ORIGINAL CONTRIBUTION
Percutaneous Transtracheal Ventilation R. Brian Smith, MD* Maciej Babinski, MDt Miroslav Klain, MD Hugo Pfaeffie, MDt
The t e c h n i q u e of p e r c u t a n e o u s transtracheal ventilation (intermittent jets of o x y g e n under high pressure, 50 p o u n d s per square inch [psi]) has been u s e d for resuscitation during a n e s t h e s i a and prior to tracheostomy, a n d has been established as an important adjunct to life-support techniques. The technical aspects are d e s c r i b e d together with experimental e v i d e n c e that intermittent jet ventilation is n e c e s s a r y to eliminate carbon dioxide. The c o m p l i c a t i o n s occurring with a series of 80 patients are r e p o r t e d along with experimental w o r k in ventilation of dogs with c o m p r e s s e d air sources, including truck tires. E m e r g e n c y p h y s i c i a n s should be familiar with this technique and e q u i p m e n t for its use s h o u l d be readily available in the e m e r g e n c y department. The potential role of transtracheal ventilation in the mobile intensive care unit at accident sites has been e x p l o r e d and appears promising. C o n v e n t i o n a l airway support t e c h n i q u e s s h o u l d be a p p l i e d p r i o r to r e s o r t i n g to transtracheal ventilation.
ventilator, found i n dogs and h u m a n s t h a t the gas flow through a 16-gauge c a n n u l a would give a flow of 400 to 500 ml/second with a 40 to 50 psi int e r m i t t e n t p r e s s u r e applied to the jet, even in the absence of air e n t r a i n ment.
Smith RB, Babinski M, Klain M, Pfaeffle H: Percutaneous transtracheal ventilation. JACEP 5"765-770, October 1976. ventilation, percutaneous transtracheal.
MATERIALS AND METHODS
INTRODUCTION Percutaneous t r a n s t r a c h e a ] ventilation with i n t e r m i t t e n t jets of oxygen u n d e r high p r e s s u r e has been used for a p p r o x i m a t e l y five years. 1 This paper will e v a l u a t e the use of this technique for the emergency dep a r t m e n t a n d the mobile i n t e n s i v e care u n i t (MICU). The a p p a r a t u s (Figure 1) used in the emergency d e p a r t m e n t consists
From the Department of Anesthesiology, The University Health Center of Pittsburgh, Pennsylvania. Address for reprints: R. Brian Smith, MD, Professor, Anesthesiologist in Chief, DePartment of Anesthesiology, Presbyteriaa-University Hospital, 230 Lothrop Street, Pittsburgh, Pennsylvania 15213_
~ [ ] ~ ) October 1976
of a connector for piped oxygen at 50 p o u n d s p e r s q u a r e i n c h (psi), a p r e s s u r e - a d j u s t m e n t valve, connecting t u b i n g , a hand-operated release valve, a n i n t r a v e n o u s extension set, and a teflon or plastic i n t r a v e n o u s catheter. V e n t i l a t i o n is at a rate of 12/min with a n i n s p i r a t o r y phase of 1 to 1.5 seconds. The a p p a r a t u s i n the MICU will h a v e to be c o n n e c t e d to o x y g e n t a n k s . A r e g u l a t o r for use w i t h a l a r g e o x y g e n t a n k , G 5,331 l i t e r s (Figure 2), and a small oxygen tank, E 659 liters (Figure 3), are shown. The l a t t e r will last for 30 to 40 minutes w h e n used at a rate of 10/min with a n i n s p i r a t o r y time of 1 to 1.5 seconds at 50 psi. Spoerel e t a ] , 1 u s i n g a Bird Mark II
It is not k n o w n if "carbon dioxide w a s h o u t " occurs d u r i n g t r a n s t r a c h e a l o x y g e n a t i o n at c o n s t a n t high pressure (high flows). In other words, is v e n t i l a t i o n (passive exhalation) necessary to e l i m i n a t e carbon d i o x i d e u n d e r s u c h a p n e i c conditions?
Our study evaluated the effect of t r a n s t r a c h e a l o x y g e n a t i o n at cons t a n t high pressure in five anesthestized dogs. A n e s t h e s i a was induced, and maintained, with thiamylal sodium in a dose of 15 mg/kg of body w e i g h t . G a l l a m i n e , 2 mg/kg, was used for muscle relaxation. The femoral v e i n and artery were c a n n u l a t e d to m o n i t o r central venous and a r t e r i a l blood pressure and for a r t e r i a l blood gas sampling. I n t r a t r a c h e a l p r e s s u r e was r e c o r d e d t h r o u g h a 10-gauge c a n n u l a inserted into the trachea close to the c a r i n a t h r o u g h the mouth. Before the onset of m u s c l e r e l a x a t i o n , a n d d u r i n g spontaneous respiration, a n arterial blood gas sample was analyzed for a baseline. A 16-gauge catheter was inserted t h r o u g h the cricothyroid m e m b r a n e
Volume 5 Number 10 Page 765
J::i
F i g . 1. Apparatus for piped oxygen.
