Airway Management

dedi atila
RJP

 Basic Life Support

 Advance Life Support
 Prolonged Life Support
Basic Life Support

 Airway:
Melindungi dan menjaga jalan nafas pasien termasuk penggunaan alat bantu
jalan nafas seperti alat bantu oral atau nasal.
 Breathing:
Pemberian bantuan aliran udara respirasi (ventilasi) termasuk pemberian
oksigen.
 Circulation:
Bantuan pemompaan jantung dengan pijat jantung tertutup atau terbuka
Airway Management

 Tetap terjaganya saluran yang menghubungkan

paru dengan udara luar.
 Paru aman dari kemungkinan terjadinya
aspirasi.
Anatomi

Inferior turbinate

Major nasal airway

Vallecula

Epiglottis

Hyoid bone
Hyoepiglottic ligament

Thyroid (laryngeal) cartilage

Cricoid cartilage
Anatomi

Hyoid bone

Laryngeal prominence
(“Adam’s appple”)

Thyroid (laryngeal) cartilage

Cricothyroid membrane
Cricothyroid cartilage

Thyroid gland
Airway assesment

 Metode “LEMON”
Menilai kemungkinan kesulitan tatalaksana jalan nafas
 L : Look externally (trauma wajah, gigi seri besar, janggut atau
kumis, dan lidah besar)
 E : Evaluate the 3-3-2 rule (3 jari pasien membuka mulut, jarak
hyoid/mental < 3 ujung jari, jarak tiroid-mulut < 2 ujung jari)
 M : Mallampati score
 O : Obstruction (adanya kondisi apapun yg bisa menyebabkan
hambatan jalan nafas)
 N : Neck Mobility (mobilitas leher terbatas)
Skor Mallampati

 Do with patient sitting,

 the head in the neutral position,
 The mouth wide open,
 The tongue protruding to the maximum.
 The patient should not be phonating.
 The Mallampati classification is then assigned based upon the visible
pharyngeal structures.
Skor Mallampati

 Class I: visualisasi pallatum molle, fauce, uvula, pilar anterior dan posterior.
 Class II: visualisasi pallatum molle, fauce, dan uvula.
 Class III: visualisasi pallatum molle, fauce, dan dasar uvula.
 Class IV: pallatum molle tidak tampak.
Obstruction

 Blood in the upper airway

 Foreign body
 Expanding hematoma
 Abscess
 Swelling of intraoral structures
 Laryngeal edema
Flexion and extension of neck
Airway management

Head Tilt / Ekstensi Kepala

Pasien tlentang & penolong di samping pasien, letakkn
di bwh leher & tlapak tgn yg lain di dahi.
Ekstensikan kepala dgn mndorong dahi ke belakang
mengangkat leher.
Indikasi : Obstruksi jaringan lunak jalan nafas atas
KI : Fraktur bagian leher
Infant
Komplikasi : Nyeri leher
Syaraf terjepit
Airway management

Chin Lift / Angkat Dagu

Pasien terlentang & penolong meletakkan satu tangan di
dahi dan ibu ajri tangan yg lain di bwh dagu.
Dahi didorong & dagu diangkat scr bersamaan.
Indikasi : Alternatif head tilt
KI : sama dg head tilt
Komplikasi : sama dg head tilt
Airway management

Jaw Thrust / Dorong Rahang

Dr atas kepala pasien, ibu jari diletakkan di maksila &
jari lain di angulus mandibula (bilateral), angkat &
dorong rahang ke depan.
Indikasi : pasien KI atau tdk efektif dg head tilt
KI : fraktur rahang
dislokasi rahang
pasien sadar
Komplikasi : dislokasi rahang
Airway management

Buka mulut
Mulut di buka dgn menggunakan ibu jari
Indikasi : obstruksi ekspiratori setelah head tilt.
KI : -
Komplikasi : -
Head tilt, jaw thrust & open mouth dikenal sebagai Triple
Airway Manuver
Lateral xanogram of the head & neck in neutral position. Patient is awake & supine.
Medial sagittal view of upper airway showing site of upper
airway obstruction in sedated patient.
Airway Management

