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Lejus-Bourdeau C, Grillot N, Dupont S, Robert-Edan V, Bazin O, Viquesnel S, Pichenot V. Randomised comparison of Enk™ and Manujet™ for emergency tracheal oxygenation with a high-fidelity full-scale simulation. Anaesth Crit Care Pain Med 2020; 39:807-812. [PMID: 33039658 DOI: 10.1016/j.accpm.2020.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/03/2020] [Accepted: 01/23/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND We aimed to compare time and difficulties of emergency tracheal oxygenation with Enk™ or Manujet™ by anaesthesiologists or intensivists, in a full-scale cannot ventilate and intubate scenarios on a SimMan3G™ high-fidelity patient simulator. METHODS After ethical committee approval and written informed consent, teams (two to three learners with at least one physician senior) participating at a difficult airway training with a massive sublingual haematoma scenario, were randomised in Enk™ (E) group (29 teams, 76 learners) and Manujet™ (M) group (31 teams, 84 learners) according to the device at disposal. Main criterion was time between taking device in hand and first insufflation delay. Data were medians [25-75%]. RESULTS The handling-insufflation time was shorter with Enk™ than with Manujet™ (74 [54-87] seconds versus 95 [73-123] seconds (s), P=0.0112). The team number performing insufflation within one minute after device handling was higher in the E group (8, 27.6%) than in the M group (2, 6.4%) (P=0.0392) as well as the team number performing insufflation within 90s in the E group (22, 75.09%) than in the M group (12, 38.7%) (P=0.0047). In E group, 75% of learners reported no difficulty versus 58.8% in M group (P=0.0443). Insufflation frequency was high in both groups and higher than 12min-1 in 51.7% of the teams. CONCLUSION In a simulation context, Enk™ use is faster and easier. A high insufflation rate was also in favour of Enk™ that generates lower airway pressures.
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Affiliation(s)
- Corinne Lejus-Bourdeau
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France.
| | - Nicolas Grillot
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
| | - Ségolène Dupont
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
| | - Vincent Robert-Edan
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
| | - Olivier Bazin
- Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
| | - Simon Viquesnel
- Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France; Pôle Anesthésie Réanimation, CHU Rennes, 2, rue Henri Le Guilloux, 35033 Rennes cedex 9, France
| | - Vincent Pichenot
- Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu - Hôpital Mère Enfant, CHU Nantes, Place Alexis Ricordeau, F-44093 Nantes, France; Laboratoire Expérimental de Simulation de Médecine Intensive de l'Université (LE SiMU) de Nantes, 9, rue Bias, 44001 Nantes, France
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Rescue oxygenation success by cannula or scalpel-bougie emergency front-of-neck access in an anaesthetised porcine model. PLoS One 2020; 15:e0232510. [PMID: 32365136 PMCID: PMC7197851 DOI: 10.1371/journal.pone.0232510] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 04/16/2020] [Indexed: 11/19/2022] Open
Abstract
In the obese, the evidence for the choice of the optimal emergency front-of-neck access technique is very limited and conflicting. We compared cannula and scalpel-bougie emergency front-of-neck access techniques in an anaesthetised porcine model with thick pretracheal tissue. Cannula and scalpel-bougie cricothyroidotomy techniques were performed in 11 and 12 anaesthetised pigs, respectively. Following successful tracheal access, oxygenation was commenced and continued for 5 min using Rapid-O2 device for cannula and circle breathing system for scalpel-bougie study groups. The primary outcome was a successful rescue oxygenation determined by maintenance of arterial oxygen saturation >90% 5 min after the beginning of oxygenation. Secondary outcomes included success rate of airway device placement, time to successful airway device placement, and trauma to the neck and airway. The success rate of rescue oxygenation was 18% after cannula, and 83% after scalpel-bougie technique (P = 0.003). The success rate of airway device placement was 73% with cannula and 92% with scalpel-bougie technique (P = 0.317). Median (inter-quartile-range) times to successful airway device placement were 108 (30–256) and 90 (63–188) seconds (P = 0.762) for cannula and scalpel-bougie emergency front-of-neck access, respectively. Proportion of animals with iatrogenic trauma additional to the procedure itself was 27% for cannula and 75% for scalpel-bougie technique (P = 0.039). Thus, in the porcine model of obesity, the scalpel-bougie technique was more successful in establishing and maintaining rescue oxygenation than cannula-based technique; however, it was associated with a higher risk of severe trauma.
