Application and Application and Devices of Jet Devices of Jet VentilationVentilation

2002-11-11 R32002-11-11 R3 陳建宇陳建宇

Monitored transtracheal jet ventilMonitored transtracheal jet ventilation using a triple lumen central ation using a triple lumen central venous cathetervenous catheter

AnaesthesiaAnaesthesia Volume 57 Issue 6 Page 578  - JuVolume 57 Issue 6 Page 578  - June 2002ne 2002

Case ICase I 32 y/o male, 4-year history of NPC s/p 32 y/o male, 4-year history of NPC s/p

R/TR/T Mouth opening was 1 cm with limited heMouth opening was 1 cm with limited he

ad extensionad extension Left nasal passage was blockedLeft nasal passage was blocked Awake fibreoptic intubation 6 months prAwake fibreoptic intubation 6 months pr

eviously, resulted in aspiration of blood, eviously, resulted in aspiration of blood, impaired oxygenationimpaired oxygenation

Case IICase II 38y/o male, 4-year history of NPC s/p R/T&OP38y/o male, 4-year history of NPC s/p R/T&OP Biopsy for recurrent mass in the oropharynxBiopsy for recurrent mass in the oropharynx Mouth opened 1 cm and very limited head extensionMouth opened 1 cm and very limited head extension Both nasal passages were completely blockedBoth nasal passages were completely blocked Sedated with midazolam 2 mg and atropine 0.3 mgSedated with midazolam 2 mg and atropine 0.3 mg Nasopharyngeal airway could not be used due to prevNasopharyngeal airway could not be used due to prev

ious operationious operation Consequently, the tongue was held out of the mouth Consequently, the tongue was held out of the mouth

with a pair of forceps to maintain a patent expiratory pwith a pair of forceps to maintain a patent expiratory pathwayathway

ProcedureProcedure 7 FG 16 cm triple lumen CVP (Arrow) 7 FG 16 cm triple lumen CVP (Arrow) Cricothyroid membrane were normalCricothyroid membrane were normal Cricothyroid blockCricothyroid block Insert the triple lumen catheter at mark 8cmInsert the triple lumen catheter at mark 8cm Distal lumen was connected to the AMS 1000 Distal lumen was connected to the AMS 1000

jet ventilatorjet ventilator Middle lumen was connected to the pressure Middle lumen was connected to the pressure

monitoring channel of the AMS 1000monitoring channel of the AMS 1000 Proximal lumen to a capnographProximal lumen to a capnograph

ProcedureProcedure 9 FG suction catheter was passed through the right 9 FG suction catheter was passed through the right

nostril into the oropharynxnostril into the oropharynx 6.0-mm nasopharyngeal airway was gently threade6.0-mm nasopharyngeal airway was gently threade

d over the suction catheter keeping expiratory pathd over the suction catheter keeping expiratory pathway guaranteed (case I)way guaranteed (case I)

Expired CO2 from the right nostril was monitored wiExpired CO2 from the right nostril was monitored with a second capnographth a second capnograph

Propofol 2 mg.kgPropofol 2 mg.kg 1 1 and maintained with propofol 10- and maintained with propofol 10-6 mg.kg6 mg.kg 1 1.h.h 1 1; muscle relaxation was achieved with ; muscle relaxation was achieved with atracurium 0.5 mg.kgatracurium 0.5 mg.kg 1 1. Morphine 0.1 mg.kg. Morphine 0.1 mg.kg 1 1 was u was used for analgesiased for analgesia

DiscussionDiscussion Cricothyroid puncture and transtracheal jet veCricothyroid puncture and transtracheal jet ve

ntilation is a useful emergency measure when ntilation is a useful emergency measure when it is impossible to secure the airwayit is impossible to secure the airway

Surgical tracheostomy may seem excessive fSurgical tracheostomy may seem excessive for minor procedures such as biopsyor minor procedures such as biopsy

Triple lumen central venous catheter for monitTriple lumen central venous catheter for monitored jet ventilation was first described in childored jet ventilation was first described in children when the catheter was placed through the ren when the catheter was placed through the larynxlarynx

