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Minitracheostomy: A new delivery system for jet ventilation
J
THoRAc CARDIOVASC SURG
92:673-675, 1986
Minitracheostomy: A new delivery system for jet ventilation Seventeen patients with respiratory failure from a variety of causes have been treated by high-frequency jet ventilation, delivered by a speciaUy designed Y connector and a standard minitracheostomy tube, for periods ranging from 12 hours to 14 days. This percutaneous system provides access for full ventilatory support and tracheobronchial suction, but without the need for a cuffed endotracheal tube or sedation. Patients can eat, drink, and talk during ventilation. Ten of the patients were male and ages ranged from 31 to 77 years. Ventilation was satisfactory in 16 patients and unsatisfactory in one, who had also been difficult to manage on conventional ventilation. Thirteen patients resumed full spontaneous respiration and four died of their underlying disease while still being supported with a ventilator. These results suggest that the combination of minitracheostomy and high-frequency jet ventilation may offer significant advantages in the management of some patients with respiratory failure.
Hugoe R. Matthews, F.R.C.S. (by invitation), Barrie J. Fischer, F.F.A.R.C.S. (by invitation), Brendan E. Smith, F.F.A.R.C.S. (by invitation), and Roland B. Hopkinson, F.F.A.R.C.S. (by invitation), Bromsgrove, Leicester, and Birmingham, United Kingdom Sponsored by Thomas R. DeMeester, M.D., Omaha. Neb.
High-frequency jet ventilation (HFJV) is usually administered through a modified endotracheal tube, an endotracheal catheter, or a cricothyroid needle. All these treatment systems, however, have significant disadvantages. An oral endotracheal tube causes laryngeal incompetence, is uncomfortable for the patient, and generally necessitates sedation; the tracheal catheter and the cricothyroid needle offer no facility for the removal of secretions present in the tracheobronchial tree and are suitable only for short-term use. To overcome these difficulties we have designed a simple Y connector that plugs into a standard minitracheostomy (MT) tube.' This provides a percutaneous route for HFJV, tracheal suction, and intra-airways pressure monitoring (Fig. 1), without the need for a cuffed endotracheal tube or sedation. This system would appear to have significant advantages over more convenFrom the Departments of Anaesthesia, Bromsgrove General Hospital, Bromsgrove, and Leicester Royal Infirmary, Leicester, and the Regional Department of Thoracic Surgery and the Department of Anaesthesia, East Birmingham Hospital, Birmingham, United Kingdom. Read at the Sixty-sixth Annual Meeting of The American Association for Thoracic Surgery, New York, N. Y, April 28-30, 1986. Address for reprints: H. R. Matthews, F.R.C.S., Regional Department of Thoracic Surgery, East Birmingham Hospital, Birmingham, United Kingdom.
tional methods of ventilation, and we therefore report our experiences with the first series of patients to be treated by this technique. Patients and methods From January, 1984, to October, 1985, 17 patients were treated for respiratory failure by a combination of MT and HFJV, using a Penlon high-frequency jet ventilator equipped with a Bromsgrove humidifier.' Ten patients were male and ages ranged from 31 to 77 years (mean 62.3 years). The causes of respiratory failure and the outcome of treatment are shown in Table I. Indications for the use of this particular method of ventilation were as follows: (1) unsuitability for long-term controlled mandatory ventilation (CMV), e.g. severe chronic bronchitis; (2) the need for respiratory assistance rather than full CMV, e.g., postoperative respiratory failure; (3) difficulty in weaning from CMV; and (4) difficulty in management on CMV. The MT and HFJV technique was used as the sole method of ventilation in four patients; in the remainder it was used either before or after CMV or HFJV via an oral endotracheal tube. MT was performed in all cases by cricothyroid puncture with the guarded scalpel and introducer from a disposable "Mini-Trach" kit (Portex Ll.K, Ltd.), according to the method previously described.' MT was 673
The Journal of
674
Thoracic and Cardiovascular
Matthews et al.
