modul airway management 2017

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MODUL AIRWAY MANAGEMENT 2017

JABATAN KESIHATAN NEGERI MELAKA

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KATA KATA ALUAN 2

PENGENALAN DAN MATLAMAT MODUL 3

OBJEKTIF MODUL 4

PENGHARGAAN 5

LATARBELAKANG/ OBJEKTIF & DESKRIPSI KURSUS 6

TEMPOH & PERSETUJUAN MODUL 7

PENGENALAN AIRWAY MANAGEMENT & TAJUK 8

NASOPHARYNGEAL AIRWAY & LARYNGOSCOPE 9

VARIOUS TYPE OF BOUGIE 10-11

ENDOTRACHEAL TUBE 12-17

TYPES OF LARYNGEAL MASK 18-23

BAG VALVE MASK 24-25

PREPARATION OF DRUGS 26-29

PELAKSANAAN 30

PELAKSANAAN BUKU LOG 31-45

RUJUKAN 46

KANDUNGAN HALAMAN

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Pengarah Kesihatan Negeri Melaka

Assalammualaikum w.b.t.

Terlebih dahulu, sekalung penghargaan saya ucapkan kepada

Unit Penolong Pegawai Perubatan Kesihatan Awam di atas

kejayaan membangunkan Modul Kursus “Airway Management” Kesihatan Awam Negeri

Melaka. Kursus ini merupakan satu pendekatan untuk memberi bimbingan , sokongan dan

bantuan secara profesional oleh Pakar Anestesiologi Hospital Melaka dan pasukannya bagi

pembangunan diri selari dengan Arahan Pekeliling Perkhidmatan Bilangan 18 Tahun 2005,

iaitu Panduan Aplikasi Psikologi dalam Pengurusan Sumber Manusia Sektor Awam. Ia

dilaksanakan bagi tujuan memantapkan tahap kecekapan pegawai di samping membantu

mengatasi kebimbangan disebabkan kurang keyakinan dan pengetahuan dalam

melaksanakan tugas.

Justeru, dengan Modul Kursus “Airway Management” di Kesihatan Awam yang

diperkenalkan ini sebagai panduan dalam pelaksanaan Program Kursus “Airway

Management” Penolong Pegawai Perubatan permulaan di Kesihatan Awam dan sekaligus

melahirkan seorang Penolong Pegawai Perubatan yang berkualiti, berkeyakinan, kompetens,

berpengetahuan dan berkemahiran sejajar dengan perkembangan bidang perubatan.

Saya berharap modul ini akan digunapakai diperingkat lapangan khususnya di semua

Kesihatan Awam di seluruh Semenanjung Malaysia.

Sekian terima kasih

Datuk Dr Ghazali bin Othman (MMC 26797)

Pengarah Kesihatan Negeri Melaka

KATA KATA ALUAN

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Penolong Pegawai Perubatan di Kesihatan Awam adalah tunggak utama di dalam

melaksanakan perkhidmatan penjagaan pra hospital selain dari tugas tugas hakiki di Klinik

Kesihatan. Tambahan pula, hasrat Kementerian Kesihatan Malaysia ingin melengkapkan

semua Klinik Kesihatan di Malaysia dengan satu ambulans yang lengkap dengan peralatan

perubatan kecemasan. Ini merupakan cabaran kepada profesion Penolong Pegawai

Perubatan di dalam memberi perkhidmatan perawatan kecemasan semasa melakukan tugas

atas panggilan di Kilinik Kesihatan. Oleh itu Penolong Pegawai Perubatan yang bekerja di

Klinik Kesihatan mestilah berpengetahuan yang luas, berkemahiran dalam melakukan

prosedur, berkeyakinan dan kompetens sepanjang masa bertugas.

Sehubungan dengan itu, bagi memantapkan dan memperkasakan kerjaya Penolong Pegawai

Perubatan di Klinik Kesihatan maka lahirlah Modul Kursus “Airway Management” bagi

Penolong Pegawai Perubatan di Kesihatan Awam berpandukan “Advanced Life Support

Training Manual” Keluaran ke 2 Kementerian Kesihatan Malaysia.. Kursus “Airway

Management” dipilih berdasarkan kepentingan kemahiran dan pengetahuan utama yang mesti

ada pada setiap Penolong Pegawai Perubatan di dalam memberi perkhidmatan perawatan

kecemasan di Kesihatan Awam.

Oleh itu, amatlah penting semua Penolong Pegawai Perubatan Kesihatan Awam menjalani

kursus “Airway Management” yang dijalankan oleh Jabatan Anestesiologi & Rawatan Rapi

Modul ini bertujuan membantu fasilitator dalam mengendalikan kursus secara

Sempurna bagi meningkatkan pengetahuan dan membina kemahiran peserta tentang

pengurusan “Airway Management”. Kumpulan sasaran kursus ini adalah Penolong Pegawai

Perubatan di Kesihatan Awam.

1.0 PENGENALAN

1.1 MATLAMAT MODUL

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OBJEKTIF UMUM

Mewujudkan Penolong Pegawai Perubatan yang bertanggungjawab, proaktif,

berpengetahuan, berkemahiran dan menjadi “Front Liner” yang cekap, berkeyakinan dalam

pengendalian kes.

