Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Percutaneous Transtracheal Jet Ventilation

  • Author: Liudvikas Jagminas, MD, FACEP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
 
Updated: Dec 31, 2015
 

Overview

Airway management is a priority in the resuscitation of critically ill patients. Generally, this can be achieved by basic or advanced airway maneuvers. In a minority of patients, these procedures fail, and a surgical airway is required in order to secure the airway.[1] A surgical airway can be obtained in the emergency setting in 1 of 2 principal methods: surgical cricothyroidotomy and needle cricothyroidotomy.[1, 2] Of these methods, needle cricothyroidotomy provides the simplest, fastest, and safest access.[2, 3]

See the videos below of percutaneous transtracheal jet ventilation and cricothyroidotomy.

Percutaneous transtracheal jet ventilation. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
Surgical cricothyroidotomy Seldinger. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.

Percutaneous transtracheal jet ventilation (PTJV) was introduced in the 1950s by Flory et al.[4] In the early 1970s, intermittent PTJV was successfully used for airway management during routine general surgical procedures lasting up to 2 hours. PTJV was also advocated as an alternative in the management of the difficult airway in conjunction with laryngoscopy.[4]

Some reports have recommended PTJV only as a transient resuscitative measure for emergent situations in which endotracheal intubation or other ventilation methods are not feasible.[5, 6] PTJV is widely thought of as a temporizing procedure to be maintained for only 30 minutes at best. However, animal experiments and clinical studies have demonstrated that transtracheal ventilation is an effective, quick, fairly simple, and safe way to obtain and maintain an airway for a prolonged period of time.[7]

The use of PTJV was not widely accepted at first because of initial reports of high complication rates.[3, 8] Also, PTJV does not provide definitive airway protection against copious secretions or aspiration. However, in a life-threatening situation in which tracheal intubation and bag-mask-valve ventilation cannot be performed to restore adequate gas exchange during acute respiratory failure, PTJV must be entertained as a viable interim maneuver. Under such circumstances, PTJV with a large bore needle provides immediate oxygenation and ventilation by providing adequate gas exchange and ensuring the patency of the airway until a definitive procedure such as oral intubation with bronchoscopy followed by surgical tracheostomy can be performed. It requires fewer instruments and can be performed more quickly than surgical cricothyrotomy.

Transtracheal jet ventilation has been used extensively as a means of ventilation during surgery and procedures of the upper airway.[9, 10] Transtracheal jet ventilation may be used even with partial airway obstruction.[11] PTJV can force oropharyngeal secretions out of the proximal trachea and may force a foreign body out of the proximal trachea (in cases of partial airway obstruction). However, upper airway patency is required for exhalation during PTJV, and an open cricothyrotomy is preferred if significant obstruction exists.

PTJV is a rapid procedure for obtaining airway control in both elective and emergency situations for patients of all ages and in many clinical situations.[12, 13, 14] It is the surgical airway of choice for children younger than 12 years because of the small tracheal diameter on which an open cricothyrotomy is often impossible. Although rarely performed, needle cricothyroidotomy is a potentially life-saving procedure. The range of adapted equipment presently used for needle cricothyroidotomy is diverse. This article describes and demonstrates a method of PTJV and oxygen delivery for needle cricothyroidotomy that is easily accessible, simple to assemble, easy to use, and readily available in every emergency setting.

Next

Indications

See the list below:

  • Indications for percutaneous transtracheal jet ventilation (PTJV) are similar to those for surgical cricothyrotomy.
  • PTJV is indicated in any situation in which intubation is contraindicated or cannot be achieved. [15]
  • The failure or inability to secure a definitive airway by endotracheal intubation in a timely fashion, and a subsequent inordinate delay in definitive airway control and oxygenation, is an indication for either needle or surgical cricothyrotomy to prevent hypoxemia.
  • PTJV has also been used electively in patients of all ages and as a rescue procedure.
  • PTJV is the surgical airway of choice for children younger than 12 years of age.
Previous
Next

Contraindications

Absolute contraindications

See the list below:

  • If a definitive airway can easily and rapidly be secured with endotracheal intubation, percutaneous transtracheal jet ventilation (PTJV) is not used.
  • PTJV is not used in the presence of known significant direct damage to the cricoid cartilage or larynx. [15]

Relative contraindications

See the list below:

  • If complete upper airway obstruction is present, surgical cricothyrotomy is preferred over PTJV. [16]
  • PTJV can be used in the presence of partial airway obstruction provided that appropriate-sized catheters are used. [16]
  • Airway obstruction below the vocal cords that renders exhalation difficult or impossible is a relative contraindication.
Previous
Next