into the trachea, connected to a high p r e s s u r e oxygen j e t device, a n d apneic o x y g e n a t i o n was s t a r t e d . Continuous flow of 100% oxygen was del i v e r e d u n d e r c o n s t a n t p r e s s u r e of 30, 40, and 50 psi respectively for a period of t e n minutes. D u r i n g apneic oxygenation, arterial blood gases were a n a l y z e d a t two m i n u t e intervals. In one a n i m a l , apneic oxygenation was delivered by continuous flow at 6 l i t e r s / m i n of 100% oxygen t h r o u g h the 14-French c a t h e t e r ins e r t e d into t h e t r a c h e a t h r o u g h the mouth. We also e v a l u a t e d the possibility of u s i n g c o m p r e s s e d a i r for p e r cutaneous t r a n s t r a c h e a l ventilation. Five h e a l t h y m o n g r e l dogs, w e i g h i n g 15 to 20 kg, were a n e s t h e t i z e d with thiamylal sodium, 6 mg/kg body weight. After tracheal intubation, t h e y were m e c h a n i c a l l y v e n t i l a t e d (tidal v o l u m e 200 ml, r a t e 25/min) for t e n m i n u t e s . A r t e r i a l blood gas s a m p l e s were o b t a i n e d as a baseline. A f t e r e x t u b a t i o n , a 1 6 - g a u g e int r a v e n o u s teflon c a t h e t e r was placed in t h e t r a c h e a t h r o u g h t h e cricot h y r o i d m e m b r a n e . A w o o d e n bite block k e p t t h e u p p e r a i r w a y open. I n t e r m i t t e n t h i g h p r e s s u r e j e t ventilation with air (rate 25/min) was started, u s i n g a d r i v i n g p r e s s u r e of 50 psi. After 20 m i n u t e s of a i r j e t v e n t i l a t i o n , a r t e r i a l blood s a m p l e s w e r e d r a w n a n d blood g a s e s w e r e analyzed. No muscle r e l a x a n t s were used since t h e b a r b i t u r a t e dose was sufficient to produce apnea. Recovery was u n e v e n t f u l a n d t h e r e w e r e no complications.
Page 766 Volume 5 Number 10
F i g . 2. Regulator for large oxygen tank.
F i g . 3. Regulator for small oxygen tank.
RESULTS There was no s t a t i s t i c a l l y signific a n t difference in the rise of PaCO2 at p r e s s u r e s of 30, 40, 50 psi a n d at a low flow of oxygen t h r o u g h a n orot r a c h e a l c a t h e t e r (Table 1). PO2 levels
r a n g e d from a low of 110 torr with low flows to a h i g h of 325 torr with h i g h flows. The i n t r a t r a c h e a l pressures at 30, 40, 50 psi were 7, 13, and 18 t o r r r e s p e c t i v e l y . No complica" tions occurred in t h e e x p e r i m e n t a l
October 1976 ~ P
Table 1 T R A N S T R A C H E A L APNEIC OXYGENATION EFFECT ON PaCOz N=5 Transtracheal Jet Pressure (TORR) 30 (1551) Time (Min)
40 (2068)
50 (2585)
Average PaCO= (mm/kg)
Oral Tracheal Catheter (low flow)
0
43
40
31
36
2
63
52
45
60
4
67
73
52
60
6
76
73
65
67
8
84
90
77
72
10
97
82
93
82
Table 2 TRANSTRACHEAL VENTILATION WITH COMPRESSED AIR N=5 Blood Gases 0 rain Experiment Number
PaO2
PaCO2
PaO2
PaCO=
1
95
36
90
40
2
92
40
88
40
3
90
35
81
37
4
87
27
73
40
5
78
40
77
42
a n i m a l s a n d t h e r e s u l t s of c h e s t x-ray films were n o r m a l . We concluded t h a t delivery of oxygen t r a n s t r a c h e a l l y u n d e r high pressure (hence h i g h flows) i n a p n e i c dogs results in the same rise i n PCO2 as oxygen delivered u n d e r low pressure. However, it is w o r t h n o t i n g that a high POe level of 325 torr can be m a i n t a i n e d w i t h h i g h flows of oxygen. The r e s u l t s (Table 2) u s i n g compressed air show t h a t the PaCO2 can be m a i n t a i n e d w i t h i n n o r m a l limits for at l e a s t 20 m i n u t e s . E v e n the lowest PaO2 of 73 t o r r provides over 90% arterial oxygen saturations. It appears t h a t compressed air can be used for resuscitation d u r i n g perCutaneous t r a n s t r a c h e a l v e n t i l a t i o n Should c o n v e n t i o n a l methods of artificial v e n t i l a t i o n fail a n d o x y g e n U~der high pressure not be available. "r~
Blood Gases After 20 min
October 1976
•
DISCUSSION Jacobs 2 a d v o c a t e d t r a n s t r a c h e a l v e n t i l a t i o n as a method for the immediate r e s t o r a t i o n of a n adequate a i r w a y i n a p a t i e n t s u f f e r i n g resp i r a t o r y d i s t r e s s or c a r d i o p u l m o n a r y arrest. He used the technique in 12 p a t i e n t s who were comatose and apneic. Oxygen u n d e r high pressure (60 psi) was applied i n t e r m i t t e n t l y using a volume-type ventilator, w h i c h J a c o b s d e s i g n e d a n d cons t r u c t e d , t h r o u g h a 1 4 - g a u g e int r a v e n o u s catheter inserted t h r o u g h the c r i c o t h y r o i d m e m b r a n e . Blood gas d e t e r m i n a t i o n s after 30 m i n u t e s r e v e a l e d a r a n g e of PaO2 b e t w e e n 180 a n d 655 torr, a n d a r a n g e of PaCO2 b e t w e e n 16 a n d 53 t o r r . I n t r a t r a c h e a l p r e s s u r e s w e r e between 15 a n d 20 cm/water. Jacobs 3 also reported on the use of t r a n s t r a c h e a l v e n t i l a t i o n i n 40 ap-
