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MANAGEMEN JALAN NAFAS MANAGEMEN JALAN NAFAS & & BANTUAN NAFAS BANTUAN NAFAS

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  • MANAGEMEN JALAN NAFAS&BANTUAN NAFAS

  • T P UPeserta mampu melakukan pengelolaan jalan nafas.T P KPeserta mampu :Mendiagnosa sumbatan jalan nafas/airwayMengetahui penyebab sumbatan jalan nafas/airwayMengelola sumbatan jalan nafas - tanpa alat - dengan alatA (AIRWAY)

  • So I said Hey Yallwatch this

  • PRIORITAS UTAMA Airway Bebas dan terjaga

    Breathing / ventilationAdekuat

    Supplemen oxygenAdekuat

  • PRIMARY SURVEYAssume C-Spine Injury

    Multisystem trauma

    Altered level of consciousness

    Blunt injury above clavicle

  • SUMBATAN JALAN NAFASPenyebab Penurunan kesadaran Tindakan anestesi Koma Trauma kepala Radang otak Obat / alkohol dll

    Suatu penyakit Laringitis Edema laring

  • sumbatan jalan nafas Trauma / Kecelakaan Maksilofacial Jalan nafas dll

    Benda asing Darah Muntahan Makanan dll

  • Macam ParsialRinganBerat

    Total

    sumbatan jalan nafas

  • SUATU SEBABPENDERITATAK SADARRELAKSASIOTOTHILANG REFLEKSPERLINDUNGANLIDAHKLEPSUMBATANJALAN NAFASMUNTAHREGURGITASIASPIRASI

  • In unconscious victim, the muscles in the tongue may relax, causing the tongue to block the airwayHead tilt and chin lift may open airway

  • SUMBATAN JALAN NAFAS Look / Lihat Perubahan Status MentalAgitasi / gelisah HipoksemiaObtundasi / teler Hiperkarbia Gerak NafasNormalSee saw / rocking Retraksi Deformitas DebrisDarah / sekretMuntahanGigi Sianosis

  • SUMBATAN JALAN NAFAS Listen / Dengar Bicara normal Tak ada sumbatan Ada suara tambahanSnoring LidahGurgling CairanStridor / crowing Penyempitan Suara parau (hoarseness / dysphonia)

    Feel / Raba Hawa nafas Krepitasi / fraktur (maxillofacial / laryngeal) Deviasi trakhea Hematoma Getaran di leher

  • MACAM SUMBATAN

    SUMBATAN

    BEBAS

    PARSIAL RINGAN

    PARSIAL BERAT

    TOTALLOOK

    GERAKNAFAS

    NORMAL

    NORMAL

    SEE SAW

    SEE SAWLISTEN

    SUARATAMBAHAN

    FEEL

    HAWAEKSHALASI

    +

  • PENGELOLAAN PERLU :CEPAT, TEPAT, CERMATSumbatan Total :

    FRC (Functional Residual Capacity): 2500 ml

    Kadar O2 15% x 2500 ml: 375 ml

    Kebutuhan O2 permenit: 250 ml

    Bila ada sumbatan total O2 dalam paru habis dalam : 375 / 250 : 1,5 menit

  • PENYEBAB SUMBATAN Lidah

    Epiglotis

    Benda asing / muntahan / darah / sekret

    Trauma jalan nafas

  • PEMBEBASAN JALAN NAFASPENYEBAB LIDAH Manual : Non trauma :Head tiltNeck liftChin liftJaw thrust- Trauma :Chin liftJaw thrustDengan in-line manual immobilization ataupasang cervical collar

    Bantuan Alat- Oropharyngeal airway- Nasopharyngeal airway

  • Pada pasien traumahead tiltneck liftDont doBe carefulneck liftchin lift

  • JAW THRUST dianjurkan

  • Oro-pharyngeal tubePerhatikan ukuran

  • 1234OROFARINGEAL TUBE

  • Naso-pharyngeal tube Tidak merangsang muntahUkuran u/ dewasa 7 mm atau jari kelingking kananNasopharyngeal tube

  • NASOFARINGEAL TUBE

  • PEMBEBASAN JALAN NAFASPENYEBAB BENDA ASING Manual

    Penghisap Definitive airway

    Pada chocking : Back blows Abdominal thrust (Heimlich manuver) Thoracal thrust Cricothyroidotomy

  • Lima kali hentakanpada punggung,diantara dua scapulaCHOKINGBack blows

  • CHOKINGHeimlichAbdominal trustKorban : sadar

  • Korban : Tidak sadarHeimlich Abdominal trust

  • DEFINITIVE AIRWAY

    Cuffed tube in trachea

    Secure airway

    Ventilation

    Types : Endotracheal intubation Surgical airwayCricothyrotomyTracheotomy

  • DEFINITIVE AIRWAY

    Cuffed tube in trachea

    Secure airway

    Ventilation

    Types : Endotracheal intubation Surgical airway - Cricothyrotomy - Tracheotomy

  • Membrana cricothyroid Pada keadaan gawat darurat - Tempat injeksi transtracheal obat emergency- Tempat untuk needle dan surgical cricothyroidotomiBagaimana caranya ??Obat apa saja boleh masuk ??

