Oxygen Therapy

and
Airway-Breathing Management

Dr. ERICA GILDA SIMANJUNTAK, SpAN

SMF Anestesiologi FK UKI-RS UKI
Jakarta

The Bodys Need for Oxygen

Living tissue must have oxygen to

survive
Brain death in human occurs within 6
to 10 minutes of tissue anoxia
Rapid and safe airway control is
paramount to the successful
management of critically ill and
injured patients
2

A basic understanding of the following is

needed to properly maintain airway :
Respiratory system anatomy and

physiology
Causes of airway failure
Available equipment
Technique utilized

Airway (jalan napas)

- bagian atas
- bagian bawah

Batas
Upper
dan
Lower
Resp tract

Upper Airway
Mouth
Nose
Pharynx
Oropharynx
Laringopharynx
Larynx

Lower Airway
Trachea
Bronchi
Bronchioles
Alveoli
Lungs

Ventilation and Respiration

Ventilation is the movement of air

into and out of lungs

Two phase of ventilation:
Inspiration
Expiration
Respiration is the exchange of gases
between a living organism and its
environments
8

Type of Respiration
Internal Respiration:
The exchange of gases between the

blood cells and tissue.

External Respiration:
The exchange of gases in the lung at the

alveolar capillary interface.

TAHAPAN RESPIRASI
1. VENTILASI
2. PERFUSI PARU - PARU
3. PERTUKARAN GAS DI PARU-PARU
4. TRANSPORT OKSIGEN
5. EKSTRAKSI ( OXYGEN UPTAKE )

10

Clinical condition associated with

decrease oxygen level are:
Hypoxemia
Insufficient oxygenation of the blood

Hypoxia
A lack of oxygen in inspired air

Anoxia
Total absence of oxygen

11

Airway
Obstruksi Total
Sadar :
Benda asing
Tidak Sadar
RPJ : berat

Heimlich
finger sweep
abd. Thrust
instrumental
12

Airway
Obstruksi Partial
Cairan
cairan)

gurgling (bunyi

Lidah

snoring (mengorok)

Laring/trakea

crowing (snoring)

13

IMMEDIATE NEED FOR DEFINITIVE AIRWAY

SUSP. CERVICAL SPINE
INJURY
OXYGENATE/
VENTILATE

APNEIC

OROTRACHEAL
INTUBATION WITH
INLINE IMMOBILIZATION

SEVERE
MAXILLOFACIAL
INJURY

UNABLE TO
INTUBATE

UNABLE TO
INTUBATE

BREATHING

NASOTRACHEAL or
OROTRACHEAL
INTUBATION WITH INLINE
CERVICAL IMMOBILIZATION

UNABLE TO
INTUBATE
PHARMACOLOGIC
ADJUNCT

SURGICAL
AIRWAY

UNABLE TO
INTUBATE

14

Manual Airway Management Maneuvers

Head tilt / chin lift
Jaw thrust without head tilt
Modified Jaw-Thrust

15

Manual Airway Management Maneuver Jaw Thrust with Head tilt

Maneuver

Head-tilt / Chin lift

Technique

Tilt head back

Lift chin forward
Open mouth

Indication

Unresponsive patient without c-spine

injury, and those who are unable to

protect their own way
Contraindication

Awake and alert patient

Patient with possible c-spine injury

Advantage

No equipment required
Simple
Safe
Non-invasive

Disadvantage

Head tilt hazardous to c-spine injured

patient
Does not protect from aspiration

16

Manual Airway Management Maneuver Jaw Thrust without Head tilt (01)

Maneuver

Jaw-Thrust without head-tilt

Technique

Head is maintained in neutral alignment

Jaw is displaced forward
Lift by grasping under chin and behind teeth
Mouth opened

Indication

For patient who are responsive, unable to

protect their own airway, or may have a cspine injury

Contraindication

Responsive patient
Patient resistant to opening mouth

17

Manual Airway Management Maneuver Jaw Thrust without Head tilt (02)
Advantage

No equipment required
Simple
Safe
Non Invasive
Maybe used in c-spine injury
May be performed with c-collar in place

Disadvantage

Cannot maintain if patient becomes

responsive or combative
Difficult to maintain for extended period
Very difficult to use in conjunction with
bag-valve-mask ventilation
Thumb must remain in patients mouth to
maintain displacement
Does not protect from aspiration
18

Manual Airway Management ManeuverModified Jaw-Thrust (01)

Maneuver

Modified jaw-thrust

Technique

Head is maintained in neutral alignment

Jaw is displaced forward at mandibular angle.