neic and t e r m i n a l l y ill p a t i e n t s . Blood gases measured at 30-minute i n t e r v a l s i n 36 p a t i e n t s showed a range of PaO2 between 120 and 650 torr, and PaCO~ between 15 and 54 torr. No serious complications were noted. Spoerel et al, 1 t e s t i n g t r a n s t r a c h e a l v e n t i l a t i o n f i r s t i n models, found t h a t a n oxygen jet through a 16-gauge needle at 50 psi could supply enough force to inflate the lungs. The flow produced was adequate to supply the tidal volume for a n adult p a t i e n t w i t h o u t air e n t r a i n m e n t . He confirmed these findings in dogs and d e m o n s t r a t e d a i r e n t r a i n m e n t of a b o u t 44% w h e n u s i n g a t r a c h e a l tube. He t h e n applied the technique to 12 patients, u n d e r g o i n g elective operations, u n d e r a n e s t h e s i a w i t h int r a v e n o u s agents and paralysis with d - T u b o c u r a r i n e chloride_ A plastic, 16-gauge catheter was inserted into the t r a c h e a and a n i n t e r m i t t e n t flow of oxygen was a d m i n i s t e r e d at 50 psi u s i n g a B i r d M a r k II v e n t i l a t o r . Blood gas a n a l y s i s revealed adequate p u l m o n a r y v e n t i l a t i o n for periods r a n g i n g from 40 to 75 minutes_ S i n g h 4 r e p o r t e d 1,500 cases i n which t r a n s t r a c h e a l v e n t i l a t i o n was used for diagnostic and surgical procedures of the upper airways. There were 1,257 cases for bronchoscopy and esophagoscopy and 135 for endolaryngeal surgery. Postoperative v e n t i l a t o r y support was carried out w i t h t h i s t e c h n i q u e in 108 cases, v e n t i l a t e d from 24 to 48 hours. T r a n s t r a c h e a l v e n t i l a t i o n prior to tracheostomy in patients u n d e r g o i n g s u r g i c a l p r o c e d u r e s i n v o l v i n g the head a n d neck has been reported in seven cases. 5 PaCO2 d e t e r m i n a t i o n s at the end of the procedure indicated t h a t the m a j o r i t y of p a t i e n t s were moderately hyperventilated. The use of this technique i n two pediatric patients, one u n d e r g o i n g a n operation for l a r y n g e a l stenosis a n d one who b e c a m e o b s t r u c t e d and cyanotic i n the recovery room, has also been described. 6 A 14-gauge (1_5 m m diameter) i n t r a v e n o u s catheter is inserted into the t r a c h e a in the m i d l i n e t h r o u g h the cricothyroid m e m b r a n e or below the first tracheal ring (Figure 4). Volume 5 Number 10 Page 767
a f t e r n e e d l e removal. For t h i s reason, the c a t h e t e r should be fixed securely. We feel the best c a t h e t e r available is a 8.5 cm long, 14-gauge one manu f a c t u r e d by D e s e r e t _ It h a s two a d d i t i o n a l holes n e a r the tip which m a k e a s p i r a t i o n of air easier because t h e tip is n o t b l o c k e d by mucosa. Also, t h e r e is less p r o b a b i l i t y of severe tissue e m p h y s e m a if it is misp l a c e d , T h e l e n g t h is i d e a l : long enough for t h i c k - n e c k e d individuals and not t o o long to reduce gas flow significantly.
F i g . 4. Transtracheal ventilation.
COMPLICATIONS
Table 3 FROM TRANSTRACHEAL
Elective Prior to A n e s t h e s i a N=52
VENTILATION
For A c u t e Respiratory Distress N=28
Total N=80
Complications
No. of Patients
%
No. of Patients
Subcutaneous Emphysema
5
9.6
2
7.1
7
8.7
Mediastinal Emphysema
1
1.9
1
3.6
2
2.5
%
No. of Patients
%
Exhalation Difficulty
•..
4
14.3
4
5.0
Arterial Perforation
•..
1
3.6
1
1.3
6
8
Total
COMPLICATIONS Local complications m a y occur during transtracheal catheterization. H e m o r r h a g e m a y occur at the site of insertion, particularly from the thyroid, and t h e r e is t h e , d a n g e r of p e r f o r a t i n g t h e esophagus if the needle is advanced too far. 7 A n o t h e r possible c o m p l i c a t i o n is s u b c u t a n e o u s e m p h y s e m a _ 7 The p l a s t i c or teflon c a t h e t e r w i t h t h e s t y l e t in p l a c e should be a d v a n c e d u n t i l it has j u s t e n t e r e d t h e trachea. The position is checked by aspirating air with a syringe. The s t y l e t is w i t h d r a w n and the catheter then inserted without Page 768 Volume 5 Number 10
14
The complications from 80 cases of t r a n s t r a c h e a ] v e n t i l a t i o n at the Eye and E a r Hospital of P i t t s b u r g h are shown (Table 3). It was used in 52 p a t i e n t s electively prior to and during g e n e r a l a n e s t h e s i a and has also been used to r e s u s c i t a t e 28 patients w i t h acute r e s p i r a t o r y distress in the o p e r a t i n g room. All of the l a t t e r had p a t h o l o g y of t h e u p p e r a i r w a y , the majority, c a r c i n o m a of the l a r y n x or tongue. T h e i r ages r a n g e d from 10 to 71 years_ A l t h o u g h t h e r e w e r e no d e a t h s in this series a n d all patients were successfully r e s u s c i t a t e d , 8 of 28 (28.6%) h a d complications. Of the total, 14 (17.5%) h a d complications. A t t h e U n i v e r s i t y of P i t t s b u r g h the t e c h n i q u e of t r a n s t r a c h e a l ventilation in a n e s t h e t i z e d dogs is taught to the t h i r d - y e a r m e d i c a l students. We believe this t e c h n i q u e has established itself as an i m p o r t a n t adjunct in life-support to be used in selected cases• A p p r o x i m a t e l y 60 a d v a n c e d emergency medical technicians (EMT) a n d 500 t h i r d - y e a r medical students have practiced transt r a c h e a l v e n t i l a t i o n on dogs. No serious c o m p l i c a t i o n s h a v e been noted up to the p r e s e n t time.
the needle_ We have found it to be of value, in a s s u r i n g t h a t the c a t h e t e r is in t h e a i r w a y , to d r i p a s m a l l a m o u n t of f l u i d , s a l i n e or l o c a l anesthetic, into the catheter. In spontaneously breathing patients, bubbles are seen on expiration. The c a t h e t e r should be directed c a u d a d at an angle of 45 degrees.
The e m e r g e n c y crash carts at the U n i v e r s i t y H e a l t h C e n t e r of Pittsb u r g h H o s p i t a l s are equipped with an a p p a r a t u s for p e r f o r m i n g transtracheal ventilation. It is our belief t h a t all e m e r g e n c y d e p a r t m e n t s s h o u l d be s i m i l a r l y equipped.
