Percutaneous transtracheal jet ventilation equipment. A, Prepackaged transtracheal catheter; B, jet ventilation tubing with flow regulator.
The prepackaged 13-gauge angiocatheter is used to enter the trachea, and its position is verified by aspirating air.
Patient with percutaneous transtracheal catheter connected to jet ventilation apparatus and held in place by neck strap.
Percutaneous transtracheal jet ventilation: algorithm for airway management.
Yusuf Gulleth, Jeffrey Spiro. Percutaneous Transtracheal Jet Ventilation in Head and Neck Surgery. Arch Otolaryngol Head Neck Surg. 2005;131(10):886–890. doi:10.1001/archotol.131.10.886
To assess the safety and efficacy of percutaneous transtracheal jet ventilation (PTJV) in the management of the difficult airway.
Retrospective case series.
Academic, tertiary care medical center.
Forty-three consecutive PTJV procedures performed on 33 patients with anticipated airway difficulty undergoing direct laryngoscopy for diagnosis and/or treatment of head and neck cancer (91%) or benign lesions.
Main Outcome Measures
Duration of PTJV, oxygen saturation values by pulse oximetry, and incidence of tracheotomy and complications.
The mean duration of PTJV was 43 minutes, and mean minimum oxygen saturation was 97%. Biopsy was performed in 27 (62%) of the cases, and a laser excision in 12 (28%). Seven tracheotomies were planned preoperatively, and 2 were performed intraoperatively. Two additional patients required tracheotomies in the immediate postoperative period. Two (5%) complications occurred: 1 pneumothorax that resolved with chest tube insertion and 1 kinked catheter resulting in soft tissue emphysema that resolved spontaneously.
Percutaneous transtracheal jet ventilation is a safe and effective method of ventilation in patients with anticipated airway difficulty. It is particularly useful in patients who are not in immediate airway distress preoperatively but who may be difficult or impossible to intubate after induction of general anesthesia. Percutaneous transtracheal jet ventilation may help to avoid tracheotomy in this setting and should be routinely available as an option for airway management in patients with head and neck cancer.
Patients with anatomical abnormalities such as a mass in the base of the tongue, glottic or subglottic tumors, or extensive pharyngeal or glottic scarring pose a challenge in airway management. While these patients might not demonstrate obvious airway compromise when awake, they can develop significant upper airway obstruction after induction of general anesthesia.1 A number of options are available to manage the airway in these situations including awake intubation, fiber optic guided intubation, tracheotomy under local anesthesia, supraglottic jet ventilation, Hunsaker jet ventilation, copper tube jet ventilation, and percutaneous transtracheal jet ventilation (PTJV). The only nonsurgical option among these that does not require supraglottic access to the trachea is PTJV.
Percutaneous transtracheal jet ventilation was introduced in 1950s by Jacoby et al1 and Reed et al.2 In the early 1970s, intermittent PTJV was successfully used for airway management during routine general surgical procedures lasting up to 2 hours.3 Percutaneous transtracheal jet ventilation was also advocated as an alternative in the management of the difficult airway in conjunction with laryngoscopy.4 Some reports have recommended PTJV only as a transient resuscitative measure for emergent situations in which endotracheal intubation or other ventilation methods are not feasible.5,6 The use of PTJV had not been widely accepted because of initial reports of high complication rates.7,8 However, in 1987 a series consisting of both emergent and nonemergent cases demonstrated better outcomes in a more controlled setting, such as elective use of PTJV in head and neck cancer surgery.9 A more recent study describing the use transtracheal jet ventilation for 90 elective laryngeal surgical cases reported adequate ventilation with minimal complications.10 These recent studies indicate that there is an important role for PTJV in the airway management of patients with head and neck cancer.
Percutaneous transtracheal jet ventilation has several advantages in the management of the difficult airway. These include the following: securing the airway before induction of general anesthesia; eliminating the need for laryngoscopy to secure the airway; providing an unobstructed view of the larynx; and the potential to leave the catheter in place postoperatively in the event that the patient needs further respiratory support.4,7,9 Possible complications include barotrauma, kinking of the catheter and resulting soft-tissue emphysema, pneumomediastinum, and pneumothorax.7,8 There have also been reports of infection at the site of the needle placement; however, these events are rare.8
This study examines our experience with 43 consecutive cases of PTJV used for management of the difficult airway at the University of Connecticut Health Center, Farmington. We assessed the safety and efficacy of PTJV for management of the difficult airway during head and neck surgery in a nonemergent setting.
