Application and Devices of Jet Ventilation.ppt

1、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 Mouth opening was 1 cm with limited head extension Lef

2、t nasal passage was blocked Awake fibreoptic intubation 6 months previously, resulted in aspiration of blood, impaired oxygenation,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 we

3、re 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,Procedure,7 FG 16 cm triple lumen CVP (Arrow) Cric

4、othyroid 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,Procedure,9 FG suction catheter was pas

5、sed 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 m

6、g.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,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

7、 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,Discussion,Two major concerns: barotrauma and carbon dioxide accumulation We addressed these by continuously monitoring

8、the airway pressure and the expired co 2 partial pressure via the separate 18 FG lumens without interrupting ventilation via the 16 FG lumen,Adventages,Easy to insert under local anaesthesia The markings on the catheter helped positioning All three lumens were opening within the trachea The catheter

9、 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.,A Potential Problems,Movement of the tip was minimised by keeping a short length with

10、in 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,Minimise the complications,Continuous monitoring of the airway pressure can minimise the risk of barotraum

11、a, 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,Measurement of CO2,The gradient between the c

12、o 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 bre

13、ath end-tidal co 2 measurement was closely correlate with Pa co 2 and useful for monitoring the adequacy of co 2 elimination,Disadvantages,No protection from contamination by blood and surgical debris Positive end-expiratory pressure help to reduce contamination Surgeon may pay attention to suction

14、of blood and debris from obstructing the expiratory pathway,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 intuba

15、tion difficult A custom-made triple lumen catheter for monitored transtracheal jet ventilation will be a welcome device in the management of difficult airways.,Respiratory Gas Monitoring During High-Frequency Jet Ventilation for Tracheal Resection Using a Double-Lumen Jet Catheter,A&A, Vol 88(1). Ja

16、n 1999,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

17、-lumen 12F polyrethane jet catheter,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/

18、min for two cycles for estimating ETCO2 & O2,Double-Lumen Catheter,12F, 70cm Designed by authors department in Germany Central/lateral lumen: 1.8/1.2mm Distance between two lumen is 10mm Cant monitor the pressure due to air trapping problem,Results,Two sets of end-tidal and arterial O2 and CO2 were

19、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,Discussion,Most of these studies show good correlation between capnographic and arterial CO2 value but only fe

20、w 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,Discussion,This double-lumen allows continuous PETCO2 and FEO2 measurements durin

21、g low- and high-frequency jet ventilation A simple, safe, and cost-effective method and increase the safety of jet ventilation,One-Lung Ventilation for Thoracotomy Using a Hunsaker Jet Ventilation Tube,Anesthesiology, Vol 87(6). Dec 1997,Case,52y/o male, laryngeal ca s/p total laryngectomy and R/T 1

22、3 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,Hunsaker jet ventilation tube,Case,Proximal end of the voice prosthesis partly obstructed the tracheost

23、omy tube Removal of the laryngectomy tube would dislocate the voice prosthesis from the tracheoesophageal fistula Prosthesis act as a one-way valve preventing aspiration,Procedure,Thoracic epidural catheter Preoxygenation Sedated by propofol, ketamine 3ml of 4% lidocaine was instilled into the trach

24、ea Hunsaker jet ventilation tube inserted into the tracheostomy tube,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

25、/min, I:E=1:1, FIO2=1,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,Procedure,SCC was confirmed and lobectomy was cancelled

26、 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,Discussion,Jet ventilation catheter (often modified nasogastric tubes) are used for tracheal resection and reconstructive surgery Never

27、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,Discussion,Complications Pneumothorax Tears in the tracheobronchial mucosa Injury caused by drying and cooling gas,Discussion,Hunsaker tube Has distal wings that cen

28、ter 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,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,Thanks for your attention,