DiscussionDiscussion Two major concerns: barotrauma and cTwo major concerns: barotrauma and c

arbon dioxide accumulationarbon dioxide accumulation We addressed these by continuously mWe addressed these by continuously m

onitoring the airway pressure and the exonitoring the airway pressure and the expired co pired co 22 partial pressure via the separ partial pressure via the separate 18 FG lumens without interrupting vate 18 FG lumens without interrupting ventilation via the 16 FG lumenentilation via the 16 FG lumen

AdventagesAdventages Easy to insert under local anaesthesia Easy to insert under local anaesthesia The markings on the catheter helped positioningThe markings on the catheter helped positioning All three lumens were opening within the tracheaAll three lumens were opening within the trachea The catheter does not obstruct even when kinkedThe catheter does not obstruct even when kinked Such catheters are widely available and economiSuch catheters are widely available and economi

cal compared to custom-made cricothyroid cannulcal compared to custom-made cricothyroid cannulation sets that do not offer the option of monitorination sets that do not offer the option of monitoring transtracheal jet ventilation.g transtracheal jet ventilation.

A Potential ProblemsA Potential Problems Movement of the tip was minimised by keepinMovement of the tip was minimised by keepin

g a short length within the trachea and by usig a short length within the trachea and by using a low driving pressureng a low driving pressure

Trauma due to whipping of the catheter with Trauma due to whipping of the catheter with each jet breatheach jet breath

Another problem is mucus plugging of the lumAnother problem is mucus plugging of the lumens particularly the capnography lumenens particularly the capnography lumen

Minimise the complicationsMinimise the complications Continuous monitoring of the airway presContinuous monitoring of the airway pres

sure can minimise the risk of barotrauma, sure can minimise the risk of barotrauma, hyperinflation and pneumothorax hyperinflation and pneumothorax

Maintenance of a patent expiratory pathwMaintenance of a patent expiratory pathway prevents stacking of breaths , hyperinfay prevents stacking of breaths , hyperinflation and barotraumalation and barotrauma

A combination of vocal cord relaxation, heA combination of vocal cord relaxation, head and neck positioning and a nasal airwaad and neck positioning and a nasal airway in the first patient were usedy in the first patient were used

Measurement of CO2Measurement of CO2 The gradient between the co The gradient between the co 22 in the airway and the in the airway and the

PPaa co co 22 caused by dilution of the expired gas by both caused by dilution of the expired gas by both the driving gas and entrained airthe driving gas and entrained air

End expiratory co End expiratory co 22 is useful for monitoring ventilator is useful for monitoring ventilatory pattern but is much lower than the true end-tidal co y pattern but is much lower than the true end-tidal co 22 and does not give a meaningful estimate of P and does not give a meaningful estimate of Paa co co 22

Intermittent single breath end-tidal co Intermittent single breath end-tidal co 22 measurement measurement was closely correlate with Pwas closely correlate with Paa co co 22 and useful for moni and useful for monitoring the adequacy of co toring the adequacy of co 22 elimination elimination

DisadvantagesDisadvantages No protection from contamination by No protection from contamination by

blood and surgical debrisblood and surgical debris Positive end-expiratory pressure help to Positive end-expiratory pressure help to

reduce contamination reduce contamination Surgeon may pay attention to suction of Surgeon may pay attention to suction of

blood and debris from obstructing the blood and debris from obstructing the expiratory pathwayexpiratory pathway

ConclusionConclusion It is a simple technique that allows uninterruptIt is a simple technique that allows uninterrupt

ed ventilation and oxygenationed ventilation and oxygenation It has continuous monitoring of airway pressuIt has continuous monitoring of airway pressu

re and expired carbon dioxidere and expired carbon dioxide It is a useful option when upper airway patholIt is a useful option when upper airway pathol

ogy makes conventional intubation difficultogy makes conventional intubation difficult A custom-made triple lumen catheter for moniA custom-made triple lumen catheter for moni

tored transtracheal jet ventilation will be a weltored transtracheal jet ventilation will be a welcome device in the management of difficult aircome device in the management of difficult airways.ways.