Indication

Unresponsive patient who may have a c-spine injury, and those

who are unable to protect their own way.

Patient resistance to opening mouth

Contraindication
Advantage

Awake, responsive patient

No equipment required
Simple
Safe
Non-invasive
May be used with c-collar in place

Disadvantage

Difficult to maintain
Requires second rescuer for bag-valve-mask (BVM) ventilation
Does not protect from aspiration

19

INDICATION DEFINITIVE AIRWAY

NEED FOR AIRWAY
PROTECTION

NEED FOR VENTILATION

UNCONSCIOUS

APNEA :
NEUROMUSCULAR PARALYSIS
UNCONSCIOUS

SEVERE MAXILLOFACIAL
FRACTURES

INADEQUATE RESPIRATORY
EFFORTS
TACHYPNEA
HYPOXIA
HYPERCARBIA
CYANOSIS

RISK FOR ASPIRATION :

BLEEDING
VOMITING

SEVERE, CLOSED HEAD INJURY

WITH NEED FOR BRIEF
HYPERVENTILATION IF ACUTE
NEUROLOGIC DETERIORATION
OCCURS

RISK FOR OBSTRUCTION :

NECK HEMATOMA
LARYNGEAL, TRACHEAL INJURY
STRIDOR

20

AIRWAY

menilai jalan napas

LIHAT - LOOK

DENGAR - LISTEN

Gerak udara napas

dengan telinga

RABA - FEEL

( Look - Listen - Feel )

Gerak dada & perut

Tanda distres napas
Warna mukosa, kulit
Kesadaran

Gerak udara napas

dengan pipi
21

fleksi

Posisi kepala fleksi,

jalan napas buntu

ekstensi

alan napas bebas karena

epala diposisikan ekstensi
engan Head tilt, Chin lift
22

Membebaskan jalan napas ( manual

)

head tilt

neck lift

chin lift

Head-tilt, juga untuk pasien

trauma
Chin lift, juga untuk pasien trauma
Neck lift, tidak boleh dilakukan
sama sekali.
23

JAW THRUST
cara ini sebagai pilihan
terakhir jika cara lain tidak
berhasil.
Untuk orang awam tidak
dianjurkan 24

Pola NAPAS SEE SAW tanda ada obstruksi total

25

Jika jalan napas tersumbat

benda asing
Dapat diketahui

jika chin lift atau

jaw thrust tidak
berhasil
membebaskan
jalan napas
Kerjakan manuver
Heimlich

26

Membersihkan benda asing padat dalam jalan napa

menggunakan alat penjepit ( Forcep )

27

Jika korban muntah

Buka mulut, bersihkan sekedarnya

agar jalan napas cukup bebas

Jika muntah lagi, baringkan miring

28

Finger sweep

29

Jika muntah lagi, baringkan miring

Pasien TIK tinggi sering muntah

Posisi baring miring

perhatikan cedera leher
30

Stable side position

31

Alat-bantu jalan napas buatan

(1). Oro-pharyngeal tube

Perhatikan ukuran

Jangan dipasang jika reflex muntah masih (+)

32

Cara memasang
oropharingeal tube

33

(2). Naso-pharyngeal
tube

- Tidak merangsang muntah

- Hati-hati pasien dengan fraktura basis cranii
- Ukuran untuk dewasa 7 mm atau
sebesar ukuran jari kelingking kanan
34