Surgery
Table I. Causes and outcome of respiratory failure in 17 patients treated by MT and HFJV
Cause Surgical Chest trauma Emergency abdominal operation Elective abdominal operation Pulmonary resection Medical Neurological conditions Primary lung disease (bronchitis, asthma, pneumonia) Totals
Died during ventilatory support
No. I 4
I (peritonitis) I (pancreatectomy)
2 3 6
17
I (pneumonectomy)
I (respiratory and hepatorenal failure)'
4
"This patient's condition deteriorated during MT and HFJV and he was returned to CMV.
Fig. 1. Minitracheostomy tube (MT) and Y connector assembled for high-frequency jet ventilation (HFJV), which is administered through the narrow arm of the connector; the shorter wide arm is used for tracheal suction or intra-airways pressure monitoring while ventilation is in progress.
performed under local anesthesia in the intensive care unit in 14 patients, while three had the tube inserted under general anesthesia in the operating room at the conclusion of emergency abdominal operations. When spontaneous respiration was reestablished, the Y connector was removed and the MT tube left in place as a route for tracheal suction for periods of up to 15 days. Results In 17 patients the combination of MT and HFJV was used continuously for periods ranging from 12 hours to 14 days, with a mean duration of 3.9 days. Ventilation was satisfactory in 16 patients, judged by blood-gas analysis, chest radiography, and clinical progress; it was unsatisfactory in one patient, who was returned to CMV. Overall results are shown in Table I: Thirteen patients resumed unsupported spontaneous respiration, but four did not and died of their primary disease or its complications while being supported with a ventilator.
In four patients the MT and HFJV technique was the sole method of ventilatory support for periods ranging from 18 hours to 9 days. Respiratory failure was due to chest trauma in one, neurologic problems in one, and chronic lung disease in two. All were successfully weaned from ventilatory support, but two died later, one of a cerebrovascular accident and one of chronic lung disease. In six cases MT and HFN were used as a method of weaning patients from CMV; four had postoperative respiratory failure and two had chronic lung disease. In these patients MT was performed, the endotracheal tube was removed, and HFJV commenced. Sedation was then stopped. All six patients were weaned from ventilatory support within 4 days, although two died later, one of cor pulmonale and the other of peritonitis. In the remaining seven patients the combination of MT and HFJV was used as an alternative to CMVin an attempt to improve blood gases or circulatory status. Respiratory failure was due to postoperative problems in three, neurologic causes in two, and chronic lung disease in two. Ventilation was performed for periods ranging from 36 hours to 14 days. Long-term results in this group were noticeably less satisfactory than in the previous two groups; three patients resumed unsupported spontaneous respiration (with survival in two and late death from the original cerebrovascular accident in one), but four did not and died of their underlying disease (Table I). In the short term the condition of one patient was improved and that of three was satisfactory on MT and HFJV, but two were not improved by this
Volume 92 Number 4
Minitracheostomy
October 1986
system; the status of one patient worsened and he was returned to CMV. Complications. No serious complications were encountered with either MT or HFJV. One patient bled from the site of insertion of the MT tube and required local exploration of a superficial vessel. One MT tube became blocked and was changed, and one patient pulled the MT tube out (and subsequently received a standard tracheostomy). Theoretically the main risk of this technique would be from tissue emphysema caused by malposition or dislodgment of the tube. This is prevented first by confirming that the tube is in the trachea before HFJV is commenced and second by the design of the tube, which, having a 9 em length inside the trachea, will not be dislodged as long as it is securely fastened around the neck. Discussion The role of HFJV in the management of respiratory failure is still being evaluated. At present, for long-term treatment, HFJV is usually administered through an oral endotracheal tube, but in our opinion this negates some of the potential advantages of HFJV. With a percutaneous delivery system such as we have described, there is no need for the sedation that is frequently required to make an endotracheal tube tolerable, and the patient is therefore likely to resume unsupported respiration at an earlier stage. This route also preserves the function of the glottis, so that the patient can eat and drink and generate an expulsive cough that aids in the clearance of secretions, particularly from the. distal bronchial tree. In addition the constant air flow out through the larynx allows the patient to speak with relatives and staff while ventilation is in progress. The design of our apparatus, with its external connector, eliminates the risk of cold injury to the trachea (as gas expansion occurs outside the body), and in vitro studies with a transparent plastic model have shown that there is no "whiplash" movement of the intratracheal end of the MT tube. Suction and intra-airways pressure monitoringcan be performed through the shorter arm of the connector during ventilation and the problem of humidification has been resolved by the use of the Bromsgrove humidifier.'