Respiratory Gas Monitoring During Respiratory Gas Monitoring During High-Frequency Jet Ventilation for High-Frequency Jet Ventilation for Tracheal Resection Using a Tracheal Resection Using a Double-Lumen Jet CatheterDouble-Lumen Jet Catheter

A&A, Vol 88(1). Jan 1999A&A, Vol 88(1). Jan 1999

CaseCase 22 y/o male, 2.5cm tracheal stenosis localize22 y/o male, 2.5cm tracheal stenosis localize

d 4.5cm below the glottisd 4.5cm below the glottis Schedule for tracheal resection and end-to-enSchedule for tracheal resection and end-to-en

d anastomosisd anastomosis After anesthesia, inspect the stenosis by fibeAfter anesthesia, inspect the stenosis by fibe

rscope and intubate a 24F ETTrscope and intubate a 24F ETT After sternotomy, withdraw the tube proximal tAfter sternotomy, withdraw the tube proximal t

o the stenosis, and advance a double-lumen o the stenosis, and advance a double-lumen 12F polyrethane jet catheter12F polyrethane jet catheter

CaseCase Central lumen connected to HFJVCentral lumen connected to HFJV Second lumen for capnography & oxygraphy (asSecond lumen for capnography & oxygraphy (as

piration 200ml/min) piration 200ml/min) Jet ventilation was used 45 min with setting: FiOJet ventilation was used 45 min with setting: FiO

2: 0.6, frequency:100/min, I/E:2:3, driving press2: 0.6, frequency:100/min, I/E:2:3, driving pressure adjust to normal ETCO2ure adjust to normal ETCO2

Temporarily slowed the frequency to 8/min for tTemporarily slowed the frequency to 8/min for two cycles for estimating ETCO2 & O2wo cycles for estimating ETCO2 & O2

Double-Lumen CatheterDouble-Lumen Catheter 12F, 70cm12F, 70cm Designed by author’s department in GermDesigned by author’s department in Germ

anyany Central/lateral lumen: 1.8/1.2mmCentral/lateral lumen: 1.8/1.2mm Distance between two lumen is 10mmDistance between two lumen is 10mm Can’t monitor the pressure due to air trappCan’t monitor the pressure due to air trapp

ing probleming problem

ResultsResults Two sets of end-tidal and arterial O2 Two sets of end-tidal and arterial O2

and CO2 were measured by and CO2 were measured by conventional mechanical ventilation conventional mechanical ventilation before tracheal resection– differences before tracheal resection– differences were 4.0-4.4mmHgwere 4.0-4.4mmHg

Three sets were obtained by HFJV Three sets were obtained by HFJV during tracheal resection– differences during tracheal resection– differences were 1.5-5 mmHgwere 1.5-5 mmHg

DiscussionDiscussion Most of these studies show good correlation betMost of these studies show good correlation bet

ween capnographic and arterial CO2 value but ween capnographic and arterial CO2 value but only few show good correspondence only few show good correspondence

Most reasons were “contamination” with room aMost reasons were “contamination” with room airir

FEO2 is better than FIO2 to estimate the actual FEO2 is better than FIO2 to estimate the actual inspired oxygen concentrationinspired oxygen concentration

Changes in FEO2 were accompanied by corresChanges in FEO2 were accompanied by correspinding changes in PaO2 pinding changes in PaO2

DiscussionDiscussion This double-lumen allows continuous This double-lumen allows continuous

PETCO2 and FEO2 measurements PETCO2 and FEO2 measurements during low- and high-frequency jet during low- and high-frequency jet ventilationventilation

A simple, safe, and cost-effective A simple, safe, and cost-effective method and increase the safety of jet method and increase the safety of jet ventilationventilation

One-Lung Ventilation for ThoracotoOne-Lung Ventilation for Thoracotomy Using a Hunsaker Jet Ventilatiomy Using a Hunsaker Jet Ventilation Tuben Tube

Anesthesiology, Vol 87(6). Dec 1997Anesthesiology, Vol 87(6). Dec 1997

CaseCase 52y/o male, laryngeal ca s/p total laryngectom52y/o male, laryngeal ca s/p total laryngectom

y and R/T 13 months agoy and R/T 13 months ago Schedule for left upper lobectomy for 2cm lunSchedule for left upper lobectomy for 2cm lun

g noduleg nodule Soft silicon noncuffed laryngectomy tube was Soft silicon noncuffed laryngectomy tube was

placed due to tracheal stenosisplaced due to tracheal stenosis Tracheoesophageal fistula inserting voice proTracheoesophageal fistula inserting voice pro

sthesis sthesis

Hunsaker jet ventilation tubeHunsaker jet ventilation tube

CaseCase Proximal end of the voice prosthesis partly Proximal end of the voice prosthesis partly

obstructed the tracheostomy tubeobstructed the tracheostomy tube Removal of the laryngectomy tube would dRemoval of the laryngectomy tube would d

islocate the voice prosthesis from the trachislocate the voice prosthesis from the tracheoesophageal fistulaeoesophageal fistula