  • DEFINITIVE AIRWAYIndications

    1. Apnea

    2. Risk of aspiration

    3. Insecure airway

    4. Poor oxygenation

    5. Impending airway compromise

    7. Closed head injury

  • TUJUAN INTUBASI ENDOTRAKHEALSebagai jalan nafasUntuk oksigenasiUntuk pemberian ventilasiMencegah aspirasiJalan pemberian obat (intra trakheal)Bronchial toiletMACAM INTUBASI ENDOTRAKHEAL Orotrakehal Lewat mulut Nasotrakheal Lewat hidung

  • ENDOTRACHEAL INTUBATIONThe trachea should be intubated by properly

    trained personnel

  • PERALATAN INTUBASI ENDOTRAKHEHAL Laryngoscope dengan blade yang sesuai Tube dengan ukuran yang sesuai Jelly Anestetik lokal / spray Forceps magill Bite block / oropharyngeal airway Adhesive tape / tali Suction metal yang kauer Connectors Synringe (20 cc) Stylet Stetoscope End tidal CO2 monitor

  • INTUBASI

  • INTUBASI ENDOTRAKHEAL Oksigenasi + ventilasi (5 menit) Alat dan obat siap Harus berhasil kurang 30 detik Bila > 30 detik belum berhasil oksigenasi + ventilasi ulang Penolong tak kuat tahan nafas Saturasi O2 menurun Monitoring :Saturasi O2 (Pulse oxymeter)End-tidal CO2 (Capnografi)

  • Ped and Adult Normal Trachea

  • They Tend to look like This:

  • And This (after failed ETT attempt)

  • Predisposing Factors for Difficult IntubationInfectionEndocrineInflammatory diseasesCongenital

    TraumaForeign BodyTumoursPhysiologic

  • Infections

  • Airway Trauma

  • Endocrine Conditions

  • Foreign Body

  • Inflammatory Diseases

  • Congenital

  • Physiologic

  • PEDIATRICAirway Anatomy Craniofacial diproportion Large occiput cervical flexion Obligate nasal breather Narrow nasal passages Small oral cavity Large tongue Adeno tonsillar hypertrophy Horseshoe shaped epiglotis Larynx anterior cauded angle Trachea short

  • T P UPeserta mampu menangani kegawatan nafas/breathingT P KPeserta mampu :Mendiagnosa kegawatan nafasMengetahui penyebab kegawatan nafasMengelola kegawatan nafas - tanpa alat - dengan alatB (BREATHING)

  • GANGGUAN VENTILASIPenyebab Tindakan anestesi Penyakit Kecelakaan trauma

    Lokasi SentralPusat nafas PeriferJalan nafasDinding dadaParuOtot nafasRongga pleuraSyaraf & jantung

  • GANGGUAN VENTILASI(penderita masih bernafas)Look / LihatSianosisTakhipneaStatus mentalDistensi vena leherAsimetri dadaParalisis otot nafas

    Listen / dengar Keluhan: Tak bisa nafas!Stridor, wheeze atau hilang suara nafas

  • Feel / rabaHawa ekspirasiEmfisema subkutanKrepitasi / tenderness / nyeriDeviasi trakhea

    AdjunctsPulse oximeterCO2 detectorGas darahX-ray dadagangguan ventilasi(penderita masih bernafas)

  • CARA PEMBERIAN VENTILASITanpa AlatMouth tomouthMouthtonoseMouthto mouth and nose

    Dengan AlatSafar airwayEsophageal obturator airwayFace mask / pocket maskLaryngeal maskBag-valve-maskBag-valve-tubeVentilator