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Stein ML, Park RS, Kovatsis PG. Emerging trends, techniques, and equipment for airway management in pediatric patients. Paediatr Anaesth 2020; 30:269-279. [PMID: 32022437 DOI: 10.1111/pan.13814] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/24/2019] [Accepted: 12/28/2019] [Indexed: 12/21/2022]
Abstract
Pediatric patients present unique anatomic and physiologic considerations in airway management, which impose significant physiologic limits on safe apnea time before the onset of hypoxemia and subsequent bradycardia. These issues are even more pronounced for the pediatric difficult airway. In the last decade, the development of pediatric sized supraglottic airways specifically designed for intubation, as well as advances in imaging technology such that current pediatric airway equipment now finally rival those for the adult population, has significantly expanded the pediatric anesthesiologist's tool kit for pediatric airway management. Equally important, techniques are increasingly implemented that maintain oxygen delivery to the lungs, safely extending the time available for pediatric airway management. This review will focus on emerging trends and techniques using existing tools to safely handle the pediatric airway including videolaryngoscopy, combination techniques for intubation, techniques for maintaining oxygenation during intubation, airway management in patients at risk for aspiration, and considerations in cannot intubate cannot oxygenate scenarios.
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Affiliation(s)
- Mary Lyn Stein
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Raymond S Park
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Pete G Kovatsis
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Lee J, Ng VV, Teo C, Wong P. Use of a trans-tracheal rapid insufflation of oxygen device in a "cannot intubate, cannot oxygenate" scenario in a parturient -a case report. Korean J Anesthesiol 2019; 72:381-384. [PMID: 30776879 PMCID: PMC6676036 DOI: 10.4097/kja.d.18.00334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/16/2019] [Indexed: 11/10/2022] Open
Abstract
Background The trans-tracheal rapid insufflation of oxygen (TRIO) device is less commonly used and is an alternative to trans-tracheal jet ventilation for maintaining oxygenation in a "cannot intubate, cannot oxygenate" (CICO) scenario. Case We report the successful use of this device to maintain oxygenation after jet ventilator failure in a parturient who presented with the CICO scenario during the procedure for excision of laryngeal papilloma. Conclusions A stepwise approach to the airway plan and preparation for an event of failure is essential for good materno-fetal outcomes. The TRIO device may result in inadequate ventilation that can lead to hypercarbia and respiratory acidosis. Hence, it should only be used as a temporizing measure before a definitive airway can be secured.
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Affiliation(s)
- John Lee
- Department of Anesthesiology, Singapore General Hospital, Singapore
| | - Von Vee Ng
- Department of Anesthesiology, Singapore General Hospital, Singapore
| | - Constance Teo
- Department of Otolaryngology, Singapore General Hospital, Singapore
| | - Patrick Wong
- Department of Anesthesiology, Singapore General Hospital, Singapore
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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 Pract 2018; 11:344-347. [PMID: 29965818 DOI: 10.1213/xaa.0000000000000823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A patient recently treated with surgery and radiation for oropharyngeal cancer presented with impending hypoxic respiratory and cardiac arrest in a difficult airway scenario. A CriCath cannula in combination with the Ventrain device and its active expiratory ventilation technology enabled oxygenation and ventilation for 60 minutes until a surgical airway was established. This case report is the first to describe the intended use of Ventrain technology in an emergent "can't ventilate-can't intubate" scenario.
