Laporan Kasus

Airway Management
Ayun Puji Lestari
I1A007081
Pembimbing:
dr. Rapto Hardian, Sp.An

Anatomy

Equipment

Oral & nasal airway

Face mask
LMA
Esophageal-Tracheal combitube
Tracheal tube
Rigid laryngoscope

Equipment
Oral & nasal airway
Maintain the opening airway
Awake or lightly anesthetized patients may
cough or even develop laryngospasm during
airway insertion if laryngeal reflexes are intact.
Nasal airway: risk of epistaxis, should not be
used in basilar skull fracture, better tolerated
than oral airway.

Face mask
Facilitate delivery of oxygen or of an anesthetic
gas from a breathing system to a patient by
creating an airtight seal with the patient's face
Transparent masks observation of exhaled
humidified gas and immediate recognition of
vomiting
Black rubber masks pliable enough to adapt
to uncommon facial structures

 Effective ventilation requires both a gas-tight

mask fit and a patent airway.
Improper face mask technique deflation of
the anesthesia reservoir bag when the adjustable
pressure-limiting valve is closed indicating a
substantial leak around the mask.

The McCoy Laryngoscope

Rigid Laryngoscope

LMA

Combitube

Specialized laryngoscopic
blades

Flexible fiberoptic
bronchoscope

Kheterpal S. Han R, Tremper RK, et al. Incidence and Predictors of Difficult and Impossible Mask
Ventilation. Anesthesiology 2006; 105:88591

Spesific test for assessment

A. Anatomical criteria
1. Relative to tongue/pharyngeal size
Mallampatti test

Class I : Visualization of the soft palate, fauces; uvula, anterior and

the posterior pillars.
Class II : Visualization of the soft palate, fauces and uvula.
Class III : Visualization of soft palate and base of uvula.
Class IV: Only hard palate is visible. Soft palate is not visible at all.

2. Atlanto occipital joint (AO) extension

feasibility to make sniffing or Magill position for
intubation, measured by simple visual estimate
or goniometer

Grade I
Grade II
Grade III
Grade IV

: > 35
: 22-34
: 12-21
: <12

3. Mandibular space
i. Thyromental (T-M) distance (difficult: <3
finger or <6 cm; less difficult: 6-6.5 cm;
normal: >6,5 cm)
ii. Sterno-mental distance (difficult intubation:
<12 cm)
iii. Mandibular-hyoid distance (N: 4 cm/ 3 finger)
iv. Inter-incisor distance ( N: 4,6 cm / more)

Lemon Airway Assessment

The score with a maximum of 10 points is calculated by assigning 1
point for each of the following LEMON criteria:
L = Look externally (facial trauma, large incisors, beard or
moustache, large tongue)
E = Evaluate the 3-3-2 rule (incisor distance-3 finger breadths,
hyoid-mental distance-3 finger breadths, thyroid-to-mouth distance2 finger breadths)
M = Mallampati (Mallampati score > 3).
O = Obstruction (presence of any condition like epiglottitis,
peritonsillar abscess, trauma).
N = Neck mobility (limited neck mobility)
Patients in the difficult intubation group have higher LEMON scores.
Gupta S, Sharma R, Jain D. AIRWAY ASSESSMENT : PREDICTORS OF DIFFICULT
AIRWAY. Indian J Anaesth 2005; 49 (4): 257-262.

B. Direct laryngoscopy and fibreoptic

bronchoscopy

Grade I Visualization of entire laryngeal aperture.

Grade II Visualization of only posterior commissure of laryngeal
aperture.
Grade III Visualization of only epiglottis.
Grade IV Visualization of just the soft palate.
Grade III and IV predict difficult intubation

C. Radiographic assessment
1. Skeletal films
2. Fluoroscopy (cord mobility, airway malacia,
emphysema)
3. Oesophagogram (inflammation, foreign body,
extensive mass or vascular ring)
4. Ultrasonography (anterior mediastinal mass,
lymphadenopathy, differentiates cyst from
mass and cellulitis from abcess)
5. CT/MRI (congenital anomalies, vascular
airway compression)
6. Video-optical intubation stylets

