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Application and Devices of Jet Ventilation

Application and Devices of Jet Ventilation. 2002-11-11 R3 陳建宇. Monitored transtracheal jet ventilation using a triple lumen central venous catheter. Anaesthesia Volume 57 Issue 6 Page 578 - June 2002. Case I. 32 y/o male, 4-year history of NPC s/p R/T

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Application and Devices of Jet Ventilation

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  1. Application and Devices of Jet Ventilation 2002-11-11 R3陳建宇

  2. Monitored transtracheal jet ventilation using a triple lumen central venous catheter AnaesthesiaVolume 57Issue 6Page 578 - June 2002

  3. Case I • 32 y/o male, 4-year history of NPC s/p R/T • Mouth opening was 1 cm with limited head extension • Left nasal passage was blocked • Awake fibreoptic intubation 6 months previously, resulted in aspiration of blood, impaired oxygenation

  4. Case II • 38y/o male, 4-year history of NPC s/p R/T&OP • Biopsy for recurrent mass in the oropharynx • Mouth opened 1 cm and very limited head extension • Both nasal passages were completely blocked • Sedated with midazolam 2 mg and atropine 0.3 mg • Nasopharyngeal airway could not be used due to previous operation • Consequently, the tongue was held out of the mouth with a pair of forceps to maintain a patent expiratory pathway

  5. Procedure • 7 FG 16 cm triple lumen CVP (Arrow) • Cricothyroid membrane were normal • Cricothyroid block • Insert the triple lumen catheter at mark 8cm • Distal lumen was connected to the AMS 1000 jet ventilator • Middle lumen was connected to the pressure monitoring channel of the AMS 1000 • Proximal lumen to a capnograph

  6. Procedure • 9 FG suction catheter was passed through the right nostril into the oropharynx • 6.0-mm nasopharyngeal airway was gently threaded over the suction catheter keeping expiratory pathway guaranteed (case I) • Expired CO2 from the right nostril was monitored with a second capnograph • Propofol 2 mg.kg 1 and maintained with propofol 10-6 mg.kg 1.h 1; muscle relaxation was achieved with atracurium 0.5 mg.kg 1. Morphine 0.1 mg.kg 1 was used for analgesia

  7. Discussion • Cricothyroid puncture and transtracheal jet ventilation is a useful emergency measure when it is impossible to secure the airway • Surgical tracheostomy may seem excessive for minor procedures such as biopsy • Triple lumen central venous catheter for monitored jet ventilation was first described in children when the catheter was placed through the larynx

  8. Discussion • Two major concerns: barotrauma and carbon dioxide accumulation • We addressed these by continuously monitoring the airway pressure and the expired co 2 partial pressure via the separate 18 FG lumens without interrupting ventilation via the 16 FG lumen

  9. Adventages • Easy to insert under local anaesthesia • The markings on the catheter helped positioning • All three lumens were opening within the trachea • The catheter does not obstruct even when kinked • Such catheters are widely available and economical compared to custom-made cricothyroid cannulation sets that do not offer the option of monitoring transtracheal jet ventilation.

  10. A Potential Problems • Movement of the tip was minimised by keeping a short length within the trachea and by using a low driving pressure • Trauma due to whipping of the catheter with each jet breath • Another problem is mucus plugging of the lumens particularly the capnography lumen

  11. Minimise the complications • Continuous monitoring of the airway pressure can minimise the risk of barotrauma, hyperinflation and pneumothorax • Maintenance of a patent expiratory pathway prevents stacking of breaths , hyperinflation and barotrauma • A combination of vocal cord relaxation, head and neck positioning and a nasal airway in the first patient were used

  12. Measurement of CO2 • The gradient between the co 2 in the airway and the Pa co 2 caused by dilution of the expired gas by both the driving gas and entrained air • End expiratory co 2 is useful for monitoring ventilatory pattern but is much lower than the true end-tidal co 2 and does not give a meaningful estimate of Pa co 2 • Intermittent single breath end-tidal co 2 measurement was closely correlate with Pa co 2 and useful for monitoring the adequacy of co 2 elimination

  13. Disadvantages • No protection from contamination by blood and surgical debris • Positive end-expiratory pressure help to reduce contamination • Surgeon may pay attention to suction of blood and debris from obstructing the expiratory pathway

  14. Conclusion • It is a simple technique that allows uninterrupted ventilation and oxygenation • It has continuous monitoring of airway pressure and expired carbon dioxide • It is a useful option when upper airway pathology makes conventional intubation difficult • A custom-made triple lumen catheter for monitored transtracheal jet ventilation will be a welcome device in the management of difficult airways.

