Transtracheal jet ventilation in management of the difficult airway.
We present the use of transtracheal jet ventilation in two uncooperative patients with a difficult airway. Although transtracheal jet ventilation is considered as a last resort option in the difficult airway algorithm, its use can be a valuable tool in selected difficult airway situations. Transtracheal jet ventilation can effectively maintain arterial oxygenation and provide extra time for attempts to intubate the trachea, either directly or fibreoptically.
Key Words: transtracheal catheter, ventilation, tracheal intubation, difficult, hypoxaemia
Difficult airway and associated hypoxaemia may be a major cause of morbidity and mortality. Transtracheal jet ventilation (TTJV) is a near last resort option in the American Society of Anesthesiologists (ASA) 2003 Difficult Airway algorithm (1). The use of TTJV early in the management of difficult airway can be useful in patients with maxillofacial trauma or any other emergency airway condition where a difficult airway is anticipated. We present two difficult airway scenarios that illustrate the value of the TTJV technique. In both our patients, TTJV was used earlier than would be indicated in the difficult airway algorithm. Patient consent for research purposes was obtained in both cases.
A 54-year old morbidly obese truck driver was involved in a motor vehicle accident and suffered a C2 cervical fracture. His head and neck were immobilised externally with a vest and halo. On the second postoperative day, the patient became confused, agitated and developed respiratory distress. Mask ventilation was difficult due to the lack of patient cooperation, presence of external fixator hardware, facial contusion, obesity and collapse of the upper airway. Arterial blood gases showed hypoxaemia (pH 7.32, [P.sub.a]C[O.sub.2] 46 mmHg, [P.sub.a][O.sub.2] 48 mmHg) despite 100% oxygen via an oxygen reservoir mask. Sedation was deemed hazardous due to concerns regarding potential loss of airway and worsening of hypoxaemia and hypercarbia. Prophylactic TTJV was initiated with a 16-gauge angiocatheter (13/4 inch Angiocath [R], Deseret Medical Inc., Park Davis and Company, Sandy, UT, U.S.A.) inserted into the trachea after skin infiltration with local anaesthetic (Figure 1). Jet ventilation was initiated at a rate of 14-16 breaths per minute with 100% oxygen at 345 kPa. The patient was then sedated and fibreoptic tracheal intubation was accomplished without difficulty. Immediate post-intubation arterial blood gases showed resolution of hypoxaemia (pH 7.22, [P.sub.a] C[O.sub.2] 58 mmHg, [P.sub.a] [O.sub.2] 362 mmHg). The trans-tracheal catheter was removed after the initiation of mechanical ventilation. Figure 1 shows the catheter in situ, capped to prevent the escape of respiratory gases, just prior to its removal.
[FIGURE 1 OMITTED]
A 26-year-old male involved in a motor vehicle accident was admitted to the emergency department with multiple injuries including facial lacerations and fractures. A computerised tomography scan was necessary to assess possible head and neck injuries as well as the extent of facial fractures. However the patient was intoxicated, uncooperative and belligerent each time we attempted to examine his airway. Total loss of airway with sedation was a concern. Using local anesthesia and carefully titrated modest amount of sedation, we were able to place a 16-gauge angiocatheter (1 3/4 inch, Acuvance[R] Jelco[R], Medex Inc., Carlsbad, CA, U.S.A.) percutaneously into the trachea. The patient was not resisting and tolerated the procedure well. We then initiated TTJV, deeply sedated the patient and then intubated his trachea over a fibreoptic bronchoscope. The transtracheal catheter was removed after the initiation of mechanical ventilation.
Transtracheal jet ventilation technique
After sterile preparation, we palpate the thyroid cartilage and identify the cricothyroid membrane. The skin is then anaesthetised with a 25-gauge needle. A 16-gauge angiocatheter is attached to a 10 ml syringe, partially filled with 2% lignocaine (4 ml) and air (2 ml). With the left hand palpating and stabilising the cricothyroid membrane a 16-gauge IV catheter is introduced through it. Intratracheal catheter placement is confirmed by air bubbling into the syringe. After the needle reaches the trachea, lignocaine is injected and the catheter is passed over the needle into the trachea. The direction of insertion is aimed at 45 degrees caudally to avoid injury of the posterior tracheal wall. After full insertion of the catheter we reconfirm free air aspiration before initiating jet ventilation. We then connect the catheter to jet ventilator and we carefully watch the first several insufflations for any signs of misplaced catheter for concern of subcutaneous emphysema. With additional time available, one may consider placing a three-way stopcock between the catheter and jet ventilator connector and attach it to an end-tidal capnograph to confirm tracheal placement of catheter to help ensure against subcutaneous emphysema. Adequacy of ventilation is judged by listening for breath sounds and observing the chest rise. During ventilation, a dedicated person should maintain the catheter stability and placement.