We performed a retrospective medical chart review of all PTJV cases performed in a 4-year period at the University of Connecticut Health Center. These cases were identified from a prospectively maintained computer database of surgical procedures. Airway compromise was anticipated preoperatively by the senior author (J.S.) in these cases, and a PTJV catheter was placed before induction of general anesthesia. Generally, laryngoscopy and/or bronchoscopy with biopsy or excision were performed. In some cases laser ablation or electrocautery excision was used for cancer debulking. Data concerning the preoperative diagnosis and prior surgery and radiation therapy were retrospectively obtained from the patient records. Operative reports were examined for duration of PTJV and minimum arterial pulse oximetry values. Incidence of tracheotomy, as well as intraoperative and postoperative complications, was also noted. After the medical charts were reviewed, our data set was stripped of all identifiers. We used descriptive statistics as appropriate. Our study was approved by our institutional review board.
Percutaneous transtracheal jet ventilation was accomplished with the patient awake and in a supine position by first locating upper airway landmarks on the neck including the cricoid cartilage, cricothyroid space, and the trachea. The catheter was placed through the cricothyroid membrane or the trachea, depending on the level of known airway obstruction or available landmarks. A 13-gauge angiocatheter prepackaged as a transtracheal catheter (VBM Medizintechnik, Sulz, Germany) was used (Figure 1A). The puncture site was infiltrated with local anesthetic, and then the needle and catheter were advanced into the trachea. The position of the catheter was verified by aspirating air into the syringe (Figure 2) and connecting the catheter to a carbon dioxide monitor. Then a small amount of topical anesthetic was injected. The catheter was fixed in place by a neck strap (Figure 3) and then connected to the jet ventilation apparatus, which consisted of a flow regulator connected to the available oxygen source (Figure 1B).
There were 43 consecutive cases of PTJV performed between July 1998 and April 2003 on 33 patients, of whom 26 were male and 6 female. The average age (range) was 60 years (37-88 years). Biopsy specimens were obtained in 27 (62%) of the PTJV cases, while 12 cases (28%) involved laser excision and 1 (2%) had electrocautery excision. There was a history of radiation therapy in 18 cases (42%), and 5 (12%) had a history of major ablative head and neck surgery. Known head and neck cancer was the indication for 29 (67%) of 43 procedures, while 4 (9%) were performed for known benign laryngeal lesions and 10 cases (23%) were undergoing a diagnostic workup for presumed head and neck cancer. Overall, 39 (91%) of the procedures were cancer related (Table 1).
The mean ± SD (range) PTJV duration was 43 ± 30 (12-132) minutes. Minimum pulse oximetry values had a mean ± SD (range) of 97% ± 2.7% (89%-100%). Nine cases (21%) required a tracheotomy, of which 7 were planned preoperatively and 2 were performed intraoperatively. There were 2 additional tracheotomies performed postoperatively owing to airway difficulties (Table 2). All cases that underwent tracheotomy were cancer related; 6 were for known head and neck malignancies and 5 were undergoing diagnostic procedures for presumed head and neck cancer.
There were 2 (4.7%) complications: 1 intraoperative pneumothorax and 1 kinked and dislodged catheter resulting in soft-tissue emphysema. Two cases were converted to other forms of jet ventilation owing to difficulties maintaining PTJV. One was managed with supraglottic jet ventilation, while another involved the placement of a Hunsaker tube. All patients had a normal emergence from anesthesia except for the 2 cases that required postoperative tracheotomy.
Percutaneous transtracheal jet ventilation has been shown to provide adequate ventilation for routine general surgery and laryngeal and oral surgery cases for up to 3.5 hours.3,4,11 However, early problems with PTJV relegated it to the role of a transient resuscitative measure in emergent settings.5- 8 Recent studies have indicated that PTJV can provide adequate ventilation with few complications during elective head and neck surgical procedures.9,10 Our experience in this study demonstrates that PTJV can be safely used on patients with anticipated airway difficulty on preoperative evaluation who might otherwise require a tracheotomy. These patients have distorted anatomy in their upper airway, which significantly reduces their chance of successful intubation using techniques that require supraglottic access to the trachea. Aside from tracheotomy, PTJV is the only technique that can directly access the subglottic airway prior to induction of general anesthesia.