Laporan Kasus
Nama : Tn. F
Umur : 46 tahun
Alamat : Komplek Kayu Tangi 2
Agama : Islam
Informed consent: 6 oktober 2012
RMK : 1-01-28-21

Anamnesis
Keluhan Utama
Keluar benjolan di selangkangan sebelah kanan
RPS
Pasien mengeluh keluar benjolan sejak 3 tahun
yang lalu, hilang timbul. Benjolan muncul tiap kali
pasien bersin. 1 bulan terakhir benjolan keluar dan
sulit masuk kembali. Pasien merasa sangat nyeri
saat keluar benjolan. Pasien lalu ke poli bedah
RSUD Ulin dan disarankan untuk operasi.

Visite Pre operatif

KU
: Baik
Batuk/pilek/demam : -/-/Gigi goyang/gigi palsu : -/R/ HT/DM/asma : -/-/R/ alergi makanan/obat : -/R/ operasi dengan GA : Merokok : + (berhenti 1 minggu yg lalu)

Pemeriksaan Fisik

Keadaan umum: Baik

Kesadaran: Komposmentis
GCS : 4-5-6
TD
: 120/90 mmHg
N
: 84 x/menit
RR
: 20 x/menit
BB
: 64 kg
Mallampati : 3

Kesulitan ventilasi pada kasus

 Cervical spine dbn

Neck anatomy thick poor flexion-extension
mobility of the head on neck.
Mallampati classification III
Full beard No
Dentition normal
Large tongue

Intraoperatif
Pethidin, propofol dan muscle relaksan sdh
diinjeksikan apnea kesulitan ventilasi
dengan face mask saturasi turun pasang
guedel (untuk mempertahankan airway)
saturasi tetap tidak meningkat pasang LMA.

Difficult Airway
Difficult airway : the clinical situation in which a
conventionally trained anesthesiologist
experiences difficulty with face mask ventilation
of the upper airway, difficulty with tracheal
intubation, or both.

Practice guidelines for management of the difficult airway: An updated report by the American Society of
Anesthesiologists Task Force on Management of the Difficult Airway. ANESTHESIOLOGY 2003; 98:126977

Difficult ventilation
(a) It is not possible for the anesthesiologist to provide adequate face
mask ventilation due to one or more of the following problems:
inadequate mask seal, excessive gas leak, or excessive resistance to
the ingress or egress of gas.
(b) Signs of inadequate face mask ventilation:
1. absent or inadequate chest movement,
2. absent or inadequate breath sounds,
3. auscultatory signs of severe obstruction,
4. cyanosis,
5. gastric air entry or dilatation,
6. decreasing or inadequate oxygen saturation (SpO2),
7. absent or inadequate exhaled carbon dioxide,
8. absent or inadequate spirometric measures of exhaled gas flow
9. hemodynamic changes associated with hypoxemia or hypercarbia
(e.g., hypertension, tachycardia, arrhythmia).

Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists
Task Force on Management of the Difficult Airway. ANESTHESIOLOGY 2003; 98:126977

Predict difficult mask ventilation (OBESE)

Difficult intubation
Difficult intubation has been defined by the need
for more than three intubation attempts or
attempts at intubation that last > 10 min.
Such patients in stable circumstances can
usually tolerate 10 min of attempted intubation
without adverse sequelae.

Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists
Task Force on Management of the Difficult Airway. ANESTHESIOLOGY 2003; 98:126977

Predict difficult intubation

a. Poor flexion-extension mobility of the head on
neck
b. A receding mandible and presence of
prominent teeth
c. A reduced atlanto-occipital distance, a reduced
space between C1 and the occiput.
d. Large tongue size- related more to the ratio of
the anterior length of the chin or mandible

If a difficult airway is known or suspected:

1. Inform the patient (or responsible patient) of the special
risk and procedures pertaining to management of the
difficult airway
2. Ascertain that there is at least one additional individual
who is immediately available to serve as an assistant in
difficult airway management
3. Administer face mask preoxygenation before initiating
management of the difficult airway. The uncooperative or
pediatric patient may impede opportunities for
preoxygenation
4. Actively pursue opportunities to deliver supplemental
oxygen throughout the process of the difficult airway
management

Difficult airway algorithm

Retrograde intubation

TERIMA KASIH