MODUL AIRWAY MANAGEMENT 2017
Transcript of MODUL AIRWAY MANAGEMENT 2017
1 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
2 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
KATA KATA ALUAN 2
PENGENALAN DAN MATLAMAT MODUL 3
OBJEKTIF MODUL 4
PENGHARGAAN 5
LATARBELAKANG/ OBJEKTIF & DESKRIPSI KURSUS 6
TEMPOH & PERSETUJUAN MODUL 7
PENGENALAN AIRWAY MANAGEMENT & TAJUK 8
NASOPHARYNGEAL AIRWAY & LARYNGOSCOPE 9
VARIOUS TYPE OF BOUGIE 10-11
ENDOTRACHEAL TUBE 12-17
TYPES OF LARYNGEAL MASK 18-23
BAG VALVE MASK 24-25
PREPARATION OF DRUGS 26-29
PELAKSANAAN 30
PELAKSANAAN BUKU LOG 31-45
RUJUKAN 46
KANDUNGAN HALAMAN
3 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Pengarah Kesihatan Negeri Melaka
Assalammualaikum w.b.t.
Terlebih dahulu, sekalung penghargaan saya ucapkan kepada
Unit Penolong Pegawai Perubatan Kesihatan Awam di atas
kejayaan membangunkan Modul Kursus “Airway Management” Kesihatan Awam Negeri
Melaka. Kursus ini merupakan satu pendekatan untuk memberi bimbingan , sokongan dan
bantuan secara profesional oleh Pakar Anestesiologi Hospital Melaka dan pasukannya bagi
pembangunan diri selari dengan Arahan Pekeliling Perkhidmatan Bilangan 18 Tahun 2005,
iaitu Panduan Aplikasi Psikologi dalam Pengurusan Sumber Manusia Sektor Awam. Ia
dilaksanakan bagi tujuan memantapkan tahap kecekapan pegawai di samping membantu
mengatasi kebimbangan disebabkan kurang keyakinan dan pengetahuan dalam
melaksanakan tugas.
Justeru, dengan Modul Kursus “Airway Management” di Kesihatan Awam yang
diperkenalkan ini sebagai panduan dalam pelaksanaan Program Kursus “Airway
Management” Penolong Pegawai Perubatan permulaan di Kesihatan Awam dan sekaligus
melahirkan seorang Penolong Pegawai Perubatan yang berkualiti, berkeyakinan, kompetens,
berpengetahuan dan berkemahiran sejajar dengan perkembangan bidang perubatan.
Saya berharap modul ini akan digunapakai diperingkat lapangan khususnya di semua
Kesihatan Awam di seluruh Semenanjung Malaysia.
Sekian terima kasih
Datuk Dr Ghazali bin Othman (MMC 26797)
Pengarah Kesihatan Negeri Melaka
KATA KATA ALUAN
4 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Penolong Pegawai Perubatan di Kesihatan Awam adalah tunggak utama di dalam
melaksanakan perkhidmatan penjagaan pra hospital selain dari tugas tugas hakiki di Klinik
Kesihatan. Tambahan pula, hasrat Kementerian Kesihatan Malaysia ingin melengkapkan
semua Klinik Kesihatan di Malaysia dengan satu ambulans yang lengkap dengan peralatan
perubatan kecemasan. Ini merupakan cabaran kepada profesion Penolong Pegawai
Perubatan di dalam memberi perkhidmatan perawatan kecemasan semasa melakukan tugas
atas panggilan di Kilinik Kesihatan. Oleh itu Penolong Pegawai Perubatan yang bekerja di
Klinik Kesihatan mestilah berpengetahuan yang luas, berkemahiran dalam melakukan
prosedur, berkeyakinan dan kompetens sepanjang masa bertugas.
Sehubungan dengan itu, bagi memantapkan dan memperkasakan kerjaya Penolong Pegawai
Perubatan di Klinik Kesihatan maka lahirlah Modul Kursus “Airway Management” bagi
Penolong Pegawai Perubatan di Kesihatan Awam berpandukan “Advanced Life Support
Training Manual” Keluaran ke 2 Kementerian Kesihatan Malaysia.. Kursus “Airway
Management” dipilih berdasarkan kepentingan kemahiran dan pengetahuan utama yang mesti
ada pada setiap Penolong Pegawai Perubatan di dalam memberi perkhidmatan perawatan
kecemasan di Kesihatan Awam.
Oleh itu, amatlah penting semua Penolong Pegawai Perubatan Kesihatan Awam menjalani
kursus “Airway Management” yang dijalankan oleh Jabatan Anestesiologi & Rawatan Rapi
Modul ini bertujuan membantu fasilitator dalam mengendalikan kursus secara
Sempurna bagi meningkatkan pengetahuan dan membina kemahiran peserta tentang
pengurusan “Airway Management”. Kumpulan sasaran kursus ini adalah Penolong Pegawai
Perubatan di Kesihatan Awam.