  • Nafas buatan

  • Nafas berhentiNafas ada

  • SUPPLEMENTAL OXYGEN1. Nasal cannula / prongLow flow systemFlow O2: 1-6 L/mFiO2: 24-44% (1 L O2/M FiO2 4%)2. Face maskLaw flow systemFlow O2: 8-10 L/mFiO2: 40-60 %3. Face mask with oxygen reservoirConstant flowFlow O2: 6-10 L/mFiO2: 6L O2 / m + 60 % ((1 L O2/M FiO2 10%)4. Venturi maskHigh gas flowFixed oxygen concentrationFlow O2 & FiO2 diatur24 %, 28%, 35% dan 40%

  • Terapi oksigenNASAL PRONGO2 flow 1 6 lpmFiO2 : 24 44 %BAG VALVE MASK (BVM) Dgn oksigen 8-10 lpm : 60%Masker sederhanaDengan reservoir bagFlow O2 : 6-10 lpmFiO2 : 60%- 100%BVM Dengan reservoir bagFlow O2 : 8-10 lpmFiO2 : 80%- 100%Jackson ReesFlow O2 : 8-10 lpmFiO2 : 100%BVM Dengan reservoir bagFlow O2 : 8-10 lpmFiO2 : 80%- 100%FACE MASK O2 8-10 lpmFiO2 : 40-60%

  • TRACHEO BRONCHIAL SUCTIONING Preoksigenasi 100% 5 menit Alat hisap :Setting suction: -80 -120 mmHgSoft catheter (steril) + lobang pengatur Tindakan aseptis sesuai prosedur Tak lebih 15 detik Diselingi oksigenasi 100% 30-60 detik KomplikasiHipoksemia Cardiac arrest aritmiaStimulasi simpatis Hipertensi takhikardiaStimulasi vagal Hipotensi bradikardiaBatuk TIKPerlukaanInfeksi

  • Isrun Masari ,2007

    * Pathological ConditionsVariations in "normal" anatomy and characteristic airway anatomy resulting from pathological conditions can result in problems despite proper positioning and equipment. A small mouth opening, protruding upper teeth, a large tongue, immobility of the head, neck, and jaw all may result in airway difficulty as may the following conditions.Conditions that predispose to a difficult airway include:Infectionsepiglottitis, abscesses, croup, bronchitis, pneumonia.Traumamaxillofacial trauma, cervical spine injury, laryngeal injury.Endocrinemorbid obesity, diabetes mellitus, acromegaly.Foreign BodyInflammatory Conditionsankylosing spondylitis, rheumatoid arthritis.Tumorsupper and lower airway tumors.Congenital Problemschoanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome, Hallermann-Streiff syndrome.Physiologic Conditionspregnancy.

    *InfectionsInfectious processes such as epiglottitis, abscesses, croup, bronchitis, and pneumonia can affect airway management. Abscess such as Ludwig's angina, a retropharyngeal or submandibular abscess, distort normal anatomy. Airway structures may be more difficult to recognize and may result in decreased oropharyngeal space available for instrumentation. In addition, lung soiling may result from abscess rupture, either spontaneously, or secondary to instrumentation of the airway. The CT or lateral neck radiograph may be helpful in defining the extent of the abscess. Epiglottitis, the acute infection of the epiglottis, results in inspiratory stridor, difficulty swallowing, and airway obstruction. Croup, bronchitis, and pneumonia may all result in a reactive airway that is more susceptible to laryngospasm and bronchospasm.

    *TraumaThe first steps in managing the trauma patient are the ABC's: Airway, Breathing, and Circulation. Indications for tracheal intubation include protection of the airway, airway obstruction, positive pressure ventilation, tracheal toilet, and a decreased level of consciousness. Alternatively, orotracheal intubation may be contraindicated or may not be possible in the patient with massive facial trauma, laryngeal or tracheal trauma. A surgical airway may be necessary instead. Often a state of urgency exists allowing little time for airway assessment because of cardiovascular instability or because the patient is already unconscious secondary to the injury. Adverse reflexes due to instrumentation of the airway may be problematic due to underlying cardiac or respiratory disease (i.e., the asthmatic patient), or may have important implications in acute injury.An open eye injury may be exacerbated by increases in intraocular pressure that result from instrumentation of the airway.Maxillofacial trauma may distort normal airway anatomy, result in trismus, a lingual hematoma, and edema. These cause difficult mask ventilation, obstruction of the upper airway, and predispose to difficult intubation. A Le Fort II fracture is a relative contraindication to nasotracheal intubation because the frontal processes of the maxilla are involved. With fractures that involve the basilar skull such as a Le Fort III fracture, positive pressure ventilation should be avoided until after the endotracheal tube is in place or after a tracheostomy is performed to prevent air from passing through the free communication between the subarachnoid space and brain tissue, resulting in pneumoencephalus.Laryngeal injury is not always obvious, but should be suspected in the patient with hoarseness, stridor, dysphagia, subcutaneous emphysema, or dyspnea in the recumbent position are present.In addition, all trauma patients need to be considered at risk for aspiration of stomach contents.