675
The results in our patients indicate that MT and HFJV can provide satisfactory ventilation and gas exchange, at least for periods of up to 14 days. The method would appear to have significant advantages over more conventional forms of ventilation, particularly in patients who only require respiratory assistance or help in weaning from CMV. There was less evidence of benefit when it was used to try to improve the condition of patients who were difficult to manage on CMV. On the basis of our experience we conclude that the combination of MT and HFJV justifies further clinical trials to establish its role in the future management of patients with respiratory failure. REFERENCES Matthews HR, Hopkinson RB: Treatment of sputum retention by minitracheotomy. Br J Surg 71:147-150, 1984 2 Smith BE: The Penlon Bromsgrove high frequency jet ventilator for adult and paediatric use. A solution to the problem of humidification. Anaesthesia 40:790-796, 1985
Discussion DR. MATTHEWS (Closing) I hope this presentation may lead to an interest in MT and HFJV as a possible method of ventilating the lungs of some patients. I would describe this study in cancer terms as a Phase 2 study: That is, is this form of ventilation feasible? My answer to that question is that it is feasible at least for a couple of weeks.
The next part of our work is to define which patients may be helped by MT and HFJV. Our tentative conclusions are that for the patient with relatively compliant lungs who may have lost his respiratory drive because of neurologic problems or may need short-term assistance rather than total ventilation, this may be the method of choice. In the heavy patient with noncompliant lungs, this system does not have the force to provide a substitute for conventional ventilation. I think in the long term there will bea place for both methods. Obviously there will be some cases in the middle in which there may be a choice. Availability of MT and HFJV depends on the Food and Drug Administration. HFJV currently is available only for investigational use. The MT tube is already available from the manufacturer.
THoRAc CARDIOVASC SURG
92:673-675, 1986
Minitracheostomy: A new delivery system for jet ventilation Seventeen patients with respiratory failure from a variety of causes have been treated by high-frequency jet ventilation, delivered by a speciaUy designed Y connector and a standard minitracheostomy tube, for periods ranging from 12 hours to 14 days. This percutaneous system provides access for full ventilatory support and tracheobronchial suction, but without the need for a cuffed endotracheal tube or sedation. Patients can eat, drink, and talk during ventilation. Ten of the patients were male and ages ranged from 31 to 77 years. Ventilation was satisfactory in 16 patients and unsatisfactory in one, who had also been difficult to manage on conventional ventilation. Thirteen patients resumed full spontaneous respiration and four died of their underlying disease while still being supported with a ventilator. These results suggest that the combination of minitracheostomy and high-frequency jet ventilation may offer significant advantages in the management of some patients with respiratory failure.
Hugoe R. Matthews, F.R.C.S. (by invitation), Barrie J. Fischer, F.F.A.R.C.S. (by invitation), Brendan E. Smith, F.F.A.R.C.S. (by invitation), and Roland B. Hopkinson, F.F.A.R.C.S. (by invitation), Bromsgrove, Leicester, and Birmingham, United Kingdom Sponsored by Thomas R. DeMeester, M.D., Omaha. Neb.
