Oleh:Slamet Sumarno251207

PengantarSuction adalah salah satu cara untuk membersihkan jalan nafas yang mengalami hambatan karena sputum, mukus atau skret sehingga jalan nafas menjadi bersih dan kebutuhan gas dapat terpenuhi.Suction harus dilakukan secara tepat, benar dan aman sehingga dilakukan dengan proses dan dianalisa tepat dilakukan suction.

TUJUAN:Mempertahankan jalan nafas yang bebas (hegienis).Untuk membersihkan sekret pada pasien yang tidak mampu batuk.

Indikasi Pasien tidak mampu batuk : neonatus, tracheatomi, indotracheal tube Pasien tidak mampu batuk efektif: Retensi skret, neonatus, gagal nafas.Membersihkan berfungsi tube.

Komplikasi

Parengeal suction akan merangsang syaraf sympatis (N. vagus) menimbulkan aktif sympatik dan menyebabkan bradicardi dan henti jantung dan henti nafas ( vagal reflek).

Keterangan umum/PerhatianSekret yang menggangu jalan nafas harus segera dikeluarkan krn dapat menyebabkan gagal nafas.Digunakan tehnik aseptik dan alat steril.Penghisapan sekret harus dilakukan dengan prosedur yang tepat untuk mencegah infeksi, luka, spasme, udema serta perdarahan jalan nafas.

Keterangan umum/PerhatianLama penghisapan lendir tidak boleh lebih dari: 5-10 dt untuk bayi dan anak. 10-15 dt untuk dewasa, Vacum presure: 8-13,6 kPa (60-100 mmHg) untuk bayi. 13 20 (100-120 mmHg) untuk anak . 20- 27 kPa ( 120-200 mmHg untuk dewasa. Botol penampung sekret harus diisi dengan cairan aseptik kira-kira bagian dicatat selama 24 jam dan diganti.

Keterangan umum/PerhatianUntuk menjegah bradikardi selama suction harus dilakukan pencegahan dengan pre suction pemberian oksigen pada pasien, Gunakan kateter suction seperti indotrache cube.Suction dapat menstimulasi batuk bila tidak ada gangguann Vagus dengan disertai batuk maka mobilisasi scret lebih mudah.

Suction pada bayi dan anakSebelum memberikan suction sebaiknya dibberikan Oksigenasi untuk memperbaiki Hypoksia, Inspirasi ooksigen pada gangguan nafas hanya meningkat k/l 10% pada bayi, hypoksia jangka pendek dapat menyebabkan Retinopathy (bayi prematur) (Robutan 1997)

IntervensiVacum presure diberikan tidak terlalu tinggi tetapi cukup kuat untuk menarik mukus ke luar dengan intensitas antara 8-20 kPa (60-150 mmHg).Kateter yg digunakan antara 6-8(french gange) FG. Ukuran 5 FG atau dibawahnya tidak efektif, ukuran >10 untuk anak dan dewasa >10ThDiameter kateter tidak digunakan 50% dari diameter jalan nafas.

Prosedur Terangkan prosedur yang akan dilakukan pada pasien.Letakkan alat-alat disamping tempat tidur pasien.Jika mungkin buat posisi semi fowler.Cuci tangan anda dengan aseptik.Hidupkan sumber penghisap dengan tekanan sesuai kebutuhan.Ukur kateter sepanjang ujung hidung sampai telinga.

Membersihkan melalui mulut.Hubungkan sumber penghisap dinding dengan penghisap logam.Masukkan penghisap logam kedalam mulut tanpa memberi tekanan penghisap, kemudian lakukan penghisapan sekret dengan hati-hati.Hindarkan mata pasien dari percikan sekret jalan nafas.Bersihkan kateter logam dengan larutan steril.Berikan oksigen pada pasien dan lakukan penghisapan lagi bila perlu.

Membersihkan memalui hidung.Hubungkan sumber penghisap dengan kateter penghisap.Berikan pelicin pada ujung kateter penghisap.Masukkan kateter penghisap melalui lubang hidung atau dapat juga melalui mulut dengan hati-hati tanpa memberikan tekanan pada penghisap, kemudian lubang penghisap ditutup dan sekret dihisap sambil kateter ditarik perlahan-lahan.Bersihkan kateter penghisap dengan larutan steril.Berikan oksigen pada pasien dan lakukan pengisapan lagi bila perlu.