1.0 PENGENALAN
1.1 MATLAMAT MODUL
5 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
OBJEKTIF UMUM
Mewujudkan Penolong Pegawai Perubatan yang bertanggungjawab, proaktif,
berpengetahuan, berkemahiran dan menjadi “Front Liner” yang cekap, berkeyakinan dalam
pengendalian kes.
OBJEKTIF KHUSUS
1.2 OBJEKTIF MODUL
1
2
3
DAPAT MENINGKATKAN SEMANGAT BEKERJA KE ARAH PERKHIDMATAN
YANG LEBIH CEMERLANG PADA MASA AKAN DATANG.
MENGGALAKKAN SEMUA PENOLONG PEGAWAI PERUBATAN
KESIHATAN AWAM NEGERI MELAKA MENAMBAH ILMU PENGETAHUAN
DALAM PELBAGAI BIDANG YANG DIMINATI.
MEMBERI KEYAKINAN, BERKEMAHIRAN DAN KOMPETENS KEPADA
PENOLONG PEGAWAI PERUBATAN KESIHATAN AWAM DALAM
MELAKSANAKAN TUGAS.
6 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
PENASIHAT
Pengarah Kesihatan Negeri Melaka : Datuk Dr Ghazali bin Othman
PENGERUSI
Timbalan Pengarah Kesihatan Negeri (KA) : Dr Hj Amirullah bin Mohd Arsyad
SEKRETARIAT
Pakar Perubatan Kesihatan Awam : Dr Suhaila bt Osman
Ketua Pakar Perubatan Keluarga Negeri Melaka : Dr Jalil bin Ishak
Ketua Jabatan & Rawatan Rapi Hospital Melaka : Dr Hj Zainal Abidin bin Othman
Pakar Anestesiologi Hospital Melaka : Dr Anuwar Ariff bin Mohamed
Ketua Pen. Peg. Perubatan Negeri Melaka : Tn Hj Rosman bin Jonet
Timb Ketua Pen. Peg. Perubatan (KA) : Tn Hj Aris bin Sahat (Editor)
Ketua Penyelia Pen Peg. Perubatan (Primer) : En Teo Cheng Teck
Ketua Penyelia Pen Peg. Perubatan (M Tengah) : Tn Hj Abdul Kahar bin Bibon
Ketua Penyelia Pen Peg. Perubatan (Jasin) : Tn Hj Mohd Isa bin Said
Ketua Penyelia Pen Peg. Perubatan (A. Gajah) : Tn Hj Wisam bin Abu Bakar
Ketua Penyelia Pen Peg. Perubatan Anestesiologi : Tn Hj Nordin bin Yaziz
Penyelia Pen. Peg. Perubatan (Primer) : Tn Hj Zulkifly bin Selamat
2.1 PENGHARGAAN
7 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Kursus “Airway management” bertujuan untuk melatih Penolong Pegawai Perubatan di
Kesihatan awam yang bekerja di bidang penjagaan kritikal dalam resusitasi pesakit Klinik
Kesihatan. Kursus ini memberi penekanan kepada peningkatan kemahiran Penolong Pegawai
Perubatan dalam pemberian rawatan kepada pesakit-pesakit yang memerlukan rawatan
kecemasan. Modul ini direka bentuk untuk mengukuhkan konsep-konsep penting dalam
proses intubasi pesakit dan penyediaan ubat untuk pesakit sebelum prosedur intubasi.
Setelah selesai kursus ini, Penolong Pegawai Perubatan dapat
➢ Melakukan prosedur intubasi dengan yakin, berkesan dan selamat
➢ Berkemahiran menggunakan alat-alat perubatan dan ubat-ubat yang betul semasa
melakukan prosedur intubasi.
➢ Deskripsi Kursus ini menumpukan kepada kemahiran secara individu dan sebagai
sebahagian daripada pasukan di tempat berkursus melalui penggunaan Buku Log
Airway Management”.
➢ Kuliah adalah pendek dan sedikit. Pendekatan pembelajaran secara VIVA digunakan
untuk kemahiran alat-alat perubatan dan ubat-ubatan dengan
➢ Oleh itu, Penolong Pegawai Perubatan yang dipilih mestilah membaca nota tentang
“Airway Management” dari “Advanced Life Support Training Manual” Keluaran ke 2
Kementerian Kesihatan Malaysia
3.1 OBJEKTIF KURSUS
3.1 DESKRIPSI KURSUS
3.0 LATARBELAKANG KURSUS
8 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Tempoh “Attachment Airway Management”
➢ Kursus selama 4 minggu di Jabatan Anestesiologi & Rawatan Rapi Hospital Melaka.
✓ 2 minggu di Dewan Bedah
✓ 2 minggu di Unit Rawatan Rapi
➢ Masa berkursus
✓ 8.00 pagi hingga 5.00 petang
MODUL KURSUS “AIRWAY MANAGEMENT”
➢ TELAH DISYORKAN OLEH KETUA JABATAN ANESTESIOLOGI &
RAWATAN RAPI HOSPITAL MELAKA MELALUI MESYUARAT
JAWATANKUASA MODUL AIRWAY MANAGEMENT KESIHATAN AWAM
YANG DIPENGERUSIKAN OLEH TIMBALAN PENGARAH KESIHATAN
NEGERI (KESIHATAN AWAM) MELAKA.