OBJEKTIF KHUSUS

1.2 OBJEKTIF MODUL

1

2

3

DAPAT MENINGKATKAN SEMANGAT BEKERJA KE ARAH PERKHIDMATAN

YANG LEBIH CEMERLANG PADA MASA AKAN DATANG.

MENGGALAKKAN SEMUA PENOLONG PEGAWAI PERUBATAN

KESIHATAN AWAM NEGERI MELAKA MENAMBAH ILMU PENGETAHUAN

DALAM PELBAGAI BIDANG YANG DIMINATI.

MEMBERI KEYAKINAN, BERKEMAHIRAN DAN KOMPETENS KEPADA

PENOLONG PEGAWAI PERUBATAN KESIHATAN AWAM DALAM

MELAKSANAKAN TUGAS.

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PENASIHAT

Pengarah Kesihatan Negeri Melaka : Datuk Dr Ghazali bin Othman

PENGERUSI

Timbalan Pengarah Kesihatan Negeri (KA) : Dr Hj Amirullah bin Mohd Arsyad

SEKRETARIAT

Pakar Perubatan Kesihatan Awam : Dr Suhaila bt Osman

Ketua Pakar Perubatan Keluarga Negeri Melaka : Dr Jalil bin Ishak

Ketua Jabatan & Rawatan Rapi Hospital Melaka : Dr Hj Zainal Abidin bin Othman

Pakar Anestesiologi Hospital Melaka : Dr Anuwar Ariff bin Mohamed

Ketua Pen. Peg. Perubatan Negeri Melaka : Tn Hj Rosman bin Jonet

Timb Ketua Pen. Peg. Perubatan (KA) : Tn Hj Aris bin Sahat (Editor)

Ketua Penyelia Pen Peg. Perubatan (Primer) : En Teo Cheng Teck

Ketua Penyelia Pen Peg. Perubatan (M Tengah) : Tn Hj Abdul Kahar bin Bibon

Ketua Penyelia Pen Peg. Perubatan (Jasin) : Tn Hj Mohd Isa bin Said

Ketua Penyelia Pen Peg. Perubatan (A. Gajah) : Tn Hj Wisam bin Abu Bakar

Ketua Penyelia Pen Peg. Perubatan Anestesiologi : Tn Hj Nordin bin Yaziz

Penyelia Pen. Peg. Perubatan (Primer) : Tn Hj Zulkifly bin Selamat

2.1 PENGHARGAAN

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Kursus “Airway management” bertujuan untuk melatih Penolong Pegawai Perubatan di

Kesihatan awam yang bekerja di bidang penjagaan kritikal dalam resusitasi pesakit Klinik

Kesihatan. Kursus ini memberi penekanan kepada peningkatan kemahiran Penolong Pegawai

Perubatan dalam pemberian rawatan kepada pesakit-pesakit yang memerlukan rawatan

kecemasan. Modul ini direka bentuk untuk mengukuhkan konsep-konsep penting dalam

proses intubasi pesakit dan penyediaan ubat untuk pesakit sebelum prosedur intubasi.

Setelah selesai kursus ini, Penolong Pegawai Perubatan dapat

➢ Melakukan prosedur intubasi dengan yakin, berkesan dan selamat

➢ Berkemahiran menggunakan alat-alat perubatan dan ubat-ubat yang betul semasa

melakukan prosedur intubasi.

➢ Deskripsi Kursus ini menumpukan kepada kemahiran secara individu dan sebagai

sebahagian daripada pasukan di tempat berkursus melalui penggunaan Buku Log

Airway Management”.

➢ Kuliah adalah pendek dan sedikit. Pendekatan pembelajaran secara VIVA digunakan

untuk kemahiran alat-alat perubatan dan ubat-ubatan dengan

➢ Oleh itu, Penolong Pegawai Perubatan yang dipilih mestilah membaca nota tentang

“Airway Management” dari “Advanced Life Support Training Manual” Keluaran ke 2

Kementerian Kesihatan Malaysia

3.1 OBJEKTIF KURSUS

3.1 DESKRIPSI KURSUS

3.0 LATARBELAKANG KURSUS

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Tempoh “Attachment Airway Management”

➢ Kursus selama 4 minggu di Jabatan Anestesiologi & Rawatan Rapi Hospital Melaka.

✓ 2 minggu di Dewan Bedah

✓ 2 minggu di Unit Rawatan Rapi

➢ Masa berkursus

✓ 8.00 pagi hingga 5.00 petang

MODUL KURSUS “AIRWAY MANAGEMENT”

➢ TELAH DISYORKAN OLEH KETUA JABATAN ANESTESIOLOGI &

RAWATAN RAPI HOSPITAL MELAKA MELALUI MESYUARAT

JAWATANKUASA MODUL AIRWAY MANAGEMENT KESIHATAN AWAM

YANG DIPENGERUSIKAN OLEH TIMBALAN PENGARAH KESIHATAN

NEGERI (KESIHATAN AWAM) MELAKA.

