Percutaneous Transtracheal Jet Ventilation

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. As a bridge to a definitive airway, supraglottic devices such as a laryngeal mask airway (LMA) or a King laryngeal tube (LT) can be employed. In a minority of patients, tracheal intubation fails, and a surgical airway is required in order to secure the airway. ^[1] This group includes patients with upper-airway foreign bodies or neoplasms, maxillofacial trauma, laryngeal edema, or infection.

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 open cricothyroidotomy has been gaining 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, it is 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 cricothyroidotomy 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, 13]}  It may be used even with partial airway obstruction. ^[14] 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 cricothyroidotomy 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. ^{[15, 16, 17]} It is the surgical airway of choice for children younger than 12 years because of the small tracheal diameter, which often renders an open cricothyroidotomy 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.

Indications for PTJV are similar to those for surgical cricothyroidotomy.

PTJV is indicated in any situation where intubation is contraindicated or cannot be achieved. ^[18]

The failure or inability to secure a definitive airway by endotracheal intubation in a timely fashion, with a subsequent inordinate delay in definitive airway control and oxygenation, is an indication for either needle or surgical cricothyroidotomy 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.

Absolute contraindications for PTJV are as follows:

• If a definitive airway can easily and rapidly be secured with endotracheal intubation, PTJV is not used
• PTJV is not used in the presence of known significant direct damage to the cricoid cartilage or larynx ^[18]

Relative contraindications for PTJV are as follows:

• If complete upper-airway obstruction is present, surgical cricothyroidotomy is preferred over PTJV ^[19]
• PTJV can be used in the presence of partial airway obstruction, provided that appropriate-sized catheters are used ^[19]
• Airway obstruction below the vocal cords that renders exhalation difficult or impossible is a relative contraindication

For cases of difficult airway management in adult coronavirus disease 2019 (COVID-19) patients, when emergency invasive airway access is required, the Society of Airway Management has recommended a surgical approach, such as scalpel-bougie-tube, rather than an aerosolizing generating procedure, such as transtracheal jet ventilation. ^[20]

Anatomy

The anterior neck allows direct access to the airway via the trachea. At the cephalad aspect of the laryngeal skeleton is the thyroid cartilage, which lies at the level of the fourth and fifth cervical vertebrae. The laryngeal prominence of the thyroid cartilage (more prominent in men) is easily palpated with the thumb and index finger. The cricoid cartilage lies just inferior to the thyroid cartilage in the midline.

Between the cricoid and thyroid cartilages lies the cricothyroid membrane. The cricothyroid membrane is a palpable membranous depression just inferior to the laryngeal prominence and is the access site for PTJV.

The cricothyroid artery travels transversely across the cricothyroid membrane just below the thyroid cartilage. Therefore, it is essential to place the catheter through the lower half of the cricothyroid membrane so as to prevent injury to the artery.