Heimlich Manuver
Pada pasien berdiri, kaitkan kedua tangan
melingkari dada pasien dgn tangan kanan
mengepal & tangan kiri dikaitkan di atas
kepalan tangan kanan.
Dgn dorongan cepat & kuat, menekan ke atas,
meningkatkan tekanan subdiagfragma &
menimbulkan batuk artifisial.
Indikasi : Obstruksi total oleh benda asing
KI : Fraktur iga (relatif)
Kontusio jantung (relatif)
Obstruksi jalan nafas parsial
Komplikasi: fraktur iga, sternum
trauma hati atau limpa
Airway Management

Heimlich Manuver
Pada pasien berdiri, kaitkan kedua tangan melingkari dada pasien dgn
tangan kanan mengepal & tangan kiri dikaitkan di atas kepalan
tangan kanan.
Dgn dorongan cepat & kuat, menekan ke atas, meningkatkan tekanan
subdiagfragma & menimbulkan batuk artifisial.
Indikasi : Obstruksi total oleh benda asing
KI : Fraktur iga (relatif)
Kontusio jantung (relatif)
Obstruksi jalan nafas parsial
Komplikasi: fraktur iga, sternum
trauma hati atau limpa
Airway Management

 Jika anda sendiri dan anda tersedak, anda dapat

melakukan manuver Heimlich sendiri.
 Sandarkan ke depan dan tekan abdomen anda
secara cepat pada benda sekitar, seperti kursi,
meja atau rel pada dinding.
 Tanpa oksigen, otak akan mulai mengalami
kematian dalam waktu 4-6 menit.
 The Heimlich Maneuver merupakan metode terbaik
untuk mengeluarkan benda asing dari jalan nafas
pada pasien yang tersedak
Airway Management

Oropharyngeal Airway
Mencegah oklusi gigi, lbh sering utk memperbaiki jalan
nafas.
Ukuran variasi 0-4
Terbuat dr plastik, metal, atau karet.
Dirancag pd bag gigitan keras, dan tepi proksimal
bersirip utk mencegah overinsersi.
Bagian distal berbentuk semisirkuler sesuai bentuk
lengkung mulut, lidan, dan faring posterior.
Airway Management

Nasopharyngeal airway
Merupakan silinder panjang yg berbentuk lengkungan
dan lentur.
Terbuat dr plastik atau karet lembut.
Panjang & lebar bervariasi.
Sirip proksimal mencegah overinsersi
Airway Management

 Sungkup Laring (LMA)

 Intubasi Endotrakeal
 Trakeostomi
 Krikotiromi
Laryngeal Mask Airways (LMA)
• The LMA was invented by Dr. Archie Brain at the
London Hospital, Whitechapel in 1981
• The LMA consists of two parts:
– The mask
– The tube
• The LMA has proven to be very effective in the
management of airway crisis
• The LMA design:
– Provides an “oval seal around the laryngeal inlet” once
the LMA is inserted and the cuff inflated.
– Once inserted, it lies at the crossroads of the digestive
and respiratory tracts.
Indications for the use of the LMA

• Situations involving a difficult mask (BVM) fit.

• May be used as a back-up device where endotracheal
intubation is not successful.
• May be used as a “second-last-ditch” airway where a
surgical airway is the only remaining option.
Equipment for LMA Insertion

 Body Substance Isolation equipment

 Appropriate size LMA
 Syringe with appropriate volume for LMA cuff inflation
 Water soluble lubricant
 Ventilation equipment
 Stethoscope
 Tape or other device(s) to secure LMA
Preparation of the LMA for Insertion

 Step 1: Size selection

 Step 2: Examination of the LMA
 Step 3: Check deflation and inflation of the cuff
 Step 4: Lubrication of the LMA
 Step 5: Position the Airway
Step 1: Size Selection

 Verify that the size of the LMA is correct for the patient
 Recommended Size guidelines:
 Size 1: under 5 kg
 Size 1.5: 5 to 10 kg
 Size 2: 10 to 20 kg
 Size 2.5: 20 to 30 kg
 Size 3: 30 kg to small adult
 Size 4: adult
 Size 5: Large adult/poor seal with size 4
Step 2: Examination of the LMA

