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Supplemental jet ventilation in conscious patients following major oesophageal surgery.


Intensive care unit patients are at particular risk of respiratory failure after major abdominal surgery. Non-invasive ventilation or application of continuous positive airway pressure through a face mask may stabilise respiratory function and avoid the need for endotracheal re-intubation. However, there are various contraindications to non-invasive ventilation and/or tracheal re-intubation, such as recent oesophageal anastomosis, anastomotic leakage or tracheal stenting for tracheo-oesophageal fistula. A specific management strategy consisting of continuous intratracheal jet ventilation to support spontaneous respiratory function is described in two patients with contraindications to non-invasive ventilation or mask continuous positive airway pressure after major oesophageal surgery.

Key Words: jet ventilation, oesophageal surgery, oesophageal fistula


Intensive care unit (ICU) patients are at particular risk of postoperative respiratory failure after major abdominal or thoracic surgery, e.g. oesophageal resection (1,2). Although tracheal extubation immediately after surgery is often uneventful, pulmonary atelectasis, oedema, pneumonia and systemic inflammation may subsequently develop and compromise respiratory function to a level that requires ventilatory support. Non-invasive ventilation (NIV) with pressure support ventilation and positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) by a high-flow face mask may stabilise respiratory function and avoid the need for endotracheal re-intubation (3,4). However, there are various contraindications to NIV and mask-CPAP, such as recent cervical anastomosis or anastomotic leakage after oesophageal surgery, due to the pressure exerted on the anastomotic sutures or the leak.

Intratracheal jet ventilation is an effective method for ventilating anaesthetised, apnoeic patients when artificial airways or bag-valve-mask ventilation interfere with the surgical procedure, e.g. during intralaryngeal or intratracheal surgery (5). Jet ventilation is widely used in premature infant and neonatal care' and, in adults, mainly restricted to the conservative treatment of bronchopleural fistula (7,8). However, jet ventilation has not been used to support respiration in conscious and spontaneously breathing adults in the ICU. We report two patients with contraindications to NIV and/or tracheal re-intubation after oesophageal surgery who were supported with endotracheal jet ventilation.


Case 1

A 76-year-old patient required tracheal re-intubation for hypoxaemic, non-hypercapnic respiratory failure on day eight after oesophageal resection. Bronchoscopic examination of the airway and CT scan revealed anastomotic leakage resulting in a tracheo-oesophageal fistula with a 4 cm long defect of the posterior tracheal wall. Treatment consisted of tracheal stenting, which was performed under general anaesthesia, and jet ventilation. Candida pneumonia made prolonged respiratory support necessary. An endotracheal tube cuff inflated within the tracheal stent was considered undesirable and placing the inflated cuff distal to the stent would have resulted in endobronchial intubation. Respiratory support was therefore provided through a size 5 laryngeal mask airway (LMA) with an ICU ventilator (Evita 4, Drager Medical AG & Co, Lubeck, Germany) using a proportional pressure support mode. On day five after tracheal stenting, pharyngeal ulceration and bleeding occurred due to the LMA, which had to be removed. CPAP via face mask was also considered contraindicated because of concerns that the stented fistula would be prevented from healing. Consequently, a 40 cm long jet catheter, 4.0 mm in external diameter (Acutronic Medical Systems AG, Hirzel, Switzerland) was advanced through the patient's nose into the trachea with its tip positioned inside the tracheal stent. Catheter placement was performed under bronchoscopic visualisation. Spontaneous breathing was supported for 10 days with a continuous jet stream (80% of oxygen; frequency: 150 /min; pressure: 1.5 bar; Monsoon[R], Jet Ventilator IfM GmbH, Wettenberg-Launsbach, Germany), with adequate oxygenation and C[O.sub.2] elimination (Table 1). The patient was lightly sedated with clonidine, remifentanil and propofol. Unfortunately, he died in the course of his ICU stay from septic shock.

Case 2

A 63-year-old patient was uneventfully extubated on postoperative day one after oesophageal resection and cervical anastomosis. The nasogastric tube dislocated due to the patient's gagging. Endoscopic reinsertion would have exerted mechanical stress on the anastomosis and was considered potentially harmful. Without a nasogastric tube, mask CPAP was likely to result in gastric hyperinflation, which, without proper decompression by a gastric drain tube, would also exert pressure on the anastomosis. Therefore, mask CPAP could not be applied when the respiratory function deteriorated on postoperative day two due to early onset pneumonia. Consequently, a nasotracheal jet catheter was placed under flexible fibreoptic guidance and the fully awake, non-sedated and mobilised patient received supplemental jet ventilation with 60% oxygen, a frequency of 170 /min and a pressure of 1.5 bar. His gas exchange improved significantly and supernormal blood gases were achieved (Table 1). Daily flexible bronchoscopy under topical airway anaesthesia using nebulised lignocaine 4% 5 ml was required for the first five days to remove bronchial secretions. Jet ventilation was continuously applied for 12 days and well tolerated by the patient (Figure 1). Repeated arterial blood gas analyses performed at two-hour intervals during the first 24 hours of sudden cessation of jet ventilation indicated stable respiratory function. When the chest X-ray examination performed on day 13 also revealed no pathology, the catheter was removed from the airway. On postoperative day 16, the patient was transferred to a general ward in good condition.