Untuk pasien dengan pipa entratrakea terpasangPerlu 2 orang untuk penghisapan bila mungkin, terutama pada anak yang aktif.Satu memberikan oksigenasi.Tekan tombal alrm ventilator jika perlu.Lepaskan hubungan dengan sirkuit ventilator atau pipa humidifer jika pasien mempergunakan alat tersebut.Gunakan ballon pemompa dan beri oksigen 3-5 kali inflasi dengan konsentrasi F1O2:

= 10% lebih besar dari konsentrasi O2 yang digunakan untuk neonatus dengan berat badan kurang dari 3 kg.=100% untuk pasien lain kecuali ada ketentuan lain.Selama prosedur, jaga agar gerakan dada tetap adekuat dan jika diberikan ventilator jaga agar tetap dalam tekanan positif, Hindari tekanan yang berlebihan.Bila berat badan bayi kurang dari 2kg harus dipasang pengukur tekanan pada sirkuit.

Orang ke dua.melakukan penghisapanHidupkan penghisap dinding dengan tekanan sesuai kebutuhan.Pasang sarung tangan dan letakkan pengalas diatas dada pasien.Hubungkan penghisap dengan kateter penghisap dengan tangan kanan.Jaga agar kateter tetap steril.Masukkan kateter kedalam lumen pipa trakea dengan cepat sejauh mungkin tanpa dipaksa, dengan lubang kateter terbuka dalam keadaan tidak menghisap.

Lakukan penghisapan sekret dengan menutup lubang penghisap yang ada disamping.Kateter penghisap ditarik perlahan-lahan untuk beberapa cm pertama, kemudian ditarik secara cepat sambil diputar (rotasi).Bila kateter sulit ditarik mungkin menempel pada dinding bronkus, buka lubang penghisap dan ulangi penghisapan dengan tekanan lebih rendah.Selama penghisapan pipa endotrakea dipegang dengan tangan kiri untuk mempertahankan posisi.Hubungkan pipa endotrakea dengan balon pemompa dan berikan oksigen.

Pada neonatus dengan berat badan kurang dari 3 kg konsentrasi O2 10% lebih tinggi dari yang sedang digunakan. Pada pasien yang lain berikan oksigen 100% kecuali ada intruksi khusus.Ulangi seluruh prosedur dengan tehnik yang sama sampai jalan nafas relatif bersih dari sekret.Selama penghisapan perhatikan warna kulit dan denyut nadi pasien. Bila terjadi kelainan hentikan penghisapan dan berikan ventilasi dengan segera.Kateter penghisap dari endotrakea boleh digunakan untuk dari mulutatau hidung sebaiknya tidak boleh.Kembalikan pasien ke sirkuit ventilator atau pipa humidifer bila sebelumnya tidak digunakan.Matikan sumber penghisap, slang dalam keadaan bersihPeralatan dikembalikan dalam keadaan bersih dan pasien dalam posisi semula.

Frekuensi penghisapanDilakukan tiap 2 jam bila perlu.Atau setelah dilakukan chest fisioterapi.Segera laporkan bila terdapat:Kesulitan memasukkan kateter penghisap.Bila skret sudah tidak bisa dihisap.Sekret yang pekat dan banyak.Sekret campur darah, berbusa dan atau berbau.Penderita sianotik, keadaan menurun, apnnu dll

Hal-hal yg perlu dicatatWaktu penghisapan.Keadaan skret: jumlah, warna, bau dan konsentrasiHal-hal yang terjadi selama penghisapan: Posisi, keadaan selama penghisapan:Hipoksia, bradikardi

Respiratory AnatomyNose and mouth : (Menghangatkan, melembabkan dan menyaring udara).PharynxOropharynxNasopharynxEpiglottisTrachea (windpipe Cricoid cartilageLarynx (voice box).Bronchi

LungsVisceral pleura (surface of lungs)Parietal pleura (internal chest wall)Interpleural space (potential space)