 Visually inspect the LMA cuff for tears or other

abnormalities
 Inspect the tube to ensure that it is free of blockage or
loose particles
 Deflate the cuff to ensure that it will maintain a vacuum
 Inflate the cuff to ensure that it does not leak
Step 3: Deflation and Inflation of the
LMA
 Slowly deflate the cuff to form a smooth flat wedge shape which will pass
easily around the back of the tongue and behind the epiglottis.
 During inflation the maximum air in cuff should not exceed:
 Size 1: 4 ml
 Size 1.5: 7 ml
 Size 2: 10 ml
 Size 2.5: 14 ml
 Size 3: 20 ml
 Size 4: 30 ml
 Size 5: 40 ml
Step 4: Lubrication of the LMA

 Use a water soluble lubricant to lubricate the LMA

 Only lubricate the LMA just prior to insertion
 Lubricate the back of the mask thoroughly
Important Notice:
 Avoid excessive amounts of lubricant
 on the anterior surface of the cuff or
 in the bowl of the mask.

 Inhalation of the lubricant following placement may result in coughing

or obstruction
Step 5: Positioning of the Airway

 Extend the head and flex the neck

 Avoid LMA fold over:
 Assistant pulls the lower jaw downwards.
 Visualize the posterior oral airway.
 Ensure that the LMA is not folding over in the oral cavity as
it is inserted.
LMA
Insertion
Technique
LMA Insertion Step 1

 Grasp the LMA by the

tube, holding it like a
pen as near as possible
to the mask end.
 Place the tip of the
LMA against the inner
surface of the patient’s
upper teeth
LMA Insertion Step 2

 Under direct vision:

 Press the mask tip upwards against
the hard palate to flatten it out.
 Using the index finger, keep
pressing upwards as you advance
the mask into the pharynx to ensure
the tip remains flattened and avoids
the tongue.
LMA Insertion Step 3

 Keep the neck

flexed and head
extended:
 Press the mask
into the posterior
pharyngeal wall
using the index
finger.
LMA Insertion Step 4

 Continue pushing
with your index
finger.
 Guide the mask
downward into
position.
LMA Insertion Step 5

 Grasp the tube firmly

with the other hand
 then withdraw your
index finger from the
pharynx.
 Press gently
downward with your
other hand to ensure
the mask is fully
inserted.
LMA Insertion Step 6

 Inflate the mask with the

recommended volume of air.
 Do not over-inflate the LMA.
 Do not touch the LMA tube
while it is being inflated
unless the position is
obviously unstable.
 Normally the mask should be
allowed to rise up slightly out of
the hypopharynx as it is inflated
to find its correct
Verify Placement of the LMA

 Connect the LMA to a Bag-Valve Mask device or

low pressure ventilator
 Ventilate the patient while confirming equal
breath sounds over both lungs in all fields and the
absence of ventilatory sounds over the
epigastrium
Securing the LMA

 Insert a bite-block or roll of gauze to prevent

occlusion of the tube should the patient bite
down.
 Now the LMA can be secured utilizing the same
techniques as those employed in the securing of
an endotracheal tube.
Problems with LMA Insertion

 Failure to press the

deflated mask up
against the hard
palate or
inadequate
lubrication or
deflation can cause
the mask tip to fold
back on itself.
Problems with LMA Insertion

 Once the mask tip

has started to fold
over, this may
progress, pushing
the epiglottis into
its down-folded
position causing
mechanical
obstruction
 If the mask tip is deflated
forward it can push down
the epiglottis causing
obstruction
 If the mask is inadequately
deflated it may either
 push down the epiglottis
 penetrate the glottis.
Intubasi Endotrakeal
Indikasi intubasi endotrakeal
 For supporting ventilation in patient with some pathologic disease
Upper airway obstruction
Respiratory failure
Loss of conciousness
 For supporting ventilation during general anesthesia
Type of surgery
Operative site near the airway
Abdominal or thoracic surgery
Prone or lateral position
Long period of surgery
 Patient has risk of pulmonary aspiration
 Difficult mask ventilation
Persiapan

 Scop : Laringoskop dan stetoskop

 Tube : Pipa (tube) endotrakeal
 Airway : Orapharyngeal airway
 Tape : Tape utk fiksasi
 Introducer : Alat bantu pengarah
 Connector : Alat yg menghubungkan antar lumen (pipa)
 Suction : Alat penghisap cairan dan perlengkapannya
Laryngoscope : handle and blade
 LARYNGOSCOPIC BLADE
 Macintosh (curved) and Miller (straight) blade
 Adult : Macintosh blade, small children : Miller
blade