4.0 TEMPOH & MASA KURSUS

4.1 PERSETUJUAN MODUL KURSUS

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Pengurusan saluran pengudaraan adalah satu prosedur yang berkait rapat dengan

pengoksigenan semasa “Cardio Pulmonary Resuscitation” (CPR). Tujuan ventilasi semasa

CPR adalah untuk mengekalkan pengoksidaan yang mencukupi dan penghapusan karbon

dioksida yang mencukupi. Pengurusan saluran pengudaraan semasa pemulihan adalah

bergantung kepada faktor pesakit, fasa resusitasi dan kemahiran penyelamat. Pelbagai

modaliti pengurusan saluran udara contohnya. “Bag Valve Mask”, Alat saluran udara

supraglottik (contohnya LMA, SUPREME, Igel) dan tiub endotrakeal sering digunakan semasa

pemulihan sebagai sebahagian daripada pendekatan langkah ke arah pengurusan saluran

udara. Selepas kembali pulih, akhirnya intubasi endotrakeal diperlukan untuk rawatan selepas

resusitasi.

5.1.1 Nasopharyngeal Airway

5.1.2 Laryngoscope – blade & size

5.1.3 Various type of bougie

5.1.4 Endotracheal tube – various size

5.1.5 Type of Laryngeal mask

5.1.6 Bag Valve Mask

5.1.7 Rigid Suction

5.1.8 Preparation of drug - Midazolam and Succinyl-choline

5.0 PENGENALAN AIRWAY MANAGEMENT

5.1 TAJUK TAJUK PEMBELAJARAN MODUL

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Nasopharyngeal Airway

•An uncuffed tube made of soft rubber or plastic

•Used in patient where mouth opening is difficult

•More tolerable by semi-comatose patient

•Used with caution in patient with base of skull fracture or with ENT bleeding

•May cause airway bleeding•Various sizes (size indicates internal diameter)

- The appropriate size is measured from tip of the nose to tragus of the ear

Laryngoscope

•Consists of handle (which contains a battery power source) and blade

•2 types of blades: Macintosh blade (curved) for adults Miller blade (straight) for newborn and

infants

•Make sure that the light on the blade works and is bright when lit up

6.0 NASOPHARYNGEAL AIRWAY

6.1 LARYNGOSCOPE -BLADE & SIZE

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Clinical Indications: Patients meet clinical indications for oral intubation Initial intubation

attempt(s) unsuccessful Predicted difficult intubation

6.2 VARIOUS TYPE OF BOUGIE

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Contraindications:

Three attempts at orotracheal intubation (utilize failed airway protocol)

Age less than eight (8) or ETT size less than 6.5 mm

Endotracheal Introducer/Bougie Procedure:

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1. Prepare, position and oxygenate the patient with 100% oxygen.

2. Select proper ET tube without stylet, test cuff and prepare suction.

3. Load the Bougie on to the ETT and lubricate the distal end and cuff of the endotracheal

tube (ETT) and the distal 1/2 of the Endotracheal Tube Introducer (Bougie) Failure to

lubricate the Bougie and the ETT may result in being unable to pass the ETT.

4. Using laryngoscopic techniques, visualize the vocal cords if possible using cricoid

pressure as needed.

5. Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords

or above the arytenoids if the cords cannot be visualized.

6. Once inserted, gently advance the Bougie until you meet resistance or “hold-up” (if you do

not meet resistance you have a probable esophageal intubation and insertion should be

re-attempted or the failed airway protocol implemented as indicated).

7. While maintaining a firm grasp on the proximal Bougie, introduce the ET tube over the

Bougie passing the tube to its appropriate depth.

8. If you are unable to advance the ETT into the trachea and the Bougie and ETT are

adequately lubricated, withdraw the ETT slightly and rotate the ETT 90 degrees

COUNTERclockwise to turn the bevel of the ETT posteriorly. If this technique fails to

facilitate passing of the ETT you may attempt direct laryngoscopy while advancing the

ETT. This will require an assistant to maintain the position of the Bougie and, if so desired,

advance the ETT.

9. Once the ETT is correctly placed, hold the ET tube securely and remove the Bougie.

10. Confirm tracheal placement according to the intubation protocol, inflate the cuff with 3 to

10mL of air, auscultate for equal breath sounds and reposition accordingly.

11. When final position is determined secure the ET tube, reassess breath sounds, apply ET

CO2 monitor, and record and monitor readings to assure continued tracheal intubation.

Endotracheal Tube (ETT)

6.3 ENDOTRACHEAL TUBE - VARIOUS SIZE

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The ETT was once considered the optimal method of managing airway during cardiac arrest.

It keeps the airway patent, permits suctioning of airway secretions, enables delivery of a high

concentration of oxygen, provides an alternative route for the administration of some drugs,

facilitates delivery of a selected tidal volume, and with the use of a cuff, may protect the

airway from aspiration. However, there is insufficient evidence to support or refute the use of

any specific technique to maintain an airway and provide positive pressure ventilation in

resuscitation. Endotracheal intubation should only be performed by trained personnel with

high level of skill and competence.

