DIFFICULT AIRWAY ENT Rotation July 2023

MANAGEMENT
ILUSTRASI KASUS
Nama : Tn. S
Umur : 65 tahun
Kelamin : Laki-laki
NRM : 4713236
Berat badan : 56 Kg
Tinggi badan : 163 cm
Diagnosis : Massa orofaring dan hipofaring suspek ganas
Prosedur : Trakeostomi sekunder, wide eksisi biopsi
ANAMNESIS
3 bulan SMRS pasien mengeluh suaranya sengau, sulit menelan seperti ada yang
mengganjal, tidur mengorok. Tidak ada keluhan sesak napas atau terbangun karena
kesulitan bernapas saat tidur
Riwayat operasi sebelumnya disangkal
Asma/ alergi obat disangkal
Komorbid:
- Hipertensi on Amlodipin 1x5 mg PO dan Captopril 1x25 mg PO
- DM tipe 2 on Metformin 2x500 mg PO
Demam/batuk/pilek disangkal
PEMERIKSAAN FISIK
Compos mentis
TD: 145/93 mmHg HR: 98 x/m RR 20 x/m S 36.9C SpO2 98% room air
Airway : Mallampati III, buka mulut 3 jari, ekstensi leher maksimal
Jantung : S1S2 normal reguler, murmur dan galop tidak ada
Paru : Vesikular, ronkhi dan wheezing tidak ada
Abdomen : Supel
Ekstremitas : Hangat, CRT < 2 detik
PEMERIKSAAN PENUNJANG
Laboratorium Radiologi
DPL: 11.2/33/7910/302000 Tidak tampak kelainan radiologis jantung
dan paru
SGOT/SGPT: 14/8
Ureum/Kreatinin: 18.5/0.3 EKG
NSR, 88 bpm, tanpa VH/BBB/ST-T
Elektrolit: 136/3.7/112.5
changes
PT/APTT: 0.9x/1x
GDS 187
KLINIS
ASESMEN
ASA 3
- Massa orofaring dan hipofaring suspek ganas, klinis dengan suara sengau, sulit menelan, tanpa keluhan
sesak, dapat berbaring terlentang. RR 20x/mnt, SpO2 98% room air. RFL: Cavum nasi lapang, septum lurus,
konka inferior eutrofi, nasofaring tenang, tampak massa irreguler orofaring, celah orofaring terbuka 10-20%,
epiglottis tegak, aritenoid tenang, tampak standing secretion, tidak ada penetrasi maupun aspirasi,
pergerakan plika vokalis simetris saat statis dan dinamis, rima glotis terbuka
- Hipertensi, TD 145/93, HR 98x/mnt. klinis FC 1, METS > 4. Tanpa sesak/nyeri dada, dapat berbaring
terlentang. EKG: NSR, 88 bpm, tanpa VH/BBB/ST-T changes. CXR 7/7/23: tanpa kardiomegali. On
Amlodipin 1x5 mg PO dan Captopril 1x25 mg PO
- DM tipe 2, klinis tenang, GDS 187, on Metformin 2x500 mg PO
- Anemia Hb11.2
- Geriatri 65 tahun, frailty score 3, managing well
- Kemungkinan sulit jalan napas ec massa orofaring dan hipofaring
RENCANA
General anesthesia: intubasi awake
- Inhalasi lidocaine di ruang persiapan
- Blok transtrakea
- Suplementasi oksigen kontinyu dengan nasal kanul 6 lpm
- Intubasi menggunakan videolaringoskop dengan guiding bougie dewasa. Insersi
ETT ukuran 6.5/7/7.5 non-kinking via bougie
- Back up plan intubasi: FOB, FONA

Post-op: ICU
REALISASI
General anesthesia: intubasi awake
- Inhalasi lidocaine di ruang persiapan V
- Blok transtrakea V
- Suplementasi oksigen kontinyu dengan nasal kanul 6 lpm V
- Intubasi menggunakan videolaringoskop POGO 50% guiding bougie dewasa.
Insersi ETT ukuran 7 non-kinking via bougie V
- Pasien dilakukan induksi anestesi V
INTRAOPERATIF
Hemodinamik intraoperatif relatif stabil tanpa topangan

Lama pembiusan: 3 jam 30 menit Obat yang diberikan:

Lama operasi: 3 jam - Asam Tranexamat 500 mg
IV
Urin tidak ditampung - Paracetamol 1 gram IV
Perdarahan: 50 ml - Ketorolac 30 mg IV
Cairan: 800 ml kristalloid
DISKUSI Difficult Airway
DEFINITION
clinical situation in which anticipated or
unanticipated difficulty or failure is experienced by
a physician trained in anesthesia care, including but not
limited to one or more of the following:

- facemask ventilation - tracheal intubation

- laryngoscopy - extubation, or
- ventilation using a - invasive airway
supraglottic airway
Difficult Facemask Ventilation
It is not possible to provide adequate ventilation (e.g.,
confirmed by end-tidal carbon dioxide detection), because
of one or more of the following problems: inadequate
mask seal, excessive gas leak, or excessive resistance to
the ingress or egress of gas.

