Small Lumen
“Tritube makes my life so much easier, as it provides a great view and an effective ventilation in the compromised airway”
Prof. Dr. Hans Mahieu
Laryngologist, Meander Hospital Amersfoort, The Netherlands
Conventional small lumen ventilation: A lifesaver with drawbacks
Emergency transtracheal jet ventilation (TTJV)
- Used in ‘cannot intubate, cannot oxygenate’ (CICO) situations to save patient’s life 1-3
- Relies on passive egress of gas via nose or mouth, requiring a patent airway
- Bears serious risk of lung damage from barotrauma in obstructed airways 4
- Has a high complication rate 4
– Barotrauma (32%)
– Device failure (42%)
– Any other complication (51%)
Upper airway surgery – challenges
- Jet ventilation requires an open airway to prevent air-trapping
– Induces movement of anatomical structures (e.g. vocal cords)
– Increases risk of aspiration - Intermittent periods of apnea during surgery
– Prolong duration of surgery
– Increase risk of desaturation and aspiration - Microlaryngeal tubes with cuff still limit surgical exposure
- Leaving a small-bore tube in situ makes extubation of high-risk patients easier 12,13.
Ultrathin Tritube allowed safe intubation and ventilation in extremely narrow airway
In a patient with extreme airway obstruction due to a huge thyroid enlargement, Evone and Tritube prevented the use of ECMO to allow required surgery, as reported by Dr. Nabil Shallik (Hamad Medical Corporation, Qatar). Preoperative examination of the patient revealed a severe tracheal stenosis with a residual airway opening of only 4 mm, excluding the use of conventional endotracheal tubes to apply controlled ventilation. Instead, Tritube could be passed through the stenosis and allowed adequate ventilation using Evone during the six hour surgery.
A patient’s life was saved with Ventrain and Cricath
Deteriorating respiratory distress and decreasing level of consciousness of a transported patient forced an ambulance to stop at the emergency department of the Meander Medical Center Amersfoort. The patient presented with near-complete upper airway obstruction and impending hypoxic arrest. After placement of Cricath, ventilation with Ventrain was conducted for almost 60 minutes, until surgical tracheotomy was performed safely. Oxygenation was restored within 90 seconds, and hemodynamic and ventilatory parameters were stabilized throughout the procedure. Read more.
Surgical and lung mechanical benefits of Tritube and FCV during laryngeal surgery
In the first randomized controlled trial Dr. Schmidt and colleagues showed clear clinical benefit of using Tritube and FCV over using a microlaryngeal tube (MLT-6) and volume-controlled ventilation (VCV) in patients undergoing laryngeal surgery. Tritube significantly reduced the concealment of laryngeal structures and thereby improved surgical conditions for surgeons with a lower level of expertise. Furthermore, the authors demonstrated that FCV enhanced lung aeration and improved the respiratory system compliance, while using similar PEEP and a lower inspiratory plateau pressure. Read more.
EVA®/FCV®– a disruptive ventilation concept
- Has saved lives 13,20-25
- Enables safe and efficient ventilation through small lumen (ID <3 mm) 13-28,31-35
- Promotes rapid reoxygenation after apneic/CICO situations 16-23
- Allows management of difficult airways 31,35
- Provides alternative options during upper airway surgery 20-35
Tritube – an ultrathin cuffed endotracheal tube (OD 4.4 mm)
- Offers unprecedented view of the intubated airway 31
- Provides large surgical exposure and hygienic and clear sight with non-moving vocal cords 31-35
- Allows easy intubation even in difficult airways due to the small OD and malleable stylet 31-35
- Allows awake intubation 31,32
- Is well tolerated when left in situ postoperatively, allowing patients to breathe and talk 31,33,35
References
- Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the management of the difficult airway. Anesthesiology 1989; 71(5): 769-78
- Weber MD, Romano MJ. A quick and simple method to provide transtracheal jet ventilation. Anesth Analg 2004; 99(4): 1271-2.
- Mchugh R, Kumar M, Sprung J, Bourke D. Transtracheal jet ventilation in management of the difficult airway. Anaesth Intensive Care 2007; 35(3): 406-8
- Duggan LV, Ballantyne Scott B, Law JA, Morri IR, Murphy MF, Griesdale DE. Transtracheal jet ventilation in the ‘can’t intubate can’t oxygenate’ emergency: a systematic review. Br J Anaesth. 2016 Sep;117 Suppl 1:i28-i38
- Cavallone LF, Vannucci A. Review article: Extubation of the difficult airway and extubation failure. Anesth Analg. 2013 Feb;116(2):368-83
- Cook TM , Scott S, Mihai R. Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995–2007. Anaesthesia 2010; 65:556–63
- Peskett MJ. Clinical indicators and other complications in the recovery room or postanaesthetic care unit. Anaesthesia 1999;54: 1143–9.