Miller blade Macintosh blade

Endotracheal tube
 Endotracheal tube
Size of endotracheal tube : internal diameter (ID)

Male: ID 8.0 mms . Female : ID 7.5 mms

 New born - 3 months : ID 3.0 mms
 3-9 months : ID 3.5 mms
 9-18 months : ID 4.0 mms
 2- 6 yrs : ID = (Age/3) + 3.5
 > 6 yrs : ID = (Age/4) + 4.5
Material : Red rubber or PVC

Endotracheal tube cuff

High volume Low volume

Low pressure cuff High pressure cuff
Oropharyngeal or nasopharyngeal airway

Oral airway
Nasal airway
Sniffing position
Preoksigenasi

 Selama tahap persiapan, pasien harus diberikan100% O2.

 Menggunakan resuscitator manual (O2 15 L/menit, dengan sistem
reservoir O2 yang berfungsi) dengan sungkup muka yang pas.
 Jika ventilasi spontan pasien dirasakan tidak memadai, diperlukan
ventilasi assisted inspirasi.
 Pada pasien apnea, ventilasi tekanan positif akan dibutuhkan.
 Preoksigenasi adalah langkah yang sangat penting. Jika langkah ini
tidak dilakukan, pasien berisiko mengalami hipoksemia berat selama
dilakukan intubasi.
KONFIRMASI LOKASI ETT

 Objektif
 Melihat langsung ETT melewati pita suara
 EtCO2

 Subjektif
 Melihat kembangan dada
 Auskultasi dada
 Auskultasi lambung
 Saturasi O2
 Adanya uap di ETT
Complication of endotracheal
intubation
During intubation
© Trauma to lip, tongue or teeth
© Hypertension and tachycardia or arrhythmia
© Pulmonary aspiration
© Laryngospasm
© Bronchospasm
© Laryngeal edema
© Arytenoid dislocation -> hoarseness
© Increased intracranial pressure
© Spinal cord trauma in cervical spine injury
© Esophageal intubation
Complication of endotracheal
intubation
During remained intubation
® Obstruction from klinking , secretion or overinflation of cuff
® Accidental extubation or endobronchial intubation
® Disconnection from breathing circuit
® Pulmonary aspiration
® Lib or nasal ulcer in case with prolong period of intubation
® Sinusitis or otitis in case with prolong nasoendotracheal intubation
Complication of endotracheal
intubation
During extubation
 Laryngospasm
 Pulmonary aspiration
 Edema of upper airway
Complication of endotracheal
intubation
After extubation
 Sore throat
 Hoarseness
 Tracheal stenosis (Prolong intubation)
 Laryngeal granuloma
Trakeostomi
 Trakeostomi

MAKING AN OPENING IN THE ANTERIOR WALL

OF TRACHEA & CONVERTING IT IN TO A STOMA
ON THE SKIN THE SURFACE
Indications of Tracheostomy

There are three main indications

 A. Respiratory obstruction.
 B. Retained secretions.
 C. Respiratory insufficiency.
Respiratory obstruction

Infections
 Acute laryngo-tracheo-bronchitis, acute epiglottitis, diphtheria Ludwig's angina, peritonsillar, retropharyngeal
or parapharyngeal abscess, tongue abscess
Trauma
 External injury of larynx and trachea ,Trauma due to endoscopies, especially in infants and children,Fractures
of mandible or maxillofacial injuries
Neoplasms
 Benign and malignant neoplasms of larynx, pharynx, upper trachea, tongue and thyroid
Foreign body larynx
Oedema larynx
 due to steam, irritant fumes or gases, allergy (angioneurotic or drug sensitivity), radiation
Bilateral abductor paralysis
Congenital anomalies
 Laryngeal web, cysts, tracheo-oesophageal fistula Bilateral choanal atresia
Retained secretions

1. Inability to cough
 Coma of any cause, e.g. head injuries, cerebrovascular accidents, narcotic
overdose
 Paralysis of respiratory muscles, e.g. spinal injuries, polio, Guillain-Barre
syndrome, myasthenia gravis
 Spasm of respiratory muscles, tetanus, eclampsia, strychnine poisoning
2. Painful cough
 Chest injuries, multiple rib fractures, pneumonia
3. Aspiration of pharyngeal secretions
 Bulbar polio, polyneuritis, bilateral laryngeal paralysis
Respiratory insufficiency

 Chronic lung conditions, viz. emphysema, chronic

bronchitis, bronchiectasis, atelectasis
Types of Tracheostomy

 Emergency tracheostomy
 Elective or tranquil tracheostomy
 Permanent tracheostomy
 Percutaneous dilatational tracheostomy
 Mini tracheostomy (cricothyroidotomy)
Technic

 Whenever possible, endotracheal intubation should be done before

tracheostomy. This is specially important in infants and children.
 Position
 supine with a pillow under the shoulders so that neck is extended.