4.0 TEMPOH & MASA KURSUS
4.1 PERSETUJUAN MODUL KURSUS
9 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Pengurusan saluran pengudaraan adalah satu prosedur yang berkait rapat dengan
pengoksigenan semasa “Cardio Pulmonary Resuscitation” (CPR). Tujuan ventilasi semasa
CPR adalah untuk mengekalkan pengoksidaan yang mencukupi dan penghapusan karbon
dioksida yang mencukupi. Pengurusan saluran pengudaraan semasa pemulihan adalah
bergantung kepada faktor pesakit, fasa resusitasi dan kemahiran penyelamat. Pelbagai
modaliti pengurusan saluran udara contohnya. “Bag Valve Mask”, Alat saluran udara
supraglottik (contohnya LMA, SUPREME, Igel) dan tiub endotrakeal sering digunakan semasa
pemulihan sebagai sebahagian daripada pendekatan langkah ke arah pengurusan saluran
udara. Selepas kembali pulih, akhirnya intubasi endotrakeal diperlukan untuk rawatan selepas
resusitasi.
5.1.1 Nasopharyngeal Airway
5.1.2 Laryngoscope – blade & size
5.1.3 Various type of bougie
5.1.4 Endotracheal tube – various size
5.1.5 Type of Laryngeal mask
5.1.6 Bag Valve Mask
5.1.7 Rigid Suction
5.1.8 Preparation of drug - Midazolam and Succinyl-choline
5.0 PENGENALAN AIRWAY MANAGEMENT
5.1 TAJUK TAJUK PEMBELAJARAN MODUL
10 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Nasopharyngeal Airway
•An uncuffed tube made of soft rubber or plastic
•Used in patient where mouth opening is difficult
•More tolerable by semi-comatose patient
•Used with caution in patient with base of skull fracture or with ENT bleeding
•May cause airway bleeding•Various sizes (size indicates internal diameter)
- The appropriate size is measured from tip of the nose to tragus of the ear
Laryngoscope
•Consists of handle (which contains a battery power source) and blade
•2 types of blades: Macintosh blade (curved) for adults Miller blade (straight) for newborn and
infants
•Make sure that the light on the blade works and is bright when lit up
6.0 NASOPHARYNGEAL AIRWAY
6.1 LARYNGOSCOPE -BLADE & SIZE
11 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Clinical Indications: Patients meet clinical indications for oral intubation Initial intubation
attempt(s) unsuccessful Predicted difficult intubation
6.2 VARIOUS TYPE OF BOUGIE
12 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Contraindications:
Three attempts at orotracheal intubation (utilize failed airway protocol)
Age less than eight (8) or ETT size less than 6.5 mm
Endotracheal Introducer/Bougie Procedure:
13 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
1. Prepare, position and oxygenate the patient with 100% oxygen.
2. Select proper ET tube without stylet, test cuff and prepare suction.
3. Load the Bougie on to the ETT and lubricate the distal end and cuff of the endotracheal
tube (ETT) and the distal 1/2 of the Endotracheal Tube Introducer (Bougie) Failure to
lubricate the Bougie and the ETT may result in being unable to pass the ETT.
4. Using laryngoscopic techniques, visualize the vocal cords if possible using cricoid
pressure as needed.
5. Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords
or above the arytenoids if the cords cannot be visualized.
6. Once inserted, gently advance the Bougie until you meet resistance or “hold-up” (if you do
not meet resistance you have a probable esophageal intubation and insertion should be
re-attempted or the failed airway protocol implemented as indicated).
7. While maintaining a firm grasp on the proximal Bougie, introduce the ET tube over the
Bougie passing the tube to its appropriate depth.
8. If you are unable to advance the ETT into the trachea and the Bougie and ETT are
adequately lubricated, withdraw the ETT slightly and rotate the ETT 90 degrees
COUNTERclockwise to turn the bevel of the ETT posteriorly. If this technique fails to
facilitate passing of the ETT you may attempt direct laryngoscopy while advancing the
ETT. This will require an assistant to maintain the position of the Bougie and, if so desired,
advance the ETT.
9. Once the ETT is correctly placed, hold the ET tube securely and remove the Bougie.
10. Confirm tracheal placement according to the intubation protocol, inflate the cuff with 3 to
10mL of air, auscultate for equal breath sounds and reposition accordingly.
11. When final position is determined secure the ET tube, reassess breath sounds, apply ET
CO2 monitor, and record and monitor readings to assure continued tracheal intubation.
Endotracheal Tube (ETT)
6.3 ENDOTRACHEAL TUBE - VARIOUS SIZE
14 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
The ETT was once considered the optimal method of managing airway during cardiac arrest.
