correct sizes of scopes and blades Correct sizes of ET tubes

36. Equipment Required for Successful Intubation (F.E / M.A.L.E.S)

37. TYPE OF INDUCTION Rapid sequence induction 2. Normal sequence induction

38. OROTRACHEAL INTUBATION 1. Position of the patient -Height of table -Elevate patient’s head -Use of head ring/ pad under occiput

39. Technique of Endotracheal Intubation

40. -Sniffing position -Align oral, pharyngeal and laryngeal axis -Lips to glottic opening - straight line -Open patient’s mouth with right thumb 2.Direct laryngoscope -Hold laryngoscope in Lt hand -Insert blade into Rt side of mouth -Deflect the tongue to the left

41. 3. VISUALIZE THE EPIGLOTTIS -Advance blade in the midline -Until epiglottis visualized -Advance tip of blade into vallecula -Or beneath epiglottis - straight blade -Forward & upward movement -Elevate epiglottis -Expose glottic opening -Depression of thyroid cartilage -Exposure of glottic opening

42. 4. PLACEMENT OF ET TUBE -Introduce tube with Rt hand -Through Rt side of mouth -Advance tube through glottic opening -Until calf just passes vocal cord -Remove scope blade -Inflate the cuff -IPPV – absence of air leak

43. 5.CONFIRMATION OF ET TUBE PLACEMENT -Co2 in exhaled gases -Bilateral breath sounds -Epigastric auscultation -Fogging of water vapour in tube -Maintenance of O2 saturation

44. 6. Secure tube with tape/ bandage 7.Continue IPPPV NASAL INTUBATION -Dental / ENT operations -Long term intubation -Pre- formed nasal tube -Smaller in size

45. -Choose nostril that breath more easily -Lubricate tube -Insert tube through nostril -Advance tube until tip visualized in the orophargynx -Advance distil end of ET tube into tracheal through visualizes glottic opening

46. -Used of magill forceps -Avoid damage to cuff -Confirm tube placement -Cuff tube -Insertion of moist gauze pack -Secure tube

47. FIBREOPTIC INTUBATION Difficult airway/ intubation Glottic opening cannot be visualised Awake intubation Oral or nasal

48. ORAL ET TUBE SITE GUIDELINE 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. ORAL ET TUBE SIZE GUIDELINES AGE ADULT INTERNAL DIAMETER (mm) LENGTH ( CM ) Female 7.0-7.5 18-20 Male 7.5-9.0 22-24

50. FORMULA : For paediatric : Internal diameter : 4+ age mm length : 12 + age mm ( oral ) nasal : 15 + age mm 4 2 2

51. COMPLICATIONS OF ENDOTRACHEAL INTUBATION 1.During intubation Aspiration Malpositioning Esophageal intubation Endobronchial intubation Aspiration Dental damage Injury to lips and gums

52. Activation of sympathetic nervous system Bronchospasm Sore throat Dislocated mandible 2. AFTER EXTUBATION Aspiration Laryngospasm Transient vocal cord incompetence Glottic or subglottic oedema Pharyngitis or tracheitis

53. DIFFICULT INTUBATION 1 in 65 patients Difficulty with laryngoscopy Cause of mobidity & mortality sequelae - dental & airway trauma - pulmonary aspiration -hypoxaemia

54. CAUSES OF DIFFICULT INTUBATION Inadequate assessment Inadequate equipment preparation Inexperience Poor technique Equipment -Malfunction -Unavailability -No trained assistant

55. PATIENT Congenital -syndromes ( Down’s, Pierre – Robin) Achondroplasia Cystic hygroma Encephalocele Acquired -Reduced jaw movement i) Trismus ii) Fibrosis

56. - tumours - Jaw wiring Reduced neck movement - Rheumatoid / osteoarthritis - ankylosing spondylitis - cervical # / fusion Airway - oedema - compression - scarring

57. - tumours/ polyps - Foreign body - Nerve palsy Others - mobid obesity - pregnancy - acromegaly

58. ANATOMICAL FACTOR : DIFFICULT LARYNGOSCOPY Short neck Protuding incisions Long high arched palate Receding lower jaw Poor mobility of mandible  anterior depth of mandible Reduced jaw opening Reduced neck extension

59. DIFFICULT INTUBATION KIT Airway adjuncts Gum elastic bougies/ ET tubes Cricothyrotomy needle Jet ventilation Maccoy Blade

60. Extreme Clinical Situations Tracheostomy LA

61. CLASSIFICATION OF MALLAMPATI TEST

62. FAIL INTUBATION PROTOCOL Kong Thau Chin

64. THANK YOU