S u b c u t a n e o u s e m p h y s e m a can be m i n i m i z e d by e n t e r i n g the s k i n dist a n t from the p l a n n e d t r a c h e a l perfor a t i o n site a n d by a p p l y i n g p r e s s u r e on the t r a c h e a after c a t h e t e r removal. A soft c a t h e t e r is more likely to be d i s p l a c e d if it b e c o m e s k i n k e d
The t y p e s of a i r w a y problems in which t r a n s t r a c h e a l v e n t i l a t i o n may be considered a r e shown (Table 4). The technique is not a substitute for t r a d i t i o n a l a i r w a y care b u t is to be used w h e n these are deemed hopeless or have failed. October 1976 J ~ P
Table 4 A I R W A Y PROBLEMS WHICH M A Y REQUIRE TRANSTRACHEAL VENTILATION
Bones and Joints
Arthritis (temporo-mandibular joint, cervical) fractured mandible or post-mandibulectomy Congenital abnormalities of the mandible, micrognathia and mandibulofacial dysostosis (Pierre Robin and Treacher Collins syndrome)
Face and Neck
Contracture from burns, scars from postirradiation Problems associated with casts (halo, arista) Masses (thyroid, cervical nodes, carotid hemorrhage) abscess Trauma from stabbing, gunshot, auto, and industrial accidents
Intraoral
Carcinoma of the mouth or tongue, peritonsillar abscess, retropharyngeal abscess Severe trismus from intraoral infection Trauma from stabbing, gunshot, auto and industrial accidents
Larynx
F i g . 6. Dog ventilated using truck tire.
Carcinoma of the larynx the same role as in the emergency department.
Subglottic stenosis Fracture larynx epiglottitis
Should this technique be t a u g h t to EMTs? Perhaps, if: 1) s t a n d a r d methods of a i r w a y m a n a g e m e n t h a v e failed; 2) technicians are t r a i n e d to use t r a n s t r a c h e a l ventilation (anatomy, mechanics, technique, complications), and 3) technicians are u n d e r the direction of a physician.
Cyst of epiglottitis
Trucks have tires u n d e r 50 to 75 psi pressure which may be available d u r i n g h i g h w a y accidents. T r a n s tracheal v e n t i l a t i o n could be used for resuscitation, p a r t i c u l a r l y in cases of t r a u m a to the face or neck, w h e n tracheal i n t u b a t i o n is difficult or impossible.
Fig. 5. Apparatus for use with truck tires.
The role of t r a n s t r a c h e a l ventilation i n u p p e r a i r w a y o b s t r u c t i o n from a f o r e i g n body is n o t e s t a b lished, b u t there is reason s to believe that it should be tried when all else,
J~P
October 1976
i n c l u d i n g the Heimlich m a n e u v e r , 9 has failed. If the MICU is physician-staffed, t r a n s t r a c h e a l v e n t i l a t i o n would have
We tested the efficacy of the techn i q u e e x p e r i m e n t a l l y in a dog which was a n e s t h e t i z e d and made apneic using intravenous barbiturates. A 1 6 - g a u g e t e f l o n c a t h e t e r w a s inserted into the trachea via the cricothyroid m e m b r a n e . V e n t i l a t i o n was accomplished using a small truck t i r e ( 7 . 0 0 - 1 4 L T ) as t h e s o u r c e of compressed air (Figures 5 and 6). At a s t a r t i n g pressure of 60 psi, the dog could be adequately ventilated for 15 minutes. After this time the PaCO2 was 43 torr a n d the PaO2 63 torr. The a n i m a l ' s recovery was u n e v e n t ful. If this technique is used in hum a n s a f i l t e r s h o u l d be u s e d to e l i m i n a t e foreign particles.
Volume 5 Number 10 Page 769
CONCLUSION P e r c u t a n e o u s t r a n s t r a c h e a l ventilation ( i n t e r m i t t e n t high pressure j e t s of o x y g e n ) is a n e s t a b l i s h e d t e c h n i q u e for m a n a g e m e n t of difficult airway problems i n the hospital. E m e r g e n c y physicians should be familiar with its use and e q u i p m e n t should be available_ E x p e r i m e n t a l evidence has shown t h a t the method is effective; this is supported by our own clinical exper]ence. Complications did occur, however, in a significant n u m b e r of our p a t i e n t s (17.5%). The potential role of the technique in the M I C U at accident sites has been explored a n d appears promising. C o n v e n t i o n a l a i r w a y s u p p o r t
Page 770 Volume 5 Number 10
techniques should be applied before r e s o r t i n g to t r a n s t r a c h e a l v e n t i l a tion.
REFERENCES 1. Spoerel WE, Narayanan PS, Singh NP: Transtracheal ventilation. Br J Anaesth 43:932, 1971. 2. Jacobs HB: Emergency percutaneous transtracheal catheter and ventilator. Trauma 12:50, 1972. 3. Jacobs HB: Needle-catheter brings oxygen to the trachea. J A M A 222:1231, 1972. 4. Singh NP: Transtracheal jet ventilation as a new technique and experiences with ketamine and propandid in India. Anesthesiology, Proceedings of the Fifth World Congress of Anesthesiologists, Kyoto, 160-161, 1972.
5. Smith RB: Transtracheal ventilation during anesthesia. Anesth Analg 53:225, 1974. 6. Smith RB, Myers EN, Sherman I-I: Transtracheal ventilation in pediatric patients, Case reports. Br J Anaesth 46:313, 1974. 7. Smith RB, Schaer WB, Pfaeffle H: Percutaneous transtracheal ventilation for anesthesia: A review and report of coraplications. Can Anaesth Soc J 22:607-612, 1975. 8. Rock JJ~ Pfaeffle H, Smith RB, et al: High pressure jet insufflation used to prevent aspiration and its effect on the tracheal mucosal wall, abstracted. Critical Care Meclicine 4:135, 1976. 9. Heimlich JJ: A life-saving maneuver to prevent food choking. JAMA 234:398, 1975.