Difficult Laryngoscopy
It is not possible to visualize any portion of the vocal
cords after multiple attempts at laryngoscopy.
Difficult Supraglottic Airway Ventilation
It is not possible to provide adequate ventilation because of
one or more of the following problems: difficult
supraglottic airway placement, supraglottic airway
placement requiring multiple attempts, inadequate
supraglottic airway seal, excessive gas leak, or excessive
resistance to the ingress or egress of gas.

Difficult or Failed Tracheal Intubation

Tracheal intubation requires multiple attempts or tracheal
intubation fails after multiple attempts.
Difficult or Failed Tracheal Extubation
The loss of airway patency and adequate ventilation after
removal of a tracheal tube or supraglottic airway from a
patient with a known or suspected difficult airway (i.e., an
“at risk” extubation).

Difficult or Failed Invasive Airway

Anatomic features or abnormalities reducing or
preventing the likelihood of successfully placing an
airway into the trachea through the front of the neck
 INDICATORS OF INADEQUATE
VENTILATION
- absent/inadequate exhaled CO2
- absent/inadequate chest movement
- absent/inadequate breath sounds
- signs of severe obstruction
- cyanosis
- gastric air entry or dilatation
- decreasing/inadequate SpO2
- absent/inadequate exhaled gas flow
- anatomic lung abnormalities as
detected by lung ultrasound
- hemodynamic changes associated
with hypoxemia or hypercarbia (e.g.,
hypertension, tachycardia,
bradycardia, arrhythmia)
- changed mental status or
somnolence.
DIFFERENT DEGREES OF
DIFFICULT AIRWAY
Two-Person Maximum Mask Ventilation Laryngoscopic Grading System
Effort
1. EVALUATION OF THE
AIRWAY
History
 Patient’s medical history, previous medical record
 Preoperative patient characteristic
Physical examination
 Certain anatomical features
 Always do airway physical examination whenever feasible
Additional evaluation
 Radiography, CT scan
 Bedside endoscopy
 Virtual laryngoscopy/bronchoscopy
2. PREPARATION FOR DIFFICULT
AIRWAY MANAGEMENT
 Ensure that airway management equipment is available in the
room
 Ensure that a portable storage unit that contains specialized
equipment for difficult airway management is immediately
available
 Ensure that, at a minimum, monitoring according to the ASA
Standards for Basic Anesthesia Monitoring are followed
immediately before, during, and after airway management of all
patients
SUGGESTED DIFFICULT
AIRWAY EQUIPMENT
Rigid laryngoscope blades alternate design and size
SUGGESTED DIFFICULT
AIRWAY EQUIPMENT
SUGGESTED DIFFICULT
AIRWAY EQUIPMENT
Tracheal tube of assorted size and tracheal tube guides
SUGGESTED DIFFICULT
AIRWAY EQUIPMENT
Supraglottic airways
SUGGESTED DIFFICULT
AIRWAY EQUIPMENT
Flexible fiberoptic intubation equipment
SUGGESTED DIFFICULT
AIRWAY EQUIPMENT
Emergency invasive airway access Exhaled carbon dioxide detector
IF A DIFFICULT AIRWAY IS
KNOWN OR SUSPECTED
 Ensure that a skilled individual is present or immediately available to
assist with airway management when feasible
 Inform the patient or responsible person of the special risks and
procedures pertaining to management of the difficult airway
 Properly position the patient, administer supplemental oxygen
before initiating management of the difficult airway continue to deliver
supplemental oxygen whenever feasible throughout the process of
difficult airway management, including extubation
3. STRATEGY OF ANTICIPATED
DIFFICULT AIRWAY
Depends on :
Anticipated surgery
Condition of the patient
Patient cooperation/consent
Skill and preferences of anesthesiologists
Identify a strategy for:
Awake intubation
The patient who can be adequately ventilated but is difficult to intubate
The patient who cannot be ventilated or intubated,
Difficulty with emergency invasive airway rescue.
2003 What’s new? 2013

video-assisted laryngoscopy, alternative

laryngoscope blades, SGA (e.g., LMA or
ILMA) as an intubation conduit (with or
without fiberoptic guidance), fiberoptic
intubation, intubating stylet or tube
changer, light wand, and blind oral or
nasal intubation.
2022
APPENDIX
LIDOCAINE
 Infiltration max dose: 5 mg/kgBB
 Topicalization: 8.2 mg/kgBB
 Nebulization: 6 mg/kgBB
TRANSTRACHEAL
(TRANSLARYNGEAL) ANESTHESIA
TERIMA KASIH
REFERENSI
Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022
American Society of Anesthesiologists Practice Guidelines for management of the difficult
airway. American Society of Anesthesiologists; 2022
Hagberg CA. Benumof’s and Hagberg’s airway management. Philadelphia, PA:
Elsevier/Saunders; 2013.
DAS guidelines for management of unanticipated difficult intubation in adults 2015
[Internet]. [cited 2023 Jul 18]. Available from:
https://das.uk.com/guidelines/das_intubation_guidelines