Equipment for Endotracheal Intubation:

The equipment necessary for endotracheal intubation may be remembered as mnemonics

MALES: M - Mask (Bag-mask), Magill forceps

A - Airways (Oropharyngeal/Nasopharyngeal Airway)

L - Laryngoscope, LMA, Lubricant gel

E - Endotracheal tubes + Stylet + tape for securing ETT

S - Suction (Catheter/Yaunker), Syringe, Stylet

Endotracheal Tube

Choosing The Correct Size ETT

Age Internal Diameter (mm) Anchor for Oral ETT

Adult Male 7.5 - 8.0 20 - 22 cm

Adult Female 7.0 - 7.5 18 - 20 cm

Newborn to 3 months 3.0 weight (kg) +6

Infants 3.0 - 3.5 weight (kg) +6

Children >1year (Age/4) + 4.0 3 times size of ETT used/

If using cuffed ETT (Age/4) + 3.5 (Age/2)+12

Preparation for Endotracheal Intubation

It is important to get ready before any attempt in intubation:

❖ Equipment ready and in good order: MALES

❖ Adequate oxygen source

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➢ wall or cylinder

➢ if oxygen source is from oxygen cylinder, check O₂ pressure

❖ Enough helping hands

❖ Equipment to confirm correct placement of ETT i.e. Stethoscope, CO2 detector

devices

❖ Resuscitation and intubation drugs available and ready

The Technique of Endotracheal Intubation

The following steps are necessary for successful endotracheal intubation during

cardiac arrest:

Step 1: Position patient in the “sniffing the morning air” position

➢ Flexion at lower cervical spine

➢ Extension at atlanto-occipital joint

To align the axes of upper airway as shown in the diagram below Extend-the-head-on-neck

(“look up”): aligns axis A relative to B Flex-the-neck-on-shoulder (“look down”): aligns axis B

relatives to C

A

C

B

B

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Extend-the-head-on-neck (“look up”): aligns axis A relative to B

Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C

Step 2: Preoxygenation

•100% O2 for 3 minutes or with 4 vital capacity breaths

Step 3: Laryngoscopy and insertion of ETT

Laryngoscopy

➢ Use left hand to hold laryngoscope

➢ Enter at right side of mouth and push tongue towards left aside

➢ Move the laryngoscope blade towards midline and advance to the base of the

tongue. Advance the blade to the vallecula if the curved blade is used or to just

beyond tip of epiglottis if the straight blade is used

➢ Lift upward and forward to bring up the larynx and vocal cords into view. The

direction of force necessary to lift the mandible and tongue is 45 degrees. Do not

use teeth as a fulcrum or a lever

C

A

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Laryngoscopic View Laryngoscope blade position

Hand Position Laryngoscope blade position

Insertion of ETT

➢ Insert the ETT through the vocal cords. View the proximal end of the cuff at the

level of the vocal cords and advance it about 1 to 2.5cm further into the trachea

➢ Inflate the ETT with enough air to occlude the airway (usually 10 to 20ml)

Important point to note:

Interruption to chest compression during endotracheal intubation should

be less than 5 seconds.

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Step 4: Confirm correct position of ETT

➢ Observe colour of patient

➢ Visualise chest rise with delivery of first manual breath•Detect vapour in ETT

➢ 5 points auscultation for breath sounds (auscultate epigastrium, anterior chestat

bilateral mid-clavicular lines and thorax at bilateral mid-axillary lines)

➢ Detect end-tidal CO2 with capnography or CO2 detector device

Step 5: Secure ETT with tape

Step 6: Ventilate with a tidal volume of 6-8 ml/kg (visible chest rise) at a rate of 8-10 breath

per minute

Waveform Capnography

Continuous waveform capnography is recommended as the most reliable method of confirming

and monitoring correct placement of the endotracheal tube (ETT). Studies of waveform

capnography to verify ETT position in patients in cardiac arrest have shown high sensitivity

and specificity in identifying correct ETT placement. It can also detect a patient’s deterioration

associated with declining clinical status or ETT displacement.

End-tidal CO2 during resuscitation:

➢ Confirms ETT placement; note that EtCO2 detection will not differentiate between

tracheal and endobronchial tube placement. Careful auscultation is essential.

➢ Correlates with cardiac index

➢ Assesses adequacy of ventilation

➢ Indicates quality of CPR

➢ Signifies ROSC

➢ Carries prognostic value for survival during resuscitation

Waveform Capnography. Normal range (approximately 35 to 45 mmhg)

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Complications of Endotracheal Intubation

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Advanced Airways

Bag-mask ventilation is not suitable for prolonged periods of ventilation as it also inflates the

stomach. Therefore, ALS providers should be trained to use advanced airways (supraglottic

airway devices (SGAs) and ETT).

Supraglottic Airway Devices (SGAs)

Supraglottic airways are devices designed to maintain an open airway and facilitate

ventilation. Insertion of a supraglottic airway device does not require visualization of vocal

cords, therefore can be done with minimal chest compression interruptions.