It keeps the airway patent, permits suctioning of airway secretions, enables delivery of a high
concentration of oxygen, provides an alternative route for the administration of some drugs,
facilitates delivery of a selected tidal volume, and with the use of a cuff, may protect the
airway from aspiration. However, there is insufficient evidence to support or refute the use of
any specific technique to maintain an airway and provide positive pressure ventilation in
resuscitation. Endotracheal intubation should only be performed by trained personnel with
high level of skill and competence.
Equipment for Endotracheal Intubation:
The equipment necessary for endotracheal intubation may be remembered as mnemonics
MALES: M - Mask (Bag-mask), Magill forceps
A - Airways (Oropharyngeal/Nasopharyngeal Airway)
L - Laryngoscope, LMA, Lubricant gel
E - Endotracheal tubes + Stylet + tape for securing ETT
S - Suction (Catheter/Yaunker), Syringe, Stylet
Endotracheal Tube
Choosing The Correct Size ETT
Age Internal Diameter (mm) Anchor for Oral ETT
Adult Male 7.5 - 8.0 20 - 22 cm
Adult Female 7.0 - 7.5 18 - 20 cm
Newborn to 3 months 3.0 weight (kg) +6
Infants 3.0 - 3.5 weight (kg) +6
Children >1year (Age/4) + 4.0 3 times size of ETT used/
If using cuffed ETT (Age/4) + 3.5 (Age/2)+12
Preparation for Endotracheal Intubation
It is important to get ready before any attempt in intubation:
❖ Equipment ready and in good order: MALES
❖ Adequate oxygen source
15 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
➢ wall or cylinder
➢ if oxygen source is from oxygen cylinder, check O₂ pressure
❖ Enough helping hands
❖ Equipment to confirm correct placement of ETT i.e. Stethoscope, CO2 detector
devices
❖ Resuscitation and intubation drugs available and ready
The Technique of Endotracheal Intubation
The following steps are necessary for successful endotracheal intubation during
cardiac arrest:
Step 1: Position patient in the “sniffing the morning air” position
➢ Flexion at lower cervical spine
➢ Extension at atlanto-occipital joint
To align the axes of upper airway as shown in the diagram below Extend-the-head-on-neck
(“look up”): aligns axis A relative to B Flex-the-neck-on-shoulder (“look down”): aligns axis B
relatives to C
A
C
B
B
16 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Extend-the-head-on-neck (“look up”): aligns axis A relative to B
Flex-the-neck-on-shoulders (“look down”): aligns axis B relative to C
Step 2: Preoxygenation
•100% O2 for 3 minutes or with 4 vital capacity breaths
Step 3: Laryngoscopy and insertion of ETT
Laryngoscopy
➢ Use left hand to hold laryngoscope
➢ Enter at right side of mouth and push tongue towards left aside
➢ Move the laryngoscope blade towards midline and advance to the base of the
tongue. Advance the blade to the vallecula if the curved blade is used or to just
beyond tip of epiglottis if the straight blade is used
➢ Lift upward and forward to bring up the larynx and vocal cords into view. The
direction of force necessary to lift the mandible and tongue is 45 degrees. Do not
use teeth as a fulcrum or a lever
C
A
17 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Laryngoscopic View Laryngoscope blade position
Hand Position Laryngoscope blade position
Insertion of ETT
➢ Insert the ETT through the vocal cords. View the proximal end of the cuff at the
level of the vocal cords and advance it about 1 to 2.5cm further into the trachea
➢ Inflate the ETT with enough air to occlude the airway (usually 10 to 20ml)
Important point to note:
Interruption to chest compression during endotracheal intubation should
be less than 5 seconds.
18 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Step 4: Confirm correct position of ETT
➢ Observe colour of patient
➢ Visualise chest rise with delivery of first manual breath•Detect vapour in ETT
➢ 5 points auscultation for breath sounds (auscultate epigastrium, anterior chestat
bilateral mid-clavicular lines and thorax at bilateral mid-axillary lines)
➢ Detect end-tidal CO2 with capnography or CO2 detector device
Step 5: Secure ETT with tape
Step 6: Ventilate with a tidal volume of 6-8 ml/kg (visible chest rise) at a rate of 8-10 breath
per minute
Waveform Capnography
Continuous waveform capnography is recommended as the most reliable method of confirming
and monitoring correct placement of the endotracheal tube (ETT). Studies of waveform
capnography to verify ETT position in patients in cardiac arrest have shown high sensitivity
and specificity in identifying correct ETT placement. It can also detect a patient’s deterioration
associated with declining clinical status or ETT displacement.
End-tidal CO2 during resuscitation:
➢ Confirms ETT placement; note that EtCO2 detection will not differentiate between
tracheal and endobronchial tube placement. Careful auscultation is essential.
➢ Correlates with cardiac index
➢ Assesses adequacy of ventilation
➢ Indicates quality of CPR
➢ Signifies ROSC
➢ Carries prognostic value for survival during resuscitation
Waveform Capnography. Normal range (approximately 35 to 45 mmhg)
19 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Complications of Endotracheal Intubation
20 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Advanced Airways
Bag-mask ventilation is not suitable for prolonged periods of ventilation as it also inflates the
stomach. Therefore, ALS providers should be trained to use advanced airways (supraglottic
airway devices (SGAs) and ETT).
