Conventional small lumen ventilation: A lifesaver with drawbacks
Ventilation through small lumen is clinically valuable in emergency “Cannot Intubate, Cannot Oxygenate” (CICO) situations, (anticipated) difficult airways and laryngeal surgery. Conventional ventilation fails in cases of severe airway obstruction, as the thick tube that is needed to enable effective ventilation cannot be advanced through the airways.
Needle cricothyroidotomy in conjunction with Transtracheal Jet Ventilation (TTJV) has been used as a last option to avoid death in CICO situations 1-3. In TTJV, oxygen is injected percutaneously under high pressure (e.g. 1.5 bar or higher) via a narrow-bore cannula, typically with an internal diameter of 2 mm. Because of the high resistance of this cannula, the expiration then relies on passive egress of gas via mouth or nose. Thus, to avoid a dangerous pressure buildup in the airways during repeated injections of oxygen, the airway should remain well open. As a consequence, in situations of partial or even complete airway obstruction, TTJV can lead to barotrauma-related lung damage such as pneumothorax or subcutaneous emphysema. As the high pressure buildup in the chest also affects blood circulation, this series of events is often followed by hemodynamic deterioration or even full cardiac arrest. Thus, despite the fact that TTJV can save lives in emergency CICO scenarios, it has clear safety drawbacks. A systematic review including 44 studies revealed that TTJV in CICO is associated with a high risk of barotrauma (32%), device failure (42%) or any other complication (51%) 4.
During upper airway surgery, jet ventilation through a small lumen allows intubation of difficult airways and provides surgical space. As described above, airway patency is required to allow passive backflow of gases, which in turn causes movements of tissue (vocal cords) and secretions/debris, hampering the surgeon’s working conditions. To avoid these movements, periods of apnea may be applied. However, during apnea the surgeon has a limited amount of time to perform the required handling, which is considered stressful, and sequential periods of apnea will significantly add to the surgical time. Alternatively, the use of a cuffed micro-laryngeal tube with a smaller inner diameter (ID) than conventional tubes (5–6 vs. 7–8 mm) allows passive expiration in most cases and prevents the undesirable movement of anatomical and physiological structures. Moreover, the cuff seals the airway and protects the patient from aspiration. However, the 5 mm ID tubes in particular may cause ventilation issues as the pressure in the lungs cannot be reduced fast enough.
Use of a small lumen tube is not only beneficial during surgery, but also in the postoperative period: First, it reduces the risk of intubation-related complications such as sore throat, which can cause substantial discomfort, or tracheal stenosis caused by damage during intubation 14,15. Second, guidelines and handbooks on the management of tracheal extubation state that small-bore tubes make extubation safer in high-risk patients, as these tubes should be left in situ until it is likely that reintubation will not be required 12,13.
Figure 1. Comparison of ultrathin Tritube with conventional tubes. The small outer diameter of Tritube is beneficial during intubation, ventilation and extubation.
EVA®/FCV® uniquely provides safe small lumen ventilation with full respiratory control
Due to the unique concept of controlling the full ventilation cycle by generating a constant and continuous flow, EVA®/FCV® enables safe and efficient ventilation through high-resistant small lumen tubes and catheters (ID 1.6 – 3 mm). EVA®/FCV® provides inspiration and active expiration through the same ventilation tube. It thereby allows the management of difficult airways and can save lives in CICO situations. Several research groups have consistently shown rapid reoxygenation using Ventrain (EVA® technology) in animal models for CICO situations, where EVA® was shown to be superior to conventional ventilation strategies 16-19. Furthermore, numerous clinicians have reportedly saved the lives of babies and adults with this technology 20-23. As such, EVA® ventilation has been acknowledged as a real life-saving technology by key opinion leaders in handbooks and articles 13,24,25.
EVA®/FCV® in conjunction with small lumen tubes and catheters has proven to be beneficial during various upper airway surgical procedures, avoiding the risk of barotrauma related to jet ventilation, or the need for an alternative tracheotomy 26-30.
