AIRWAY and VENTILATORY

MANAGEMENT
Nur Surya Wirawan
(dibawakan pada kelas terminal Novmber
2011)

Objective
Able to recognize and clear airway

obstruction
Able to maintain airway patency and
deliver supportive breathing
Able to manage airway and
supportive breathing with airwaybreathing equipment
Able to apply cricothyrotomy

Anatomy
Upper air way tract:
Nasal /oral cavities Vocal cord
Lower air way tract:
Vocal cord alveoli

Air way :
Passage path of the breathing air
Exchange path of O2 and CO2
Other physiological functions in each

part.

Airway Problems
Every problems on

the air way passage

which disrupt air
exchange
(ventilation) totally
or partially.
E.g.:
Foreign body obstruction
Base of the tongue

obstruction on
unconscious patients
Air way tract edema or
spasm
Air way damage

Evaluation of Airway Problems

Make sure patients consciousness level
Conscious patients
Able to speak
clearly
Airway clear

Unconscious
patients
Clear the airway:
Triple Airway Maneuver
(Head tilt, chin lift, jaw
thrust)
Evaluation:
(Look, Listen,
Feel)

No spontaneous
breathing:
Deliver supportive
breathing and oxygen

Spontaneous breathing with additional

sound:
Snoring - base of the tongue
Gurgling - fluid
Crowing - plica vocalis edema/spasm

Main Priority: Clear airway (+ cervical spine

stabilization)

Assessing the Airway

Look
Listen
Feel
Evaluation: Look, Listen & Feel

Assessing the Airway

Grade of the airway obstruction
Clear airway
Look

Listen

Feel

Mild

Moderate

Severe

Normal

Normal

Disrupt

Sea saw
No
movement

Clear breath
sound

Additional
breath
sound

High pitch of
additional
breath
sound

No breath
sound

Normal

Normal

Slightly air
flows

No air flows

Signs of airway obstruction

Snoring
: base of the tongue
Gurgling : fl uid
Crowing
: plica vocalis

spasm/edema
Worsening
Early signs :
Agitation (sign of hypoxia)
Activation of additional breathing muscle

(trachel tag, intercostal retraction)

Paradoxal movement of chest and abdominal wall
Late sign :
Cyanosis

Relieving (Clear) the Airway

Relieving from mechanical obstruction
by base of the tongue:
Triple Airway Maneuver

Head tilt

Chin lift

Jaw thrust

Placement of Oropharyngeal

airway/tube

Do not attempt the oropharyngeal airway

when vomiting reflex still intact .
(grade A-V from AVPU grading or GCS 10 )

Triple Airway Maneuver

Head tilt Chin lift
Method
Put the patients on supine
position
Put the palm on the patients
forehead, push gently
backward
Support patients chin with
index and middle finger, right
in the middle of arcus
mandibula, then push it
upward
Evaluate ventilation

Head tilt

Chin lift

Triple Airway Maneuver

Jaw thrust
Method
Put the patients on supine
position
Push upward right and left
ramus mandibula, until lower
dental line position is above
the upper dental line.
Use the thumbs to push the
chin forward
Evaluate the ventilation

Jaw
thrust

Relieving (Clear) the Airway

Relieving from mechanical obstruction
by base of the tongue:
Placement of Nasopharyngeal
airway/tube

Not to cause the vomiting reflex

Use with caution in patients with suspected

basis cranii fracture
Tube diameter for an adult is about 7 mm or
can be estimated from his/her small finger

Placement of endotraceal tube or

LMA
as an advanced airway management

Relieving (Clear) the Airway

(cont.)

Relieving from obstruction by fl uid:

Finger sweep
Suction
Stable sideways position
Relieving from obstruction on plica
vocalis
Cricothyrodotomy
as an advanced airway management

Endotrachel Intubation
Consideration:
Failure to relieve the airway from

other ways
Diffi culty to deliver supportive
breathing
High risk of pulmonary aspiration
The need to prevent hypercarbia (head
injury)
GCS 8 or lower

Definitive air way management

Most effective

Endotracheal Intubation Equipment

Fibreoptics

Endotracheal tube

Laryngoscope

Combitube

Risk of Endotracheal Intubation

Hypoxia, plica vocalis spasm
Increased blood pressure,

bradycardia/asystole
Increased intracranial pressure
Movement on the neck may worsen the
coexisting cervical spine injury
Ideally, endotracheal intubation procedure
involved anesthetic and muscle relaxant drugs
(must be done by an expert)

Consideration of
Cricothyrodotomy
Failure to apply endotracheal

intubation, while in need of secure

the air way.
Failure to deliver supportive
breathing
Crico-Thyroido-tomy:
Emergency path for
oxygenation
Maintain protective airway
for
10 minutes only
Unable to exhale CO

Cricothyroydotomy
Patients on supine

position
Mark the crico-thyroid
membrane
Puncture the crico-thyroid
membrane with venous
catheter (14-16G) gently
until loss of resistance
sensation
Aspirate to confi rm
catheter placement,
which air aspiration
indicate correct
placement
Deliver oxygen