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Affiliation(s)
- Derrek A Heuveling
- From the Department of Otorhinolaryngology, Meander Medical Center, Amersfoort, the Netherlands
| | - Hans F Mahieu
- From the Department of Otorhinolaryngology, Meander Medical Center, Amersfoort, the Netherlands
| | | | - Volker Gerling
- Anesthesiology, Meander Medical Center, Amersfoort, the Netherlands
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Schmidt J, Wenzel C, Mahn M, Spassov S, Cristina Schmitz H, Borgmann S, Lin Z, Haberstroh J, Meckel S, Eiden S, Wirth S, Buerkle H, Schumann S. Improved lung recruitment and oxygenation during mandatory ventilation with a new expiratory ventilation assistance device: A controlled interventional trial in healthy pigs. Eur J Anaesthesiol 2018; 35:736-744. [PMID: 29734208 PMCID: PMC6133202 DOI: 10.1097/eja.0000000000000819] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND In contrast to conventional mandatory ventilation, a new ventilation mode, expiratory ventilation assistance (EVA), linearises the expiratory tracheal pressure decline. OBJECTIVE We hypothesised that due to a recruiting effect, linearised expiration oxygenates better than volume controlled ventilation (VCV). We compared the EVA with VCV mode with regard to gas exchange, ventilation volumes and pressures and lung aeration in a model of peri-operative mandatory ventilation in healthy pigs. DESIGN Controlled interventional trial. SETTING Animal operating facility at a university medical centre. ANIMALS A total of 16 German Landrace hybrid pigs. INTERVENTION The lungs of anaesthetised pigs were ventilated with the EVA mode (n=9) or VCV (control, n=7) for 5 h with positive end-expiratory pressure of 5 cmH2O and tidal volume of 8 ml kg. The respiratory rate was adjusted for a target end-tidal CO2 of 4.7 to 6 kPa. MAIN OUTCOME MEASURES Tracheal pressure, minute volume and arterial blood gases were recorded repeatedly. Computed thoracic tomography was performed to quantify the percentages of normally and poorly aerated lung tissue. RESULTS Two animals in the EVA group were excluded due to unstable ventilation (n=1) or unstable FiO2 delivery (n=1). Mean tracheal pressure and PaO2 were higher in the EVA group compared with control (mean tracheal pressure: 11.6 ± 0.4 versus 9.0 ± 0.3 cmH2O, P < 0.001 and PaO2: 19.2 ± 0.7 versus 17.5 ± 0.4 kPa, P = 0.002) with comparable peak inspiratory tracheal pressure (18.3 ± 0.9 versus 18.0 ± 1.2 cmH2O, P > 0.99). Minute volume was lower in the EVA group compared with control (5.5 ± 0.2 versus 7.0 ± 1.0 l min, P = 0.02) with normoventilation in both groups (PaCO2 5.4 ± 0.3 versus 5.5 ± 0.3 kPa, P > 0.99). In the EVA group, the percentage of normally aerated lung tissue was higher (81.0 ± 3.6 versus 75.8 ± 3.0%, P = 0.017) and of poorly aerated lung tissue lower (9.5 ± 3.3 versus 15.7 ± 3.5%, P = 0.002) compared with control. CONCLUSION EVA ventilation improves lung aeration via elevated mean tracheal pressure and consequently improves arterial oxygenation at unaltered positive end-expiratory pressure (PEEP) and peak inspiratory pressure (PIP). These findings suggest the EVA mode is a new approach for protective lung ventilation.
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Affiliation(s)
- Johannes Schmidt
- From the Department of Anesthesiology and Critical Care (JS, CW, MM, SS, HCS, SB, ZL, SW, HB, SS), Experimental Surgery, Centre for Experimental Models and Transgenic Service (JH) and Department of Neuroradiology (SM, SE), Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Affiliation(s)
- T Asai
- Department of Anesthesiology, Dokkyo Medical University Koshigaya Hospital, 2-1-50 Minamikoshigaya, Koshigaya, Saitama 343-8555, Japan
| | - E P O'Sullivan
- Department of Anaesthesia, St James's Hospital, Dublin, Ireland
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Cook TM. Strategies for the prevention of airway complications - a narrative review. Anaesthesia 2017; 73:93-111. [DOI: 10.1111/anae.14123] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2017] [Indexed: 12/17/2022]
Affiliation(s)
- T. M. Cook
- Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
- School of Clinical Sciences; Bristol University; Bristol UK
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Wahlen BM, Al-Thani H, El-Menyar A. Ventrain: from theory to practice. Bridging until re-tracheostomy. BMJ Case Rep 2017; 2017:bcr-2017-220403. [PMID: 28814580 DOI: 10.1136/bcr-2017-220403] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Imminent upper airway obstruction due to life-threatening tracheal stenosis of any cause is challenging. A 77-year-old woman, with a history of temporal tracheostomy for prolonged mechanical ventilation, presented with life-threatening tracheal stenosis to the emergency department. After failed intubation with a 5.0 mm internal diameter endotracheal tube, the patient was ventilated via a tube exchanger using Ventrain. Ventrain is a manual ventilation device that, in addition to oxygen supply during inspiration, initiates expiration by actively removing gas from the lungs by suction. Despite the nearly obstructed airway the patient was adequately ventilated with 'permissive' hypercarbia of 50 mm Hg and Saturation of peripheral Oxygen (SpO2) 95%-98% until surgical re-tracheostomy was performed. The haemodynamic stability of the patient indicated that the active expiration prevented intrapulmonary pressure build-up by air trapping and subsequent barotrauma and/or haemodynamic deterioration, which may well be observed during traditional jet ventilation especially in case of a completely obstructed airway.