EVA®/FCV® allows the use of Tritube, an ultrathin cuffed endotracheal tube with an ID of only 2.4 mm, offering several new possibilities during laryngeal surgery. Tritube provides a large surgical exposure due to the OD of only 4.4 mm. Due to its cuff, it also offers a clear and hygienic sight for the surgeon, as undesired movement of vocal cords or debris is prevented (Figure 1). Dr. Kristensen published on the use of Tritube in combination with Ventrain in seven patients undergoing laryngeal surgery 31 (Figure 2). He noted that this arrangement provided an “unprecedented view of the intubated airway during oral, pharyngeal, laryngeal or tracheal procedures” and stated that the technique has the “potential to replace temporary tracheostomy, jet-ventilation or extra-corporeal membrane oxygenation in selected patients.” In this series of cases, two very complicated airway patients at high risk of losing the airway during intubation under anesthesia were intubated while awake. The described technique was slightly adapted and used by others 32. For safety reasons, one patient was transported to the PACU with a Tritube in place (with the cuff deflated) to ensure airway access in case of any postoperative swelling or bleeding. This patient was subsequently uneventfully extubated one hour after surgery 32.
Figure 2. Comparison of conventional MLT-6 tube (left) with Tritube (right) for management of difficult airway. Tritube provides improved view of the intubated airway. Adapted from Kristensen et al., Acta Anaesthesiol Scand 2017 31.
Furthermore, the first observational multicenter study using Evone in combination with Tritube for patients undergoing ENT surgery shows stable ventilatory parameters throughout the procedures 33. Videos illustrate good visibility of the laryngeal structures during and after placement of Tritube. With Tritube’s cuff deflated, patients could comfortably breathe spontaneously after emergence from anesthesia. The authors state that “FCV in combination with Tritube contributes to the armamentarium for airway management” 33. Two randomized controlled trials additionally highlight the benefits of Tritube during ENT surgery: A study by Schmidt et al., comparing Tritube with a conventional MLT-6 tube, revealed a significantly reduced concealment of laryngeal structures (7±2 vs. 22±8 %, P<0.001) and improved surgical conditions as judged by residents in training (P=0.006) 34. Preliminary data from a second study by Kristensen and colleagues, comparing Tritube with MLT-6 in patients with predicted difficult airways, revealed clearly improved intubation and surgical conditions in the Tritube patients versus the control group 35. Additionally, this study showed that, with a deflated cuff, Tritube was equally well tolerated as compared to a standard tube exchanger when left in situ postoperatively, allowing patients to freely breathe and talk 35.
- Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology 1989; 71(5): 769-78
- Weber MD, Romano MJ. A quick and simple method to provide transtracheal jet ventilation. Anesth Analg 2004; 99(4): 1271-2.
- Mchugh R, Kumar M, Sprung J, Bourke D. Transtracheal jet ventilation in management of the difficult airway. Anaesth Intensive Care 2007; 35(3): 406-8
- Duggan LV, Ballantyne Scott B, Law JA, Morri IR, Murphy MF, Griesdale DE. Transtracheal jet ventilation in the ‘can’t intubate can’t oxygenate’ emergency: a systematic review. Br J Anaesth. 2016 Sep;117 Suppl 1:i28-i38
- Cavallone LF, Vannucci A. Review article: Extubation of the difficult airway and extubation failure. Anesth Analg. 2013 Feb;116(2):368-83
- Cook TM , Scott S, Mihai R. Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995–2007. Anaesthesia 2010; 65:556–63
- Peskett MJ. Clinical indicators and other complications in the recovery room or postanaesthetic care unit. Anaesthesia 1999;54: 1143–9.
- Rose DK, Cohen MM, Wigglesworth DF, DeBoer DP. Critical respiratory events in the postanesthesia care unit. Patient, surgical, and anesthetic factors. Anesthesiology 1994; 81:410–8
- Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985-2003. Anesthesiology 2007; 106: 1096–104
- Auroy Y, Benhamou D, Péquignot F, Bovet M, Jougla E, Lienhart A. Mortality related to anaesthesia in France: analysis of deaths related to airway complications. Anaesthesia 2009; 64: 366–70
- Lewis G. The Conﬁdential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to make Motherhood Safer—2003–2005. The Seventh Report on Conﬁdential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH, 2007
- Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012;67:318–4
- Cooper R Hagberg and Benumof’s Airway Management 2018, 4th edition, Chapter 48, pages 44-47
- El-Boghdadly K, Bailey CR, Wiles MD. Postoperative sore throat: a systematic review. Anaesthesia. 2016 Jun;7
- Wain JC. Postintubation tracheal stenosis. Semin Thorac Cardiovasc Surg. 2009 Fall;21(3):284-9
- Berry M, Tzeng Y, Marsland C. Percutaneous transtracheal ventilation in an obstructed airway model in post-apnoeic sheep. Br J Anaesth. 2014 Dec;113(6):1039–1045
- Paxian M, Preussler NP, Reinz T, Schlueter A, Gottschall R. Transtracheal ventilation with a novel ejector-based device (Ventrain) in open, partly obstructed, or totally closed upper airways in pigs. Br J Anaesth. 2015 Aug;115(2):308–316
- Hamaekers AE, van der Beek T, Theunissen M, Enk D. Rescue ventilation through a small-bore transtracheal cannula in severe hypoxic pigs using expiratory ventilation assistance. Anesth Analg. 2015 Apr;120(4):890-4
- De Wolf MWP, Gottschall R, Preussler NP, Paxian M, Enk D. Emergency ventilation with the Ventrain® through an airway exchange catheter in a porcine model of complete upper airway obstruction. Can J Anaesth. 2017 Jan;64(1):37–44.