Laryngeal Mask Airway

❖ An advanced airway device that is considered an acceptable alternative to the ETT

❖ Technically easier to insert and minimally interrupt chest compression during

resuscitation

❖ Ventilating patient via LMA may still cause gastric aspiration

❖ Composed of a tube with a cuffed mask-like projection at the end of the tube and

connected to a pilot balloon.

6.4 Types of Laryngeal Mask

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Recommended Size Guidelines for LMA

The following table shows the Recommended Size Guidelines and the Amount of Air needed

to inflate the LMA cuff:

Insertion of LMA

Before any attempt to insert an LMA, the following equipment has to be prepared:

➢ Personal protective equipment - mask, eye shield/goggle, gloves

➢ Appropriate size LMA

➢ Syringe with appropriate volume (10, 20 or 50 ml) for LMA cuff inflation •Water

soluble lubricant

➢ Ventilation equipment

➢ Tape or other device(s) to secure LMA

➢ StethoscopeThe following are the steps necessary for successful insertion of LMA:

Step 1: Size selection - as per Recommended Size Guidelines

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Step 2: Examination of LMA

➢ Inspect surface of LMA for damage, including cuts, tears, or scratches

- Do not use the LMA if the airway tube is damaged in any way

➢ Inspect interior of LMA airway tube to ensure that it is free from blockage or loose

particles

- Any particles present in the airway tube should be removed as patient may inhale

them after insertion

➢ Inflate cuff to ensure that it does not leak

➢ Deflate cuff to ensure that it maintains a vacuum

Step 3: Check inflation and deflation of cuff

➢ Inflate cuff with the recommended volume of air

➢ Slowly deflate cuff to form a smooth flat wedge shape which will pass easily around

the back of the tongue and behind the epiglottis

Step 4: Lubrication of LMA Cuff/Mask

➢ Use a water soluble lubricant to lubricate

➢ Only lubricate LMA cuff/mask just prior to insertion

➢ Only lubricate back of LMA cuff/mask thoroughly

➢ Avoid excessive lubricants on interior surface or in the bowl of cuff/mask as inhalation

of the lubricant following placement may result in coughing or obstruction

Step 5: Position head for insertion

➢ LMA can be inserted even if the head is in the neutral position as long as the

mouthopening is adequate

➢ Avoid LMA fold over:

- Assistant pulls the lower jaw downwards

- Visualize the posterior oral cavity

- Ensure that LMA is not folding over in the cavity as it is inserted

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Below are a series of diagrams showing the insertion of LMA:

Method for holding the LMA for standard With the head tilt and the neck flexed

insertion technique insert the cuff of LMA into the oral cavity;

direction of force goes against the hard palate

To facilitate introduction of LMA into the The index finger pushes LMA in a cranial oral in cavity, gently press the middle direction following the contours of the finger down onto the jaw hard and soft palates

1

4 3

2

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Maintaining pressure with finger on LMA in the cranial direction, advance LMA until definite resistance is felt at the base of the hypopharynx: note flexion of the wrist

Gently maintain cranial pressure with non-dominant hand while removing index finger

To allow LMA to seat optimally, inflate without holding LMA Inflate cuff with just enough air to obtain a seal - this should correspond to intracuff pressures around 60 cm H2O; do not over-inflate

Tape the bite-block and LMA airway tube downwards against the chin

5 6

7 8

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Final words on LMA

❖ Test cuff before use

❖ Don’t lubricate anterior side of LMA mask

❖ Insert only in comatose patient

❖ Keep cuff inflated until patient awake

LIMITATION OF SGAs

1.In the presence of high airway resistance or poor lung compliance (pulmonary

oedema,bronchospasm) there is a risk of significant leak around the cuff causing

hypoventilation.The leaks gas normally escapes through the patient’s mouth but some gastric

inflation may occur.

2.No data demonstrating whether or not it is possible to provide adequate ventilation

viaSGAs without interruption of the chest compression. Uninterrupted chest compressions

are likely to cause some leaks around the SGAs cuff when ventilation is attempted. Attempt

continuous chest compression initially but abandon this if persistent leaks occur.

3.There is theoretical risk of aspiration of stomach contents; however this complication

hasnot been documented widely in clinical practice.

4.If the patient is not deeply unconscious, insertion of the SGAs may cause coughing,

straining or laryngospasm. This will not occur in cardiopulmonary arrest patients.

5.If adequate ventilation is not achieved, withdraw the SGAs and re-attempt insertion after

ensuring good alignment of the head and neck.