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Affiliation(s)
| | - Hassan Al-Thani
- Department of Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Department of Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
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Kristensen MS, de Wolf MWP, Rasmussen LS. Ventilation via the 2.4 mm internal diameter Tritube ® with cuff - new possibilities in airway management. Acta Anaesthesiol Scand 2017; 61:580-589. [PMID: 28436022 DOI: 10.1111/aas.12894] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/15/2017] [Accepted: 03/17/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND A small tube may facilitate tracheal intubation and improve surgical access. We describe our initial experience with the Tritube® that is a novel cuffed endotracheal tube with a 2.4 mm internal diameter. METHODS The Tritube® was used in seven adult Ear-Nose-and Throat surgical patients with airway narrowing or whose surgical access was facilitated by this small-bore endotracheal tube. Ventilation through Tritube® is performed with the manually operated Ventrain® -ventilator that allows active suctioning during expiration, therefore facilitating normoventilation through small diameter airways. RESULTS The small diameter of Tritube® seemed to improve glottis visualisation during intubations and gave excellent working conditions for surgery. Two patients were intubated awake with a flexible scope and a guide wire or with an angulated video laryngoscope. One patient had almost complete glottic occlusion that just allowed for passage of the Tritube® . Adequate ventilation was achieved in all patients and intratracheal pressure was kept between 5 and 20 cm H2 O. The tube was well tolerated after emergence from anaesthesia and kept intratracheally in five awake patients in the post-operative recovery unit, in one case for more than 1 h. Ventilating with Ventrain® through Tritube® demands meticulous breath by breath measurement and adjustment of the intratracheal pressure. CONCLUSION The 2.4 mm internal diameter Tritube® seems to facilitate tracheal intubation and to provide unprecedented view of the intubated airway during oral, pharyngeal, laryngeal or tracheal procedures in adults. This technique has the potential to replace temporary tracheostomy, jet-ventilation or extra-corporal membrane oxygenation in selected patients.
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Affiliation(s)
- M. S. Kristensen
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - M. W. P. de Wolf
- Department of Anaesthesia & Pain Therapy; Maastricht University Medical Centre; Maastricht The Netherlands
| | - L. S. Rasmussen
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Affiliation(s)
- M de Wolf
- Department of Anesthesiology and Pain Therapy, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, Niederlande.
| | - R Gottschall
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - D Enk
- Department of Anesthesiology and Pain Therapy, Maastricht University Medical Center, PO Box 5800, 6202 AZ, Maastricht, Niederlande
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de Wolf MWP, Schutzer-Weissmann JM. Response to "Impact of oxygen sources on performance of the Ventrain ventilation device". Acta Anaesthesiol Scand 2016; 60:1477-1478. [PMID: 27620640 DOI: 10.1111/aas.12786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M. W. P. de Wolf
- Department of Anaesthesiology and Pain Medicine; Maastricht University Medical Center; Maastricht The Netherlands
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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 2016; 64:37-44. [PMID: 27796837 PMCID: PMC5192045 DOI: 10.1007/s12630-016-0760-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 09/24/2016] [Accepted: 10/13/2016] [Indexed: 12/17/2022] Open
Abstract
Purpose During difficult airway management, oxygen insufflation through airway-exchange and intubating catheters (AEC/IC) can lead to life-threatening hyperinflation. Ventrain® was originally designed to facilitate emergency ventilation using active expiration through short, small-bore cannulas. Herein, we studied its efficacy (oxygenation and ventilation) and safety (avoidance of hyperinflation) in a long, small-bore AEC. Methods In six anesthetized pigs, the upper airway was obstructed, except for a 100 cm long, 3 mm internal diameter AEC. After apneic desaturation to a peripheral oxygen saturation (SpO2) of < 70%, ventilation through the AEC was started with Ventrain at an oxygen flow of 15 L·min−1, a frequency of 30 breaths·min−1, and an inspiration/expiration ratio of approximately 1:1. It was continued for ten minutes. Results Within one minute, severe hypoxia was reversed from a median [interquartile range] arterial saturation (SaO2) of 48 [34-56] % before initiation of Ventrain ventilation to 100 [99-100] % afterward (median difference 54%; 95% confidence interval [CI] 44 to 67; P = 0.028). In addition, hypercarbia was reversed from PaCO2 of 59 [53-61] mmHg to 40 [38-42] mmHg (median difference of −18 mmHg; 95% CI −21 to −15; P = 0.028). After ten minutes of Ventrain use, peak inspiratory and end-expiratory pressures were lower than during baseline pressure-controlled ventilation (8 [7-9] mmHg vs 12 [10-14] mmHg and −2 [−3 to +1] mmHg vs 4 [2 to 4] mmHg, respectively; P = 0.027 for both). No hemodynamic deterioration occurred. Conclusion Ventrain provides rapid reoxygenation and effective ventilation through a small-bore AEC in pigs with an obstructed airway. In clinical emergency situations of obstructed airways, this device may be able to overcome problems of unintentional hyperinflation and high intrapulmonary pressures when ventilating through long, small-bore catheters and could therefore minimize the risks of barotrauma and hemodynamic instability.