High-frequency jet ventilation (HFJV) is usually administered through a modified endotracheal tube, an endotracheal catheter, or a cricothyroid needle. All these treatment systems, however, have significant disadvantages. An oral endotracheal tube causes laryngeal incompetence, is uncomfortable for the patient, and generally necessitates sedation; the tracheal catheter and the cricothyroid needle offer no facility for the removal of secretions present in the tracheobronchial tree and are suitable only for short-term use. To overcome these difficulties we have designed a simple Y connector that plugs into a standard minitracheostomy (MT) tube.' This provides a percutaneous route for HFJV, tracheal suction, and intra-airways pressure monitoring (Fig. 1), without the need for a cuffed endotracheal tube or sedation. This system would appear to have significant advantages over more convenFrom the Departments of Anaesthesia, Bromsgrove General Hospital, Bromsgrove, and Leicester Royal Infirmary, Leicester, and the Regional Department of Thoracic Surgery and the Department of Anaesthesia, East Birmingham Hospital, Birmingham, United Kingdom. Read at the Sixty-sixth Annual Meeting of The American Association for Thoracic Surgery, New York, N. Y, April 28-30, 1986. Address for reprints: H. R. Matthews, F.R.C.S., Regional Department of Thoracic Surgery, East Birmingham Hospital, Birmingham, United Kingdom.
tional methods of ventilation, and we therefore report our experiences with the first series of patients to be treated by this technique. Patients and methods From January, 1984, to October, 1985, 17 patients were treated for respiratory failure by a combination of MT and HFJV, using a Penlon high-frequency jet ventilator equipped with a Bromsgrove humidifier.' Ten patients were male and ages ranged from 31 to 77 years (mean 62.3 years). The causes of respiratory failure and the outcome of treatment are shown in Table I. Indications for the use of this particular method of ventilation were as follows: (1) unsuitability for long-term controlled mandatory ventilation (CMV), e.g. severe chronic bronchitis; (2) the need for respiratory assistance rather than full CMV, e.g., postoperative respiratory failure; (3) difficulty in weaning from CMV; and (4) difficulty in management on CMV. The MT and HFJV technique was used as the sole method of ventilation in four patients; in the remainder it was used either before or after CMV or HFJV via an oral endotracheal tube. MT was performed in all cases by cricothyroid puncture with the guarded scalpel and introducer from a disposable "Mini-Trach" kit (Portex Ll.K, Ltd.), according to the method previously described.' MT was 673
The Journal of
674
Thoracic and Cardiovascular
Matthews et al.
Surgery
Table I. Causes and outcome of respiratory failure in 17 patients treated by MT and HFJV
Cause Surgical Chest trauma Emergency abdominal operation Elective abdominal operation Pulmonary resection Medical Neurological conditions Primary lung disease (bronchitis, asthma, pneumonia) Totals
Died during ventilatory support
No. I 4
I (peritonitis) I (pancreatectomy)
2 3 6
17
I (pneumonectomy)
I (respiratory and hepatorenal failure)'
4
"This patient's condition deteriorated during MT and HFJV and he was returned to CMV.
Fig. 1. Minitracheostomy tube (MT) and Y connector assembled for high-frequency jet ventilation (HFJV), which is administered through the narrow arm of the connector; the shorter wide arm is used for tracheal suction or intra-airways pressure monitoring while ventilation is in progress.
performed under local anesthesia in the intensive care unit in 14 patients, while three had the tube inserted under general anesthesia in the operating room at the conclusion of emergency abdominal operations. When spontaneous respiration was reestablished, the Y connector was removed and the MT tube left in place as a route for tracheal suction for periods of up to 15 days. Results In 17 patients the combination of MT and HFJV was used continuously for periods ranging from 12 hours to 14 days, with a mean duration of 3.9 days. Ventilation was satisfactory in 16 patients, judged by blood-gas analysis, chest radiography, and clinical progress; it was unsatisfactory in one patient, who was returned to CMV. Overall results are shown in Table I: Thirteen patients resumed unsupported spontaneous respiration, but four did not and died of their primary disease or its complications while being supported with a ventilator.