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Bag-mask Ventilation

The bag-mask device consists of a self-inflating bag with a non-rebreathing valve

➢ Can be used with a face mask or an advanced airway eg Supraglottic airway devices

(SGAs) or endotracheal tube (ETT)

➢ Provides positive pressure ventilation

➢ Cannot be used to allow spontaneous breathing

The provider should use an adult (1 to 2 L) bag and deliver just enough volume to produce

visible chest rise

Bag-mask ventilation can produce gastric inflation with complications, including regurgitation

and aspiration

Two ways of holding the bag-mask device on the face for adequate ventilation:

6.5 BAG VALVE MASK

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Hand (E-C Clamp Technique) 2 Hand (E-C Clamp Technique)

Tracheobronchial Suctioning

Suction Catheter

➢ Size (FG) = ETT internal diameter (mm) x 3/2 or outer diameter should not exceed 1/2

to 2/3 ETT internal diameter

➢ Minimal trauma to mucosa with molded ends and side holes

➢ Long enough to pass through tip of ETT

➢ Minimal friction resistance during insertion through ETT

➢ Sterile and disposable

Suction Pressure

➢ 100 to-120mmHg (adults)• 80 to-100mmHg (children)• 60 to-80 mmHg (infants)

Complications of Tracheobronchial Suctioning:

➢ Sudden severe hypoxia, secondary to decrease in functional residual capacity during

the application of negative pressure in the trachea

➢ Cardiac arrest if severe hypoxia

➢ Increase in intra-arterial pressure and tachycardia due to sympathetic response to

suction

6.6 RIGID SUCTION

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Medications for Rapid Sequence Endotracheal Intubation

In order to achieve a successful intubation, various classes of medications are needed to

achieve specific pharmacologic effects. These effects include providing sedation, analgesia

from pain, amnestic effects, anesthesia, anticholinergic effects to control secretions, and

paralysis.

Intubation, when performed using the rapid sequence intubation (RSI) protocol, is typically

discussed in several stages (ie, pretreatment, induction and paralysis, and post-intubation);

each stage requires specific medications. The medication choices described below provide the

specific effects that are essential to creating the optimal conditions for endotracheal intubation.

Usually the medication used for rapid sequence intubation in anesthesiology department and

intensive care of the government hospital is midazolam and succinyl-choline

Midazolam (Dormicum)

Although this agent has the most rapid onset of all the benzodiazepines, it falls far short in this

category compared with other classes of induction agents. Midazolam has the major

disadvantage of requiring titration, which is far from feasible in RSI. Also, optimal effects are

not observed for 3-5 minutes. This time does not allow the patient to be properly anesthetized

if the midazolam is administered immediately before succinylcholine. In fact, studies have

shown that patients are awake if midazolam is administered back to back with succinylcholine.

Although the standard dose for RSI is 0.1 mg/kg, doses as high as 0.3 mg/kg have not

consistently induced true unconsciousness. Midazolam does mildly decrease Cerebral

Perfusion Pressure (CPP). Also, minimal cardiovascular and respiratory effect may be

observed.

Because of its slow onset and variable potency, midazolam is no longer recommended as a

first-line induction agent in RSI. All drugs administered for RSI must possess rapid onset and

extreme potency.

6.7 PREPARATION OF DRUG

http://reference.medscape.com/drug/versed-midazolam-342907

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Anesthesia

Induction

• <55 years without premedication: 300-350 mcg/kg IV injection over 20-30 seconds; wait

2-3 minutes to evaluate sedative effect after each dose adjustment; may use increments

of 25% of initial dose PRN to complete induction; may use up to 0.6 mg/kg total dose in

resistant cases, but such dosing may prolong recovery

• >55 years without premedication and with no systemic disease, in a patient who is not

weak: 300 mcg/kg over 20-30 seconds initially; wait 2-3 minutes to evaluate sedative

effect after each dose adjustment

• >55 years without premedication but presence of systemic disease or weak patient:

200-250 mcg/kg over 20-30 seconds usually enough; 0.15 mg/kg enough in some

cases; wait 2-3 minutes to evaluate sedative effect after each dose adjustment

• >55 years with premedication: 150-350 mcg/kg IV injection over 20-30 seconds; wait 2-

3 minutes to evaluate sedative effect after each dose adjustment; a dose of 250 mcg/kg

usually enough to achieve desired effect

Maintenance

• May administer increments of 25% of induction dose PRN when there are signs that

anesthetic effects are lightening

Sedation of Intubated/Ventilated Patients

Load: 10-50 mcg/kg (dose range 0.5-4 mg) slow IV injection or infusion over several minutes;

repeat q5-15min PRN

Maintenance: Initial, 20-100 mcg/kg/hr infusion; titrate up or down 25-50% PRN

Dosing Considerations

Because it is water soluble, takes approximately 3 times longer than diazepam to peak EEG

effects; thus, clinician must wait 2-3 minutes to fully evaluate sedative effects before initiating

procedure or repeating dose.

javascript:openCalc('/calculator/dosing/weight-dosing','Anesthesia','Adult','%3c55%20years%20without%20premedication:%20300-350%20mcg/kg%20IV%20injection%20over%2020-30%20seconds;%20wait%202-3%20minutes%20to%20evaluate%20sedative%20effect%20after%20each%20dose%20adjustment;%20may%20use%20increments%20of%2025%20percent%20of%20initial%20dose%20PRN%20to%20complete%20induction;%20may%20use%20up%20to%200.6%20mg/kg%20total%20dose%20in%20resistant%20cases,%20but%20such%20dosing%20may%20prolong%20recovery');

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Anesthesia: Typical adult induction and maintenance doses may need to be decreased in

some elderly patients by 20-50%, because the elderly overall are more susceptible to CNS

depressants than is the general population

Succinylcholine (Suxamethonium Chloride)

Succinylcholine was introduced in 1949 and has passed the test of time. To this day,

succinylcholine is the only depolarizing agent used for rapid sequence induction. Because of

its rapid onset, ultrashort duration of action, and safety, it is the paralytic of choice in almost

all cases of rapid sequence induction in adults.

