NUR HAJRIYA BRAHMI

Intubasi Sulit

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

Incidens

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

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

Evaluasi Kesulitan Intubasi

Kriteria :- Skala LEMON atau MELON- LM MAP- 4 D- Wilson Risk Scale- Magboul 4M

Skala LEMON atau MELON

Look externallyEvaluate 3-3-2-1 ruleMallampatiObstructionNeck mobility

Tabel Skala LEMON

Grading the Airway (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

Figure 2 – Cormack-Lehane

LM-MAP

Look for external face deformitiesMallampatiMeasure 3-3-2-1 fingersAtlanto-occipital extensionPathological obstructive conditions

4 D

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)

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

Magboul 4 MS

MallampatiMeasurementMovementMalformation of STOP

(Skull,Teeth,Obstruction,Pathology)

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

- Preoksigenisasi 100% O2 - Posisi pasien optimal untuk ventilasi dan

intubasi- Konfirmasi ETT setelah intubasi dilakukan

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

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

Failed intubation - Overview of failed intubation drill

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)

The ASA Algorithm for Recognized and Unrecognized Difficult Airways

REMEMBER.....

- Pada jalan nafas sulit (ventilasi dan intubasi), intubasi awake adalah pilihan terbaik

- Pelumpuh otot diberikan apabila sudah pasti tidak ada kesulitan ventilasi