RESPIRATORY FAILURE & AIRWAY

MANAGEMENT
 CLINICAL DEATH — a patient
is clinically dead the moment
breathing stops and the heart stops
beating.
 BIOLOGICAL DEATH — if a
patient is not breathing and the heart
is not circulating oxygenated blood,
potentially lethal changes begin to
take place in the brain within 4 to 6
minutes. Biological death occurs
when the patient's brain cells die.
Usually, brain cell death begins within
10 minutes after the heart stops
beating (this can be delayed by cold
temperatures, see p. 489). You may be
able to reverse clinical death, but
biological death is irreversible.
 Respiratory System Anatomy
• The major structures of the airway include:
 NOSE — the primary pathway for air to enter and leave the system.
 MOUTH — the secondary pathway for air.
 PHARYNX — the throat.The common passageway for air and food.
 LARYNX — the neck structure that connects the pharynx and the
trachea.
 TRACHEA — the windpipe.
 BRONCHIAL TREE — branching from the trachea to the
microscopic air sacs of the lungs. The first branches are the right and
left main stem (primary) bronchi. These branch into secondary
bronchi. The smaller branches coming off the secondary bronchi are
called the bronchioles
 LUNGS — the spongy, elastic organs containing alveoli, the
microscopic air sacs where oxygen and carbon dioxide exchange takes
place.
 Respiratory Function
 automatic function
 Involuntary
 automatically adjust the rate, depth,
and rhythm of breathing
 intercostal muscles
 inspiration
 expiration
RESPIRATORY FAILURE
 Simply stated, respiratory failure is
either the cessation of normal
breathing or the reduction of
breathing to the point where oxygen
intake is not sufficient to support life.
When breathing stops completely,
the patient is in respiratory arrest.
 Respiratory arrest can develop during
heart attack, stroke, airway
obstruction, drowning, electrocution,
drug overdose, poisoning, brain
injury, severe chest injury,
suffocation, and prolonged
respiratory failure.
DIAGNOSTIC SIGNS
 To determine the Signs of normal
breathing, you should:
 LOOK for the even (bilateral) rise and
fall of the chest associated with
breathing.
 LISTEN for air entering and leaving the
nose or mouth. The sounds should be
typical, free of gurgling, gasping,
crowing, and wheezing.
 FEEL for air moving out of the nose or
mouth.
 CHECK for typical skin coloration.
There should be no blue or gray
colorations.
 NOTE that the rate and depth of
breathing should be typical for a
person at rest
SIGNS OF INADEQUATE BREATHING
• Chest movements are absent, minimal, or uneven.
• Movements associated with breathing are limited to the abdomen
(abdominal breathing).
• The use of neck muscles during respirations.
• No air can be felt or heard at the nose or mouth, or exchange is
evaluated as below normal.
• Breathing is noisy.
• The breathing rate is too rapid or too slow
• Breathing is very shallow or very deep and
labored.
• The patient's skin is blue or gray. This is called cyanosis.
• Inspirations are prolonged (possible upper airway obstruction) or
expirations are prolonged (possible lower airway obstruction).
• The patient is unable to speak or cannot speak in a normal fashion
PULMONARY RESUSCITATION
• Opening the Airway
 Head-Tilt Maneuver

 Head-Tilt, Chin-Lift Maneuver

 Jaw-Thrust Maneuver
 RESCUE BREATHING
Mouth-to-Mouth Ventilation
Primarily, this procedure is used when the
patient is in respiratory arrest, that is, when he
is no longer breathing. The procedure may be
used when a patient's respiratory rate or depth
is not sufficient to sustain life
IMPORTANT: For artificial respirations provided
to the adult patient, you must deliver breaths •
to the patient at one every 5 seconds to give a
rate of 12 breaths per minute. To help establish
this rate, count, "One, one thousand; two, one
thousand; three, one thousand; four, one
thousand; five, one thousand.

adequately ventilating the patient if you:

 SEE the chest rise and fall.
 HEAR and FEEL air leaving the patient's lungs.
 FEEL resistance to your ventilations as the patient's lungs expand.
Airway Management
Techniques
• NON-INVASIVE TECHNIQUES
– BAG MASK VENTILATION
– ORO- AND NASOPHARYNGEAL
AIRWAYS
– LARYNGEAL MASK AIRWAY (LMA)
 INVASIVE TECHNIQUES
 Endotracheal Intubation
 Direct Laryngoscopy
 Stylet Guide (Introducer)
 Fibreoptic Bronchoscopic Intubation
 Blind Nasal Intubation
 Cricothyroidotomy
 Tracheostomy
 THE DIFFICULT AIRWAY
 ASSISTANCE AND ENVIRONMENT
 ANTICIPATING AND GRADING A DIFFICULT AIRWAY
Intubation difficulty can be anticipated or predicted by the following (although
the sensitivity and specificity, of individual features and classifications tends to
be low):
1. Anatomical or pathological features of difficult intubation in subjects who
otherwise appear normal:
 short neck, especially if obese or muscular (thyro-mental distance <6 cm)
 limited neck and jaw movements (e.g. as a result of trismus,
osteoarthritis, ankylosing spondylitis, rheumatoid arthritis or perioral
scarring)
 protruding teeth, small mouth, long high curved palate, or receding lower
jaw
 space-occupying lesions of the oropharynx and larynx
 congenital conditions with any of the above features (e.g. Marfan's
syndrome).
2. Mallampatti classification of visualizing the oropharyngeal structures
(a co-operative sitting patient is required for this assessment):
a) Class 1: visible soft palate, uvula, fauces and pillars
b) Class 2: visible soft palate, uvula and fauces
c) Class 3: visible soft palate and base of uvula
d) Class 4: soft palate is not visible