Prosthesis act as a one-way valve preventiProsthesis act as a one-way valve preventing aspiration ng aspiration

ProcedureProcedure Thoracic epidural catheterThoracic epidural catheter PreoxygenationPreoxygenation Sedated by propofol, ketamineSedated by propofol, ketamine 3ml of 4% lidocaine was instilled into th3ml of 4% lidocaine was instilled into th

e tracheae trachea Hunsaker jet ventilation tube inserted intHunsaker jet ventilation tube inserted int

o the tracheostomy tubeo the tracheostomy tube

ProcedureProcedure Wings of the tube were squeezed togetWings of the tube were squeezed toget

her and were totally inserted into the righer and were totally inserted into the right main bronchus under a pediatric bronht main bronchus under a pediatric bronchoscopechoscope

Sulfentanil, pancuroniumSulfentanil, pancuronium Jet port was positioned at the entrance Jet port was positioned at the entrance

of the right main bronchusof the right main bronchus 90/min, I:E=1:1, FIO2=190/min, I:E=1:1, FIO2=1

ProcedureProcedure Good visual expansion of right chestGood visual expansion of right chest PaO2: 376mmHg, PaCO2: 39mmHg(5PaO2: 376mmHg, PaCO2: 39mmHg(5

min)min) Left lung fully collapsed 30min laterLeft lung fully collapsed 30min later Thoracotomy lasted 95min and Sao2 vaThoracotomy lasted 95min and Sao2 va

ried from 100% to 92%ried from 100% to 92% OLV(30’,50’): PaO2=65 and 69mmHg, OLV(30’,50’): PaO2=65 and 69mmHg,

PaCO2=28mmHgPaCO2=28mmHg

ProcedureProcedure SCC was confirmed and lobectomy was cancSCC was confirmed and lobectomy was canc

elledelled Hunsaker tube was withdrawn into the tracheaHunsaker tube was withdrawn into the trachea Adjusted the rate to 15/min (inspiratory time, 2Adjusted the rate to 15/min (inspiratory time, 2

s)s) Rapid reinflation of left lungRapid reinflation of left lung PaO2 448-398mmHg and PCO2 37-39mmHgPaO2 448-398mmHg and PCO2 37-39mmHg

DiscussionDiscussion Jet ventilation catheter (often modified nJet ventilation catheter (often modified n

asogastric tubes) are used for tracheal rasogastric tubes) are used for tracheal resection and reconstructive surgeryesection and reconstructive surgery

Never been used as an altermative to a Never been used as an altermative to a DLT for lung resectionDLT for lung resection

2mm catheter passed through a standar2mm catheter passed through a standard ETT and fed into the left main bronchud ETT and fed into the left main bronchuss

DiscussionDiscussion Complications—Complications—1.1. PneumothoraxPneumothorax2.2. Tears in the tracheobronchial mucosaTears in the tracheobronchial mucosa3.3. Injury caused by drying and cooling gaInjury caused by drying and cooling ga

ss

DiscussionDiscussion Hunsaker tube—Hunsaker tube—1.1. Has distal wings that center the high pressure jHas distal wings that center the high pressure j

et in the tracheal or bronchial lumen 3cm from et in the tracheal or bronchial lumen 3cm from the of the catheterthe of the catheter

2.2. The wings limit the movement of the catheter pThe wings limit the movement of the catheter preventing the direct mucosal injuryreventing the direct mucosal injury

3.3. Side port allows monitoring of either tidal CO2 Side port allows monitoring of either tidal CO2 or tracheal pressureor tracheal pressure

4.4. More reliably placed in position than a narrow tMore reliably placed in position than a narrow tubeube

結論結論 因應不同術式而發展出不同的因應不同術式而發展出不同的 devicesdevices 就地取材就地取材 Well-monitored to prevent complicatiWell-monitored to prevent complicationsons 對對 airway managementairway management 活用且大膽活用且大膽 可用於常規手術可用於常規手術

Thanks for your Thanks for your attentionattention