Larynx

Upper AirwayTongueGlottisEpiglottis

Lower Airway

Sistempersarafan pada jalan nafas

V - Trigeminal NerveSensoriknya ke daerah wajah (touch, pain and temperature) dan motoriknya ke Temporal, massesterBila terganggu n. V sensasi & motorik terganggu or dapat menimbulkan nyeri = trigeminal neuralgia

Trigeminal neuralgia

VII - Facial NerveEkpresi wajah, sensasi lidah anterior 2/3s, salivary glands and tear, nasal & palatine glandsKerusakan otot-otot fasial & penyampaian sensasi(missing sweet & salty) called Bells Palsy

IX - Glossopharyngeal NerveProvides control over swallowing, salivation, gagging, sensations from posterior 1/3 of tongue, control of BP and respirationDamage results in loss of bitter & sour taste & impaired swallowing.

X - Vagus NerveThe wondererProvides swallowing, speech, regulation of 2/3 of GI tractDamage causes impaired voice, swallowing and digestion

Sensory supply of upper airway1) Mucouse membrane of nose : n. cranial. V (trigeminal .) ophthalmic div. V1 (ant. Ethmoidal n. ) : ant. part of nose maxillary div. V2 (sphenopaltine n.) : post. part of nose2) Soft and hard palate : palatine n.3) Tongue br. of mandibular div V3 (lingual n.) : ant. 2/3 general sensation dan 1/3 oleh n. IX (glossopharyngeal n.) branch of VII ( facial n.) & IX : sensation of taste

Sensory supply of upper airway

4) Glossopharyngeal n (IX) : pharynx roof, tonsil soft, palate under-surface innervation

5) Vagus n.(X) : epiglottis , airway , sensation Sup. Laryngeal br. : ext. br (motor) int. br (sensory) epiglottis, vocal cord , sensory supply Recurrent laryngeal n. : vocal cord , trachea , sensory supply

ANATOMY

Laryngeal n. injury1) Sup. laryngeal n. (ext. laryngeal n. motor n. cricothyroid m) unilat. : minimal effect bilat. : hoaresness, tiring of voice (but airway effect voice)2) Recurrent laryngeal n. unilat. : ipsilat. Vocal cord paralysis (voice quality ) bilat . : acute : stridor, respiratory distress chronic : aphonia 3) Vagus n. unilat. :hoarseness bilat. : aphonia

Respiratory physiologyDiaphragmInhalation (active process)Diaphragm and intercostal muscles contract, increasing the size of the thoracic cavity.Diaphragm moves slightly downward, ribs move upward and outward.The negative pressure in the chest cavity causes air flow into the lungs.

Respiratory physiologyExhalation (passive process)Diaphragm and intercostal muscles relax decreasing the size of the thoracic cavity.Diaphragm moves upward, ribs move downward and inward.The positive pressure inside the chest cavity causes air flow out of the lungs.

Respiratory PhysiologyOxygenation - blood and the cells become saturated with oxygenHypoxia - inadequate oxygen levels in the bloodSigns of HypoxiaIncreased or decreased heart rateAltered mental status (early sign)AgitationInitial elevation of B.P. followed by a decreaseCyanosis (often a late sign)

Alveolar Gas ExchangeOxygen-rich air enters the alveoli during each inspiration.Oxygen enters the blood in the capillaries as carbon dioxide enters the alveoli for exhalation.

Infant and Child ConsiderationsMouth and nose - generally all structures are smaller and more easily obstructed than in adults.Pharynx - infants and childrens tongues take up proportionally more space in the mouth than adults.Trachea - (windpipe) Infants and children have narrower tracheas that are obstructed more easily by swelling.Trachea is softer and more flexible in infants and children.

Infant and Child ConsiderationsCricoid cartilage - like other cartilage in the infant and child, the cricoid cartilage is less developed and less rigid. It is the narrowest part of the infants or childs airway.Diaphragm - chest wall is softer, infants and children tend to depend more heavily on the diaphragm for breathing.

