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