October 1976 J ~ )
Percutaneous Transtracheal Ventilation R. Brian Smith, MD* Maciej Babinski, MDt Miroslav Klain, MD Hugo Pfaeffie, MDt
The t e c h n i q u e of p e r c u t a n e o u s transtracheal ventilation (intermittent jets of o x y g e n under high pressure, 50 p o u n d s per square inch [psi]) has been u s e d for resuscitation during a n e s t h e s i a and prior to tracheostomy, a n d has been established as an important adjunct to life-support techniques. The technical aspects are d e s c r i b e d together with experimental e v i d e n c e that intermittent jet ventilation is n e c e s s a r y to eliminate carbon dioxide. The c o m p l i c a t i o n s occurring with a series of 80 patients are r e p o r t e d along with experimental w o r k in ventilation of dogs with c o m p r e s s e d air sources, including truck tires. E m e r g e n c y p h y s i c i a n s should be familiar with this technique and e q u i p m e n t for its use s h o u l d be readily available in the e m e r g e n c y department. The potential role of transtracheal ventilation in the mobile intensive care unit at accident sites has been e x p l o r e d and appears promising. C o n v e n t i o n a l airway support t e c h n i q u e s s h o u l d be a p p l i e d p r i o r to r e s o r t i n g to transtracheal ventilation.
ventilator, found i n dogs and h u m a n s t h a t the gas flow through a 16-gauge c a n n u l a would give a flow of 400 to 500 ml/second with a 40 to 50 psi int e r m i t t e n t p r e s s u r e applied to the jet, even in the absence of air e n t r a i n ment.
Smith RB, Babinski M, Klain M, Pfaeffle H: Percutaneous transtracheal ventilation. JACEP 5"765-770, October 1976. ventilation, percutaneous transtracheal.
MATERIALS AND METHODS
INTRODUCTION Percutaneous t r a n s t r a c h e a ] ventilation with i n t e r m i t t e n t jets of oxygen u n d e r high p r e s s u r e has been used for a p p r o x i m a t e l y five years. 1 This paper will e v a l u a t e the use of this technique for the emergency dep a r t m e n t a n d the mobile i n t e n s i v e care u n i t (MICU). The a p p a r a t u s (Figure 1) used in the emergency d e p a r t m e n t consists
From the Department of Anesthesiology, The University Health Center of Pittsburgh, Pennsylvania. Address for reprints: R. Brian Smith, MD, Professor, Anesthesiologist in Chief, DePartment of Anesthesiology, Presbyteriaa-University Hospital, 230 Lothrop Street, Pittsburgh, Pennsylvania 15213_
~ [ ] ~ ) October 1976
of a connector for piped oxygen at 50 p o u n d s p e r s q u a r e i n c h (psi), a p r e s s u r e - a d j u s t m e n t valve, connecting t u b i n g , a hand-operated release valve, a n i n t r a v e n o u s extension set, and a teflon or plastic i n t r a v e n o u s catheter. V e n t i l a t i o n is at a rate of 12/min with a n i n s p i r a t o r y phase of 1 to 1.5 seconds. The a p p a r a t u s i n the MICU will h a v e to be c o n n e c t e d to o x y g e n t a n k s . A r e g u l a t o r for use w i t h a l a r g e o x y g e n t a n k , G 5,331 l i t e r s (Figure 2), and a small oxygen tank, E 659 liters (Figure 3), are shown. The l a t t e r will last for 30 to 40 minutes w h e n used at a rate of 10/min with a n i n s p i r a t o r y time of 1 to 1.5 seconds at 50 psi. Spoerel e t a ] , 1 u s i n g a Bird Mark II
It is not k n o w n if "carbon dioxide w a s h o u t " occurs d u r i n g t r a n s t r a c h e a l o x y g e n a t i o n at c o n s t a n t high pressure (high flows). In other words, is v e n t i l a t i o n (passive exhalation) necessary to e l i m i n a t e carbon d i o x i d e u n d e r s u c h a p n e i c conditions?
Our study evaluated the effect of t r a n s t r a c h e a l o x y g e n a t i o n at cons t a n t high pressure in five anesthestized dogs. A n e s t h e s i a was induced, and maintained, with thiamylal sodium in a dose of 15 mg/kg of body w e i g h t . G a l l a m i n e , 2 mg/kg, was used for muscle relaxation. The femoral v e i n and artery were c a n n u l a t e d to m o n i t o r central venous and a r t e r i a l blood pressure and for a r t e r i a l blood gas sampling. I n t r a t r a c h e a l p r e s s u r e was r e c o r d e d t h r o u g h a 10-gauge c a n n u l a inserted into the trachea close to the c a r i n a t h r o u g h the mouth. Before the onset of m u s c l e r e l a x a t i o n , a n d d u r i n g spontaneous respiration, a n arterial blood gas sample was analyzed for a baseline. A 16-gauge catheter was inserted t h r o u g h the cricothyroid m e m b r a n e
Volume 5 Number 10 Page 765
J::i
F i g . 1. Apparatus for piped oxygen.