Supraglottic Airway Devices (SGAs)
Supraglottic airways are devices designed to maintain an open airway and facilitate
ventilation. Insertion of a supraglottic airway device does not require visualization of vocal
cords, therefore can be done with minimal chest compression interruptions.
Laryngeal Mask Airway
❖ An advanced airway device that is considered an acceptable alternative to the ETT
❖ Technically easier to insert and minimally interrupt chest compression during
resuscitation
❖ Ventilating patient via LMA may still cause gastric aspiration
❖ Composed of a tube with a cuffed mask-like projection at the end of the tube and
connected to a pilot balloon.
6.4 Types of Laryngeal Mask
21 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Recommended Size Guidelines for LMA
The following table shows the Recommended Size Guidelines and the Amount of Air needed
to inflate the LMA cuff:
Insertion of LMA
Before any attempt to insert an LMA, the following equipment has to be prepared:
➢ Personal protective equipment - mask, eye shield/goggle, gloves
➢ Appropriate size LMA
➢ Syringe with appropriate volume (10, 20 or 50 ml) for LMA cuff inflation •Water
soluble lubricant
➢ Ventilation equipment
➢ Tape or other device(s) to secure LMA
➢ StethoscopeThe following are the steps necessary for successful insertion of LMA:
Step 1: Size selection - as per Recommended Size Guidelines
22 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Step 2: Examination of LMA
➢ Inspect surface of LMA for damage, including cuts, tears, or scratches
- Do not use the LMA if the airway tube is damaged in any way
➢ Inspect interior of LMA airway tube to ensure that it is free from blockage or loose
particles
- Any particles present in the airway tube should be removed as patient may inhale
them after insertion
➢ Inflate cuff to ensure that it does not leak
➢ Deflate cuff to ensure that it maintains a vacuum
Step 3: Check inflation and deflation of cuff
➢ Inflate cuff with the recommended volume of air
➢ Slowly deflate cuff to form a smooth flat wedge shape which will pass easily around
the back of the tongue and behind the epiglottis
Step 4: Lubrication of LMA Cuff/Mask
➢ Use a water soluble lubricant to lubricate
➢ Only lubricate LMA cuff/mask just prior to insertion
➢ Only lubricate back of LMA cuff/mask thoroughly
➢ Avoid excessive lubricants on interior surface or in the bowl of cuff/mask as inhalation
of the lubricant following placement may result in coughing or obstruction
Step 5: Position head for insertion
➢ LMA can be inserted even if the head is in the neutral position as long as the
mouthopening is adequate
➢ Avoid LMA fold over:
- Assistant pulls the lower jaw downwards
- Visualize the posterior oral cavity
- Ensure that LMA is not folding over in the cavity as it is inserted
23 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Below are a series of diagrams showing the insertion of LMA:
Method for holding the LMA for standard With the head tilt and the neck flexed
insertion technique insert the cuff of LMA into the oral cavity;
direction of force goes against the hard palate
To facilitate introduction of LMA into the The index finger pushes LMA in a cranial oral in cavity, gently press the middle direction following the contours of the finger down onto the jaw hard and soft palates
1
4 3
2
24 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Maintaining pressure with finger on LMA in the cranial direction, advance LMA until definite resistance is felt at the base of the hypopharynx: note flexion of the wrist
Gently maintain cranial pressure with non-dominant hand while removing index finger
To allow LMA to seat optimally, inflate without holding LMA Inflate cuff with just enough air to obtain a seal - this should correspond to intracuff pressures around 60 cm H2O; do not over-inflate
Tape the bite-block and LMA airway tube downwards against the chin
5 6
7 8
25 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Final words on LMA
❖ Test cuff before use
❖ Don’t lubricate anterior side of LMA mask
❖ Insert only in comatose patient
❖ Keep cuff inflated until patient awake
LIMITATION OF SGAs
1.In the presence of high airway resistance or poor lung compliance (pulmonary
oedema,bronchospasm) there is a risk of significant leak around the cuff causing
hypoventilation.The leaks gas normally escapes through the patient’s mouth but some gastric
inflation may occur.
2.No data demonstrating whether or not it is possible to provide adequate ventilation
viaSGAs without interruption of the chest compression. Uninterrupted chest compressions
are likely to cause some leaks around the SGAs cuff when ventilation is attempted. Attempt
continuous chest compression initially but abandon this if persistent leaks occur.
3.There is theoretical risk of aspiration of stomach contents; however this complication
hasnot been documented widely in clinical practice.
4.If the patient is not deeply unconscious, insertion of the SGAs may cause coughing,
straining or laryngospasm. This will not occur in cardiopulmonary arrest patients.
5.If adequate ventilation is not achieved, withdraw the SGAs and re-attempt insertion after
ensuring good alignment of the head and neck.