Opening the MouthCrossed-finger techniqueInspect the mouthVomitBloodSecretionsForeign bodiesBe extremely cautiousFingersGag or vomit

Opening the AirwayHead-tilt, chin lift maneuverAdults vs.. Infants and ChildrenJaw thrust maneuver

Techniques of SuctioningDasar intervensi suction: precautionsMaksud/ tujuanMengalirkan benda asing dlm saluran nafas spt: blood, liquids, and food particles.Patient needs to be suctioned dengan segera saat pasien ada suara meneguk

Types of Suction Units1. Mounted Suction DevicesFixed on-board the ambulance300mmHg pull on gauge when tubing is clampedShould be adjustable (disesuaikan) for infants and children

2. Portable Suction DevicesElectric - battery powered Oxygen - poweredHand - poweredEach device must haveWide-bore, thick walled, nonkink tubingPlastic collection bottle, supply of waterEnough vacuum to clear the throat

3. Suction CathetersCatheter keras (yankaeur) Penyulit pemakaian :Masuk lewat mulut. Terhambat Tonsil dan lidah.Used to suction mouth and oropharynxInserted a limited depthUse caution on infants and childrenSoft tissue damage

Suction CathetersSoft catheter (French catheter)Used to suction mouth or nose and nasopharynxMeasured from tip of the nose to the tip of the ear.Not inserted beyond the base of the tongue

Techniques of SuctioningPosisikan pasienn yg baik terlentang atau miring kan kepala dan badan bila bayi/anak. (Best positioned at patients head)Perhatikan perubahan suction unitPilih catheter yg pas ukurannya, diameter catheter 50% Diameter jalan nafas. Ukur/periksa dan berapa dalam chateter dapat masukSuction from side to sideDewasa tidak lebih 15 secondsInfants & children Kurang dari 15 seconds (5-10)Bilas catheter dengan air desinfectance.

Special Considerations(pertimbangan khusus).Bila Secret tidak dapat terhisap dianjurkan dibantu dengan dibersihkan dengan jari.Patient producing frothy secretions as rapidly as suctioning can remove themSuction 15 secondsPositive pressure with supplemental oxygen for 2 minutes then suction again and repeat the processResidual air removed from lungs, monitor pulse and heart rate

SuctionThe importance of readiness can not be overstated.

Prehosp Emerg Care 1997 Apr-Jun; 1(2):91-5Kozak RJ, Ginther BE, Bean Study of suction equipment utilization. The paramedics reported:carrying suction equipment to the scene of medical aid calls less than 25% of the time. suction equipment is utilized during 50% of advanced airway procedures. WS.Study of suction equipment utilization.

Suction - Key PointsDiingatkan agar memahami dasar-dasar pemberian suction. Suctions are limited in what they removeImmediate action is neededHave a secondary device

Oropharyngeal Airway (OPA)Used to maintain a patent airway only on deeply unresponsive patientsNo gag reflexDesigned to allow suctioning while in placeMust have the proper sizeIf patient becomes responsive and starts to fight the OPA remove it...

Inserting the OPASelect the proper size (corner of the mouth to tip of the ear)Open the patients mouthInsert the OPA with the tip facing the roof of the mouth Advance while rotating 180Continue until flange rests on the teethInfants and children insertion

Nasopharyngeal Airway (NPA)Nose hose, nasal trumpetUsed on patients who are unable to tolerate an OPA or is not fully responsiveDo not use on suspected basilar skull fractureStill need to maintain head-tilt chin lift or jaw thrust when insertedMust select the proper sizeMade to go into right nare or nostril

Inserting the NPASelect the proper size in length and diameterLubricateInsert into right nostril with bevel always toward the septumContinue inserting until flange rests against the nostrilInsertion into left nostril

Assessment of BreathingAfter establishing an airway your next step should be to assess breathingLookBreathing pattern regular or irregularNasal flaringAdequate expansion, retractions

Assessment of BreathingListenShortness of breath when speakingUnresponsive place ear next to patients mouthIs there any movement of air?