into the trachea, connected to a high p r e s s u r e oxygen j e t device, a n d apneic o x y g e n a t i o n was s t a r t e d . Continuous flow of 100% oxygen was del i v e r e d u n d e r c o n s t a n t p r e s s u r e of 30, 40, and 50 psi respectively for a period of t e n minutes. D u r i n g apneic oxygenation, arterial blood gases were a n a l y z e d a t two m i n u t e intervals. In one a n i m a l , apneic oxygenation was delivered by continuous flow at 6 l i t e r s / m i n of 100% oxygen t h r o u g h the 14-French c a t h e t e r ins e r t e d into t h e t r a c h e a t h r o u g h the mouth. We also e v a l u a t e d the possibility of u s i n g c o m p r e s s e d a i r for p e r cutaneous t r a n s t r a c h e a l ventilation. Five h e a l t h y m o n g r e l dogs, w e i g h i n g 15 to 20 kg, were a n e s t h e t i z e d with thiamylal sodium, 6 mg/kg body weight. After tracheal intubation, t h e y were m e c h a n i c a l l y v e n t i l a t e d (tidal v o l u m e 200 ml, r a t e 25/min) for t e n m i n u t e s . A r t e r i a l blood gas s a m p l e s were o b t a i n e d as a baseline. A f t e r e x t u b a t i o n , a 1 6 - g a u g e int r a v e n o u s teflon c a t h e t e r was placed in t h e t r a c h e a t h r o u g h t h e cricot h y r o i d m e m b r a n e . A w o o d e n bite block k e p t t h e u p p e r a i r w a y open. I n t e r m i t t e n t h i g h p r e s s u r e j e t ventilation with air (rate 25/min) was started, u s i n g a d r i v i n g p r e s s u r e of 50 psi. After 20 m i n u t e s of a i r j e t v e n t i l a t i o n , a r t e r i a l blood s a m p l e s w e r e d r a w n a n d blood g a s e s w e r e analyzed. No muscle r e l a x a n t s were used since t h e b a r b i t u r a t e dose was sufficient to produce apnea. Recovery was u n e v e n t f u l a n d t h e r e w e r e no complications.
Page 766 Volume 5 Number 10
F i g . 2. Regulator for large oxygen tank.
F i g . 3. Regulator for small oxygen tank.
RESULTS There was no s t a t i s t i c a l l y signific a n t difference in the rise of PaCO2 at p r e s s u r e s of 30, 40, 50 psi a n d at a low flow of oxygen t h r o u g h a n orot r a c h e a l c a t h e t e r (Table 1). PO2 levels
r a n g e d from a low of 110 torr with low flows to a h i g h of 325 torr with h i g h flows. The i n t r a t r a c h e a l pressures at 30, 40, 50 psi were 7, 13, and 18 t o r r r e s p e c t i v e l y . No complica" tions occurred in t h e e x p e r i m e n t a l
October 1976 ~ P
Table 1 T R A N S T R A C H E A L APNEIC OXYGENATION EFFECT ON PaCOz N=5 Transtracheal Jet Pressure (TORR) 30 (1551) Time (Min)
40 (2068)
50 (2585)
Average PaCO= (mm/kg)
Oral Tracheal Catheter (low flow)
0
43
40
31
36
2
63
52
45
60
4
67
73
52
60
6
76
73
65
67
8
84
90
77
72
10
97
82
93
82
Table 2 TRANSTRACHEAL VENTILATION WITH COMPRESSED AIR N=5 Blood Gases 0 rain Experiment Number
PaO2
PaCO2
PaO2
PaCO=
1
95
36
90
40
2
92
40
88
40
3
90
35
81
37
4
87
27
73
40
5
78
40
77
42
a n i m a l s a n d t h e r e s u l t s of c h e s t x-ray films were n o r m a l . We concluded t h a t delivery of oxygen t r a n s t r a c h e a l l y u n d e r high pressure (hence h i g h flows) i n a p n e i c dogs results in the same rise i n PCO2 as oxygen delivered u n d e r low pressure. However, it is w o r t h n o t i n g that a high POe level of 325 torr can be m a i n t a i n e d w i t h h i g h flows of oxygen. The r e s u l t s (Table 2) u s i n g compressed air show t h a t the PaCO2 can be m a i n t a i n e d w i t h i n n o r m a l limits for at l e a s t 20 m i n u t e s . E v e n the lowest PaO2 of 73 t o r r provides over 90% arterial oxygen saturations. It appears t h a t compressed air can be used for resuscitation d u r i n g perCutaneous t r a n s t r a c h e a l v e n t i l a t i o n Should c o n v e n t i o n a l methods of artificial v e n t i l a t i o n fail a n d o x y g e n U~der high pressure not be available. "r~
Blood Gases After 20 min
October 1976
•
DISCUSSION Jacobs 2 a d v o c a t e d t r a n s t r a c h e a l v e n t i l a t i o n as a method for the immediate r e s t o r a t i o n of a n adequate a i r w a y i n a p a t i e n t s u f f e r i n g resp i r a t o r y d i s t r e s s or c a r d i o p u l m o n a r y arrest. He used the technique in 12 p a t i e n t s who were comatose and apneic. Oxygen u n d e r high pressure (60 psi) was applied i n t e r m i t t e n t l y using a volume-type ventilator, w h i c h J a c o b s d e s i g n e d a n d cons t r u c t e d , t h r o u g h a 1 4 - g a u g e int r a v e n o u s catheter inserted t h r o u g h the c r i c o t h y r o i d m e m b r a n e . Blood gas d e t e r m i n a t i o n s after 30 m i n u t e s r e v e a l e d a r a n g e of PaO2 b e t w e e n 180 a n d 655 torr, a n d a r a n g e of PaCO2 b e t w e e n 16 a n d 53 t o r r . I n t r a t r a c h e a l p r e s s u r e s w e r e between 15 a n d 20 cm/water. Jacobs 3 also reported on the use of t r a n s t r a c h e a l v e n t i l a t i o n i n 40 ap-
