Ainul Rofik

(Materi dari internet)

The Difference Between Life and Death
• Basic anatomy and
physiology.
• Advantages of
endotracheal intubation.
• Indications of intubation.
• Contraindications of
intubation.
• Complications of
intubation.
• Equipment required for
intubation.
• Technique of
endotracheal intubation.
• Rules of endotracheal
intubation.
• Tube sizes.
• Rules and principals of
suctioning.
• Other airway adjuncts.
• Conclusion.
• Difficult intubations.
The airways can be divided in to parts namely:
The upper airway.
The lower airway.
Airway (jalan nafas) - bagian atas
- bagian bawah

Batas
Upper
dan
Lower
Resp tract
• Cuffed E.T tubes protect the airway from aspiration.
• E.T tube provides access to the tracheobronchial tree
for suctioning of secretions.
• E.T tube does not cause gastric distention and
associated danger of regurgitation.
• E.T tube maintains a patent airway and assists in
avoiding further obstruction.
• E.T tube enables delivery of aerosolized medication.
• Inadequate oxygenation(decreased arterial PO2) that
is not corrected by supplemental oxygen via
mask/nasal.
• Inadequate ventilation (increased arterial PCO2).
• Need to control and remove pulmonary secretions.
• Any patient in cardiac arrest.
• Ant patient in deep coma who cannot protect his
airway.(Gag reflex absent.).
• Any patient in imminent danger of upper airway
obstruction (e.g. Burns of the upper airways).
• Any patient with decreased L.O.C, GCS <= 8.
• Severe head and facial injuries with compromised
airway.
• Any patient in respiratory arrest
• Respiratory failure :
1. Hypoventilation/Hypercarbia
A. PaCO2 > 55mmhg
2. Arterial hypoxemia refractory to O2
A. PaO2 < 70 on 100% O2
• Patients with an intact gag reflex.
• Patients likely to react with laryngospasm to an
intubation attempt. e.g. Children with epiglottitis.
• Basilar skull fracture – avoid naso-tracheal intubation
and nasogastric/pharyngeal tube.
• Trauma of the teeth, cords, arytenoid cartilages,
larynx and related structures.
• Nasotracheal tubes can damage the turbinates, cause
epistaxis, and even perforate the nasopharyngeal
mucosa.
• Hypertension and tachycardia can occur from the
intense stimulation of intubation; This is potentially
dangerous in the patient with coronary heart disease.
• Transient cardiac arrhythmias related to vagal
stimulation or sympathetic nerve traffic may occur .
• Damage to the endotracheal tube cuff, resulting in a
cuff leak and poor seal.
• Intubation of the esophagus, resulting in gastric
distention and regurgitation upon attempting
ventilation.
• Baro-trauma resulting from over ventilating with a bag
without a pressure release valve( phneumothorax).
• Over stimulation of the larynx resulting in
laryngospasm, causing a complete airway obstruction.
• Inserting the tube to deep resulting in unilateral
intubation (right bronchus).
• Tube obstruction due to foreign material, dried
respiratory secretion and/or blood.
• Laryngoscope with relevant size blades.
• Magill forceps.
• Flexible introducer.
• 10-20 ml syringe.
• Oropharangeal airways – all sizes.
• Tape or adhesive plaster.
• E.T tubes – relevant sizes.
• Bag-valve-mask with oxygen connected.
• Suction unit with Yankauer nozzle and endotracheal
suction catheter.
 MASKER & BAG Ventilasi
Dapat dilakukan tanpa Intubasi
Endotracheal tube (ETT) : salah satu Sarana
Untuk Mengamankan Jalan nafas
 “Intubasi trachea”
Pemasangan endotracheal tube
dengan laryngoscopy
Membersihkan benda asing padat dalam jalan napas
menggunakan alat penjepit ( Forcep )
• Position the patient supine, open the airway with a
head-tilt chin-lift maneuver.(Suspected spinal injury,
attempt naso-tracheal intubation, spine in neutral
position.).
• Open mouth by separating the lips and pulling on
upper jaw with the index finger.
• Hold laryngoscope in left hand, insert scope into mouth
with blade directed to right tonsil.
• Once right tonsil is reached, sweep the blade to the
midline keeping the tongue on the left.
• This brings the epiglottis into view.” DO NOT LOOSE SIGHT OF
IT!”
• Advance the blade until it reaches the angle between the base
of the tongue and epiglottis.( volecular space)
• Lift the laryngoscope upwards and away from the nose –
towards the chest. This should bring the vocal cords into view. It
may be necessary for a colleague to press on the trachea to
improve the view of the larynx.
• Place the ETT in the right hand. Keep the concavity of the tube
facing the right side of the mouth.
• Insert the tube watching it enter through the cords.
• Insert the tube just so the cuff has passed the cords
and then inflate the cuff.
• Listed for air entry at both apices and both axillae
to ensure correct placement using a stethoscope.
• Always have a suction unit available.
• An intubation attempt should never exceed 30
seconds.
• Oxygenate the patient pre and post intubation with
a bag-valve-mask.(100% O2).
• Have sedative medication available if needed.
(e.g. Midazolam 15mg/3ml)
• Always recheck tube placement manually guided by
oxygen saturation readings.(Spo2).
Dalam melakukan INTUBASI
Hindari terjadinya HIPOKSI
• Newborn – to 4 kg - 2.5 mm (uncuffed).
• 1-6 months 4-6 kg – 3.5 mm (uncuffed).
• 7-12 months 6-9 kg – 4.0 mm (uncuffed).
• 1 year 9 kg – 4.5 mm (uncuffed).
• 2 years 11 kg – 5.0 mm (uncuffed).
• 3-4 years 14–16 kg - 5.5 mm (uncuffed).
• 5-6 years 18–21 kg – 6.0 mm (uncuffed).
• 7-8 years 22-27 kg – 6.5 mm ( uncuffed).
• 9-11 years 28-36 kg – 7.0 mm(cuffed).
• 14 to adults 46+ kg – 7.0 – 80 mm (cuffed).
• Adult female 7.0 – 8.0mm (cuffed).
• Adult male 7.5 – 8.5 mm (cuffed).
• The size of the tube may also be determined by the
size of the patients little finger.

NB : patients below the age of 8 require uncuffed ETT

due to damage caused by the cuff in younger patients.
Always monitor the ECG activity during intubation.
• Never suction further than you can see.
• Always suction on the way out.
• Never suction for longer than15 seconds.
• Always oxygenate the patient before and after
suctioning.
• Kombi-tube.
• Oropharangeal airways/tubes.
• Nasopharyngeal airways/tubes.
• Oro-tracheal tubes.
• Naso-tracheal tubes.
• Always oxygenate patient before and after
intubation.
• Do not attempt intubation unless you are totally skilled,
rather perform bag-valve-mask ventilation.
• Always monitor the spo2 readings.
• Always reconfirm tube placement from time to time.