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Affiliation(s)
- Michiel W P de Wolf
- Department of Anesthesiology and Pain Therapy, Maastricht University Medical Center, PO Box 5800, Maastricht, AZ, 6202, The Netherlands.
| | - Reiner Gottschall
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Bachstrasse, Jena, Germany
| | - Niels P Preussler
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Bachstrasse, Jena, Germany
| | - Markus Paxian
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Bachstrasse, Jena, Germany
| | - Dietmar Enk
- Department of Anesthesiology and Pain Therapy, Maastricht University Medical Center, PO Box 5800, Maastricht, AZ, 6202, The Netherlands
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[Monitoring tidal volumes when using the Ventrain® emergency ventilator]. Anaesthesist 2016; 65:514-20. [PMID: 27245923 DOI: 10.1007/s00101-016-0161-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 02/23/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Ventrain® emergency ventilation device allows active inspiration and expiration through transtracheal catheters or the lumen of an airway exchange catheter. This single-use handheld device is manually operated and driven by an external pressurized oxygen source. The Ventrain® may be used to ventilate patients with a complete or pending upper airway obstruction reducing the risk of barotrauma due to the possibility of active expiration. However tidal volumes (V T) applied and withdrawn with the Ventrain® can only be controlled by visual inspection of chest movements; V T monitoring is not provided. Excessive inspiratory volumes or air trapping due to insufficient expiration may remain clinically undetected until pulmonary trauma and/or cardio-respiratory deterioration occur. Active expiration itself carries the risk of overwhelming lung deflation with the formation of atelectasis. Thus, an inspiratory and expiratory tidal volume monitor is urgently required. The aim of this study was to evaluate efficacy and precision of the Florian respiratory function monitor (RFM) to monitor in- and expiratory V T administered by the Ventrain® emergency ventilation device through a small cannula to the ASL 5000 test lung (ASL). METHODS In an in-vitro setting the RFM was used with its neonatal flow sensor to monitor inspiratory and expiratory V T applied by the Ventrain® emergency ventilation device through a 2 mm internal diameter (ID) transtracheal catheter to the ASL. Driving flows of 6, 9, 12 and 15 l min(-1) were chosen to vary tidal volumes at a constant respiratory rate of 15 min(-1) and an I:E ratio of 1:1. Experiments were repeated five times with two flow sensors. An initial set-up calibration run was performed to calculate a bias correction factor for inspiratory and expiratory V T measured by the RFM. This bias correction factor was used to simulate a correction of the in the RFM programmed linearization table. In a second, identical setting the experiments were repeated five times with two flow sensors. V T measured by the adjusted RFM were compared with those obtained from the ASL 5000 in this second run and the percentage differences were calculated. Bland Altman analysis was used to investigate the agreement of inspiratory or expiratory VT measured by both methods (ASL and RFM). Calculation of the mean of differences between both methods is given as bias and the 95 % agreement interval as precision. RESULTS Tidal volumes measured by the ASL ranged from 140 to 675 ml. The percentage correction factor was 16.27 % (2.60 %) during inspiration for V T ranged from 0 to 700 ml and 11.51 % (2.56 %) during expiration for V T of 0 to 225 ml, 7.41 % (2.94 %) for VT 226 to 325 ml and 5.35 % (3.57 %) for TV e > 325 ml. Inspiratory and expiratory tidal volumes measured by the adjusted RFM demonstrated a percentage deviation (mean [SD]) of 2.59 % (1.86 %) during inspiration and 1.66 % (1.14 %) during expiration when compared with the ASL 5000. Bias (precision) of the Bland Altman plot for the adjusted RFM is 2.05 ml (23.20) during inspiration and 4.62 ml (10.40) for expiration. CONCLUSION The tested respiratory function monitor using hot-wire anemometer technology has the potential to monitor tidal volumes applied by the Ventrain®. With the software thus adapted, the RFM measures precise inspiratory and expiratory tidal volumes within common technical tolerance. This could help perform adequate patient ventilation with Ventrain® and reduce the potential risk of patient trauma.