neic and t e r m i n a l l y ill p a t i e n t s . Blood gases measured at 30-minute i n t e r v a l s i n 36 p a t i e n t s showed a range of PaO2 between 120 and 650 torr, and PaCO~ between 15 and 54 torr. No serious complications were noted. Spoerel et al, 1 t e s t i n g t r a n s t r a c h e a l v e n t i l a t i o n f i r s t i n models, found t h a t a n oxygen jet through a 16-gauge needle at 50 psi could supply enough force to inflate the lungs. The flow produced was adequate to supply the tidal volume for a n adult p a t i e n t w i t h o u t air e n t r a i n m e n t . He confirmed these findings in dogs and d e m o n s t r a t e d a i r e n t r a i n m e n t of a b o u t 44% w h e n u s i n g a t r a c h e a l tube. He t h e n applied the technique to 12 patients, u n d e r g o i n g elective operations, u n d e r a n e s t h e s i a w i t h int r a v e n o u s agents and paralysis with d - T u b o c u r a r i n e chloride_ A plastic, 16-gauge catheter was inserted into the t r a c h e a and a n i n t e r m i t t e n t flow of oxygen was a d m i n i s t e r e d at 50 psi u s i n g a B i r d M a r k II v e n t i l a t o r . Blood gas a n a l y s i s revealed adequate p u l m o n a r y v e n t i l a t i o n for periods r a n g i n g from 40 to 75 minutes_ S i n g h 4 r e p o r t e d 1,500 cases i n which t r a n s t r a c h e a l v e n t i l a t i o n was used for diagnostic and surgical procedures of the upper airways. There were 1,257 cases for bronchoscopy and esophagoscopy and 135 for endolaryngeal surgery. Postoperative v e n t i l a t o r y support was carried out w i t h t h i s t e c h n i q u e in 108 cases, v e n t i l a t e d from 24 to 48 hours. T r a n s t r a c h e a l v e n t i l a t i o n prior to tracheostomy in patients u n d e r g o i n g s u r g i c a l p r o c e d u r e s i n v o l v i n g the head a n d neck has been reported in seven cases. 5 PaCO2 d e t e r m i n a t i o n s at the end of the procedure indicated t h a t the m a j o r i t y of p a t i e n t s were moderately hyperventilated. The use of this technique i n two pediatric patients, one u n d e r g o i n g a n operation for l a r y n g e a l stenosis a n d one who b e c a m e o b s t r u c t e d and cyanotic i n the recovery room, has also been described. 6 A 14-gauge (1_5 m m diameter) i n t r a v e n o u s catheter is inserted into the t r a c h e a in the m i d l i n e t h r o u g h the cricothyroid m e m b r a n e or below the first tracheal ring (Figure 4). Volume 5 Number 10 Page 767
a f t e r n e e d l e removal. For t h i s reason, the c a t h e t e r should be fixed securely. We feel the best c a t h e t e r available is a 8.5 cm long, 14-gauge one manu f a c t u r e d by D e s e r e t _ It h a s two a d d i t i o n a l holes n e a r the tip which m a k e a s p i r a t i o n of air easier because t h e tip is n o t b l o c k e d by mucosa. Also, t h e r e is less p r o b a b i l i t y of severe tissue e m p h y s e m a if it is misp l a c e d , T h e l e n g t h is i d e a l : long enough for t h i c k - n e c k e d individuals and not t o o long to reduce gas flow significantly.
F i g . 4. Transtracheal ventilation.
COMPLICATIONS
Table 3 FROM TRANSTRACHEAL
Elective Prior to A n e s t h e s i a N=52
VENTILATION
For A c u t e Respiratory Distress N=28
Total N=80
Complications
No. of Patients
%
No. of Patients
Subcutaneous Emphysema
5
9.6
2
7.1
7
8.7
Mediastinal Emphysema
1
1.9
1
3.6
2
2.5
%
No. of Patients
%
Exhalation Difficulty
•..
4
14.3
4
5.0
Arterial Perforation
•..
1
3.6
1
1.3
6
8
Total
COMPLICATIONS Local complications m a y occur during transtracheal catheterization. H e m o r r h a g e m a y occur at the site of insertion, particularly from the thyroid, and t h e r e is t h e , d a n g e r of p e r f o r a t i n g t h e esophagus if the needle is advanced too far. 7 A n o t h e r possible c o m p l i c a t i o n is s u b c u t a n e o u s e m p h y s e m a _ 7 The p l a s t i c or teflon c a t h e t e r w i t h t h e s t y l e t in p l a c e should be a d v a n c e d u n t i l it has j u s t e n t e r e d t h e trachea. The position is checked by aspirating air with a syringe. The s t y l e t is w i t h d r a w n and the catheter then inserted without Page 768 Volume 5 Number 10
14
The complications from 80 cases of t r a n s t r a c h e a ] v e n t i l a t i o n at the Eye and E a r Hospital of P i t t s b u r g h are shown (Table 3). It was used in 52 p a t i e n t s electively prior to and during g e n e r a l a n e s t h e s i a and has also been used to r e s u s c i t a t e 28 patients w i t h acute r e s p i r a t o r y distress in the o p e r a t i n g room. All of the l a t t e r had p a t h o l o g y of t h e u p p e r a i r w a y , the majority, c a r c i n o m a of the l a r y n x or tongue. T h e i r ages r a n g e d from 10 to 71 years_ A l t h o u g h t h e r e w e r e no d e a t h s in this series a n d all patients were successfully r e s u s c i t a t e d , 8 of 28 (28.6%) h a d complications. Of the total, 14 (17.5%) h a d complications. A t t h e U n i v e r s i t y of P i t t s b u r g h the t e c h n i q u e of t r a n s t r a c h e a l ventilation in a n e s t h e t i z e d dogs is taught to the t h i r d - y e a r m e d i c a l students. We believe this t e c h n i q u e has established itself as an i m p o r t a n t adjunct in life-support to be used in selected cases• A p p r o x i m a t e l y 60 a d v a n c e d emergency medical technicians (EMT) a n d 500 t h i r d - y e a r medical students have practiced transt r a c h e a l v e n t i l a t i o n on dogs. No serious c o m p l i c a t i o n s h a v e been noted up to the p r e s e n t time.
the needle_ We have found it to be of value, in a s s u r i n g t h a t the c a t h e t e r is in t h e a i r w a y , to d r i p a s m a l l a m o u n t of f l u i d , s a l i n e or l o c a l anesthetic, into the catheter. In spontaneously breathing patients, bubbles are seen on expiration. The c a t h e t e r should be directed c a u d a d at an angle of 45 degrees.
The e m e r g e n c y crash carts at the U n i v e r s i t y H e a l t h C e n t e r of Pittsb u r g h H o s p i t a l s are equipped with an a p p a r a t u s for p e r f o r m i n g transtracheal ventilation. It is our belief t h a t all e m e r g e n c y d e p a r t m e n t s s h o u l d be s i m i l a r l y equipped.
