Percutaneous Transtracheal Jet Ventilation Technique

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

Percutaneous Transtracheal Jet Ventilation

Before percutaneous transtracheal jet ventilation (PTJV) can begin (see the first video below), a needle cricothyrotomy must be performed (see the second video below.)

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

Needle cricothyrotomy

Position the patient as previously described (see Patient Preparation).

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 gauge). 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, skin, and the cricothyroid membrane (see the image below). 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.

Percutaneous transtracheal jet ventilation (PTJV). Percutaneous transtracheal jet ventilation (PTJV). 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 guide wire technique may result in fewer complications. [20, 21]

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

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 the image below.)

Percutaneous transtracheal jet ventilation (PTJV). Percutaneous transtracheal jet ventilation (PTJV). Jet ventilation setup.

The hypoxic patient should receive 100% oxygen in intermittent bursts of less than 50 psi at a rate of 20 bursts/min. 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 fraction of inspired oxygen (FiO2) 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. [6]  An adequate expiratory phase is important to minimize the risk of barotrauma.

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Complications

Complications that may occur with PTJV include the following:

  • Aspiration
  • Bleeding
  • Subcutaneous  emphysema
  • Barotrauma (eg, pneumothorax, pneumomediastinum)
  • Catheter-related problems (eg, obstruction or blockage of the catheter, kinking of the catheter, catheter displacement, or misplaced or unsuccessful needle or catheter placement) [9]
  • Inadequate ventilation [5, 20]

The exact incidence of such complications is not known, but it is thought to be low, given that the complication rate of translaryngeal puncture alone is in the range of 0.03-0.8%. [22]

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

A systematic review by Duggan et al found that PTJV was associated with a high risk of device failure and barotrauma in the setting of "can't intubarte, can't oxygenate" (CICO) emergencies. [23]

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