- Rose DK, Cohen MM, Wigglesworth DF, DeBoer DP. Critical respiratory events in the postanesthesia care unit. Patient, surgical, and anesthetic factors. Anesthesiology 1994; 81:410–8
- Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985-2003. Anesthesiology 2007; 106: 1096–104
- Auroy Y, Benhamou D, Péquignot F, Bovet M, Jougla E, Lienhart A. Mortality related to anaesthesia in France: analysis of deaths related to airway complications. Anaesthesia 2009; 64: 366–70
- Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing Maternal Deaths to make Motherhood Safer—2003–2005. The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London: CEMACH, 2007
- Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012;67:318–4
- Cooper R Hagberg and Benumof’s Airway Management 2018, 4th edition, Chapter 48, pages 44-47
- El-Boghdadly K, Bailey CR, Wiles MD. Postoperative sore throat: a systematic review. Anaesthesia. 2016 Jun;7
- Wain JC. Postintubation tracheal stenosis. Semin Thorac Cardiovasc Surg. 2009 Fall;21(3):284-9
- Berry M, Tzeng Y, Marsland C. Percutaneous transtracheal ventilation in an obstructed airway model in post-apnoeic sheep. Br J Anaesth. 2014 Dec;113(6):1039–1045
- Paxian M, Preussler NP, Reinz T, Schlueter A, Gottschall R. Transtracheal ventilation with a novel ejector-based device (Ventrain) in open, partly obstructed, or totally closed upper airways in pigs. Br J Anaesth. 2015 Aug;115(2):308–316
- Hamaekers AE, van der Beek T, Theunissen M, Enk D. Rescue ventilation through a small-bore transtracheal cannula in severe hypoxic pigs using expiratory ventilation assistance. Anesth Analg. 2015 Apr;120(4):890-4
- De Wolf MWP, Gottschall R, Preussler NP, Paxian M, Enk D. Emergency ventilation with the Ventrain® through an airway exchange catheter in a porcine model of complete upper airway obstruction. Can J Anaesth. 2017 Jan;64(1):37–44.
- Willemsen MG, Noppens R, Mulder AL, Enk D. Ventilation with the Ventrain through a small lumen catheter in the failed paediatric airway: two case reports. Br J Anaesth. 2014 May;112(5):946-7
- Escribá Alepuz J, Alonso García JV, Cuchillo Sastriques E, Alcalá P, Argente Navarro. Emergency Ventilation of Infant Subglottic Stenosis Through Small-Gauge Lumen Using the Ventrain: A Case Report. A A Prac 2018 Mar 15; 10(6):136-138
- Wahlen BM, Al-Thani H, El-Menyar A. Ventrain: from theory to practice. Bridging until re-tracheostomy. BMJ Case Rep 2017 Aug 16;2017
- Heuveling DA, Mahieu HF, Jongsma-van Netten HG, Gerling V.Transtracheal Use of the CriCath® Cannula in Combination With the Ventrain Device for Prevention of Hypoxic Arrest due to Severe Upper Airway Obstruction: A Case Report. A&A Practice July 2018 epub
- Noppens RR. Ventilation through a ‘straw’: the final answer in a totally closed upper airway? Br J Anaesth. 2015 Aug;115(2):168-70 1(6):706-17
- Doyle DJ. Ventilation via Narrow-Bore Catheters: Clinical and Technical Perspectives on the Ventrain Ventilation System. The Open Anaesthesia Journal Sep 2018; 12, 49-60
- Borg PA, Hamaekers AE, Lacko M, Jansen J, Enk D. Ventrain for ventilation of the lungs. Br J Anaesth. 2012 Nov;109(5):833-4
- Fearnley RA, Badiger S, Oakley RJ, Ahmad I. Elective use of the Ventrain for upper airway obstruction during high-frequency jet ventilation. J Clin Anesth. 2016 Sep;33:233-5
- Onwochei, El-Boghdadly K, Ahmad I. Two-Stage Technique Used to Manage Severe Upper Airway Obstruction and Avoid Surgical Tracheostomy: A Case Report. A A Pract 2018 Mar 1;10(5):118-120
- Rosenblatt W, Popescu W. https://youtu.be/49u9Yw6BvfU
- Rosenblatt W. http://ventinovamedical.com/ventrain
- Kristensen MS, de Wolf MWP, Rasmussen LS. Ventilation via the 2.4 mm internal diameter Tritube® with cuff – new possibilities in airway management. Acta Anesthesiol. Scand. 2017 Jul; 61(6):580-589D.N.
- Jeyarajah K, Ahmad I. Awake tracheal placement of the Tritube under flexible bronchoscopic guidance. Anaesthesia Cases / 2018-0097 / ISSN 2396-8397 epub Jul 2018
- Schmidt J, Günther F, Weber J, Wirth S, Brandes I, Barnes T, Zarbock A, Schumann S, Enk D. Flow-controlled ventilation (FCV) in the perioperative setting – an observational two-centre first-in-human study. Eur J Anaesthesiol. ePub 2019 Feb 5
- Schmidt J, Günther F, Weber J, Wirth S, Schumann s. Improved airway management and ventilation with a cuffed endotracheal tube with an outer diameter of 4.4 mm for laryngeal surgery – a randomized controlled trial. Euroanaesthesia 2019, Abstract 3269
- Kristensen MS, Abildstrøm HH. Endotracheal video-laryngoscope guided intubation with a 2.4 mm cuff’ed tube and active expiration by a dedicated ventilator versus a standard tube/ventilator. A randomized single blinded study in patients with a predicted difficult airway. – A paradigm shift in airway management? Euroanaesthesia 2019, Abstract 3755
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