Oxygen Therapy

and
Airway-Breathing Management

Dr. ERICA GILDA SIMANJUNTAK, SpAN

SMF Anestesiologi FK UKI-RS UKI
Jakarta
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The Body’s 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

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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

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Airway (jalan napas) - bagian atas
- bagian bawah

Batas
Upper
dan
Lower
Resp tract

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Upper Airway

 Mouth
 Nose
 Pharynx
 Oropharynx
 Laringopharynx
 Larynx

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Lower Airway

 Trachea
 Bronchi
 Bronchioles
 Alveoli
 Lungs

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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

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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.

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TAHAPAN RESPIRASI

1. VENTILASI

2. PERFUSI PARU - PARU

3. PERTUKARAN GAS DI PARU-PARU

4. TRANSPORT OKSIGEN

5. EKSTRAKSI ( OXYGEN UPTAKE )

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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

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Airway

Obstruksi Total
 Sadar :
Benda asing Heimlich
 Tidak Sadar
RPJ : berat finger sweep
abd. Thrust
instrumental

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Airway

Obstruksi Partial
 Cairan gurgling (bunyi cairan)

 Lidah snoring (mengorok)

 Laring/trakea crowing (snoring)

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 IMMEDIATE NEED FOR DEFINITIVE AIRWAY

SUSP. CERVICAL SPINE INJURY

OXYGENATE/
APNEIC BREATHING
VENTILATE

OROTRACHEAL INTUBATION NASOTRACHEAL or

SEVERE
WITH INLINE OROTRACHEAL INTUBATION
IMMOBILIZATION
MAXILLOFACIAL
WITH INLINE CERVICAL
INJURY
IMMOBILIZATION

UNABLE TO UNABLE TO UNABLE TO

INTUBATE INTUBATE INTUBATE

PHARMACOLOGIC
ADJUNCT

SURGICAL UNABLE TO
AIRWAY INTUBATE 14
Manual Airway Management Maneuvers

 Head tilt / chin lift

 Jaw thrust without head tilt
 Modified Jaw-Thrust

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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
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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 c-
spine injury
Contraindication  Responsive patient
 Patient resistant to opening mouth

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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 patient’s mouth to maintain
displacement
 Does not protect from aspiration

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Manual Airway Management Maneuver—Modified 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  Awake, responsive patient
Advantage  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

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 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 : SEVERE, CLOSED HEAD INJURY WITH NEED
•BLEEDING FOR BRIEF HYPERVENTILATION IF ACUTE
•VOMITING NEUROLOGIC DETERIORATION OCCURS
RISK FOR OBSTRUCTION :
•NECK HEMATOMA
•LARYNGEAL, TRACHEAL INJURY
•STRIDOR

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A AIRWAY - menilai jalan napas
 LIHAT - LOOK
 Gerak dada & perut
 Tanda distres napas
 Warna mukosa, kulit
 Kesadaran

 DENGAR - LISTEN
 Gerak udara napas
dengan telinga

 RABA - FEEL
 Gerak udara napas
( Look - Listen - Feel ) dengan pipi
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 fleksi Posisi kepala fleksi,
jalan napas buntu

ekstensi

Jalan napas bebas karena

kepala diposisikan ekstensi
dengan Head tilt, Chin lift
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 Membebaskan jalan napas ( manual )

head tilt chin lift

Head-tilt, juga untuk pasien

trauma
Chin lift, juga untuk pasien
trauma
Neck lift, tidak boleh dilakukan
neck lift
x 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

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Jika jalan napas tersumbat benda asing

 Dapat diketahui jika

chin lift atau jaw
thrust tidak berhasil
membebaskan jalan
napas
 Kerjakan manuver
Heimlich

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Membersihkan benda asing padat dalam jalan napas
menggunakan alat penjepit ( Forcep )

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Jika korban muntah

 Buka mulut, bersihkan sekedarnya

agar jalan napas cukup bebas
 Jika muntah lagi, baringkan miring

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Finger sweep

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 Jika muntah lagi, baringkan miring

Posisi baring miring

Pasien TIK tinggi sering muntah perhatikan cedera leher

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Stable side position

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 Alat-bantu jalan napas buatan
(1). Oro-pharyngeal tube

Perhatikan ukuran

Jangan dipasang jika reflex muntah masih (+)

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Cara memasang
oropharingeal tube

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 (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