In four patients the MT and HFJV technique was the sole method of ventilatory support for periods ranging from 18 hours to 9 days. Respiratory failure was due to chest trauma in one, neurologic problems in one, and chronic lung disease in two. All were successfully weaned from ventilatory support, but two died later, one of a cerebrovascular accident and one of chronic lung disease. In six cases MT and HFN were used as a method of weaning patients from CMV; four had postoperative respiratory failure and two had chronic lung disease. In these patients MT was performed, the endotracheal tube was removed, and HFJV commenced. Sedation was then stopped. All six patients were weaned from ventilatory support within 4 days, although two died later, one of cor pulmonale and the other of peritonitis. In the remaining seven patients the combination of MT and HFJV was used as an alternative to CMVin an attempt to improve blood gases or circulatory status. Respiratory failure was due to postoperative problems in three, neurologic causes in two, and chronic lung disease in two. Ventilation was performed for periods ranging from 36 hours to 14 days. Long-term results in this group were noticeably less satisfactory than in the previous two groups; three patients resumed unsupported spontaneous respiration (with survival in two and late death from the original cerebrovascular accident in one), but four did not and died of their underlying disease (Table I). In the short term the condition of one patient was improved and that of three was satisfactory on MT and HFJV, but two were not improved by this
Volume 92 Number 4
Minitracheostomy
October 1986
system; the status of one patient worsened and he was returned to CMV. Complications. No serious complications were encountered with either MT or HFJV. One patient bled from the site of insertion of the MT tube and required local exploration of a superficial vessel. One MT tube became blocked and was changed, and one patient pulled the MT tube out (and subsequently received a standard tracheostomy). Theoretically the main risk of this technique would be from tissue emphysema caused by malposition or dislodgment of the tube. This is prevented first by confirming that the tube is in the trachea before HFJV is commenced and second by the design of the tube, which, having a 9 em length inside the trachea, will not be dislodged as long as it is securely fastened around the neck. Discussion The role of HFJV in the management of respiratory failure is still being evaluated. At present, for long-term treatment, HFJV is usually administered through an oral endotracheal tube, but in our opinion this negates some of the potential advantages of HFJV. With a percutaneous delivery system such as we have described, there is no need for the sedation that is frequently required to make an endotracheal tube tolerable, and the patient is therefore likely to resume unsupported respiration at an earlier stage. This route also preserves the function of the glottis, so that the patient can eat and drink and generate an expulsive cough that aids in the clearance of secretions, particularly from the. distal bronchial tree. In addition the constant air flow out through the larynx allows the patient to speak with relatives and staff while ventilation is in progress. The design of our apparatus, with its external connector, eliminates the risk of cold injury to the trachea (as gas expansion occurs outside the body), and in vitro studies with a transparent plastic model have shown that there is no "whiplash" movement of the intratracheal end of the MT tube. Suction and intra-airways pressure monitoringcan be performed through the shorter arm of the connector during ventilation and the problem of humidification has been resolved by the use of the Bromsgrove humidifier.'
675
The results in our patients indicate that MT and HFJV can provide satisfactory ventilation and gas exchange, at least for periods of up to 14 days. The method would appear to have significant advantages over more conventional forms of ventilation, particularly in patients who only require respiratory assistance or help in weaning from CMV. There was less evidence of benefit when it was used to try to improve the condition of patients who were difficult to manage on CMV. On the basis of our experience we conclude that the combination of MT and HFJV justifies further clinical trials to establish its role in the future management of patients with respiratory failure. REFERENCES Matthews HR, Hopkinson RB: Treatment of sputum retention by minitracheotomy. Br J Surg 71:147-150, 1984 2 Smith BE: The Penlon Bromsgrove high frequency jet ventilator for adult and paediatric use. A solution to the problem of humidification. Anaesthesia 40:790-796, 1985
Discussion DR. MATTHEWS (Closing) I hope this presentation may lead to an interest in MT and HFJV as a possible method of ventilating the lungs of some patients. I would describe this study in cancer terms as a Phase 2 study: That is, is this form of ventilation feasible? My answer to that question is that it is feasible at least for a couple of weeks.
The next part of our work is to define which patients may be helped by MT and HFJV. Our tentative conclusions are that for the patient with relatively compliant lungs who may have lost his respiratory drive because of neurologic problems or may need short-term assistance rather than total ventilation, this may be the method of choice. In the heavy patient with noncompliant lungs, this system does not have the force to provide a substitute for conventional ventilation. I think in the long term there will bea place for both methods. Obviously there will be some cases in the middle in which there may be a choice. Availability of MT and HFJV depends on the Food and Drug Administration. HFJV currently is available only for investigational use. The MT tube is already available from the manufacturer.