1Service dAnesthésie, Institut Gustave Roussy, Rue Camille Desmoulins, F-94800 Villejuif, France. 2Service dAnesthésie, Hôpital Foch, 40 rue Worth, F-92151 Suresnes, France. 3Département dAnesthésiologie et de réanimation, CHU Sion and Lausanne, Switzerland*Corresponding author
Accepted for publication: August 16, 2001
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Abstract |
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Br J Anaesth 2001; 87: 8705
Keywords: larynx, laryngoscopy; surgery, laser; ventilation, high frequency; ventilation, high frequency jet; complications
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Introduction |
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We assessed transtracheal jet ventilation (TTJV) during laryngoscopic and laser surgery procedures in a prospective multicentre study.
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Methods |
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After induction of anaesthesia, a catheter was introduced through the cricothyroid membrane into the trachea, 13 or 14 gauge for adult patients and 18 gauge for children aged less than 3 yr. Two types of tracheal catheters were used: a Teflon 14-gauge, 10 cm length, arterial catheter (Seldicath® Plastimed, France) introduced using the Seldinger method11 or a Ravussin 13-gauge catheter directly introduced into the trachea under endoscopic control by the surgeon (VBM Laboratory, Germany).12 The number of punctures and the experience of the anaesthetist (consultant or resident) were recorded. In all cases, 2 ml of 2% lidocaine were injected through the injector. Taking into account the usual tracheal length, the distal tip of the injector was expected to be located between 2 and 4 cm above the carina. After induction, HFJV was started using the following settings: rate 2 Hz, inspiratory/expiratory ratio 0.5, driving pressure 2.84 bar according to age, weight and chest expansion, FIO2=1 except during laser surgery. The patients were not intubated and passive expiration was facilitated by manually lifting the jaw before and after laryngoscopy. Two HFJVs were used: the GR300 (LSSA, Fontenay sous bois, France) or the AMS 1000 (Acutronic medical systems, Hirzel, Switzerland). Both were equipped with a fail-safe system allowing the measurement of expiratory airway pressure through the transtracheal catheter.11 Each end-expiratory pressure value was recorded by a microprocessor located in the ventilator. This microprocessor allowed the next inflation only when end-expiratory pressure was less than a pre-set value (usually 4 cm H2O). This feature detects overinflation during laryngoscopy. Driving pressure was progressively decreased during emergence and HFJV was stopped when patients became conscious. Mechanical ventilation was restarted if breathing was inadequate. The tracheal catheter was withdrawn in the recovery room.
Duration of laryngoscopy, upper airway disease (benign or cancer), use of laser and episodes of desaturation (<90% for >1 min) were recorded. After the procedure, the surgeon graded the extent of upper airway obstruction by allocating a numerical score for each of the following features: tumour position, tumour infiltration, the severity of tumour vegetation, oedema, and fibrosis (Table 1). To summarize these values, two final scores were calculated, by addition and also by multiplication of the individual component values. Each of these values was used for comparisons.7
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Results are expressed as mean (SD). Predictive factors were determined only in adult patients. Children were included in the assessment of complications but were excluded from statistical analysis because of the small number of patients and the different clinical context. Univariate non-parametric tests were first used, followed by stepwise multiple logistic regression which was used to examine the relationships between complications and perioperative data. The results were considered significant if P<0.05.
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Results |
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Subcutaneous emphysema was limited to the neck in 53 of 643 patients (8.4%) and extended to the face or the thorax in 14 patients(2%). Subcutaneous emphysema was more frequent after multiple tracheal punctures (2% after a single tracheal puncture and 8% after multiple punctures) (Table 3). Pneumomediastinum was diagnosed in 16 patients (2.5%) and was always associated with subcutaneous emphysema.
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Discussion |
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TTJV has been used routinely in our institutions for more than 10 yr and we have a large experience in this field. Transtracheal ventilation can be unsafe in unexperienced hands.6 In a retrospective study of 58 hospitals, complications were more frequent when experience of jet ventilation was limited.14 Potential problems exist and a good understanding of the technique is necessary.8 Even when used for resuscitation, the anaesthetist should carry out transtracheal ventilation under supervision in a more controlled situation.15
The cricothyroid membrane is the route of choice for transtracheal ventilation as it has no blood vessels, with a low risk of bleeding.16 The puncture can be done with general or local anaesthesia, or directly in emergency situations. It must be strictly in the midline to avoid misplacement. Passing a catheter through the infracricoid membrane should be avoided because of potential bleeding but can be done when the cricothyroid membrane cannot be punctured, for example if a surgical scar or subglottic tumour are present. Mucosal lesions related to laryngoscopy and intubation and inadvertent placement or migration of an injection catheter into the oesophagus can be avoided.17 In patients with an abnormality of the upper airway, such as in cases of head and neck cancer, it can be valuable. In these patients, a TTJV catheter allows rapid induction and adequate control of the airway.8
Adverse events were infrequent and complications were mainly related to (1) the puncture itself, (2) mechanical problems (subcutaneous emphysema, pneumomediastinum and pneumothorax, (3) episodes of low-oxygen saturation, and (4) recovery.