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Cara memasang
nasopharingeal tube

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Laryngeal mask
• Tehnik pemasangan
mudah.
• Harga mahal
• Tidak mencegah
aspirasi

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Malampati

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 “Intubasi trachea”
Pemasangan endotracheal tube
dengan laryngoscopy

Perlu alat dan

ketrampilan khusus

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 “Intubasi trachea”
Pemasangan endotracheal tube
dengan laryngoscopy

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Cricothyroidotomy
Jalur darurat untuk oksigenasi

Bertahan 10 menit
Tidak dapat membuang CO2

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Yakinkan jalan napas bebas dan
secepat mungkin berikan
tambahan Oksigen

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Napas buatan

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BAG VALVE MASK (BVM)
oksigen 8-10 lpm : 60%

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 Pasien dengan
jalan napas buatan
Endotracheal tube (ETT)

Napas dibantu alat :

VENTILATOR

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 Masker sederhana
Dengan reservoir bag Jackson Rees
FACE MASK O2 8-10 lpm Flow O2 : 6-10 lpm Flow O2 : 8-10 lpm
FiO2 : 40-60% FiO2 : 60%- 100% FiO2 : 100%

Terapi oksigen

BVM Dengan reservoir bag NASAL PRONG

Flow O2 : 8-10 lpm O2 flow 1 – 6 lpm
FiO2 : 80%- 100% FiO2 : 24 – 44 %

BVM Dengan reservoir bag

BAG VALVE MASK (BVM) Flow O2 : 8-10 lpm
Dgn oksigen 8-10 lpm : 60% 50
FiO2 : 80%- 100%
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TERAPI OKSIGEN

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 OKSIGEN

DIPERLUKAN PADA PROSES METABOLISME

UNTUK PEMBENTUKAN
ENERGI BIOLOGIS ( ATP )

METABOLISME SECARA ANAEROBIK

AKAN MENGAKIBATKAN
GANGGUAN PEMBENTUKAN ATP
DAN PEMBENTUKAN
ASAM LAKTAT/ ASIDOSIS
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 Proses Produksi Energi

Glukosa + O2  H2O + CO2 + 38 ATP

Glukosa tanpa O2  Lactic Acid + 2 ATP

(Anerobik)

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TERAPI OKSIGEN
DIINDIKASIKAN

• BILA TERJADI GANGGUAN OKSIGENASI

JARINGAN

• UNTUK MENCEGAH PENYULIT YANG TERJADI

KARENA HIPOKSEMIA

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DERAJAT HIPOKSEMIA DITENTUKAN OLEH :

1. A - a DO2 ( Alveolar - arterial O2 Difference )

= PAO2 - PaO2

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

2. PaO2 / FiO2

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TRANSPORT OKSIGEN :

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

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 Transport oksigen

1. Kecukupan transport Oksigen Jaringan (Nunn-Freeman)

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)

Volume aliran darah yang membawa oksigen ke jaringan
CO = Heart Rate x Stroke Volume
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GEJALA - TANDA HIPOKSIA :

1. DYSPNEU ( SESAK )
2. DIAPHORESIS ( BERKERINGAT )
3. GELISAH
4. TAKIPNEU
5. TEKANAN DARAH / NADI MENINGKAT
6. PERUBAHAN POLA NAPAS
7. GANGGUAN MENTAL
8. SIANOSIS ( BIRU )

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INDIKASI TERAPI OKSIGEN :
1. HENTI NAPAS - JANTUNG
2. GAGAL NAPAS - TIPE I ATAU TIPE II
3. PAYAH JANTUNG
4. INFARK MIOKARD AKUT
5. SHOCK APAPUN PENYEBABNYA
6. PENINGKATAN KEBUTUHAN METABOLISME
( LUKA BAKAR,SEPSIS , MULTI TRAUMA )
7. PASCA BEDAH
8. KERACUNAN KARBONMONOKSIDA.

