DR. FACHRUL JAMAL, SpAn. KIC.

DEPT.ANASTESI & PERAWATAN INTENSIVE. FK-

USK/RSUZA
BANDA ACEH
ANATOMY OF RESPIRATORY
SYSTEM
I. Upper Respiratory System
1. Nose and mouth
2. Nasopharynx
3. Oropharynx
4. Laryngopharynx
5. Larynx

II.Lower Respiratory System
1. Trachea
2. Main bronchi
3. Lobar bronchi
4. Segmental bronchi
5. Small bronchi
6. Bronchioles
7. Terminal bronchioles
8. Respiratory bronchioles
9. Alveolar ducts
10. Alveolar sacs



Conduits or
connecting tube
Respiratory
part
The upper airway
The lower airways
Alveolus
Airway Obstruction


Coma
Aspiration
Maxillofacial
trauma
Neck trauma


DAPAT BERUPA GANGGUAN PD
JALAN NAFAS.(AIR WAY)
DAPAT JUGA PADA SISTEM
PERNAFASAN.(VENTILASI)
AIR WAY & VENTILATORY FAILURE.
DAPAT BERUPA OBSTRUKSI JALAN
NAFAS & DEPRESI PERNAFASAN
HIPOVENTILASI SAMPAI APNOE
PENYEBABNYA BISA BERMACAM2,
SPT : ANESTESIA,PENYAKIT, TRAUMA
BILA TIDAK DIATASI DENGAN CEPAT
BISA TIMBUL HIPOKSEMIA DAN
HIPERCARBIA.-KEMATIAN.
TANDA-TANDA OBSTRUKSI
JALAN NAPAS
Cara : Look(Lihat), Listen(dengar),
feel(rasa).
Lihat =gelisah,kesadaran,pergerakan
dada/perut(see saw,rocking resp), retraksi iga dan
supra sternal,sianosis, dan pada trauma sering
adanya pergeseran trachea dan otot leher.
Dengar = adanya bunyi nafas tambahan ? Spt
snoring,gurgling dan crowing dan whizing.
Rasa = adanya udara dari hidung dan mulut,
adanya pergeseran trachea.


Airway evaluation
LOOK
Chest and abdomen
movement
Signs of respiratory distress
Color of skin, mucosa
Consciousness
LISTEN
air movement with your ear
FEEL
air movement with your
cheek ( Look - Listen - Feel )
Penurunan kesadaran relaksasi otot
lidah, pangkal lidah jatuh ke posterior
menutup orofaring sumbatan jalan
napas.
Keadaan relaksasi spinter cardiac oeso
akan terjadi regurgitasi,aspirasi isi
lambung dan pneumonia Aspirasi.
Trauma wajah sering Kesulitan intubasi
segera krikotiroidotomi, trakheotomi ?
Signs of obstruction
snoring : base of tongue
gargling : liquid
stridor : vocal cord spasm or edema

restlessness due to hypoxia
secondary breathing muscle
(tracheal tug, intercostal retraction)
paradoxal chest & abdominal
movement
cyanosis (late sign)
MORE
SEVERE
Clearing the airway
Obstruction due to the base of
tongue
jaw thrust
chin lift
oro or naso-pharyngeal airway
tracheal intubation / LMA
Obstruction due to Liquid
suction
Obstruction at the plica vocalis
cricothyroidotomy
Safest : Jaw thrust
Head Tilt-Neck lift
Avoid head tilt
Oro-pharyngeal tube
Not to be used in the presence of gag reflex
(Level A and V in AVPU or GCS > 10)
Naso-pharyngeal tube
Doesnot stimulate vomiting
Be careful in patient suffering fractura basis cranii
Size 7 mm for adult or equiv to right little finger
Advanced Airway Management
1. Tracheal intubation
with laryngoscopy
2. Cricothyroidotomy
needle / surgical
3. Laryngeal mask


ACS 16
Laryngeal Mask Airway
Laryngeal Mask Airway
dipasang tanpa laringoskopi
TRACHEAL INTUBATION
is indicated
Other airway methods failed
Difficult to ventilate with mask
Risk of pulmonary aspiration
Prevention of pCO2 (head injury)
GCS < 8
Risk of tracheal intubation
Hypoxia, vocal cord spasm
Increasing BP, bradycardia / asystole
Increasing ICP
Neck movement may aggravate cervical
lesion
Patient with hypoxia and or convulsion used
to clench the jaw. Forcing laryngoscopy may
be deleterious to the head injured
Ideally, intubation require anesthesia and muscle
relaxant


cricothyroidotomy
When tracheal intubation failed
while clear airway is still needed
Patient can be ventilated
Emergency oxygenation
Work up to 10 minutes
Can not eliminate CO2
Crico-thyroido-tomy
TERSEDAK
(CHOKING)
PADA KORBAN TERSEDAK SERING
DIJUM-
PAI HAL-HAL SEBAGAI BERIKUT:
KORBAN MERASA TERCEKIK
ADA KAITANNYA DENGAN MAKANAN
TIDAK DAPAT BICARA < BERNAPAS
MUKA SEMBAB DAN BIRU
SEMULA SADAR TIDAK SADAR
PERTOLONGAN PADA TERSEDAK DAPAT
DILAKUKAN SEBAGAI BERIKUT:

BACKBLOW / BACK SLAPS DILAKUKAN
PADA SEMUA USIA KORBAN
ABDOMINAL THRUST TIDAK DILAKUKAN
PADA : BAYI, DEWASA GEMUK/ HAMIL.
CHEST THUST DILAKUKAN PADA BAYI <
DEWASA GEMUK/HAMIL.
PERTOLONGAN TERSEDAK PADA ANAK >
8 TAHUN SEPERTI PADA DEWASA.
Heimlichs Manuver
Abdominal Thrust
Pukulan antara dua
skapula
Back Blows
PERIKSA LAGI
TIUP LAGI
TIDAK MASUK
TENGKURAPKAN
BACK BLOW / BACK SLAPS
TERLENTANGKAN.
PERIKSA MULUT
TIUP LAGI
DST
PENILAIAN NYA ADALAH ADANYA
GANGGUAN PADA PARAMETER
VENTILASI DAN ATAU PARAMETER
OKSIGENISASI. {PaCO2 & PaO2}.
PARAMETER VENTILASI :
PaCO2 : 35-45 mmHg.
ETCO2 : 25-35 mmHg.
PARAMETER OKSIGENISASI :
PaO2 : 80-100 mmHg.
SaO2 : 95-100 mmHg.
33
Breathing Evaluation
Look - chest movement, flaring nostrils,
intercostal retraction
Listen - breath sound, abnormal sounds
Feel - air movement through mouth / nose
Palpation - chest movement, symmetrical?
Percussion - Damped? Hypersonor ?
Symmetrical?
Auscultation (stethoscope) - Breath sound
presents? Symmetrical?

34
Rapid shallow breathing
Flaring nostrils
Intercostal and neck
retraction
Rapid pulse
Hypotension
Distended neck veins
Cyanosis (late sign)
ADA 3 CARA :
PONTOPPIDAN :RR>35,PaO2<70,PaCO2>60

SHAPIRO :PaO2 <50 mmHg, PaCO2>50.

Petty : PaO2 <50 mmHg,dg @ Tanpa
naikPaCO2. (Acute Respiratory Failure)
PaCO2>50 mmHg(Acute Ventilatory
Failure).

36
Open chest
wound? Sucking
wound?
Penetrating chest wound
Sucking chest wound
Close the wound
37
A piece of plastic sheet
fix with adhesive tape on
3 sides one way valve
to prevent pressure build-up
inside pleural cavity while
closing the wound



previous method:
cover with sterile gauze
impregnated with vaselin
(risk of pressure build-up)
How to Cover Penetrating Chest Wound
38
Diagnosis by clinical signs only
Affected side will show
Palpation less chest expansion
Palpation of trachea shifts away to normal
side
Percussion hypersonor (empty sound)
Auscultation reduced breath sound

Do needle thoracostomy,
do not wait for X-ray confirmation
39
Palpate The Trachea at
Sternal Notch
Look more
carefully for
pneumothorax in
the presence of
Rib fractures
Subcutaneous
emphysema

40
Needle Thoracostomy to Confirm
Pneumothorax
(Needle and Filled Syringe System)
Bubble (+)
= pneumothorax
Dont pull out the
needle until thoracic
drain is inserted

Bubble (-) and the
water was sucked
slowly inside
= no pnumothorax
Pull needle out before
the syringe emptied
to avoid inducing
pneumothorax
lenght
5 cm
water
42
Rib fractures? Flail Chest ?
4.
Inspiration
Expiration
43
1
2
Hemothorax? 5.
44
Subcutaneous Emphysema
Feels like grasping thin plastic sheet
Most caused by pneumothorax
45
THERAPY: Artificial ventilation
12-20 x / minute, until chest rises
start ventilation to abnormal breathing, do not
delay until apnea occurs
additional oxygen (if available)
if air enters the stomach, do not deflate by
pressing the epigastrium (risk of aspiration).
Insert a nasogastric tube instead
ACS 46
Goal: Achieve Maximal cellular O
2

O
2
at 10-12 liters / minute
Tight-fitting oxygen reservoir mask
Ventilate
Avoid prolonged attempts at
intubation without oxygenation
47
Artificial ventilation was provided along with
in-line immobilisation (hold the head and
neck)
to prevent the neck from moving excessively
48
Artificial ventilation via tracheal tube:
1. More effective oxygenation and removal of CO2
2. Prevent pulmonary aspiration
3. No interruption of cardiac compression during CPR

VENTILATOR



Masa kini
ACS 50
Pulse Oximeter
Measures O
2

hemoglobin sat.
Utility
Difficult
intubation
During transport
Pa O
2
O
2
Hgb Sat

90 mm Hg 100%
60 mm Hg 90%
30 mm Hg 60%
27 mm Hg 50%

ACS 51
2
52
Any Question.
Bila pasien telah di diagnosa gagal nafas
maka Intubasi Endotracheal segera
harus di pasang dan dilanjutkan dengan
ventilasi mekanik.(ventilator).
Bila pasien dlm kondisi Impending dapat
di coba dengan Pemberin oksigen kadar
tinggi denga Face Mask 10-12 L/mnt.
Segera cari penyebab utama dan obati.
WASSALAMUALAIKUM
WARAHMATULLAHI WABARAKATUH.