- Willemsen MG, Noppens R, Mulder AL, Enk D. Ventilation with the Ventrain through a small lumen catheter in the failed paediatric airway: two case reports. Br J Anaesth. 2014 May;112(5):946-7
- Escribá Alepuz J, Alonso García JV, Cuchillo Sastriques E, Alcalá P, Argente Navarro. Emergency Ventilation of Infant Subglottic Stenosis Through Small-Gauge Lumen Using the Ventrain: A Case Report. A A Prac 2018 Mar 15; 10(6):136-138
- Wahlen BM, Al-Thani H, El-Menyar A. Ventrain: from theory to practice. Bridging until re-tracheostomy. BMJ Case Rep 2017 Aug 16;2017
- Heuveling DA, Mahieu HF, Jongsma-van Netten HG, Gerling V.Transtracheal Use of the CriCath® Cannula in Combination With the Ventrain Device for Prevention of Hypoxic Arrest due to Severe Upper Airway Obstruction: A Case Report. A&A Practice July 2018 epub
- Noppens RR. Ventilation through a ‘straw’: the final answer in a totally closed upper airway? Br J Anaesth. 2015 Aug;115(2):168-70 1(6):706-17
- Doyle DJ. Ventilation via Narrow-Bore Catheters: Clinical and Technical Perspectives on the Ventrain Ventilation System. The Open Anaesthesia Journal Sep 2018; 12, 49-60
- Borg PA, Hamaekers AE, Lacko M, Jansen J, Enk D. Ventrain for ventilation of the lungs. Br J Anaesth. 2012 Nov;109(5):833-4
- Fearnley RA, Badiger S, Oakley RJ, Ahmad I. Elective use of the Ventrain for upper airway obstruction during high-frequency jet ventilation. J Clin Anesth. 2016 Sep;33:233-5
- Onwochei, El-Boghdadly K, Ahmad I. Two-Stage Technique Used to Manage Severe Upper Airway Obstruction and Avoid Surgical Tracheostomy: A Case Report. A A Pract 2018 Mar 1;10(5):118-120
- Rosenblatt W, Popescu W. https://youtu.be/49u9Yw6BvfU
- Rosenblatt W. https://www.ventinovamedical.com/ventrain
- Kristensen MS, de Wolf MWP, Rasmussen LS. Ventilation via the 2.4 mm internal diameter Tritube® with cuff – new possibilities in airway management. Acta Anesthesiol. Scand. 2017 Jul; 61(6):580-589D.N.
- Jeyarajah K, Ahmad I. Awake tracheal placement of the Tritube under flexible bronchoscopic guidance. Anaesthesia Cases / 2018-0097 / ISSN 2396-8397 epub Jul 2018
- Schmidt J, Günther F, Weber J, Wirth S, Brandes I, Barnes T, Zarbock A, Schumann S, Enk D. Flow-controlled ventilation (FCV) in the perioperative setting – an observational two-centre first-in-human study. Eur J Anaesthesiol. ePub 2019 Feb 5
- Schmidt J, Günther F, Weber J, Wirth S, Schumann s. Improved airway management and ventilation with a cuffed endotracheal tube with an outer diameter of 4.4 mm for laryngeal surgery – a randomized controlled trial. Euroanaesthesia 2019, Abstract 3269
- Kristensen MS, Abildstrøm HH. Endotracheal video-laryngoscope guided intubation with a 2.4 mm cuff’ed tube and active expiration by a dedicated ventilator versus a standard tube/ventilator. A randomized single blinded study in patients with a predicted difficult airway. – A paradigm shift in airway management? Euroanaesthesia 2019, Abstract 3755
Our journey to redefine ventilation continues. Tuesday evening Prof. Dr. med. Dietmar Enk spoke at the Spring Symposium in Gent, Belgium. Topics were ventilation method FCV® and energy minimalization. During day time, there were various clinical demonstrations....