26 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Bag-mask Ventilation
The bag-mask device consists of a self-inflating bag with a non-rebreathing valve
➢ Can be used with a face mask or an advanced airway eg Supraglottic airway devices
(SGAs) or endotracheal tube (ETT)
➢ Provides positive pressure ventilation
➢ Cannot be used to allow spontaneous breathing
The provider should use an adult (1 to 2 L) bag and deliver just enough volume to produce
visible chest rise
Bag-mask ventilation can produce gastric inflation with complications, including regurgitation
and aspiration
Two ways of holding the bag-mask device on the face for adequate ventilation:
6.5 BAG VALVE MASK
27 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Hand (E-C Clamp Technique) 2 Hand (E-C Clamp Technique)
Tracheobronchial Suctioning
Suction Catheter
➢ Size (FG) = ETT internal diameter (mm) x 3/2 or outer diameter should not exceed 1/2
to 2/3 ETT internal diameter
➢ Minimal trauma to mucosa with molded ends and side holes
➢ Long enough to pass through tip of ETT
➢ Minimal friction resistance during insertion through ETT
➢ Sterile and disposable
Suction Pressure
➢ 100 to-120mmHg (adults)• 80 to-100mmHg (children)• 60 to-80 mmHg (infants)
Complications of Tracheobronchial Suctioning:
➢ Sudden severe hypoxia, secondary to decrease in functional residual capacity during
the application of negative pressure in the trachea
➢ Cardiac arrest if severe hypoxia
➢ Increase in intra-arterial pressure and tachycardia due to sympathetic response to
suction
6.6 RIGID SUCTION
28 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Medications for Rapid Sequence Endotracheal Intubation
In order to achieve a successful intubation, various classes of medications are needed to
achieve specific pharmacologic effects. These effects include providing sedation, analgesia
from pain, amnestic effects, anesthesia, anticholinergic effects to control secretions, and
paralysis.
Intubation, when performed using the rapid sequence intubation (RSI) protocol, is typically
discussed in several stages (ie, pretreatment, induction and paralysis, and post-intubation);
each stage requires specific medications. The medication choices described below provide the
specific effects that are essential to creating the optimal conditions for endotracheal intubation.
Usually the medication used for rapid sequence intubation in anesthesiology department and
intensive care of the government hospital is midazolam and succinyl-choline
Midazolam (Dormicum)
Although this agent has the most rapid onset of all the benzodiazepines, it falls far short in this
category compared with other classes of induction agents. Midazolam has the major
disadvantage of requiring titration, which is far from feasible in RSI. Also, optimal effects are
not observed for 3-5 minutes. This time does not allow the patient to be properly anesthetized
if the midazolam is administered immediately before succinylcholine. In fact, studies have
shown that patients are awake if midazolam is administered back to back with succinylcholine.
Although the standard dose for RSI is 0.1 mg/kg, doses as high as 0.3 mg/kg have not
consistently induced true unconsciousness. Midazolam does mildly decrease Cerebral
Perfusion Pressure (CPP). Also, minimal cardiovascular and respiratory effect may be
observed.
Because of its slow onset and variable potency, midazolam is no longer recommended as a
first-line induction agent in RSI. All drugs administered for RSI must possess rapid onset and
extreme potency.
6.7 PREPARATION OF DRUG
29 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Anesthesia
Induction
• <55 years without premedication: 300-350 mcg/kg IV injection over 20-30 seconds; wait
2-3 minutes to evaluate sedative effect after each dose adjustment; may use increments
of 25% of initial dose PRN to complete induction; may use up to 0.6 mg/kg total dose in
resistant cases, but such dosing may prolong recovery
• >55 years without premedication and with no systemic disease, in a patient who is not
weak: 300 mcg/kg over 20-30 seconds initially; wait 2-3 minutes to evaluate sedative
effect after each dose adjustment
• >55 years without premedication but presence of systemic disease or weak patient:
200-250 mcg/kg over 20-30 seconds usually enough; 0.15 mg/kg enough in some
cases; wait 2-3 minutes to evaluate sedative effect after each dose adjustment
• >55 years with premedication: 150-350 mcg/kg IV injection over 20-30 seconds; wait 2-
3 minutes to evaluate sedative effect after each dose adjustment; a dose of 250 mcg/kg
usually enough to achieve desired effect
Maintenance
• May administer increments of 25% of induction dose PRN when there are signs that
anesthetic effects are lightening
Sedation of Intubated/Ventilated Patients
Load: 10-50 mcg/kg (dose range 0.5-4 mg) slow IV injection or infusion over several minutes;
repeat q5-15min PRN
Maintenance: Initial, 20-100 mcg/kg/hr infusion; titrate up or down 25-50% PRN
Dosing Considerations
Because it is water soluble, takes approximately 3 times longer than diazepam to peak EEG
effects; thus, clinician must wait 2-3 minutes to fully evaluate sedative effects before initiating
procedure or repeating dose.
