Percutaneous Transtracheal Jet Ventilation

Updated: Apr 02, 2018
  • Author: Liudvikas Jagminas, MD, FACEP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Overview

Background

Airway management is a priority in the resuscitation of critically ill patients. Generally, this can be achieved by means of 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 through one of the following two principal methods [1, 2] :

  • Open surgical cricothyroidotomy
  • Needle cricothyroidotomy

Needle cricothyroidotomy has commonly been held to provide simpler, faster, and safer access, [2, 3]  though in the past few years open cricothyrotomy has gained increasing favor. [4]

Percutaneous transtracheal jet ventilation (PTJV) was introduced in the 1950s by Flory et al. [5] 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. [5]

Some reports have recommended PTJV only as a transient resuscitative measure for emergencies in which endotracheal intubation or other ventilation methods are not feasible. [6, 7] PTJV is widely thought of as a temporizing procedure to be maintained for 30 minutes at most. 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. [8]

At first, PTJV was not widely accepted, because of initial reports of high complication rates. [3, 9] It was also noted that PTJV does not provide definitive airway protection against copious secretions or aspiration.

Nevertheless, in a life-threatening situation where tracheal intubation and bag-mask-valve ventilation cannot be performed to restore adequate gas exchange during acute respiratory failure, is it reasonable to consider PTJV 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 (eg, oral intubation with bronchoscopy followed by surgical tracheostomy) can be performed [10] ; it requires fewer instruments than surgical cricothyrotomy and can be performed more quickly.

Transtracheal jet ventilation has been used extensively as a means of ventilation during surgery and procedures of the upper airway. [11, 12] Transtracheal jet ventilation may be used even with partial airway obstruction. [13] 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 means for obtaining airway control in both elective and emergency situations for patients of all ages and in many clinical situations. [14, 15, 16] It is the surgical airway of choice for children younger than 12 years because of the small tracheal diameter, which often renders an open cricothyrotomy 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.

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Indications

Indications for percutaneous transtracheal jet ventilation (PTJV) are similar to those for surgical cricothyrotomy.

PTJV is indicated in any situation where intubation is contraindicated or cannot be achieved. [17]

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.

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Contraindications

Absolute contraindications for PTJV are as follows:

  • 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 [17]

Relative contraindications for PTJV are as follows:

  • If complete upper airway obstruction is present, surgical cricothyrotomy is preferred over PTJV [18]
  • PTJV can be used in the presence of partial airway obstruction provided that appropriate-sized catheters are used [18]
  • Airway obstruction below the vocal cords that renders exhalation difficult or impossible is a relative contraindication
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