Anesthesia

See the list below:

  • Lidocaine 1-2% at a dose of 2-3 mL is generally sufficient for local skin anesthesia via infiltrative administration in patients who are alert and awake. Injection of a small amount of anesthetic percutaneously into the trachea itself will blunt the cough response as well.
Previous
Next

Equipment

Equipment for needle cricothyrotomy and percutaneous transtracheal jet ventilation (PTJV) consists of the following:[6, 17]

  • High-pressure noncollapsible oxygen tubing
  • Needle catheter, 13 or 14 gauge (ga)
  • Oxygen source with a flow at 10-15 L/min
  • Manual jet ventilator/insufflator device

If a manual jet ventilator/insufflator device is not available, needle cricothyrotomy and PTJV can be performed with equipment that is readily accessible in emergency settings, is simple to assemble, and is easy to use. This equipment includes the following:

  • Oxygen source with a flow at 10-15 L/min
  • Commercial bag-valve-mask device (Ambu bag) that includes noncollapsible oxygen tubing and a reservoir bag
  • Large-bore, over-the-needle intravenous catheter (14 ga; 2 in)
  • Plastic syringe, 3 mL, with Luer lock tip, that fits tightly into a 7.5-mm inner diameter endotracheal tube adapter
  • Inner adapter of 7.5 mm endotracheal tube

Equipment assembly

See the list below:

  • Connect the intravenous catheter to a 3-mL syringe barrel (with its plunger removed).
  • Connect the 3-mL syringe barrel to a 7.5-mm inner diameter endotracheal tube adapter.
  • Lock the valve of the bag-valve-mask device and connect its oxygen tubing to an oxygen source with a flow at 10-15 L/min.
  • Connect the endotracheal tube adapter to the bag-valve-mask device.
  • Manually ventilate at a rate of 1-second compression with 4-second relaxation (ventilations are guided with chest rise).
Previous
Next

Positioning

See the list below:

  • The patient ideally should be positioned to expose the neck and its landmarks (see image below). If no contraindications are present (eg, known or suspected cervical spine injury), place the patient's head in a hyperextended or "sniffing" position. Extension of the neck aids identification of the anatomy and control of the cricoid space.
    Landmarks and positioning. Landmarks and positioning.
  • The cricothyroid membrane is located by identifying the dip or notch in the neck below the laryngeal prominence. The cricothyroid membrane is bounded by the thyroid cartilage superiorly and the cricoid cartilage inferiorly. The landmarks are most easily found by placing the index finger on the prominence of the thyroid cartilage and slowly palpating downward until the finger "drops off" the thyroid cartilage and onto the cricoid membrane.
  • Airway protection during percutaneous transtracheal jet ventilation (PTJV) is attained by positioning the patient to allow drainage of secretions away from the larynx during expiration, so upward gas flow through the larynx causes secretions and blood, for example, to be blown away from the larynx.
Previous
Next

Technique

Before percutaneous transtracheal jet ventilation (PTJV) can begin, a needle cricothyrotomy must be performed.

Needle cricothyrotomy

See the list below:

  • Attach a small (3-5 mL) syringe containing 1-2 mL of sterile normal saline or water to a large-bore needle (13 or 14 ga). A small bend in the distal 2.5 cm segment of the needle can facilitate advancing the catheter once the trachea has been cannulated. There are also commercially available catheters with a slight bend at the tip specifically for PTJV.
  • Some advocate that 2 mL of lidocaine be sprayed into the larynx/trachea percutaneously to suppress the cough reflex.
    • If the patient is alert or concern exists about the cough reflex, prepare another 5-mL syringe containing 4 mL of 1% lidocaine with a 25-ga needle.
    • Use 1-2 mL of the lidocaine to anesthetize the skin overlying the cricothyroid membrane.
    • Then advance the needle through the cricothyroid membrane and spray the remaining 2 mL of 1% lidocaine into the trachea. Then remove the needle and syringe.
  • While the dominant hand holds the syringe and needle containing saline, with the needle directed caudally at 30-45° to the skin, hold and stabilize the larynx with the nondominant hand. Stabilize the cricoid cartilage with the thumb and middle fingers of the nondominant hand, and palpate the cricothyroid membrane with the nondominant index finger.
  • Insert the needle through soft tissues, the skin, and the cricothyroid membrane. The cricothyroid membrane should be punctured in the inferior aspect (ie, nearer the cricoid cartilage than the thyroid cartilage) to avoid puncturing the cricothyroid arteries. See image below.
    Transtracheal needle introduction. Transtracheal needle introduction.
  • While exerting negative pressure on the barrel of the syringe, insert the needle through the cricothyroid membrane into the larynx. Air bubbles in the fluid-filled syringe signify entry into the larynx.
  • After entering the larynx, advance the cannula into the larynx and trachea, and then remove the needle.
  • If much resistance is encountered when the needle or catheter is passing through the skin, subcutaneous tissue, or cricothyroid membrane, kinking or bending of the catheter may occur unless a stiffer catheter is used. A small nick in the skin may be needed to facilitate passage through the dermis into the subcutaneous tissue. A percutaneous dilational or Seldinger guidewire technique may result in fewer complications. [18, 19]
  • Secure the cannula by suturing it to the skin or by placing a circumferential tie around the neck. The proximal end of the cannula must be snug or tightly fitting and securely held around the puncture wound opening. If the cannula is not securely held in place, subcutaneous emphysema may result, the cannula may be dislodged from the larynx, or both.
  • Connect the oxygen source to the cannula.