 Anaesthesia
 No anaesthesia }unconscious patients/ emergency procedure.
 conscious patients, 1-2% lignocaine with epinephrine
 GA with intubation+/-
1. A vertical incision
 in the midline of neck,
extending from cricoid
cartilage to just above the
sternal notch.
 This is the most favoured
incision and can be used in
emergency and elective
procedures.
 It gives rapid access with
minimum of bleeding and tissue
dissection.
A transverse incision, 5 cm
long, made 2 fingers'
breadth above the sternal
notch can be used in
elective procedures. It has
the advantage of a
cosmetically better scar .
 2. After incision, tissues are dissected in the midline.
Dilated veins are either displaced or ligated.
 3. Strap muscles are separated in the midline and
retracted laterally.
 4. Thyroid isthmus is displaced upwards or divided
between the clamps, and suture-ligated.
 6. Trachea is fixed with a hook and opened with a vertical incision in the
region of 3rd and 4th or 3rd and 2nd rings. This is then converted
into a circular opening. The first tracheal ring is never divided as
perichondritis of cricoid cartilage with stenosis can result (Fig. 63.2).
 7. Tracheostomy tube of appropriate size is inserted and secured by tapes
 8. Skin incision should not be sutured or packed tightly as it may lead to
development of subcutaneous emphysema.
 9. Gauze dressing is placed between the skin and flange of the tube
around the stoma.
Complications

 A. Immediate (at the time of operation):

1. Haemorrhage.
2. Apnoea.
This follows opening of trachea in a patient who had prolonged respiratory
obstruction. This is due to sudden washing out of CO2 which was acting as a
respiratory stimulus. Treatment is to administer 5% CO in oxygen or assisted
ventilation.
3. Pneumothorax due to injury to apical pleura.
4. Injury to recurrent laryngeal nerves.
5. Aspiration of blood.
6. Injury to oesophagus. This can occur with tip of knife while incising the trachea
and may result in tracheo-oesophageal fistula.
Complications

 B. Intermediate (during first few hours or days):

1. Bleeding, reactionary or secondary.
2. Displacement of tube.
3. Blocking of tube.
4. Subcutaneous emphysema.
5. Tracheitis and tracheobronchitis with crusting in trachea.
6. Atelectasis and lung abscess.
7. Local wound infection and granulations.
Complications

 C. Late (with prolonged use of tube for weeks and months):

1. Haemorrhage, due to erosion of major vessel.
2. Laryngeal stenosis, due to perichondritis of cricoid cartilage.
3. Tracheal stenosis, due to tracheal ulceration and infection.
4. Tracheo-oesophageal fistula, due to prolonged use of cuffed tube or erosion of
trachea by the tip of tracheostomy tube.
5. Problems of decannulation. Seen commonly in infants and children.
6. Persistent tracheocutaneous fistula.
7. Problems of tracheostomy scar. Keloid or unsightly scar.
8. Corrosion of tracheostomy tube and aspiration of its fragments into the
tracheobronchial tree.
Krikotirotomi
Krikotirotomi