Cara memasang
nasopharingeal tube

35

Laryngeal
mask
Tehnik pemasangan
mudah.
Harga mahal
Tidak mencegah
aspirasi

36

Malampati

37

Intubasi trachea
Pemasangan endotracheal tube
dengan laryngoscopy
Perlu alat dan
ketrampilan khusus
38

39

Intubasi trachea
Pemasangan endotracheal tube
dengan laryngoscopy

40

41

Cricothyroidotomy
Jalur darurat untuk oksigenasi
Bertahan 10 menit
Tidak dapat membuang CO2

42

43

44

45

Yakinkan jalan napas bebas

dan
secepat mungkin berikan
tambahan Oksigen

46

Napas
buatan

47

BAG VALVE MASK (BVM)

oksigen 8-10 lpm : 60%

48

Pasien dengan
jalan napas buatan
Endotracheal tube (ETT)

Napas dibantu alat :

VENTILATO
R
49

FACE MASK O2 8-10

lpm
FiO2 : 40-60%

BVM Dengan reservoir

bag
Flow O2 : 8-10 lpm
FiO2
: 80%- 100%

BAG VALVE MASK (BVM)

Dgn oksigen 8-10 lpm :

Masker sederhana
Dengan reservoir bag
Flow O2 : 6-10 lpm
FiO2
: 60%- 100%

Jackson Rees
Flow O2 : 8-10
lpm
FiO2
: 100%

Terapi
oksigen

NASAL PRONG
O2 flow 1 6 lpm
FiO2 : 24 44 %

BVM Dengan reservoir bag

Flow O2 : 8-10 lpm
FiO2
: 80%- 100%

50

51

52

53

54

TERAPI OKSIGEN

55

OKSIGEN
DIPERLUKAN PADA PROSES METABOLISME
UNTUK PEMBENTUKAN
ENERGI BIOLOGIS ( ATP )
METABOLISME SECARA ANAEROBIK
AKAN MENGAKIBATKAN
GANGGUAN PEMBENTUKAN ATP
DAN PEMBENTUKAN
ASAM LAKTAT/ ASIDOSIS
56

Proses Produksi
Energi
Glukosa + O2 H2O + CO2 + 38 ATP
Glukosa tanpa O2 Lactic Acid + 2 ATP
(Anerobik)
57

TERAPI OKSIGEN
DIINDIKASIKAN
BILA TERJADI GANGGUAN OKSIGENASI
JARINGAN
UNTUK MENCEGAH PENYULIT YANG
TERJADI
KARENA HIPOKSEMIA
58

DERAJAT HIPOKSEMIA DITENTUKAN OLEH :

1.

A - a DO2 ( Alveolar - arterial O2 Difference )

= PAO2 - PaO2

PAO2 = ( PB - PH2O ) X FiO2 - PaCO2 / R

2. PaO2 / FiO2

59

TRANSPORT OKSIGEN :
DO2 = (Hb X CO X SaO2 X 1,34) + (0,003 X PaO2)

60

Transport
oksigen
1. Kecukupan transport Oksigen Jaringan
Freeman)

(Nunn-

Av. O2
= CO {(Hb x SaO2 x 1.34)+(pO2 x
0.003)}
Available O2 = CO x Ca O2
Bila Ca O2 turun --> di-kompensasi dengan
menaikkan CO
2. Oksigen dalam darah
Ca O2 = (Hb x Sa O2 x 1,34) + (Pa O2 x 0,003)
3. Cardiac Output (CO)

61

GEJALA - TANDA HIPOKSIA :

1. DYSPNEU ( SESAK )

2.
3.
4.
5.
6.
7.
8.

DIAPHORESIS ( BERKERINGAT )
GELISAH
TAKIPNEU
TEKANAN DARAH / NADI MENINGKAT
PERUBAHAN POLA NAPAS
GANGGUAN MENTAL
SIANOSIS ( BIRU )

62

INDIKASI TERAPI OKSIGEN :

1.
2.
3.
4.
5.
6.