Percutaneous transtracheal jet ventilation

See the list below:

  • A trial of several bursts of oxygen flow is recommended to make certain that the cannula is correctly placed and that the setup is working and ventilating properly. See image below.
    Jet ventilation setup. Jet ventilation setup.
  • The hypoxic patient should receive 100% oxygen in intermittent bursts < 50 psi at a rate of 20 bursts per minute. For this, an oxygen source capable of 50 psi is needed, along with a regulator to ensure delivery of no more than 50 psi. For children, 30 psi has been recommended. The percentage of inspired oxygen concentration can then be adjusted, depending on blood gas laboratory results.
  • The inspiratory phase or insufflation with the burst of oxygen should last approximately 1 second, and the expiratory phase should last long enough to allow for adequate exhalation, typically 3-4 seconds. [5] An adequate expiratory phase is important to minimize the risk of barotrauma.
Previous
Next

Pearls

See the list below:

  • To avoid subcutaneous emphysema or a dislodged cannula, be sure to snugly secure the cannula after insertion.
  • A small nick in the skin may be needed to facilitate passage through the dermis into the subcutaneous tissue. Thin catheters may kink or bend in the presence of too much resistance during insertion.
  • Percutaneous transtracheal jet ventilation (PTJV) can be performed in patients of all ages. And it is the surgical airway of choice for children younger than 12 years.
Previous
Next

Complications

See the list below:

  • Complications with this technique include aspiration, bleeding, pneumothorax, subcutaneous emphysema, barotrauma (eg, pneumothorax, pneumomediastinum), catheter-related problems (eg, obstruction or blockage of the catheter, kinking of the catheter, catheter displacement, misplaced or unsuccessful needle or catheter placement), [8] and inadequate ventilation. [4, 18]
  • The exact incidence of complications with percutaneous transtracheal jet ventilation (PTJV) is not known, but it is thought to be low, considering that the complication rate of translaryngeal puncture alone is in the range of 0.03-0.8%. [20]
  • Disadvantages of PTJV include the following:
    • Incomplete control of the airway with subsequent greater potential for aspiration than with a cuffed endotracheal tube
    • Potential for barotrauma (subcutaneous emphysema or pneumothorax) if exhalation is inadequate and airway pressure is elevated
Previous
 
Contributor Information and Disclosures
Author

Liudvikas Jagminas, MD, FACEP Associate Professor and Vice-Chair, Department of Emergency Medicine, Yale University School of Medicine; Director of Clinical Operations, Department Emergency Medicine, Yale New Haven Hospital

Liudvikas Jagminas, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Trauma Society, Rhode Island Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Senior Clinical Professor of Nursing, George Washington University

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, FACP, FCCP Geri and Richard Brawerman Chair in Pulmonary and Critical Care Medicine, Professor and Executive Vice Chairman, Department of Medicine, Medical Director, Women's Guild Lung Institute, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael R Filbin, MD, FACEP Clinical Instructor, Department of Emergency Medicine, Massachusetts General Hospital

Michael R Filbin, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society for Academic Emergency Medicine

Disclosure: Received research grant from: Nihon Kohden Corporation, Tokyo Japan.

Acknowledgements

The author thanks his sons Darius and Aleksus Jagminas for contributing the illustrations for this article.