  15. Respiratory Gas Monitoring During High-Frequency Jet Ventilation for Tracheal Resection Using a Double-Lumen Jet Catheter A&A, Vol 88(1). Jan 1999

  16. Case • 22 y/o male, 2.5cm tracheal stenosis localized 4.5cm below the glottis • Schedule for tracheal resection and end-to-end anastomosis • After anesthesia, inspect the stenosis by fiberscope and intubate a 24F ETT • After sternotomy, withdraw the tube proximal to the stenosis, and advance a double-lumen 12F polyrethane jet catheter

  17. Case • Central lumen connected to HFJV • Second lumen for capnography & oxygraphy (aspiration 200ml/min) • Jet ventilation was used 45 min with setting: FiO2: 0.6, frequency:100/min, I/E:2:3, driving pressure adjust to normal ETCO2 • Temporarily slowed the frequency to 8/min for two cycles for estimating ETCO2 & O2

  18. Double-Lumen Catheter • 12F, 70cm • Designed by author’s department in Germany • Central/lateral lumen: 1.8/1.2mm • Distance between two lumen is 10mm • Can’t monitor the pressure due to air trapping problem

  19. Results • Two sets of end-tidal and arterial O2 and CO2 were measured by conventional mechanical ventilation before tracheal resection– differences were 4.0-4.4mmHg • Three sets were obtained by HFJV during tracheal resection– differences were 1.5-5 mmHg

  20. Discussion • Most of these studies show good correlation between capnographic and arterial CO2 value but only few show good correspondence • Most reasons were “contamination” with room air • FEO2 is better than FIO2 to estimate the actual inspired oxygen concentration • Changes in FEO2 were accompanied by correspinding changes in PaO2

  21. Discussion • This double-lumen allows continuous PETCO2 and FEO2 measurements during low- and high-frequency jet ventilation • A simple, safe, and cost-effective method and increase the safety of jet ventilation

  22. One-Lung Ventilation for Thoracotomy Using a Hunsaker Jet Ventilation Tube Anesthesiology, Vol 87(6). Dec 1997

  23. Case • 52y/o male, laryngeal ca s/p total laryngectomy and R/T 13 months ago • Schedule for left upper lobectomy for 2cm lung nodule • Soft silicon noncuffed laryngectomy tube was placed due to tracheal stenosis • Tracheoesophageal fistula inserting voice prosthesis

  24. Hunsaker jet ventilation tube

  25. Case • Proximal end of the voice prosthesis partly obstructed the tracheostomy tube • Removal of the laryngectomy tube would dislocate the voice prosthesis from the tracheoesophageal fistula • Prosthesis act as a one-way valve preventing aspiration

  26. Procedure • Thoracic epidural catheter • Preoxygenation • Sedated by propofol, ketamine • 3ml of 4% lidocaine was instilled into the trachea • Hunsaker jet ventilation tube inserted into the tracheostomy tube

  27. Procedure • Wings of the tube were squeezed together and were totally inserted into the right main bronchus under a pediatric bronchoscope • Sulfentanil, pancuronium • Jet port was positioned at the entrance of the right main bronchus • 90/min, I:E=1:1, FIO2=1

  28. Procedure • Good visual expansion of right chest • PaO2: 376mmHg, PaCO2: 39mmHg(5min) • Left lung fully collapsed 30min later • Thoracotomy lasted 95min and Sao2 varied from 100% to 92% • OLV(30’,50’): PaO2=65 and 69mmHg, PaCO2=28mmHg

  29. Procedure • SCC was confirmed and lobectomy was cancelled • Hunsaker tube was withdrawn into the trachea • Adjusted the rate to 15/min (inspiratory time, 2s) • Rapid reinflation of left lung • PaO2 448-398mmHg and PCO2 37-39mmHg

  30. Discussion • Jet ventilation catheter (often modified nasogastric tubes) are used for tracheal resection and reconstructive surgery • Never been used as an altermative to a DLT for lung resection • 2mm catheter passed through a standard ETT and fed into the left main bronchus

  31. Discussion • Complications— • Pneumothorax • Tears in the tracheobronchial mucosa • Injury caused by drying and cooling gas

  32. Discussion • Hunsaker tube— • Has distal wings that center the high pressure jet in the tracheal or bronchial lumen 3cm from the of the catheter • The wings limit the movement of the catheter preventing the direct mucosal injury • Side port allows monitoring of either tidal CO2 or tracheal pressure • More reliably placed in position than a narrow tube

  33. 結論 • 因應不同術式而發展出不同的devices • 就地取材 • Well-monitored to prevent complications • 對airway management活用且大膽 • 可用於常規手術

  34. Thanks for your attention

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