3. The degree of difficult)' experienced visualizing the larynx by direct

laryngoscopy should be recorded and is commonly graded by the
classification of Cormack and Lehane:
a) Grade I: complete glottis is visible
b) Grade II; anterior glottis is not visible
c) Grade III: epiglottis but not glottis is visible
d) Grade IV: epiglottis is not visible
 UPPER AIRWAY OBSTRUCTION
Clinical conditions associated with acute
upper airway obstruction
Functional causes
Central nervous system depression
Head injury, cerebrovascular accident,
cardiorespiratory arrest, siiock, hypoxia,
drug overdose, metabolic
encephalopathies
Peripheral nervous system and
neuromuscular abnormalities
Recurrent laryngeal nerve palsy
(postoperative, inflammatory or tumour
infiltration), obstructive sleep apnoea,
laryngospasm, myasthenia gravis,
Guillain-Barre polyneuritis,
hypocatcaemic vocal cord spasm
Mechanical causes
Foreign body aspiration
Infections
Epiglottitis, retropharyngeal cellulitis or
abscess, Ludwig's angina, diphtheria
and tetanus, bacterial tracheitis,
laryngotracheobronchitis
Laryngeal oedema
Allergic laryngeal oedema, angiotensin
converting enzyme inhibitor associated,
hereditary angioedema, acquired CI
esterase deficiency
Haemorrhage and haematoma
Postoperative, anticoagulation therapy,
inherited or acquired coagulation factor
deficiency ,
Trauma
Burns
Inhalational thermal injury, inger.tion of
toxic chemical and caustic agents
Neoplasm
Pharyngeal, laryngeal and
tracheobronchial carcinoma, vocal cord
polyposis
Congenital
Vascular rings, laryngeal webs, laryngocele
Miscellaneous
Cricoarytenoid arthritis, achalasia of the
oesophagus, hysterical stridor,
myxoedema
 Indikasi Manajemen Jalan Napas
Tujuan manajemen jalan napas adalah patensi dan proteksi
dengan memasang ETT dalam trakea dengan mengembangkan cuff
dan dihubungkan dengan sumber O2. Tindakan intubasi sering kali
menyebabkan komplikasi dan tergantung dari berbagai faktor. Ada 5
alasan mengapa pasien membutuhkan jalan napas :
• Gagal ventilasi atau oksigenasi
• Ketidakmampuan mempertahankan atau melindungi jalan napas
• Timbulnya gangguan yang disebabkan oleh penyakit pasien
• Delivery of treatment
• Keamanan dan perlindungan pasien (patient safety and protection)
 Manajemen jalan napas
Immediate "crash" intubation
• Pasien dengan henti napas yang membutuhkan intubasi segera tanpa
medikasi tambahan. Keuntungan tindakan ini secara teknik mudah dan
cepat. Kerugiannya dapat meningkatkan tekanan intrakranial akibat stres
intubasi, muntah dan aspirasi.

Rapid sequence intubation

• Rapid sequence intubation (RSI) adalah serangkaian langkah tindakan
intubasi tanpa ventilasi BVM. Sebagian besar pasien yang dilakukan
intubasi darurat tidak dalam keadaan puasa dan dengan lambung terisi,
sehingga pemakaian BVM mungkin dapat menyebabkan distensi abdomen
dan meningkatkan risiko aspirasi. Untuk mencegah komplikasi pertama
kali dilakukan pemberian O2 100% agar O2 terpenuhi selama periode
apnea. Selanjutnya dilakukan induksi dan pemberian pelumpuh otot kerja
cepat agar pasien tidak sadar dan paralisis. Lalu pasien diintubasi tanpa
bantuan ventilasi BVM. Agar lebih mudah diingat, langkah-langkah RSI
disingkat dengan 9P
9 langkah P Rapid sequence intubation
Time Action
0 – 10 minutes Possibility of success
0 – 10 minutes Preparation
0 – 5 minutes Pre-oxygenation
0 – 3 minutes Pre-treatment
Time zero Paralysis (with induction)
0 + 20 – 30 seconds Protection and positioning
0 + 45 seconds Placement
0 + 45 seconds Proof
0 + 1 minute Post-intubation management
TERIMA KASIH