This depolarizing agent works via persistent activation and resultant blockade of the

postsynaptic nicotinic acetylcholine receptor at the neuromuscular junction. In contrary,

nondepolarizing agents competitively block the binding of acetylcholine at the same

postsynaptic receptor.

Neuromuscular Blockade

Load

• 0.3-1.1 mg/kg IV x1 dose, OR

• 3-4 mg/kg IM x1 dose

• Short Procedures: usually 0.6 mg/kg IV injection

Maintenance for Prolonged Procedures

• 0.04-0.07 mg/kg IV q5-10min PRN OR

• 2.5 mg/min IV infusion

Administration

Dose should be calculated based on ideal body weight

Pre treatment: Atropine may reduce vagally mediated bradycardia/hypotension/drooling

Solution contains 1% benzyl alcohol

http://reference.medscape.com/drug/anectine-quelicin-succinylcholine-343102

javascript:openCalc('/calculator/dosing/weight-dosing','Neuromuscular%20Blockade','Adult','0.3-1.1%20mg/kg%20IV%20x1%20dose,%20OR');

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Prior administration of "defasciculating" dose of nondepolarizing neuromuscular blocker

(such as 0.01 mg/kg IV vecuronium) will prevent muscular fasciculations that may increase

ICP/IOP

Adequate ventilatory support mandatory, may experience increased sensitivity with

electrolyte disorders (hyperMg, hypoK, hypoCa)

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7.0 PELAKSANAAN

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7.1 PELAKSANAAN BUKU LOG AIRWAY MANAGEMENT

BUKU LOG

“ATTACHMENT AIRWAY MANAGEMENT”

UNTUK

PENOLONG PEGAWAI PERUBATAN

KESIHATAN AWAM

JABATAN KESIHATAN NEGERI

MELAKA

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Maklumat Peribadi

Nama:____________________________________

KP/IC:____________________________________

Jawatan: PENOLONG PEGAWAI PERUBATAN

Annual Practice No:________________________

Tempat bertugas:__________________________

Tarikh tamat latihan:________________________

Tempat latihan:____________________________

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BUKU PROSEDUR INTUBASI

Pendahuluan :

Buku prosedur ini adalah salah satu keperluan bagi kursus latihan intubasi

Dengan adanya buku ini diharapkan dapat membantu para peserta dalam melakukan

tatacara secara betul dan selamat.

Anggota kesihatan terlibat adalah terdiri daripada Penolong Pegawai Perubatan.

Objektif :

Untuk meningkatkan kemahiran dan kecekapan para peserta dalam melakukan intubasi.

Pegawai Penilai / Penyelia ialah pegawai yang menyelia anggota kesihatan:

Pakar bius

Pegawai Perubatan Bius

Penyelia OT / ICU

Tugas dan Tanggungjawab Pegawai Penyelia

1. Memastikan anggota kesihatan menjalankan prosedur dalam tempoh 4 minggu.

2. Memastikan prosedur dilaksanakan dengan lebih mahir dan yakin.

3. Penyelia perlu membuat pengesahan di ruang catatan.

4. Memastikan prosedur dilakukan mengikut senarai semak.

5. Meluangkan masa untuk memberi bimbingan dan tunjuk ajar.

Pegawai Yang Dinilai / Diselia adalah anggota kesihatan yang mengikuti latihan C&P

intubasi.

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Tugas dan Tanggungjawab Pegawai Yang Dinilai / Diselia.

1. Hadiri penempatan di OT 2 minggu / ICU 2 minggu dari tarikh kursus.

2. Melakukan amali intubasi ke atas 10 orang pesakit (dengan pengawasan Pegawai

Perubatan Bius / Penyelia ) dan 5 orang pesakit (dengan pengawasan). Rujuk manual.

3. Menggunakan senarai semak yang disediakan.

4. Memberi perhatian kepada komen dan cadangan pegawai penyelia untuk membaiki

kemahiran.

5. Mendapatkan tandatangan pegawai penyelia sebagai pengesahan menjalankan

prosedur tersebut.

6. Menjaga buku prosedur dengan baik.

KRITERIA KELULUSAN CREDENTIALING DAN PRIVILEGING

Telah hadiri kursus Advance Airway Management.

Telah mengikuti penempatan latihan intubasi dengan jayanya.

Pegawai Penyelia yang berhak menandatangani selepas prosedur dilakukan dengan

jayanya : Pakar bius..

PENGEKALAN TAHAP KECEKAPAN

Setiap 3 tahun :-

Pengekalan kecekapan melakukan sendiri tatacara tersebut sekurang-kurangnya 1 kes

dalam setahun secara berterusan.berpandukan buku manual.

