Use of Percutaneous Transtracheal Jet Ventilation (PTJV) during Difficult Airway Management

Rajesh G Patel

摘要

A life threatening situation can occur if tracheal intubation and bag-mask-valve ventilation are unable to be performed in restoring adequate gas exchange during acute respiratory failure. Under these circumstances, percutaneous transtracheal jet ventilation (PTJV) using a large bore needle provides immediate oxygenation and ventilation. In the present case, PTJV proved to be a life saving procedure by providing adequate gas-exchange and ensuring the patency of the airway until a definitive procedure such as oral intubation with bronchoscopy followed by surgical tracheostomy was performed. Therapeutic indications and complications of PTJV are discussed. INTRODUCTION Incidence of laryngeal edema following extubation is reported to be 4.2% with only 1% of patients requiring re-intubation for acute respiratory failure (1). The inability to view the glottic opening during direct laryngoscopy makes endotracheal intubation difficult. A life threatening situation can occur if intubation and bag-mask-valve ventilation are not performed to restore adequate gas exchange. Under these circumstances, percutaneous transtracheal jet ventilation (PTJV) using a large bore angiocath at the cricothyroid membrane is a life saving procedure. The objective of this report is to increase physician awareness of the potential benefit from PTJV as a temporary life saving procedure in cases of difficult or failed endotracheal intubation in the adult intensive care unit. CASE REPORT A 67-year old male was admitted to a community hospital with an acute stroke and respiratory failure, and transferred to the medical intensive care unit for mechanical ventilation. He was orally intubated with an 8 mm Internal Diameter (I.D.) endotracheal tube without any difficulty on admission. Past medical history was significant for radiation therapy for laryngeal carcinoma 4 years prior to this admission. He was weaned from mechanical ventilation and extubated on day 14. Following extubation, he developed respiratory distress and oxygen desaturation. Non-invasive face-mask continuous positive airway pressure failed to provide adequate oxygenation. Several attempts at oral intubation with direct laryngoscope were attempted, but proved unsuccessful because of inability to visualize the supraglottic and glottic structures. Pulse oxygen saturation could not be maintained with bag-mask-valve ventilation with 100% oxygen. In addition, his heart rate decreased to 30 beats/minute and systolic blood pressure was 70 mm of Hg. Immediately the cricothyroid membrane was cannulated with a 6 French (2 mm I.D, Cook Co., IN) angiocath and high-pressurized oxygen was provided with a jet ventilator (BE 183-SUR, Instrumentation Industries, Inc., Bethel Park, PA). While maintaining 100% oxygen saturation with manual trigger jet ventilator at 12 – 20 times per minute, an attempt at oral intubation was done with an 8 mm ID endotracheal tube. PTJV was discontinued. However, bronchoscopy evaluation was required because of oxygen desaturation, which confirmed esophageal intubation. The cricothyroid membrane was recannulated with an angiocath. He was ventilated and oxygenated with PTJV until oral intubation with a 7-mm ID endotracheal tube over bronchoscopy was performed using the jet bubbles coming from the glottic aperture as a guide. This was followed by tracheostomy. PTJV was discontinued. He was subsequently weaned from mechanical ventilation over 48 hours, and transferred from the medical intensive care unit with a tracheostomy collar to the ward. DISCUSSION Resuscitation with the use of PTJV during difficult intubation is not a new concept for the anesthesiologist (2, 3, 4), otolaryngologist (5, 6), and emergency room physician (7, 8). PTJV is not popular in the medical intensive care unit where the majority of endotracheal intubations in critically ill patients are managed by non-anesthesiologists. Familiarity with PTJV for immediate oxygenation during difficult or failed intubation can be

机译：如果在急性呼吸衰竭期间无法恢复足够的气体交换而无法进行气管插管和面罩瓣膜通气，可能会危及生命。在这种情况下，使用大口径针的经皮气管喷射通气（PTJV）可立即进行充氧和通气。在目前的情况下，PTJV通过提供足够的气体交换并确保气道通畅，直到进行了确定的程序（例如，先用支气管镜进行口腔插管再进行气管切开术），才证明是挽救生命的程序。讨论了PTJV的治疗适应症和并发症。引言据报道，拔管后喉头水肿的发生率为4.2％，只有1％的患者因急性呼吸衰竭而需要再次插管（1）。直接喉镜检查期间无法看到声门开口，使气管插管变得困难。如果不进行插管和面罩气门通气以恢复足够的气体交换，可能会危及生命。在这种情况下，在环甲膜上使用大口径血管导管经皮经气管喷射通气（PTJV）可以挽救生命。本报告的目的是提高医师对成人重症监护病房气管插管困难或失败的情况下，PTJV作为临时性挽救生命程序的潜在益处的认识。病例报告一名67岁的男性因急性中风和呼吸衰竭被送进社区医院，并被送往医疗重症监护室进行机械通气。用8毫米内径（I.D.）气管导管对他进行了口腔插管，入院没有任何困难。入院前4年，过去的医学史对于喉癌的放射治疗具有重要意义。他从机械通气中断奶，并在第14天拔管。拔管后，他出现呼吸窘迫和氧饱和度下降。无创口罩持续气道正压不能提供足够的氧合。尝试了几次使用直接喉镜进行口腔插管的尝试，但是由于无法可视化声门上和声门结构而被证明不成功。使用100％氧气的袋式面罩通气无法维持脉冲血氧饱和度。此外，他的心率降低至30次/分钟，收缩压为70毫米汞柱。立即用6 French（2 mm ID，Cook Co.，IN）血管导管插入环甲膜，并用射流通气机（BE 183-SUR，Instrumentation Industries，Inc.，Bethel Park，PA）提供高压氧气。使用手动触发式射流呼吸机以每分钟12 – 20次保持100％的氧饱和度的同时，尝试使用8 mm内径的气管插管进行口腔插管。 PTJV已停产。但是，由于氧饱和度下降，需要进行支气管镜检查，这证实了食管插管。环甲膜被血管造影剂再造。给他通气并用PTJV充氧，直到使用来自声门孔的喷射气泡作为指导进行7毫米ID气管导管经气管镜进行口腔插管。随后进行气管切开术。 PTJV已停产。随后，他在48小时内从机械通气中断奶，并通过气管切开术衣领从医疗重症监护室转移到病房。讨论对于麻醉医师（2，3，4），耳鼻喉科医生（5，6）和急诊室医师（7，8），在困难的插管过程中使用PTJV进行复苏并不是一个新的概念。 PTJV在重症监护病房中不受欢迎，在重症监护病房中，大多数气管插管均由非麻醉师进行管理。熟悉PTJV在插管困难或失败时可以立即充氧

Use of Percutaneous Transtracheal Jet Ventilation (PTJV) during Difficult Airway Management

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