HENTI NAPAS - JANTUNG

GAGAL NAPAS - TIPE I ATAU TIPE II
PAYAH JANTUNG
INFARK MIOKARD AKUT
SHOCK APAPUN PENYEBABNYA
PENINGKATAN KEBUTUHAN METABOLISME
( LUKA BAKAR,SEPSIS , MULTI TRAUMA )
7. PASCA BEDAH
8. KERACUNAN KARBONMONOKSIDA.

63

Tanda mengarah ke GAGAL NAPAS :

1. PERNAPASAN ABDOMINAL DOMINAN
2. GERAK OTOT NAPAS TAMBAHAN
- STERNOCLEIDOMASTOID
- INTERCOSTAL
3. RETRAKSI SUPRASTERNAL.INTERCOSTAL

64

HIPOKSIA

TERAPI OKSIGEN
65

PEDOMAN UMUM TERAPI OKSIGEN :

1. PaO2 < 60 mmHg

2. SaO2 < 90 %

66

METODE TERAPI OKSIGEN

SYARAT :
1. FiO2 DAPAT DIKENDALIKAN
2. PENCEGAHAN PENUMPUKAN CO2
3. RESISTENSI MINIMAL
4. EFFISIEN DAN EKONOMIS
5. NYAMAN BAGI PASIEN
67

KASKADE OKSIGEN /OXYGEN GRADIENT

LEVEL

TEKANAN (mmHg)

AIR

150

ALVEOLI

103

ARTERI

100

KAPILER

50

MITOKONDRIA

1-20

68

Klasifikasi
Hipoksia

Hypoxic hypoxia
Stagnant hypoxia
Anemic hypoxia
Cytotoxc hypoxia
Demand hypoxia

Gangguan respirasi
Gangguan sirkulasi
Gangguan Hb
Gangguan penggunaan O2 di se
Peningkatan kebutuhan O2

69

70

ALAT TERAPI OKSIGEN

I . FIXED SYSTEM ( FiO2 TIDAK DIPENGARUHI FAKTOR
PASIEN )
1. SISTIM VENTURI - HIGH FLOW
2. LOW FLOW BREATHING CIRCUITS ( CPAP,
BAG-MASK,JAKSON-REES ,MESIN ANESTESI )
II. VARIABLE SYSTEM ( FiO2 TERGANTUNG PADA FLOW
OKSIGEN,ALAT YANG DIGUNAKAN DAN PASIEN )
1. NASAL KATETER / PRONG
2. SIMPLE MASK
3. MASKER DAN REBREATHING BAG
III. BAYI - ANAK :
1, HEAD BOX
2. INKUBATOR
71

NASAL PRONG

24 - 40 %

SIMPEL MASK

40 - 50 %

VENTURI - MASK
PARTIAL REBREATHING

24 - 50 %
60 - 80 %

NON REBREATHING

- 90 %

CPAP

- 100 %

VENTILATOR

- 100 %

72

Konsentrasi Oksigen yang dihasilkan

tergantung pada :
1. Alat

2. Cara pemberian
3. Pasien kooperatif atau tidak
4. Pola napas pasien.
Pasien dengan tidal volume rendah,
takhipneu dan pola napas tidak normal ,
konsentrasi Oksigen
yang masuk ke pasien akan berubah
73

Konsentrasi Oksigen tergantung dari jenis

alat dan flowrate (aliran permenit)
JENIS ALAT

KONSENTRASI O2

ALIRAN O2

Nasal kanula

24% - 54%

1 - 2 LPM

Simple face
mask

35% - 60%

6 - 12 LPM

Partial
rebreather

35% - 95%

6 10 LPM

Non Rebreater

80% 50%

8 12 LPM

Venturi

24% - 50%

4 12 LPM

Bag Valve Mask

Tanpa Oksigen

21% (UDARA)

Dng Oksigen

50% - 100%

Positive Press

> 100%

8 12 Lpm
74

8 12 Lpm

FACE MASK O2 8-10

lpm
FiO2 : 40-60%

BVM Dengan reservoir

bag
Flow O2 : 8-10 lpm
FiO2
: 80%- 100%

BAG VALVE MASK (BVM)

Dgn oksigen 8-10 lpm :