S u b c u t a n e o u s e m p h y s e m a can be m i n i m i z e d by e n t e r i n g the s k i n dist a n t from the p l a n n e d t r a c h e a l perfor a t i o n site a n d by a p p l y i n g p r e s s u r e on the t r a c h e a after c a t h e t e r removal. A soft c a t h e t e r is more likely to be d i s p l a c e d if it b e c o m e s k i n k e d
The t y p e s of a i r w a y problems in which t r a n s t r a c h e a l v e n t i l a t i o n may be considered a r e shown (Table 4). The technique is not a substitute for t r a d i t i o n a l a i r w a y care b u t is to be used w h e n these are deemed hopeless or have failed. October 1976 J ~ P
Table 4 A I R W A Y PROBLEMS WHICH M A Y REQUIRE TRANSTRACHEAL VENTILATION
Bones and Joints
Arthritis (temporo-mandibular joint, cervical) fractured mandible or post-mandibulectomy Congenital abnormalities of the mandible, micrognathia and mandibulofacial dysostosis (Pierre Robin and Treacher Collins syndrome)
Face and Neck
Contracture from burns, scars from postirradiation Problems associated with casts (halo, arista) Masses (thyroid, cervical nodes, carotid hemorrhage) abscess Trauma from stabbing, gunshot, auto, and industrial accidents
Intraoral
Carcinoma of the mouth or tongue, peritonsillar abscess, retropharyngeal abscess Severe trismus from intraoral infection Trauma from stabbing, gunshot, auto and industrial accidents
Larynx
F i g . 6. Dog ventilated using truck tire.
Carcinoma of the larynx the same role as in the emergency department.
Subglottic stenosis Fracture larynx epiglottitis
Should this technique be t a u g h t to EMTs? Perhaps, if: 1) s t a n d a r d methods of a i r w a y m a n a g e m e n t h a v e failed; 2) technicians are t r a i n e d to use t r a n s t r a c h e a l ventilation (anatomy, mechanics, technique, complications), and 3) technicians are u n d e r the direction of a physician.
Cyst of epiglottitis
Trucks have tires u n d e r 50 to 75 psi pressure which may be available d u r i n g h i g h w a y accidents. T r a n s tracheal v e n t i l a t i o n could be used for resuscitation, p a r t i c u l a r l y in cases of t r a u m a to the face or neck, w h e n tracheal i n t u b a t i o n is difficult or impossible.
Fig. 5. Apparatus for use with truck tires.
The role of t r a n s t r a c h e a l ventilation i n u p p e r a i r w a y o b s t r u c t i o n from a f o r e i g n body is n o t e s t a b lished, b u t there is reason s to believe that it should be tried when all else,
J~P
October 1976
i n c l u d i n g the Heimlich m a n e u v e r , 9 has failed. If the MICU is physician-staffed, t r a n s t r a c h e a l v e n t i l a t i o n would have
We tested the efficacy of the techn i q u e e x p e r i m e n t a l l y in a dog which was a n e s t h e t i z e d and made apneic using intravenous barbiturates. A 1 6 - g a u g e t e f l o n c a t h e t e r w a s inserted into the trachea via the cricothyroid m e m b r a n e . V e n t i l a t i o n was accomplished using a small truck t i r e ( 7 . 0 0 - 1 4 L T ) as t h e s o u r c e of compressed air (Figures 5 and 6). At a s t a r t i n g pressure of 60 psi, the dog could be adequately ventilated for 15 minutes. After this time the PaCO2 was 43 torr a n d the PaO2 63 torr. The a n i m a l ' s recovery was u n e v e n t ful. If this technique is used in hum a n s a f i l t e r s h o u l d be u s e d to e l i m i n a t e foreign particles.
Volume 5 Number 10 Page 769
CONCLUSION P e r c u t a n e o u s t r a n s t r a c h e a l ventilation ( i n t e r m i t t e n t high pressure j e t s of o x y g e n ) is a n e s t a b l i s h e d t e c h n i q u e for m a n a g e m e n t of difficult airway problems i n the hospital. E m e r g e n c y physicians should be familiar with its use and e q u i p m e n t should be available_ E x p e r i m e n t a l evidence has shown t h a t the method is effective; this is supported by our own clinical exper]ence. Complications did occur, however, in a significant n u m b e r of our p a t i e n t s (17.5%). The potential role of the technique in the M I C U at accident sites has been explored a n d appears promising. C o n v e n t i o n a l a i r w a y s u p p o r t
Page 770 Volume 5 Number 10
techniques should be applied before r e s o r t i n g to t r a n s t r a c h e a l v e n t i l a tion.
REFERENCES 1. Spoerel WE, Narayanan PS, Singh NP: Transtracheal ventilation. Br J Anaesth 43:932, 1971. 2. Jacobs HB: Emergency percutaneous transtracheal catheter and ventilator. Trauma 12:50, 1972. 3. Jacobs HB: Needle-catheter brings oxygen to the trachea. J A M A 222:1231, 1972. 4. Singh NP: Transtracheal jet ventilation as a new technique and experiences with ketamine and propandid in India. Anesthesiology, Proceedings of the Fifth World Congress of Anesthesiologists, Kyoto, 160-161, 1972.
5. Smith RB: Transtracheal ventilation during anesthesia. Anesth Analg 53:225, 1974. 6. Smith RB, Myers EN, Sherman I-I: Transtracheal ventilation in pediatric patients, Case reports. Br J Anaesth 46:313, 1974. 7. Smith RB, Schaer WB, Pfaeffle H: Percutaneous transtracheal ventilation for anesthesia: A review and report of coraplications. Can Anaesth Soc J 22:607-612, 1975. 8. Rock JJ~ Pfaeffle H, Smith RB, et al: High pressure jet insufflation used to prevent aspiration and its effect on the tracheal mucosal wall, abstracted. Critical Care Meclicine 4:135, 1976. 9. Heimlich JJ: A life-saving maneuver to prevent food choking. JAMA 234:398, 1975.
October 1976 J ~ )