Our complication rates were low and comparable to those in other published studies.9,10 There was 1 minor complication involving a kinked catheter with resultant subcutaneous emphysema. This resolved when the catheter was removed and ventilation was switched to a Hunsaker jet ventilation tube. One major complication consisted of an intraoperative pneumothorax. This patient underwent a tracheotomy and a left chest tube placement. This patient had received high doses of radiation therapy, and his magnetic resonance image showed extensive tumor infiltration extending to prevertebral fascia and into the base of skull. His extensive disease and postradiation fibrosis and edema might have increased the risk of outflow obstruction, thereby predisposing him to barotrauma and pneumothorax.12
There is a small risk of barotrauma with the use of PTJV, which may be exacerbated by any outflow obstruction or chronic obstructive pulmonary disease. It is rare to have outflow obstruction given the anatomy of the upper airway, which acts like a ball valve permitting gas to escape at relatively low pressures.2,3 Usually pressures of 40 to 50 pounds per square inch through a 16-gauge catheter provide adequate ventilation. In our experience lower pressures, typically 15 to 25 psi, through a 13-gauge catheter were adequate. Outflow obstruction which may be encountered during the placement or manipulation of the laryngoscope can be avoided by temporarily stopping ventilation when the laryngoscope is being introduced or manipulated.4,13 This phenomenon was not observed in our series.
The contribution of obstructive pulmonary diseases such as chronic bronchitis, asthma, and emphysema to the risk of barotrauma and pneumothorax is difficult to quantify. Earlier studies suggested increased risks of barotrauma and pneumothorax because of the diseased lung parenchyma.14 However, a recent study that examined the risk factors for outflow obstruction was not able to show any difference in risk of outflow obstruction or barotrauma between patients with or without chronic obstructive pulmonary disease.12 Thus, it seems that chronic obstructive pulmonary disease may not be a major risk factor for barotrauma.
The risk of outflow obstruction and barotrauma is determined primarily by factors in the upper airway such as the size, location, and morphology of any obstructing mass.12 These characteristics, along with edema and fibrosis, have been used to formulate an upper airway obstruction score, which has been shown by Desruennes and coworkers12 to be the reliable predictor of outflow obstruction with jet ventilation. The upper airway obstruction score increases with increasing size of the lesion, closer proximity to the larynx, and more infiltrative and exophytic lesions, and when edema and fibrosis are present.12 Our patient who experienced a pneumothorax had an extensive laryngeal tumor with infiltration into prevertebral fascia and the base of skull and had been treated with high doses of radiation. These factors almost certainly increased the risk of outflow obstruction and subsequent pneumothorax in this patient.
We follow a specific decision-making algorithm in the management of the potentially difficult airway in patients with known or suspected head and neck cancer (Figure 4). Patients with anticipated airway difficulty undergo placement of a PTJV catheter to secure the airway and avoid the risk of airway obstruction on induction of general anesthesia. After direct laryngoscopy, with or without biopsies and tumor excision, the airway is reassessed. Those patients with an adequate airway then emerge from general anesthesia. If there are any concerns, the PTJV catheter can be left in place in the recovery room in case further ventilatory support is needed. Those patients who still have an inadequate airway have an endotracheal tube placed and then undergo tracheotomy.
In our series of 43 cases in which PTJV was performed, 34 (79%) were judged to have an adequate airway after direct laryngoscopy. In this group, 2 patients needed supplemental oxygen via the catheter postoperatively for 30 to 60 minutes, and 2 patients developed respiratory distress ultimately requiring tracheotomy. Overall, 11 patients (25%) required tracheotomy: 2 were the postoperative tracheotomies; 2 cases were decided intraoperatively; and the remaining 7 cases were planned preoperatively. Overall, only a quarter of these patients with difficult airways required tracheotomy. We believe that the use of PTJV can reduce the need for tracheotomy in patients with head and neck cancer if it is used as an adjunct in the management of the difficult airway in a nonemergent setting.
Percutaneous transtracheal jet ventilation is a safe and effective technique to establish ventilation in the patient with a difficult airway. It is particularly useful in patients who are not in immediate airway distress preoperatively, but who may have a difficult or unsuccessful intubation after induction of general anesthesia. Percutaneous transtracheal jet ventilation can help to avoid tracheotomy in this setting and should be available for patients with head and neck cancer undergoing general anesthesia when airway difficulty is anticipated.
Correspondence: Jeffrey Spiro, MD, Division of Otolaryngology–Head and Neck Surgery, University of Connecticut School of Medicine, 263 Farmington Ave, Farmington, CT 06030 (firstname.lastname@example.org).
Submitted for Publication: October 4, 2004; final revision received April 25, 2005; accepted June 1, 2005.
Financial Disclosure: None.
Previous Presentation: This study was presented at the Sixth International Conference on Head and Neck Cancer; September 9, 2004; Washington, DC.