Chocking
Signs:
Related with food
Unable to speak nor

breath
Swollen face and
cyanosis
Conscious
Unconscious

Back blow/Back slap

Method:
Embrace the patients

from behind
Hold patients body with
one arm
Prevent the patients
from fall
The other free arm do

the back slap/back blow

Back slap/back blow by
slap patients back,
right between 2
scapulas

Heimlich Maneuver
Method:
Embrace patients from

behind
Do Heimlich maneuver by
put rescuers fist on patients
abdomen right between
umbilicus and epigastrium
level

Pull the fist 5 times

Evaluation
Indicated for conscious adult patients

Abdominal thrust
Method:
Put the unconscious patients on supine position
Rescuers take horse ride position above or beside

patients body on the patients hip level

Abdominal thrust done by put both rescuers arm
on patients abdomen right between umbilicus and
epigastrium level
Do abdominal thrust 5 times
Evaluation

Indicated for unconscious adult

patients

Chocking in infant
Signs:
Related with feeding
Troublesome, whimpering
Diffi culty on breathing
Swollen face

What to do:
Back blow/back slap
In turn
Chest thrust

Back blow/Back slap

Put on prone position above

one of rescuers arm, with

head lower than body
Keep the mouth open with
middle fi nger
Hold the shoulder with palm
and other fi nger
Do back blow/back slap between
scapulas, with base of the other
rescuers palm
Back slap/back blow fi ve

times gentely

Chest thrust
Put on supine

position above
rescuers thigh
Chest thrust:
Used index and middle

finger
Placed both finger above
the sternum, right about 1
cm below imaginary line
between two nipples
Do chest thrust 5 times
Evaluation

Instead on infant chest thrust was also

indicated for:
Pediatrics, pregnant, and obese victims

Chocking treatment
Back blow/back slap available for all

ages
Abdominal thrust is not available for
infant, pregnant or obese patients
Chest thrust available for infant,
pregnant and obese patients
For patients age more than eight years
old, treatment as the way as for an
adult patient
Failure to release the air way consider :
Cricothyrodotomy
Followed with tracheostomy

Breathing & Ventilation

Objective
Deliver oxygen into the lungs with

positive pressure which replace

active inspirational phase.
Deliver CO 2 passively through out the
lungs within exhalation period as the
positive pressure stopped.

Breathing Problems
Respiratory distress
Penetrating chest injury
Simple-tension pneumothoraks
Flail chest
Hemothoraks
Subcutaneous emphysema

Assessing breathing problems

Look

Nostril movement
Retraction of chest wall , trachea
Additional accessory breathing muscle
(intercostal,
supraclavicular muscle)

Listen

Breathing sound
Additional breathing sound

Feel

Air flow sensation

Palpation

Chest wall alignment

Percussion

Dull or hyper-sonor sound

Auscultatio
n

Breath sound
Breath sound equality within both lungs

Respiratory distress
All breathing problems are related to
respiratory distress, which is the signs
are :
Shallow and fast breathing
Nostril movement
Retraction of the chest wall and neck
Tachycardia
Hypotension
Distended of the neck veins
Cyanosis (as the later sign)

Artificial Breathing Delivery

Rescuers mouth to patients

mouth/nose
Rescuers mouth to breathing mask
attached to patients
Ambu-bag / self infl ating bag
Jackson Rees, Waters and others
anesthetic breathing equipment with
oxygen reservoar
Ventilator

Artificial Breathing Delivery

Application key
points:
Deliver 80-120 ml of

breathing air into the

patient lungs.
Space between two
artifi cial breath as
exhalation time (I:E
ratio = 1:2)
Put an attention to
chest wall expansion,
which indicate
inspiration adequacy

Mouth to breathing mask

Avoid direct contact between

patients and rescuers lips

Insuffl ate breathing air into
the mask
Face barrier with plastics

Mouth to mouth/nose
Confi rmation clear air way related to

the position and obstruction

Rescuers mouth covers patients
mouth/nose
Used barrier as protection (tissue or
gauze)

Mouth to
Mouth

Mouth to
Nose

Ambu Bag / Self Inflating Bag

Elastic rubber bag

which fl ows amount

of air when it
pumped, and will re
expand automatically
Contain one
direction valve
Deliver oxygen at
60-80%
concentration
Oxygen
concentration may
rise until 100% by

Artificial breathing via endotracheal tube :

Oxygen delivery and CO22 exhalation more effective
Beneficial to prevent pulmonary aspiration or regurgitation
Beneficial in application of CPCR in term of no need to interrupt
while applying chest compression

Jackson Rees
Elastic rubber bag,

which expanded by
oxygen fl ow at
around 10-12
lt/min. fl ow rate.
For that reason this
breathing
equipment depend
on oxygen fl ows.
Contain no
breathing valve
Deliver oxygen at
100% concentration

Ventilators
Mechanical equipment

to deliver artifi cial

breathing into the
lungs.
Require electricity and
high pressure gas as it
activator.
Available basic settings:
Tidal volume (6 ml/kg body

weight)
Frequency 12-20 times/min.
Peak inspiratory pressure 40
cmH2O

Cautions
Risk of barotraumas from artifi cial

breathing with positive pressure

Delivery of the artifi cial breathing
without placement of endo-tracheal
tube may lead the air fl ows into the
stomach instead to the lungs.
Constant delivery of the artifi cial
breathing within 3-4 hours or more,
require humidifi cation.

Thank You
acoanestesi@yahoo.com
081 146 6603