Both cases suggest that supplemental jet ventilation can be effective in managing respiratory failure in spontaneously breathing patients with contraindications to NIV. In case 1, an endotracheal tube could not be placed because the 8 cm long stent was too close to both the carina and the larynx. The cuff of the endotracheal tube would have been inflated within the stent, resulting in potential life-threatening stent damage. The use of an LMA could not be continued due to pharyngeal ulceration and airway bleeding. In the second patient, endotracheal re-intubation was the only alternative to the regimen applied. The nasotracheal jet catheter was well tolerated without any sedative or analgesic requirements, resulting in a cooperative, alert and satisfied patient who was mobilised within the room.

Daily bronchoscopic removal of tenacious bronchial secretions was required in both patients, a disadvantage of jet ventilation. Although the patients received nebulised salbutamol and tyloxapol (a mucolytic agent) at four-hour intervals, insufficient humidification of the jet stream contributed to the formation of extremely tenacious secretions. Blind insertion of a suction catheter into the tracheobronchial tree was considered inappropriate because the risk of inadvertent and undetected oesophageal catheter advancement with subsequent injury of the anastomotic site. Flexible fibreoptic bronchoscopy was required which resulted in significant patient discomfort despite topical airway anaesthesia with nebulised lignocaine. Additional intravenous sedation, otherwise being the standard of care for awake flexible fibreoptic bronchoscopy in our institution, was not performed because it was feared that even a small dose of propofol for example could have resulted in significant respiratory depression in this particular patient.

In conclusion, supplemental intratracheal jet ventilation represents an appropriate alternative to endotracheal re-intubation in patients with contraindications to NIV and in those with contraindications to endotracheal intubation or tracheostomy. Patient compliance is absolutely essential and the most determining factor of success or failure of jet ventilation in spontaneously breathing, conscious patients. Although supplemental jet ventilation should be taken into consideration in patients with respiratory failure and contraindications to NIV, mask-CPAP or re-intubation, this regimen will be limited to a selected patient population.

Accepted for publication on July 19, 2007.


(1.) Arozullah AM, Khuri SF, Henderson WG, Daley J, Participants in the National Veterans Affairs Surgical Quality Improvement Program. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major non-cardiac surgery. Ann Intern Med 2001; 135:847-857.

(2.) Atkins BZ, Shah AS, Hutcheson KA, Mangum JH, Pappas TN, Harpole DH Jr et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004; 78:1170-1176.

(3.) Antonelli M, Conti G, Rooco M, Bufi M, De Blasi RA, Vivino G et al. A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 1998; 339:429-435.

(4.) Delclaux C, L'Her F, Alberti C, Mancebo J, Abroug F, Conti G et al. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: a randomized, controlled trial. JAMA 2000; 284:2352-2360.

(5.) Shikowitz MJ, Abramson AL, Liberatore L. Endolaryngeal jet ventilation: a 10-year review. Laryngoscope 1991; 101:455-461.

(6.) Joshi VH, Bhuta T. Rescue high frequency jet ventilation versus conventional ventilation for severe pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev 2006; Jan 25: CD000437.

(7.) Ihra G, Gockner G, Kashanipour A, Aloy A. High-frequency jet ventilation in European and North American institutions: developments and clinical practice. Eur J Anaesthesiol 2000; 17:418-430.

(8.) Smith BE, Scott PV, Fischer HB. High frequency jet ventilation in intensive care--a review of 63 patients. Anaesthesia 1988; 43:497-505.

T. M. BINGOLD *, B. SCHELLER [[dagger]], S. KLOESEL *, H. WISSING [[double dagger]], B. ZWISSLER [[section]], C. BYHAHN [[double dagger]]

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, J.W. Goethe-University School of Medicine, Frankfurt, Germany

* M.D., Senior Intensivist.

[[dagger]] M.D., Senior Anaesthesiologist.

[[double dagger]] M.D., Assistant Professor of Anaesthesiology.

[[section]] M.D., Professor of Anaesthesiology.

Address for reprints: Dr C. Byhahn, Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, J.W. Goethe-University School of Medicine, Theodor-Stern-Kai 7, D-60590 Frankfurt, Germany.
Arterial blood gas analyses one hour before and one hour after
initiation of jet ventilation

 Case 1

 Before JV During JV

Fi[0.sub.2] 0.6 via LMA 0.8
[P.sub.a][0.sub.2] (mmHg) 105.6 168.3
[P.sub.a]C[0.sub.2] (mmHg) 45.4 47.1
pH 7.49 7.48
Base excess (mmol/1) +5.5 +5.3

 Case 2

 Before JV During JV

Fi[0.sub.2] 15 1/min [O.sub.2] via 0.6
 face mask
[P.sub.a][0.sub.2] (mmHg) 68.2 154.5
[P.sub.a]C[0.sub.2] (mmHg) 26.4 38.2
pH 7.52 7.43
Base excess (mmol/1) -2.6 -2.1

JV = jet ventilation, LMA = laryngeal mask airway.
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Article Details
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Title Annotation:Case Reports
Author:Bingold, T.M.; Scheller, B.; Kloesel, S.; Wissing, H.; Zwissler, B.; Byhahn, C.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Geographic Code:4EUGE
Date:Dec 1, 2007
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