Our two patients illustrate that in selected difficult airway situations (maxillofacial trauma, unstable neck, etc) TTJV may be used as a first manoeuvre in gaining definitive control of the airway. Managing a difficult airway in an alert and cooperative patient can present problems. In an agitated, uncooperative, or combative patient, the problems are compounded. The exact incidence of hypoxaemia during attempted tracheal intubations of a difficult airway is not known. However, Mateer et a1Z in their study of endotracheal intubation in the emergency room reported the time required for orotracheal intubation to be 0.9 [+ or -] 0.6 minute. Even this relatively short time needed for tracheal intubation was associated with a 10.4% incidence of hypoxaemia. The duration of intubation attempts and the incidence of hypoxaemia are likely to be much greater in difficult airway situations. Early TTJV can prevent hypoxia, permit sedation and provide extra time to perform a tracheal intubation by the most appropriate technique. In addition, fibreoptic tracheal intubation may be facilitated during TTJV as the air escaping the trachea helps in remobilising the collapsed airway tissues and air exiting trachea helps to identify the glottic opening if excessive secretions are present (3).
The safety and efficacy of transtracheal ventilation is well documented (4). Controlled, early use of TTJV in selected patients can prevent airway trauma caused by repeated direct laryngoscopy attempts, hypercarbia and, most importantly, hypoxaemia. Although we did not encounter any difficulty in TTJV placement in our patients, dislodgement of the catheter tip with the resultant complication of misplaced air insufflation is described in the literature (5, 6). Bleeding, haematoma, oesophageal perforation, barotrauma, pneumothorax and soft tissue emphysema are some of the reported complications (7-9). Indeed, complications were more than twice as likely to occur during emergency placement than during elective placement of a TTJV catheter (28.6% vs. 11.5 %) (5). TTJV can improve arterial oxygenation and provide extra time for attempts to intubate the trachea, either directly or fibreoptically.
Accepted for publication on January 29, 2007.
(1.) American Society of Anesthesiologists Task Force. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 2003; 98:1269-1277.
(2.) Mateer JR, Olson DW, Stueven HA, Aufderheide TP Continuous pulse oximetry during emergency endotracheal intubation. Ann Emerg Med 1993; 22:675-679.
(3.) Chandradeva K, Palin C, Ghosh SM, Pinches SC. Percutaneous transtracheal jet ventilation as a guide to tracheal intubation in severe upper airway obstruction from supraglottic oedema. Br J Anaesth 2005; 94:683-686.
(4.) Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology 1989; 71:769-778.
(5.) Smith RB, Schaer WB, Pfaeffle H. Percutaneous transtracheal ventilation for anaesthesia and resuscitation: a review and report of complications. Can Anaesth Soc J 1975; 22:607-612.
(6.) Patel RG. Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful. Chest 1999; 116:1689-1694.
(7.) Weymuller EA, Jr., Pavlin EG, Paugh D, Cummings CW Management of difficult airway problems with percutaneous transtracheal ventilation. Ann Otol Rhinol Laryngol 1987; 96:34-37.
(8.) Bourgain JL, Desruennes E, Fischler M, Ravussin P Transtracheal high frequency jet ventilation for endoscopic airway surgery: a multicentre study. Br J Anaesth 2001; 87:870-875.
(9.) Chang JL, Bleyaert A, Bedger R. Unilateral pneumothorax following jet ventilation during general anesthesia. Anesthesiology 1980; 53:244-246.
R. McHUGH *, M. KUMAR ([dagger]), J. SPRUNG ([double dagger]), D. BOURKE ([section])
Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, Minnesota, United States of America
* M.D., Resident.
([dagger]) M.D., Assistant Professor.
([double dagger]) M.D., Professor.
([section]) M.D., Professor, Anesthesiology, Veterans Administration Medical Center, Baltimore, Maryland.
Address for reprints: Dr J. Sprung, Department of Anesthesiology, Mayo Clinic College of Medicine, Mary Brigh 2-752, 200 First Street Sw, Rochester, MN 55905, U.S.A.
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|Title Annotation:||Case Reports|
|Author:||McHugh, R.; Kumar, M.; Sprung, J.; Bourke, D.|
|Publication:||Anaesthesia and Intensive Care|
|Article Type:||Clinical report|
|Date:||Jun 1, 2007|
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