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High-Frequency Jet Ventilation: Experienced Operators Only
LETTERS TO THE EDITOR
763
In our institution, we routinely use high-frequency jet ventilation on 1 routine thoracic list so that trainees are comfortable using this technique in an emergency situation like major hemorrhage. Anjum Ahmed-Nusrath, DA, FRCA* Rajani Annamanneni, DA, DNB, FRCA, EDIM* Richard Wyatt, MRCS, LRCP, FRCA* Joe Leverment, FRCS (Eng)† Departments of *Anaesthetics and †Thoracic Surgery Glenfield Hospital Leicester, United Kingdom REFERENCES 1. Lohser J, Donington JS, Mitchell JD: Anaesthetic management of major hemorrhage during mediastinoscopy. J Cardiothorac Vasc Anesth 19:678-683, 2005 2. Ihra G, Gocha G, Kashanpour A, et al: High-frequency jet ventilation in European and American institution: Developments and clinical practice. Eur J Anaesthesiol 17:418-430, 2000 3. Gothard J, Porter H: Controversies in thoracic anaesthesia, in Ghosh P, Latimer RD (eds): Thoracic Anaesthesia Principles and Practice. Oxford, Butterworth Heinmann, 1999, pp 307-328 doi:10.1053/j.jvca.2006.03.016
High-Frequency Jet Ventilation: Experienced Operators Only To the Editor: I thank Dr Ahmed-Nusrath and colleagues for their interest in our case conference on management of major hemorrhage during mediastinoscopy.1 The classic absolute indication for lung isolation is protection from tracheobronchial blood, pus, or air, which did not apply in this scenario. Surgery on the great vessels is a relative indication for lung isolation to provide surgical exposure. High-frequency jet ventilation (HFJV) therefore is a reasonable alternative for ventilatory management during sternotomy or thoracotomy for hemorrhage, particularly if one is worried about a difficult airway. However, I disagree with their comment that surgical access is “not hampered in any way.” HFJV uses lower mean airway pressures than conventional ventilation, but airway pressure is consistently above atmospheric pressure, similar to continuous positive airway pressure. As such, when jetting through a single-lumen tube, without the placement of a jet catheter into the nonoperative mainstem bronchus, both lungs are distended to some degree, which would not occur during true lung isolation. Additionally, HFJV carries the risk of barotrauma, with a potential for pneumothorax, pneumomediastinum, or pneumopericardium, which in a hypovolemic, bleeding patient could spell trouble. With this in mind, I have to concur with Ihra et al2 who stated that the application of HFJV in cases of acute ventilatory problems is to be “recommended only for well-trained personnel.” Jens Lohser, MD, FRCPC Department of Anesthesia Vancouver General Hospital University of British Columbia Vancouver, BC, Canada REFERENCES 1. Lohser J, Donington JS, Mitchell JD: Anesthetic management of major hemorrhage during mediastinoscopy. J Cardiothorac Vasc Anesth 19:678-683, 2005 2. Ihra G, Gocha G, Kashanpour A, et al: High-frequency jet ventilation in European and American institution: Developments and clinical practice. Eur J Anaesthesiol 17:418-430, 2000 doi:10.1053/j.jvca.2006.03.017
763
In our institution, we routinely use high-frequency jet ventilation on 1 routine thoracic list so that trainees are comfortable using this technique in an emergency situation like major hemorrhage. Anjum Ahmed-Nusrath, DA, FRCA* Rajani Annamanneni, DA, DNB, FRCA, EDIM* Richard Wyatt, MRCS, LRCP, FRCA* Joe Leverment, FRCS (Eng)† Departments of *Anaesthetics and †Thoracic Surgery Glenfield Hospital Leicester, United Kingdom REFERENCES 1. Lohser J, Donington JS, Mitchell JD: Anaesthetic management of major hemorrhage during mediastinoscopy. J Cardiothorac Vasc Anesth 19:678-683, 2005 2. Ihra G, Gocha G, Kashanpour A, et al: High-frequency jet ventilation in European and American institution: Developments and clinical practice. Eur J Anaesthesiol 17:418-430, 2000 3. Gothard J, Porter H: Controversies in thoracic anaesthesia, in Ghosh P, Latimer RD (eds): Thoracic Anaesthesia Principles and Practice. Oxford, Butterworth Heinmann, 1999, pp 307-328 doi:10.1053/j.jvca.2006.03.016
High-Frequency Jet Ventilation: Experienced Operators Only To the Editor: I thank Dr Ahmed-Nusrath and colleagues for their interest in our case conference on management of major hemorrhage during mediastinoscopy.1 The classic absolute indication for lung isolation is protection from tracheobronchial blood, pus, or air, which did not apply in this scenario. Surgery on the great vessels is a relative indication for lung isolation to provide surgical exposure. High-frequency jet ventilation (HFJV) therefore is a reasonable alternative for ventilatory management during sternotomy or thoracotomy for hemorrhage, particularly if one is worried about a difficult airway. However, I disagree with their comment that surgical access is “not hampered in any way.” HFJV uses lower mean airway pressures than conventional ventilation, but airway pressure is consistently above atmospheric pressure, similar to continuous positive airway pressure. As such, when jetting through a single-lumen tube, without the placement of a jet catheter into the nonoperative mainstem bronchus, both lungs are distended to some degree, which would not occur during true lung isolation. Additionally, HFJV carries the risk of barotrauma, with a potential for pneumothorax, pneumomediastinum, or pneumopericardium, which in a hypovolemic, bleeding patient could spell trouble. With this in mind, I have to concur with Ihra et al2 who stated that the application of HFJV in cases of acute ventilatory problems is to be “recommended only for well-trained personnel.” Jens Lohser, MD, FRCPC Department of Anesthesia Vancouver General Hospital University of British Columbia Vancouver, BC, Canada REFERENCES 1. Lohser J, Donington JS, Mitchell JD: Anesthetic management of major hemorrhage during mediastinoscopy. J Cardiothorac Vasc Anesth 19:678-683, 2005 2. Ihra G, Gocha G, Kashanpour A, et al: High-frequency jet ventilation in European and American institution: Developments and clinical practice. Eur J Anaesthesiol 17:418-430, 2000 doi:10.1053/j.jvca.2006.03.017