30 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Anesthesia: Typical adult induction and maintenance doses may need to be decreased in
some elderly patients by 20-50%, because the elderly overall are more susceptible to CNS
depressants than is the general population
Succinylcholine (Suxamethonium Chloride)
Succinylcholine was introduced in 1949 and has passed the test of time. To this day,
succinylcholine is the only depolarizing agent used for rapid sequence induction. Because of
its rapid onset, ultrashort duration of action, and safety, it is the paralytic of choice in almost
all cases of rapid sequence induction in adults.
This depolarizing agent works via persistent activation and resultant blockade of the
postsynaptic nicotinic acetylcholine receptor at the neuromuscular junction. In contrary,
nondepolarizing agents competitively block the binding of acetylcholine at the same
postsynaptic receptor.
Neuromuscular Blockade
Load
• 0.3-1.1 mg/kg IV x1 dose, OR
• 3-4 mg/kg IM x1 dose
• Short Procedures: usually 0.6 mg/kg IV injection
Maintenance for Prolonged Procedures
• 0.04-0.07 mg/kg IV q5-10min PRN OR
• 2.5 mg/min IV infusion
Administration
Dose should be calculated based on ideal body weight
Pre treatment: Atropine may reduce vagally mediated bradycardia/hypotension/drooling
Solution contains 1% benzyl alcohol
31 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Prior administration of "defasciculating" dose of nondepolarizing neuromuscular blocker
(such as 0.01 mg/kg IV vecuronium) will prevent muscular fasciculations that may increase
ICP/IOP
Adequate ventilatory support mandatory, may experience increased sensitivity with
electrolyte disorders (hyperMg, hypoK, hypoCa)
32 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
7.0 PELAKSANAAN
33 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
7.1 PELAKSANAAN BUKU LOG AIRWAY MANAGEMENT
BUKU LOG
“ATTACHMENT AIRWAY MANAGEMENT”
UNTUK
PENOLONG PEGAWAI PERUBATAN
KESIHATAN AWAM
JABATAN KESIHATAN NEGERI
MELAKA
34 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Maklumat Peribadi
Nama:____________________________________
KP/IC:____________________________________
Jawatan: PENOLONG PEGAWAI PERUBATAN
Annual Practice No:________________________
Tempat bertugas:__________________________
Tarikh tamat latihan:________________________
Tempat latihan:____________________________
35 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
36 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
BUKU PROSEDUR INTUBASI
Pendahuluan :
Buku prosedur ini adalah salah satu keperluan bagi kursus latihan intubasi
Dengan adanya buku ini diharapkan dapat membantu para peserta dalam melakukan
tatacara secara betul dan selamat.
Anggota kesihatan terlibat adalah terdiri daripada Penolong Pegawai Perubatan.
Objektif :
Untuk meningkatkan kemahiran dan kecekapan para peserta dalam melakukan intubasi.
Pegawai Penilai / Penyelia ialah pegawai yang menyelia anggota kesihatan:
Pakar bius
Pegawai Perubatan Bius
Penyelia OT / ICU
Tugas dan Tanggungjawab Pegawai Penyelia
1. Memastikan anggota kesihatan menjalankan prosedur dalam tempoh 4 minggu.
2. Memastikan prosedur dilaksanakan dengan lebih mahir dan yakin.
3. Penyelia perlu membuat pengesahan di ruang catatan.
4. Memastikan prosedur dilakukan mengikut senarai semak.
5. Meluangkan masa untuk memberi bimbingan dan tunjuk ajar.
Pegawai Yang Dinilai / Diselia adalah anggota kesihatan yang mengikuti latihan C&P
intubasi.
37 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Tugas dan Tanggungjawab Pegawai Yang Dinilai / Diselia.
1. Hadiri penempatan di OT 2 minggu / ICU 2 minggu dari tarikh kursus.
2. Melakukan amali intubasi ke atas 10 orang pesakit (dengan pengawasan Pegawai
Perubatan Bius / Penyelia ) dan 5 orang pesakit (dengan pengawasan). Rujuk manual.
3. Menggunakan senarai semak yang disediakan.
4. Memberi perhatian kepada komen dan cadangan pegawai penyelia untuk membaiki
kemahiran.
5. Mendapatkan tandatangan pegawai penyelia sebagai pengesahan menjalankan
prosedur tersebut.
6. Menjaga buku prosedur dengan baik.
KRITERIA KELULUSAN CREDENTIALING DAN PRIVILEGING
Telah hadiri kursus Advance Airway Management.
Telah mengikuti penempatan latihan intubasi dengan jayanya.
Pegawai Penyelia yang berhak menandatangani selepas prosedur dilakukan dengan
jayanya : Pakar bius..
PENGEKALAN TAHAP KECEKAPAN
Setiap 3 tahun :-
Pengekalan kecekapan melakukan sendiri tatacara tersebut sekurang-kurangnya 1 kes
dalam setahun secara berterusan.berpandukan buku manual.