Assessment of BreathingFeelCheck the volume of breathing by placing you ear and cheek next to the patients mouth

Assessment of BreathingAuscultateStethoscopeMid clavicular about the second intercostal space and the fourth or fifth anterior midaxillary line or next to sternumCheck both sidesPresent and equal bilaterallyDiminished or absent

Adequate BreathingNormal rateAdult 12 - 20/minChild 15 - 30/minInfant 25 - 50/minRhythmRegular Irregular

Ventilation VolumeTidal volume-air inspired in each breathMinute volume-tidal volume multiplied by the respiratory rate

Adequate BreathingQualityBreath sounds present and equalChest expansion adequate and equalEffort of breathinguse of accessory muscles predominately in infants and childrenDepth (tidal volume)Adequate chest rise and fallFull breath sounds heard

Inadequate BreathingRateOutside the normal limitsTachypnea (rapid breathing) >20Badypnea (slow breathing)

Inadequate BreathingQualityBreath sounds diminished, noisy or absentExcessive use of accessory muscles, retractionsReduced air flow at nose/mouthInadequate chest expansionNostril flaring (infants & children)DepthShallow (impaired depth) breathingAgonal respirations - occasional gasping respirations

Inadequate BreathingSkin ColorRetractionsSeesaw breathing (abd & chest move in opposite directions)

Any of these signs is by itself may be reason to ventilate a patient without delay

Positive Pressure ventilationThe practice of artificially ventilating, or forcing air into a patient who is breathing inadequately or not breathing at all

Techniques of Artificial VentilationIn order of preferenceMouth to maskTwo-person bag-valve-maskFlow-restricted oxygen-powered ventilation deviceOne-person bag-valve-mask

Considerations When Using Artificial VentilationMaintain a good mask sealDevice must deliver adequate volume of air to sufficiently inflate the lungsSupplemental oxygen must be used

Adequate Artificial VentilationsChest rises and falls with each ventilationRate of ventilations are sufficientHeart rate returns to normalColor improves

Inadequate Artificial VentilationsChest does not rise and fallVentilation rate is too fast or slowHeart rate does not return to normalColor is not improved

Mouth-to-Mouth VentilationAir we breath contains 21% oxygen5% used by the body16% is exhaledDanger of infectious disease

Mouth-to-MaskEliminates direct contact with patientOne-way valve systemCan provide adequate or greater volume than a BVMOxygen port (should be connected to 15 lpm)

Bag-Valve-Mask (BVM)EMT-B can feel the lung complianceConsists of self-inflating bag, one-way valve, face mask, intake/oxygen reservoir valve, and an oxygen reservoir.By adding oxygen and a reservoir close to 100% oxygen can be delivered to the patientWhen using a BVM an OPA/NPA should be used if possible

Bag-Valve-Mask Cont...Volume of approximately 1,600 millilitersProvides less volume than mouth-to-maskSingle EMT may have trouble maintaining sealTwo EMTs more effectivePop-off valve must be disabledAvailable in infant, child, and adult sizes

Bag-Valve-Mask Cont...Breaths should be 1.5 to 2 secondsGuard against overinflationMonitor the sealBring the jaw to the mask

Bag-Valve-Mask Cont...Assisted ventilations for hyper or hypoventilating patientsExplain procedurePlace the maskSqueeze bag on inhalationOver next 5 to 10 breaths slowly adjust rate and tidal volume to desired rate and volume

Sellick Maneuver

Sellick Maneuver

Mask ventilation will be made difficult by:poor mask seal -- beards facial burns facial scarring/cuts facial dressings edentulous patients any evidence of airway obstruction neck instability penetrating neck trauma repeated failed direct laryngoscopy obesity/bull neck

Other ventilation techniques will be made difficult by:lack of knowledge and experience lower airway obstruction neck instability penetrating neck injury

Flow-Restricted, Oxygen-Powered Ventilation DeviceKnown as a demand-valve deviceCan be operated by patient or EMTUnable to feel lung complianceWith proper seal will deliver 100% oxygenDesigned for use on adult patientsGastric distensionRupture of the lungsA trigger positioned to allow EMT to keep both hands on the mask

Automatic Transport VentilatorsDeliver 100% oxygenProvide and maintain a constant rate and tidal volume during ventilationAdvantagesFrees both handsRate, & tidal volume can be setAlarm for low oxygen tankDisadvantagesOxygen powerednot used in children under 5Cannot feel increase in airway resistance

Oxygen TherapyOxygen is a drug that can be given by the EMT-BGenerally speaking, a patient who is breathing less than 12 and more than 24 times a minute needs oxygen