Masker sederhana
Dengan reservoir bag
Flow O2 : 6-10 lpm
FiO2
: 60%- 100%

Jackson Rees
Flow O2 : 8-10
lpm
FiO2
: 100%

Terapi
oksigen

NASAL PRONG
O2 flow 1 6 lpm
FiO2 : 24 44 %

BVM Dengan reservoir bag

Flow O2 : 8-10 lpm
FiO2
: 80%- 100%

75

SUPPLEMENTAL
OXYGEN

1. Nasal cannula / prong

Low flow system
Flow O2
: 1-6 L/m
FiO2
: 24-44% (1 L O2/M FiO2 4%)
2. Face mask
Low flow system
Flow O2
: 8-10 L/m
FiO2
: 40-60 %

76

Nasal prong
Keuntungan : mudah penggunaan
ringan
ekonomis
disposable
nyaman,pasien bisa mobilisasi
Kerugian :mudah lepas
maksimum FiO2 40 %
iritasi telinga
Tehnik lain dengan kateter :
1. Nasal kateter
2. Transytracheal kateter.
77

Masker oksigen

Umum : digunakan bila perlu pemberian Oksigen secara

untuk jangka waktu singkat
Konsentrasi Oksigen bervariasi antara 24 - 100 %

Kerugian :
1. Tidak nyaman,
2. Iritasi kulit akibat pemakaian masker ketat
3. Kontrol FiO2 sukar,( kecuali dengan sistim ventur
4. Kalau pasien makan harus dilepas

Komplikasi :
1. Bila pasien muntah dapat terjadi aspirasi
2. Dapat mengakibatkan retensi CO2 dan hipoventi
kalau flow terlalu rendah atau lubang ekshalasi
tersumbat.
78

Masker Oksigen :
1. Simple mask ( 35 - 60 % dengan flow 6 - 10 L )
2. Partial rebreathing ( 35 - 60 % dengan flow 6 - 10
3. Non rebreathing ( 90 % ,bila tidak ada kebocoran

79

3. Face mask with oxygen reservoir

Constant flow
Flow O2 : 6-10 L/m
FiO2
: 6L O2 / m : 60 % (1 L O2/M FiO2 10%)

80

Chest physical
therapy, oxygen,Intubation
close
Tracheotomy
Acceptable
monitoring Ventilation
Range
Mechanics
Respiratory rate
Vital capacity,
ml/kg
Inspiratory
force,cm,H2O
Oxygenation
A-aDO2,mm,hgt
paO2,mm,Hg
Ventilation
Vp/Vt
paO2,mm,Hg

12-25
70-30
100-550-200
100-75
(air)
0.3-04
35-45

25-35
> 35
30-15
< 15
50-25
< 25
200-350
> 35C
200-70
< 70
(on mask O2) (on mask (,)
> 0.t
0.4-0.6
> 60
45-60

From: Pontoppidan,H.,Laver,M.B.,and Geffin,B,Acute respiratory failure in the surgical patient,

in Welch.,C.E.(ed): Advances in surgery, volume 4,Chicago, Year.
Book Medical Publishers,1970,p.163
After 15 minutes of 100% O2
Except in chronic hypercapnia
81

KRITERIA PONTOPPIDAN

From: Pontoppidan,H.,Laver,M.B.,and Geffin,B,Acute respiratory failure in the surgical patient,

in Welch.,C.E.(ed): Advances in surgery, volume 4,Chicago, Year.
Book Medical Publishers,1970,p.163
After 15 minutes of 100% O2
Except in chronic hypercapnia

82

GAGAL NAPAS
Napas dibantu alat - ventilator

83

84

85

Flow meter
regulator

humidifier
86

Monitoring
1. Klinis :
keluhan subyektif
pemeriksaan klinis
2. Laboratoris:
Gas darah
Saturasi Oksigen

87

Evaluasi dan monitoring

Klinis
Pulse oximetry
Kapnograf
ABG
X-ray
EKG

Terapi penyebab/definitif
88

89

90

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TERIMA KASIH
SHALOOM

92