Menghadiri kursus / latihan dalam perkhidmatan sekali setahun
38 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
TARIKH AKTIVITI MAKLUMAT PEGAWAI YANG MEMBERI TAKLIMAT
Nama Tanda
tangan
Cop Pegawai
Orientasi Dewan
Bedah/ ICU
Organisasi 7
Fungsi Dewan
Bedah / ICU
Tugas &
Tanggungjawab
Kod Etika &
Peranan PPP
Protokol &
Standard OP
Pengenalan
Airway device &
alat alat
AKTIVITI (OREINTASI DEWAN BEDAH & ICU)
39 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
TARIKH TAJUK
CERAMAH/CME
NAMA
PENCERAMAH
MASA/
TEMPOH
T/TANGAN/COP
CONTINOUS MEDICAL EDUCATION/ BEDSIDE
TEACHING
40 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
PEMERHATIAN PROSEDUR INTUBASI (10 kes)
Bil. Nama Dan KP
Butir Penyeliaan
Tarikh Tanda-
tangan Cop/Nama Penyelia
1
2
3
4
5
6
7
8
9
10
MEMBANTU PROSEDUR INTUBASI (10 KES)
BIL. Nama dan KP Ulasan
Tandatangan
L/Preseptor
1
2
3
4
5
6
7
8
9
10
41 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
MELAKUKAN PROSEDUR INTUBASI DENGAN PENGAWASAN (5 KES)
VERIFIKASI
Buku rekod ini telah disemak dan didapati telah memenuhi semua syarat yang ditetapkan.
ULASAN PENYELIA
---------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------————-
TANDATANGAN PENYELIA
--------------------------------------
Bil Nama I/C / Kp Diagnosis Tandatangan L/Preseptor
1
2
3
4
5
42 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
SENARAI SEMAK PROSEDUR INTUBASI
Bil
Aktiviti/Prosedur Intubation
Ulasan
1 Prepare all equipment and have suction ready.
2
Pre-oxygenate the patient, if time permits.Open the
patient’s airway.
3.
While holding the laryngoscope in the left hand,
insert the blade into the right side of the patient’s
mouth, sweeping the tongue to the left.
4.
Use the blade to lift the tongue and the epiglottis,
either directly with the straight (Miller) blade, or
indirectly with the curved (Macintosh) blade.
5.
Once the glottic opening is visualized, insert the
tube through the vocal cords and continue to
visualize while passing the cuff through the cords.
6.
Remove the laryngoscope and then the stylet from
the ETT.
7. Inflate the cuff with 5 – 10ml of air.
8.
Assess for adequate placement by auscultation
(equal breath sounds over the chest and a lack of
sounds over the epigastrium with bagging),
condensation in the ETT, symmetrical chest-wall
rise, and at least one additional method:
colorimetric end-tidal CO2 detector, capnography,
or esophageal tube detector (Note: to be accurate,
the tube detector should be used prior to
ventilation).
9. Secure the tube
10.
Document the ETT size, time, results, and
placement depth (in cm at the level of the patient’s
teeth or gums) on the PCR. Also, include in
documentation the procedures and devices used for
confirmation of tube placement (e.g., bilateral, equal
breath sounds and absence of epigastric sounds,
end-tidal CO2, etc.).
43 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
SENARAI SEMAK PREPARATION
A1 Nasopharyngeal airway - appropriate
size
A2 Laryngoscope - appropriate blade
and handle size
A3 Bougie
A4 ETT - appropriate size
A5 Laryngeal mask airway
A6 Bag valve mask
A7 Rigid Suction
B1 Prepare and determine dose drugs:
Midazolam
Succinyl-choline
44 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
KRITERIA INTUBASI
No Prosedur Kelulusan
Asas
Kriteria Kompetensi Penyelia
1 Prosedur
Intubasi
Penolong
Pegawai
Perubatan
Menghadiri
kursus
Advance
Airway
Management
Penempatan di
OT dan ICU
yang telah
dikhaskan oleh
penganjur
kursus
1.Penempatan
selama 4
minggu
2.Mestilah
memenuhi
kehendak buku
Log
1.Setiap tahun
mestilah
melakukan
sekurang-
kurangnya 1
prosedure
intubasi untuk
mengekalkan
kemahiran
intubasi.
2.Menghadiri
kursus/latihan
dalam
perkhidmatan
sekali setahun
Pakar bius.
Pegawai Perubatan Bius
Penyelia OT / ICU
45 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
GAMBAR PROSEDUR INTUBASI
46 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
47 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
CATATAN:
48 | P a g e
MODUL AIRWAY MANAGEMENT 2017
JABATAN KESIHATAN NEGERI MELAKA
Advanced Life Support Training Manual Second published in Malaysia in September
2017 by Medical Development Division Ministry of Health Malaysia
© The Ministry of Health Malaysia 2017 www.moh.gov.my
Institute for Medical Research Cataloging in Publication Data A catalogue record for this
book is available from the Institute for Medical Research, Ministry of Health Malaysia
National Library of Malaysia Cataloging in Publication Data A catalogue record for this
book is available from the National Library of Malaysia
Arahan Pekeliling Perkhidmatan Bilangan 18 Tahun 2005, iaitu panduan aplikasi
psikologi dalam Pengurusan Sumber Manusia Sektor Awam
8.0 RUJUKAN