Intubasi Sulit

NUR HAJRIYA BRAHMI

 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
- 4D
- Wilson Risk Scale
- Magboul 4M
 Skala LEMON atau MELON

Look externally
Evaluate 3-3-2-1 rule
Mallampati
Obstruction
Neck mobility
Tabel Skala LEMON
 Grading the Airway (Cormack-Lehane)

Figure 2 – 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
 LM-MAP

Look for external face deformities

Mallampati
Measure 3-3-2-1 fingers
Atlanto-occipital extension
Pathological obstructive conditions
 4D

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

Mallampati
Measurement
Movement
Malformation 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