The puncture
The failure rate of cricothyroid membrane puncture was small (0.3%). The number of complications was not influenced by the experience of the anaesthetist (junior vs senior) or the type of transtracheal catheter (Seldicath® or Ravussin catheter). Most of the puncture difficulties were related to abnormal anatomy, which is previous radiotherapy, and should be identifiable preoperatively. Conventional i.v. catheters are not safe for jet ventilation because they are short, thin-walled, and easily kinked. The use of metallic needles has been proposed but the risk of tracheal perforation during patient movements seems high.18 19
Mechanical problems
The major concern during jet ventilation is the risk of subcutaneous emphysema, pneumomediastinum, pneumothorax, and even pneumoperitoneum. Such complications have been reported after endotracheal intubation (0.04%), but with less incidence than after jet ventilation (0.2%).14 They are related either to barotrauma or tracheal mucoseal trauma and have been reported in adults and children, using orotracheal, nasotracheal, or transtracheal catheters.19 Subcutaneous cervical emphysema is more frequent after difficult tracheal puncture, especially in patients with previous cervical radiotherapy. The gas mixture enters the subcutaneous space around the puncture site. This is of no major clinical consequence, but patients, anaesthetist, and surgeon should be aware of this potential complication. Pneumomediastium may be related to the extension of the subcutaneous emphysema or to some damage to the tracheal mucosa. The Seldicath® catheter is relatively rigid and may hit the tracheal wall at the end of each insufflation, allowing a high-pressure gas mixture to penetrate the submucosal space. We report a 1% incidence of pneumothorax which is similar to normal rate jet ventilation.4 Pneumothorax can occur despite the use of ventilators equipped with a system to control end-expiratory tracheal pressure. Few prospective studies have quantified this risk when using jet ventilation: two pneumothoraces were reported in a series of 318 patients using the jet insufflation technique via a foil wrapped catheter.4 In our study, two bilateral pneumothoraces followed a laser impact on the catheter during laryngeal dis-obstruction. In this condition, transtracheal ventilation should be used very cautiously, and HFJV through a nasotracheal catheter could be a better method. In any case, the anaesthetist must check the position of the catheter endoscopically. A laser resistant tracheal tube may be an alternative method. This is less convenient for the surgeons, does not prevent the occurrence of pneumothorax completely and exposes the patient to the risk of tracheal tube fire.14 In the remaining five cases, the pneumothoraces were small and were recognized in the recovery room. They were always associated with subcutaneous emphysema with no evidence of upper airway obstruction. Disruption of the perivisceral fascia can follow cricothyroid membrane puncture or a lesion to the tracheal wall at the injector tip. As we did not inspect the tracheal wall at the end of the laryngoscopy, we cannot be sure of this. Finally, a pneumothorax may be related to high-airway pressure during recovery (cough or active expiration). This could explain some complications diagnosed after endoscopy. End-expiratory pressure monitoring has been found to indicate tracheal pressure measured with a separate catheter in model lung studies and relate to change in pulmonary volume in patients during laryngoscopy.11 Although barotrauma may be related to excessive peak airway pressure, we used end-expiratory pressure because of technical constraints. As pressure changes are small during TTJV,20 this difference was neglected.
Episodes of low-oxygen saturation
During HFJV, oxygenation depends upon several factors:21 the injected oxygen concentration, the ratio of entrained gas, and the increase in functional respiratory capacity (PEEP effect). Inspired gas is a mixture of injected gas and entrained air. Entrained air is limited during transtracheal HFJV,22 23 so FIO2 was high and oxygenation was always adequate during laryngoscopic and microsurgical procedures. Episodes of oxygen desaturation were more frequent during laser surgery when FIO2 was decreased (the use of FIO2 greater than 0.4 is contraindicated during laser surgery24 25). In most of these patients, it was necessary to stop laser surgery during short periods of time in order to increase FIO2. In two patients, hypoxic episodes were related to bilateral pneumothorax, and tracheal intubation was required before pleural drainage. One case of oxygen desaturation was caused by the cricothyroid catheter lying in the right main bronchus; this complication should be detected by systematic pulmonary auscultation. Carbon dioxide retention can occur during jet ventilation, particularly in COPD and obese patients. Blood gas analysis was not performed in our study but it is likely that some patients were hypercapnic. To provide non-invasive ventilation monitoring during laryngoscopy, tracheal gas can be aspirated through the injector after stopping the ventilator. This allows the diagnosis of hypo- or hyperventilation.26 Obesity is considered a risk factor for hypoxaemia during conventional ventilation and HFJV7 and our data support this. A low PaO2 has also been reported in COPD patients under HFJV,7 but we did not confirm this observation.
Recovery
Upper airway obstruction is common after direct laryngoscopy. This complication was not quantified in our study because of the difficulty in assessing the level of obstruction. Emergency tracheotomy or reintubation was never indicated in this large group of patients partially because of the use of short-acting anaesthetics and reversal of neuromuscular blocking agents. The catheter was left in place and withdrawn before the patient returned to the ward, so that immediate reventilation and/or oxygenation were possible. As patients were not intubated, weaning from the ventilator was easy to achieve by decreasing the driving pressure before stopping jet ventilation. Low-pressure (<2 bar) HFJV may be restarted and superimposed on spontaneous breathing in a conscious or semi-conscious patient; if expiration is easy, the risk of barotrauma is limited and this method can be used even in patients with severe upper airway obstruction.13 TTJV is an attractive alternative to tracheotomy in this difficult situation.27
Specific methods have been developed to prevent fire, such as foil-tape and saline-soaked pledgets protected tubes or special tubes designed to resist a laser beam.2430 A transtracheal catheter can be touched by the laser beam but its low flammability (Teflon) reduces the risk of fire with this technique.28 Its cost is less than that of the special tubes designed to resist a laser. Finally, perfect surgical conditions need an immobile field, with no vocal cord movement. In case of abnormal forced movements of vocal folds or any other cause of obstruction, jet ventilation can be stopped transiently during laser treatment (apneic oxygenation).
As vapourisers are not available on jet ventilators, total i.v. anaesthesia was used in all cases. Propofol provides satisfactory conditions31 and muscle relaxation was added to prevent any movement of the vocal cords. Awareness was not encountered in our study, probably because propofol was supplemented with opiates.32
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Conclusion |
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References |
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