Normofrequent Intratracheal Jet Ventilation - Simple and

Useful for Endolaryngeal andAirway Stenosis Surgery.

J.Samarütel, M.Kull Dept of Anaesthesia and Intensive Care

and ENT, University of Tartu, Estonia.

Jet ventilation (JV), the term used for pulsed application of gas (mostly O2) jet into the airway without airtight connection of the patient to the ventilator, is the core element of modern techniques of management of this kind of ENT surgery under general anaesthesia (GA).

JV could be subdivided: High frequency (HF) techniques - HF Positive

Pressure Ventilation, HFJV, HF Oscillation- mostly applicable only with sophisticated, expensive equipment

Normofrequent JV (rarely used, known mostly as part of Difficult Airway algorithms)

Henderson Y. et al – 1915

Emerson JH – 1959

Sanders RD – 1967

Öberg PÅ & Sjöstrand U – 1967

HFPPV, HFJV, HFO, HFFI, HFPV

HFV and JV – history

In ENT surgery JV is further subdivided: Supraglottic, endopharyngeal - jet pipe

situated higher than vocal cords, usually connected to surgeon's laryngoscope.

Infraglottic, intratracheal - jet pipe is introduced translaryngeally, transtracheally or through tracheostomy opening. Oxygen jet is blown into the trachea distally to vocal cords or stenotic area.

Up to December 2005 we have performed more than 1900 endoscopic operations with intratracheal (infraglottic) JV on patients of both sexes, in age 4 months to 86 yrs, BW 5,2-170 kg. In first 200 cases original electronic HFJV equipment (so called Double Frequency Jet Ventilation, DFJV) and hand-operated valve with FiO2 1,0 were used alternatively. Both provided full oxygenation and acceptable CO2 removal for up to 140 minutes duration of anaesthesia. In last > 1700 procedures hand-operated valve was used exclusively. Ventilation through small metal pipe provided surgeon with best possible operating conditions for correction of endolaryngeal pathology, removal of obstructing masses, dilatation and stenting of stenoses, use of original NdYAG laser in contact regimen.

Jet pipe or catheter could be introduced through tracheostomy. The x-ray shows end of tracheal dilatation and stenting procedure with ventilation managed through metal pipe, introduced through tracheostomy and to be removed after awakening of the patient.

Most of our cases have been managed as outpatients. Anaesthesia includes:

Paracetamol preload (1,5-2,0 g p.o. in adults) TIVA:

Atropine, Fentanyl, Lidocaine, Methohexital (Etomidate), Propofol

Succinylcholine (with antidepolarizer pre-treatment) Special cases - awake intubation Introduction of j et catheter or pipe through tracheostomy Monitoring includes NIBP, EKG and SpO2

We have succeeded in avoiding barotraumas by: Gradual increase of jet driving pressure

(from 0,5-1,0 up to 3,5 bar) Continuous checking of chest movement and

expiration Alignment of jet cannula with axis of trachea Close collaboration of surgeon and anaesthesiologist

There is predisposition for laryngospasm at the end of procedures. It could be prevented by repeated topical Lidocaine spray + i/v Lidocaine + positioning of the patient to keep laryngeal inlet the highest point of the airway + ventilating the patient until full recovery of consciousness and muscle power.

1 yr girl, BW 5,5 kg VACTERL association Since birth in ICU

Due to: Cheap and simple equipment Provision of ENT surgeon with best possible operating

conditions and practically unlimited operating time

We consider the technic acceptable and continue its use and development. At present we have not completely solved the problem of alignment of jet pipe with axis of trachea; also we are making first steps for introducing Remifentanil into our TIVA sequence.

Спасибо за вимание!