Menghadiri kursus / latihan dalam perkhidmatan sekali setahun

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TARIKH AKTIVITI MAKLUMAT PEGAWAI YANG MEMBERI TAKLIMAT

Nama Tanda

tangan

Cop Pegawai

Orientasi Dewan

Bedah/ ICU

Organisasi 7

Fungsi Dewan

Bedah / ICU

Tugas &

Tanggungjawab

Kod Etika &

Peranan PPP

Protokol &

Standard OP

Pengenalan

Airway device &

alat alat

AKTIVITI (OREINTASI DEWAN BEDAH & ICU)

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TARIKH TAJUK

CERAMAH/CME

NAMA

PENCERAMAH

MASA/

TEMPOH

T/TANGAN/COP

CONTINOUS MEDICAL EDUCATION/ BEDSIDE

TEACHING

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PEMERHATIAN PROSEDUR INTUBASI (10 kes)

Bil. Nama Dan KP

Butir Penyeliaan

Tarikh Tanda-

tangan Cop/Nama Penyelia

1

2

3

4

5

6

7

8

9

10

MEMBANTU PROSEDUR INTUBASI (10 KES)

BIL. Nama dan KP Ulasan

Tandatangan

L/Preseptor

1

2

3

4

5

6

7

8

9

10

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MELAKUKAN PROSEDUR INTUBASI DENGAN PENGAWASAN (5 KES)

VERIFIKASI

Buku rekod ini telah disemak dan didapati telah memenuhi semua syarat yang ditetapkan.

ULASAN PENYELIA

---------------------------------------------------------------------------------------------------------------------------

-----------------------------------------------------------------------------------------------------————-

TANDATANGAN PENYELIA

--------------------------------------

Bil Nama I/C / Kp Diagnosis Tandatangan L/Preseptor

1

2

3

4

5

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SENARAI SEMAK PROSEDUR INTUBASI

Bil

Aktiviti/Prosedur Intubation

Ulasan

1 Prepare all equipment and have suction ready.

2

Pre-oxygenate the patient, if time permits.Open the

patient’s airway.

3.

While holding the laryngoscope in the left hand,

insert the blade into the right side of the patient’s

mouth, sweeping the tongue to the left.

4.

Use the blade to lift the tongue and the epiglottis,

either directly with the straight (Miller) blade, or

indirectly with the curved (Macintosh) blade.

5.

Once the glottic opening is visualized, insert the

tube through the vocal cords and continue to

visualize while passing the cuff through the cords.

6.

Remove the laryngoscope and then the stylet from

the ETT.

7. Inflate the cuff with 5 – 10ml of air.

8.

Assess for adequate placement by auscultation

(equal breath sounds over the chest and a lack of

sounds over the epigastrium with bagging),

condensation in the ETT, symmetrical chest-wall

rise, and at least one additional method:

colorimetric end-tidal CO2 detector, capnography,

or esophageal tube detector (Note: to be accurate,

the tube detector should be used prior to

ventilation).

9. Secure the tube

10.

Document the ETT size, time, results, and

placement depth (in cm at the level of the patient’s

teeth or gums) on the PCR. Also, include in

documentation the procedures and devices used for

confirmation of tube placement (e.g., bilateral, equal

breath sounds and absence of epigastric sounds,

end-tidal CO2, etc.).

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SENARAI SEMAK PREPARATION

A1 Nasopharyngeal airway - appropriate

size

A2 Laryngoscope - appropriate blade

and handle size

A3 Bougie

A4 ETT - appropriate size

A5 Laryngeal mask airway

A6 Bag valve mask

A7 Rigid Suction

B1 Prepare and determine dose drugs:

Midazolam

Succinyl-choline

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KRITERIA INTUBASI

No Prosedur Kelulusan

Asas

Kriteria Kompetensi Penyelia

1 Prosedur

Intubasi

Penolong

Pegawai

Perubatan

Menghadiri

kursus

Advance

Airway

Management

Penempatan di

OT dan ICU

yang telah

dikhaskan oleh

penganjur

kursus

1.Penempatan

selama 4

minggu

2.Mestilah

memenuhi

kehendak buku

Log

1.Setiap tahun

mestilah

melakukan

sekurang-

kurangnya 1

prosedure

intubasi untuk

mengekalkan

kemahiran

intubasi.

2.Menghadiri

kursus/latihan

dalam

perkhidmatan

sekali setahun

Pakar bius.

Pegawai Perubatan Bius

Penyelia OT / ICU

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GAMBAR PROSEDUR INTUBASI

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CATATAN:

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Advanced Life Support Training Manual Second published in Malaysia in September

2017 by Medical Development Division Ministry of Health Malaysia

© The Ministry of Health Malaysia 2017 www.moh.gov.my

Institute for Medical Research Cataloging in Publication Data A catalogue record for this

book is available from the Institute for Medical Research, Ministry of Health Malaysia

National Library of Malaysia Cataloging in Publication Data A catalogue record for this

book is available from the National Library of Malaysia

Arahan Pekeliling Perkhidmatan Bilangan 18 Tahun 2005, iaitu panduan aplikasi

psikologi dalam Pengurusan Sumber Manusia Sektor Awam

8.0 RUJUKAN

http://www.moh.gov.my/

modul airway management 2017

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