    *ObesityObesity results in airway and respiratory problems due to altered respiratory pathophysiology and distorted upper airway anatomy. Because of a lowered functional residual capacity, the available oxygen "stores" during apnea are lowered. The increased work of breathing along with the changes in lung volumes that result in closure of small airways results in less time available to the anesthesiologist to secure the airway. A higher minute volume is required to maintain normocarbia even though the overall basal metabolic rate is normal. Fat tissue has high metabolic activity. Oxygen consumption is increased. With each breath, a large mass of tissue in the chest wall and abdomen must be mobilized. The chest wall compliance is decreased. The functional residual capacity and expiratory reserve volumes are reduced.The reduced functional residual capacity is near closing capacity, especially in the supine position. This results in distal airway collapse despite continued perfusion to the corresponding alveoli. V/Q mismatch with venous admixture results. These factors limit the period of "safe" apnea during unconscious laryngoscopy and intubation. Obese patients are at a higher risk of aspirating due to larger gastric residual volumes and more acidic pH.The upper airway examination should be carefully performed with special attention given to the presence of excessive, redundant folds of tissue in the oropharynx and neck. A history suggestive of obstructive sleep apnea such as excessive nocturnal snoring with or without apneic episodes suggest the potential of mechanical airway obstruction as consciousness is lost. Patients scheduled for tracheostomy or palatoplasty are especially likely to have upper airway problems.

    *Foreign BodyThe primary problem with a foreign body of the airway is obstruction. Instrumentation of the airway may result in advancing the foreign body deeper into the airway. Positive pressure ventilatory assistance may cause further obstruction or result in a ball-valve effect which may result in a tension pneumothorax. Radiographic studies may help to delineate the precise location of the foreign body, provided the aspirated objects are radiopaque.

    *Rheumatoid ArthritisPatients with rheumatoid arthritis and other connective tissue diseases frequently have difficult airways due to temporomandibular joint ankylosis, limitation of motion of the cervical spine, deviation of the larynx, and cricoarytenoid arthritis. Alert signs include a hoarse voice, dysphagia, dysarthria, stridor, stridorous snoring, and a sense of fullness in the oropharynx. One should carefully examine the patient during flexion, extension, and rotation of the neck, and look for deviation of the trachea.If a positive history is elicited, it would be prudent to have indirect laryngoscopy performed to evaluate the patient for vocal cord involvement--edematous, hyperemic cords, arytenoid mucosa with swollen aryepiglottic folds and false cords, and presence of cricoarytenoid joint ankylosis. With laryngeal involvement, a smaller endotracheal tube and awake fiberoptic-assisted intubation may be required. Ankylosing SpondylitisPatients with ankylosing spondylitis have decreased mobility which can involve the entire vertebral column. The degree of involvement of the cervical spine will determine how difficult endotracheal intubation may be. Special care must be given to avoid excessive manipulation of the cervical spine which could injure the spinal cord.

    *Congenital ProblemsCongenital problems may be associated with airway difficulty due to mandibular hypoplasia, cervical vertebral abnormalities, large tongue, a high arched palate or cleft palate.Examples of congenital problems resulting in airway difficulty include: Down's syndrome, choanal atresia, tracheomalacia, cleft palate, Pierre Robin syndrome, Treacher Collins syndrome, and Hallermann-Streiff syndrome.

    *PregnancyPregnancy is associated with a difficult upper airway, an increased risk of aspiration, and also increasing metabolic demands which limit the time of apnea for securing the airway. Increased extracellular fluid and vascular engorgement typically lead to edema of the airway. The mucous membrane can become friable and even bleed. Therefore insertion of devices through the nasal passages is relatively contraindicated in these patients. It is often more difficult to place the laryngoscope in the mouth when the handle abuts against enlarged breasts. A short-handled laryngoscope may facilitate this maneuver.The higher metabolic rate and higher minute ventilation of the pregnant patient increases the demand for oxygen. As the uterus enlarges, the expiratory reserve volume, residual volume, and functional residual capacity all decrease. These factors cause desaturation to occur more quickly during apnea during laryngoscopy and intubation.Engel, Thomas P., MD, Ruskin, Keith J., MD. and Doyle, D. John, MD. Airway management for cesarean section. The Online Journal of Anesthesiology, 1996 Dec;3(12).