 Merupakan prosedur darurat yang penting yang digunakan untuk

mendapatkan jalan nafas saat metode lain yang lebih rutin (misalnya,
jalan nafas topeng laryngeal [LMA] dan intubasi endotrakeal) tidak
efektif atau dikontraindikasikan.
 Menetapkan jalan napas yang efektif dalam menghadapi keadaan
darurat medis merupakan keterampilan yang harus dimiliki petugas
kesehatan untuk mencegah morbiditas atau mortalitas pasien.
 Kegagalan untuk mendapatkan jalan nafas dengan metode tradisional dalam situasi berikut :
 Trauma yang menyebabkan pendarahan oral, faring, atau nasal
 Spasme otot-otot wajah atau laringospasme
 Muntah yang tidak terkendali
 Stenosis atau kelainan bawaan saluran napas bagian atas
 Gigi yang terkatup
 Tumor, kanker, atau proses penyakit lain atau trauma yang menimbulkan efek massa
 Obstruksi jalan nafas meliputi:
 Edema Orofaringeal (misalnya anafilaksis)
 Obstruksi karena benda asing
 Indikasi relatif
 Imobilisasi tulang belakang servikal sekunder akibat cedera
 Cedera maksilofasial
 Indikasi non-emergensi
 Intubasi lama (prolonged)
 Operasi di daerah maksillofacial, laring atau oral
 Bronkoskopi
Kontraindikasi

 Kontraindikasi absolut, umur (batasan masih kontroversial ; dibawah 5-12

tahun
 Anak-anak di bawah 12 tahun memiliki selaput kriotiroid yang lebih kecil dan
laring yang lebih berbentuk corong
Pertimbangan Teknis

 Trakeostomi permanen harus ditempatkan dalam waktu 24 jam.

 Jarum krikotirotomi dapat digunakan selama kurang lebih 40 menit, setelah
waktu dimana karbon dioksida terakumulasi; hal ini bisa sangat berbahaya
pada pasien trauma kepala.
 Stoma dgn krikotiroidotomi yang dipertahankan selama lebih dari 2 hari
berkaitan dengan risiko stenosis glotis dan subglotis yang lebih tinggi daripada
trakeostomi.
Teknik Pemasangan

 Krikotirotomi dgn jarum (needle krikotirotomi)

 Krikotirotomi perkutan (teknik Seldinger)
 Krikotiromi pembedahan
Krikotiromi Jarum

 Posisikan pasien, oleskan lidokain (jika diindikasikan),

dan siapkan bidang steril, termasuk pembersihan
dengan larutan antiseptik.
 Identifikasi landmark anatomi.
 Siapkan jarum suntik yang diisi larutan NaCl
 Tusukkan jarum, seiring jarumnya maju, lakukan
aspirasi
 Saat melintasi membran dan memasuki trakea, akan
terasa spt memasuki rongga, dan ada gelembung
udara
 Sambungkan dgn kateter
 Berikan ventilasi jet
Krikotirotomi Perkutan

 Melanjutkan tahapan krikotirotomi

jarum
 Masukkan kawat penuntun mll lubang
jarum.
 Cabut jarum, pertahankan kawat
penuntun
 Insisi kecil pada stoma
 Lebarkan dgn dilatator
 Pasang pipa krikotiromi
 Cabut kawat penuntun
 Fiksasi
Krikotirotomi Pembedahan

 Setelah menentukan landmark

 Dengan tangan dominan, buat sayatan vertikal garis tengah, kira-kira panjangnya 3 cm dan
kulit dalam, di atas membran krikotiroid.
 Palpasi membran krikotiroid melalui sayatan, dengan menggunakan telunjuk tangan
nondominan.
 Buat sayatan tusukan horizontal melalui selaput.
 Sebuah pop yang berbeda akan terasa saat pisau bedah menembus membran dan memasuki
trakea.
 Dilatasi sayatan secara vertikal, gunakan dilator Trousseau dengan tangan nondominan.
 Dengan tangan yang dominan, masukkan tabung trakeostomi di antara 2 bilah dilator, arahkan
awalnya ke satu sisi pasien. Setelah tabung melewati membran, putar 90 o dan sisipkan secara
kaudal.
 Lepaskan obturator, dan masukkan kanula bagian dalam. Kunci ke tempatnya.
 Kembangkan balon dengan 5-10 mL udara. Pasang tabung ke BVM dan berikan ventilasi.
Komplikasi

Dini Lama
 Perdarahan  Disfonia
 Malposisi  Infeksi
 Emfisema subkutis
 Hematoma
 Obstruksi
 Stoma persisten
 Perforasi esofagus/mediastinum
 Aspirasi  Jaringan parut

 Cedera pita suara  Stenosis glotis atau sub glotis

 Pneumtorak  Stenosis laring
 Cedera laring  Fistula trakeoesofageal
 Perforasi dinding posterior trakea
 Trakeomalasia
 Perforasi tiroid
 Hiperkarbia (krikotiromi jarum)