Professional Documents
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Airway Management 2
Airway Management 2
Departement of Neurosurgery
Faculty of Medicine Universitas Padjadjaran
Hasan Sadikin General Hospital
Bandung 2022
●
Anatomy
This anatomical and functional distribution of the oropharynx, nasopharynx, and larynx allow for
communication, mastication, swallowing, and continuous respiration.
●
Introduction
This anatomical and functional distribution of the oropharynx, nasopharynx, and larynx allow for
communication, mastication, swallowing, and continuous respiration.
● Airway difficulties 50–70% of head injuries experiencing associated facial injury. Airway compromise can
arise from associated soft tissue swelling (often with frightening speed of onset), hemorrhage and secretions,
and fractured teeth.
● Maxillary fractures Facial edema and pharyngeal blood, but may also disrupt the skeletal support of the
oropharyngeal musculature Obstruction.
● Focal neurological insults to the midbrain, cerebellum, or brain stem (injury, stroke, demyelination) can
adversely affect airway control centers. More diffuse disease (injury, infection, inflammation, ischemia) can
threaten consciousness with the consequent impairment of cough and swallow. A decreased level of
consciousness can lead to a reduction in airway muscle tone airway obstruction Hypoxia, Hypercarbia,
and further Diminishes airway control.
Assesment
The urgency of intubation consider the neurological condition of the patient and the
potential effects of hypercarbia and/or hypoxia. Either will lead to cerebral
vasodilation with subsequent increases in cerebral blood volume and intracranial
pressure. The need for intubation requires clinical judgment. Once the decision has
been made to intubate the patient, a number of questions will need to be addressed. .
● Protection against aspiration Blood in upper airway, Pus in upper airway, persistant vomiting
• Difficult mask ventilation (3-8% cases) (DMV) Unable to keep the arterial pulse oximetry
saturations above 92%, or to avoid and correct for signs of inadequate ventilation during positive-
pressure mask ventilation.
• A useful mnemonic to identify a possible DMV patient is O-B-E-S-E, where:
1. O = Obese patient (BMI > 26),
2. B = Bearded patient,
3. E = Elderly patient (age > 55),
4. S= Snoring history of patient,
5. E =Edentulous patient.
• Alternatively, should be kept by the bedside anticipated laterNasal airways can be used with
caution, having a higher frequency of bleeding on insertion (Contraindicated in facial injuries or
basal skull fractures) In circumstances of difficulty in bag/mask ventilation, there are now a large
variety of supraglottal airways, which all offer the ability to bring the airway closer to the
epiglottis, and stay securely seated in the pharynx. They do not protect the lungs from aspiration,
and indeed may obscure the presence of vomitus in the pharynx.
Preparation
(Difficult Airway Intubation)
• Difficult intubation has a similar
prevalence (1–8%) A need for more
than three attempts at intubation or
attempts that last longer than 10 minutes.
Difficult intubation is usually associated with
limited exposure of the glottis on direct
laryngoscopy. The best known is the
Mallampati score introduced in 1985. This
requires patient cooperation, which limits its
utility in the ICU, but may be available from
a previous assessment. Classification from
grade I to IV is associated with an increasing
difficulty of intubation (and also of mask
ventilation). Shows the scores obtained on
examining the soft tissues of the pharynx in a
seated patient with his mouth open and silent
extension of the tongue. Specificity and
sensitivity for this scale range widely in the
literature, from 40 to 60% and 70 to 95%
respectively.
Preparation
(Difficult Airway Intubation)
• The LEMON score summates a variety
of anthropometric features along with
somatypic characteristics and neck
mobility. It uses four “look” criteria,
three “evaluate” criteria, the presence of
airway obstruction,
Airway 22
DEFINITIVE
SURGICAL : Krikotiroidotomy
: Trakeostomy
NON DEFINITIVE
OROPHARYNGEAL AIRWAY
NASOPHARNGEAL AIRWAY
(Difficult Airway Intubation, When To Stop )
• Be carefull for Hypoventilation and Hypoxia in the patient, in their desire to place an
endotracheal tube. After three unsuccessful attempts to intubate, the ASA task force recommends
proceeding through their difficult airway algorithm (irrespective of the experience of the provider).
A failure of intubation does not necessarily mean a failure to ventilate.
1. Changes in the patient’s position may improve the intubating conditions;
2. The insertion of a supraglottic airway is appropriate; or
3. a cricothyroidotomy is required.
• A 14 g intravenous cannula can be placed through the
cricothyroid membrane into the trachea, the needle
withdrawn and the catheter connected to the empty barrel
of a 5 mL syringe with the plunger removed.
• This syringe barrel will serendipitously connect to a 7 mm
or 7.5 mm ET tube connector. This allows connection to a
standard oxygen source for small-volume ventilation.
Preparation
(Difficult Airway Intubation)
Suspected Cervical Spine Injury and Intubation
• Trauma patients should always be considered to have a cervical spine injury until
otherwise cleared.
• Immobilization of the neck during intubation by an assistant in either of two positions:
1. stabilizing the head from “above” by crouching to the side of the intubator and
supporting the head between outstretched hands with the fingers stabilized on the
patient’s shoulders;
2. Stabilizing from “below” with the fingers on the mastoid processes and the thumbs on
the zygomas with wrist and forearms bracing the patient’s neck on the shoulders.
• Once the neck is supported, the front of the collar is removed to allow mandibular
movement. There should be no flexion or extension of the neck iatrogenic spinal cord
damage. The back of the collar may be left on. The head is left in a neutral position for
laryngoscopy. Once the ET tube is placed, the collar is reassembled
Suspected Cervical Spine Injury and Intubation
EXTUBATIO
N