References
  1. European Resuscitation Council. Guidelines for the advanced management of the airway and ventilation during resuscitation. A statement by the Airway and Ventilation Management of the Working Group of the European Resuscitation Council. Resuscitation. 1996 Jun. 31(3):201-30. [Medline].

  2. Leibovici D, Fredman B, Gofrit ON, Shemer J, Blumenfeld A, Shapira SC. Prehospital cricothyroidotomy by physicians. Am J Emerg Med. 1997 Jan. 15(1):91-3. [Medline].

  3. Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology. 1989 Nov. 71(5):769-78. [Medline].

  4. Flory FA, Hamelberg W, Jacoby JJ, Jones JR, Ziegler CH. Transtracheal resuscitation. J Am Med Assoc. 1956 Oct 13. 162(7):625-8. [Medline].

  5. Stothert JC Jr, Stout MJ, Lewis LM, Keltner RM Jr. High pressure percutaneous transtracheal ventilation: the use of large gauge intravenous-type catheters in the totally obstructed airway. Am J Emerg Med. 1990 May. 8(3):184-9. [Medline].

  6. Walls RM. Management of the difficult airway in the trauma patient. Emerg Med Clin North Am. 1998 Feb. 16(1):45-61. [Medline].

  7. Jorden RC. Percutaneous transtracheal ventilation. Emerg Med Clin North Am. 1988 Nov. 6(4):745-52. [Medline].

  8. Patel RG. Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful. Chest. 1999 Dec. 116(6):1689-94. [Medline].

  9. Smith RB, MacMillan BB, Petruscak J, Pfaeffle HH. Transtracheal ventilation for laryngoscopy. A case report. Ann Otol Rhinol Laryngol. 1973 May-Jun. 82(3):347-50. [Medline].

  10. Doi T, Miyashita T, Furuya R, Sato H, Takaki S, Goto T. Percutaneous Transtracheal Jet Ventilation with Various Upper Airway Obstruction. Biomed Res Int. 2015. 2015:454807. [Medline].

  11. Ward KR, Menegazzi JJ, Yealy DM, Klain MM, Molner RL, Goode JS. Translaryngeal jet ventilation and end-tidal PCO2 monitoring during varying degrees of upper airway obstruction. Ann Emerg Med. 1991 Nov. 20(11):1193-7. [Medline].

  12. O'Connor JV, Reddy K, Ergin MA, Griepp RB. Cricothyroidotomy for prolonged ventilatory support after cardiac operations. Ann Thorac Surg. 1985 Apr. 39(4):353-4. [Medline].

  13. Carden E, Ferguson GB. A new technique for micro-laryngeal surgery in infants. Laryngoscope. 1973 May. 83(5):691-9. [Medline].

  14. Chong CF, Wang TL, Chang H. Percutaneous transtracheal ventilation without a jet ventilator. Am J Emerg Med. 2003 Oct. 21(6):507-8. [Medline].

  15. Yealy DM, Stewart RD, Kaplan RM. Myths and pitfalls in emergency translaryngeal ventilation: correcting misimpressions. Ann Emerg Med. 1988 Jul. 17(7):690-2. [Medline].

  16. Yealy DM, Menegazzi JJ, Ward KR. Transtracheal jet ventilation and airway obstruction. Am J Emerg Med. 1991 Mar. 9(2):200. [Medline].

  17. Sasano N, Tanaka A, Muramatsu A, Fujita Y, Ito S, Sasano H, et al. Tidal volume and airway pressure under percutaneous transtracheal ventilation without a jet ventilator: comparison of high-flow oxygen ventilation and manual ventilation in complete and incomplete upper airway obstruction models. J Anesth. 2014 Jun. 28 (3):341-6. [Medline].

  18. Ciaglia P, Brady C, Graniero KD. Emergency percutaneous dilatational cricothyroidostomy: use of modified nasal speculum. Am J Emerg Med. 1992 Mar. 10(2):152-5. [Medline].

  19. Ophir D, Konichezky S. Minicricothyrotomy for tracheobronchial toilet. Ann Otol Rhinol Laryngol. 1990 May. 99(5 Pt 1):337-9. [Medline].

  20. Spencer CD, Beaty HN. Complications of transtracheal aspiration. N Engl J Med. 1972 Feb 10. 286(6):304-6. [Medline].

 
Previous
Next
 
Transtracheal needle introduction.
Jet ventilation setup.
Landmarks and positioning.
Percutaneous transtracheal jet ventilation. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
Surgical cricothyroidotomy Seldinger. Video courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, Brown University.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.