Oxygen DangersOxygen supports combustion, (it is not flammable)Avoid contact with petroleum productsSmokingHandle carefully since contents are under pressure

Oxygen CylindersAll of the cylinders when full are the same pressure of 2,000 psi.Usually green or aluminum greyD cylinder - 350 litersE cylinders - 625 litersM cylinders - 3,000 litersG cylinders - 5,300 litersH cylinders - 6,900 liters

High-Pressure RegulatorProvides 50 psi to an oxygen-powered, ventilation device.Flow rate cannot be controlled

Low Pressure/Therapy RegulatorPermit oxygen delivery to the patient at a desired rate in liters per minuteFlow rate can go from 1 to 25 liters/min.

Oxygen HumidifiersDry oxygen is not harmful in the short termGenerally not needed in prehospital careTransport time of an hour or more humidifier should be considered

Changing Oxygen BottleCheck cylinder for oxygen remove protective sealQuickly open and shut tank to remove debrisPlace regulator over yoke and and align pins.Make sure new O ring is in placeHand tighten the T screwOpen to check for leaks

Nonrebreather MaskPreferred method of giving oxygen to prehospital patientsUp to 90% oxygen can be deliveredBag should be filled before placing on patientFlow rate should be adjusted to 15 liters/min.Patients who are cyanotic, cool, clammy or short of breath need oxygenConcerns of too much oxygenDifferent size masks

Nasal CannulaProvides limited oxygen concentrationUsed when patients cannot tolerate maskProngs and other usesConcentration of 24 to 44%Flow rate set between 1 to 6 litersFor every liter per minute of flow delivered, the oxygen concentration the patient inhales increases by 4%

Nasal Cannula Flow Rates1 liters/min. =24%2 liters/min. = 28%3 liters/min. = 32%4 liters/min. = 36%5 liters/min. = 40%6 liters/min. = 44%

Simple Face MaskNo reservoirCan deliver up to 60% concentrationRate 6 to 10 liters/min.Not recommended for prehospital use

Partial Rebreather MaskSimilar to nonrebreather except it has a two-way valve allowing patient to rebreath his exhaled air.Flow rate 6 to 10 liters/min.Oxygen concentration between 35 to 60%

Venturi MaskProvides precise concentrations of oxygenEntrainment valve to adjust oxygen deliveryMostly used in the hospital setting for COPD patients

Special Situations

Inhaler TherapyHistoryMedical DirectionReview of specific bronchodilator medication

Laryngectomies (Stomas)A breathing tube may be presentIf obstructed, suction itSome patients may have partial laryngectomiesBe sure to close the mouth and nose to prevent air escaping

Infants and Child PatientsNeutral position infantJust a little past neutral for childAvoid hyperextension of headAvoid excessive BVM pressureGastric distension more common in childrenOral or nasal airway may be considered when other procedures fail to clear the airway

ObstructionAnything (food, blood, swollen tissue, vomit) that blocks the airway will cause some level of decrease of available oxygen to the body.

ObstructionThe size of obstruction affects the available air exchange.

For example, snoring will reduce air Exchange while a food bolus can actually stop air exchange.

ObstructionWhen obstruction persists, repeat FBAO procedures three times and transport as soon as possible.

Facial InjuriesRich blood supply to the faceBlunt injuries and burns to the face result in severe swellingBleeding into the airway can be a challenge to manage

Jaw Thrust

Technique Suction. Gunakan cateter steril untuk mencegah nasocomial (infeksi dirumah sakit).Sebelum suction informasikan ke keluarga/pasien apa maksud anda melakukan suction.Siapkan alat siap pakai.Sebelum dan sesudah suction dapat diberikan terapi oksigen untuk mencegah vagal reflek.Lakukan dengan waktu suction 3-5 detik untuk anak dan 5-10 atau 10-15 detik untuk dewasa. Vacum presure =60-150 mmHg untuk dewasa dan 40-80 mmHg untuk anak ( 8- 20 kPa dewasa) 6-12 kPa anak (Tergantung kepekatan mukus).Dengan nafas dalam akan merangsang batuk pada sebagian pasien.