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Tanda mengarah ke GAGAL NAPAS :

1. PERNAPASAN ABDOMINAL DOMINAN

2. GERAK OTOT NAPAS TAMBAHAN

- STERNOCLEIDOMASTOID
- INTERCOSTAL

3. RETRAKSI SUPRASTERNAL.INTERCOSTAL

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 HIPOKSIA

TERAPI OKSIGEN

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PEDOMAN UMUM TERAPI OKSIGEN :

1. PaO2 < 60 mmHg

2. SaO2 < 90 %

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METODE TERAPI OKSIGEN
SYARAT :

1. FiO2 DAPAT DIKENDALIKAN

2. PENCEGAHAN PENUMPUKAN CO2

3. RESISTENSI MINIMAL

4. EFFISIEN DAN EKONOMIS

5. NYAMAN BAGI PASIEN

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KASKADE OKSIGEN /OXYGEN GRADIENT

LEVEL TEKANAN (mmHg)

AIR 150

ALVEOLI 103

ARTERI 100

KAPILER 50

MITOKONDRIA 1-20

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 Klasifikasi Hipoksia

• Hypoxic hypoxia • Gangguan respirasi

• Stagnant hypoxia • Gangguan sirkulasi
• Anemic hypoxia • Gangguan Hb
• Cytotoxc hypoxia • Gangguan penggunaan O2 di sel
• Demand hypoxia • Peningkatan kebutuhan O2

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PERALATAN UNTUK
PEMBERIAN OKSIGEN

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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

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NASAL PRONG 24 - 40 %

SIMPEL MASK 40 - 50 %

VENTURI - MASK 24 - 50 %

PARTIAL REBREATHING 60 - 80 %

NON REBREATHING - 90 %

CPAP - 100 %

VENTILATOR - 100 %

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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

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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% 8 – 12 Lpm
Positive Press > 100% 8 – 12 Lpm
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 Masker sederhana
Dengan reservoir bag Jackson Rees
FACE MASK O2 8-10 lpm Flow O2 : 6-10 lpm Flow O2 : 8-10 lpm
FiO2 : 40-60% FiO2 : 60%- 100% FiO2 : 100%

Terapi oksigen

BVM Dengan reservoir bag NASAL PRONG

Flow O2 : 8-10 lpm O2 flow 1 – 6 lpm
FiO2 : 80%- 100% FiO2 : 24 – 44 %

BVM Dengan reservoir bag

BAG VALVE MASK (BVM) Flow O2 : 8-10 lpm
Dgn oksigen 8-10 lpm : 60% 75
FiO2 : 80%- 100%
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 %

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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.
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Masker oksigen
Umum : digunakan bila perlu pemberian Oksigen secara cepat
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 venturi )
4. Kalau pasien makan harus dilepas

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

1. Simple mask ( 35 - 60 % dengan flow 6 - 10 L )

2. Partial rebreathing ( 35 -  60 % dengan flow 6 - 10 L )

3. Non rebreathing (  90 % ,bila tidak ada kebocoran )

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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%)

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 Chest physical
therapy, oxygen, Intubation
Acceptable close Tracheotomy
Range monitoring Ventilation
Mechanics 25-35
12-25 > 35
Respiratory rate 30-15
70-30 < 15
Vital capacity, ml/kg 50-25
100-5- < 25
Inspiratory force,cm,H2O 200-350
50-200 > 35C
Oxygenation 200-70
100-75 < 70
A-aDO2,mm,hgt (on mask O2)
(air) (on mask (,)
paO2,mm,Hg 0.4-0.6
0.3-04 > 0.t
Ventilation 45-60
35-45 > 60
Vp/Vt
paO2,mm,Hg

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
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 KRITERIA PONTOPPIDAN
FISIOTERAPI INTUBASI
ACCEPTABLE
NO PARAMETER TERAPI OKSIGEN TRACHEOSTOMI
RANGE
PEMANTAUAN KETAT VENTILASI

1 FREKUENSI NAPAS 12-25 25-35 >35

KAPASITAS VITAL
2 70-30 30-15 <15
PARU (mL/Kg)

GAS DARAH
3
(mmHg)
100-70
PaO2 200-70 (MASKER O2) <70 (MASKER O2)
(UDARA)
PaCO2 35-45 45-60 >60
AaD02 50-200 200-350 >350
4 VD/VT 0,3-0,4 0,4-0,6 >0,6
5 INSP. FORCE 100-50 50-25 <25

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

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 Flow meter
regulator

humidifier
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Monitoring

1. Klinis :
keluhan subyektif
pemeriksaan klinis

2. Laboratoris:
Gas darah
Saturasi Oksigen

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 Evaluasi dan monitoring
Klinis
Pulse oximetry
Kapnograf
ABG
X-ray
EKG

 Terapi penyebab/definitif

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TERIMA KASIH
SHALOOM

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