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Schmidt AR, Ruetzler K, Haas T, Schmitz A, Weiss M. Impact of oxygen sources on performance of the Ventrain(®) ventilation device in an in vitro set-up. Acta Anaesthesiol Scand 2016; 60:241-9. [PMID: 26612252 DOI: 10.1111/aas.12663] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 08/26/2015] [Accepted: 09/23/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Ventrain(®) (Dolphys Medical, Eindhoven, The Netherlands) is a disposable handheld ventilation device allowing active inspiration and expiration through a transtracheal catheter. This study investigated Ventrain(®) 's performance when used with different clinical oxygen sources in an in vitro set-up. METHODS Three anesthesia oxygen sources (wall-mounted flowmeter, respirator oxygen outlet port, and anesthesia ventilator circuit) were used at gas flow rates of 6, 9, 12, and 15 l/min. First, the sources' driving pressures (DP), the insufflation pressure (IP), and the flow at the catheter tip were measured using a gas flow analyzer. Tidal volumes (VT) delivered by the Ventrain(®) were assessed by the ASL5000 test lung (respiratory rate: 15 min(-1), I:E = 1:1, compliance: 100 ml/cmH2O, resistance: 3.06 cmH2O/l/s). RESULTS VT ranged from 82 to 483 ml for inspiration and 82 to 419 ml for expiration. Measured IP, flow, and VT were less dependent on the set gas flow rate but more on the source's DP. With rising DP the IP, the flow at the catheter tip and consequently VT increased. At an approximate target I:E ratio of 1:1, the ratio of inspiratory to expiratory VT increased with higher DP and gas flow rates. CONCLUSION The oxygen sources resulted in clinically different IP, flows, and VT delivered by the Ventrain(®) at given gas flow rates. This needs to be considered in a clinical emergency situation. Integrating an adjustable pressure valve into Ventrain(®) to allow regulation of the lowest necessary IP would make its use safer.
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Affiliation(s)
- A. R. Schmidt
- Department of Anaesthesia; University Children′s Hospital; Zurich Switzerland
| | - K. Ruetzler
- Institute of Anaesthesiology; University Hospital; Zurich Switzerland
- Departments of General Anesthesiology and Outcomes Research; Cleveland Clinic; Cleveland Ohio USA
| | - T. Haas
- Department of Anaesthesia; University Children′s Hospital; Zurich Switzerland
| | - A. Schmitz
- Department of Anaesthesia; University Children′s Hospital; Zurich Switzerland
| | - M. Weiss
- Department of Anaesthesia; University Children′s Hospital; Zurich Switzerland
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Noppens R. Ventilation through a ‘straw’: the final answer in a totally closed upper airway? Br J Anaesth 2015; 115:168-70. [DOI: 10.1093/bja/aev253] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ziebart A, Garcia-Bardon A, Kamuf J, Thomas R, Liu T, Schad A, Duenges B, David M, Hartmann EK. Pulmonary effects of expiratory-assisted small-lumen ventilation during upper airway obstruction in pigs. Anaesthesia 2015; 70:1171-9. [PMID: 26179167 DOI: 10.1111/anae.13154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2015] [Indexed: 11/28/2022]
Abstract
Novel devices for small-lumen ventilation may enable effective inspiration and expiratory ventilation assistance despite airway obstruction. In this study, we investigated a porcine model of complete upper airway obstruction. After ethical approval, we randomly assigned 13 anaesthetised pigs either to small-lumen ventilation following airway obstruction (n = 8) for 30 min, or to volume-controlled ventilation (sham setting, n = 5). Small-lumen ventilation enabled adequate gas exchange over 30 min. One animal died as a result of a tension pneumothorax in this setting. Redistribution of ventilation from dorsal to central compartments and significant impairment of the distribution of ventilation/perfusion occurred. Histopathology demonstrated considerable lung injury, predominantly through differences in the dorsal dependent lung regions. Small-lumen ventilation maintained adequate gas exchange in a porcine airway obstruction model. The use of this technique for 30 min by inexperienced clinicians was associated with considerable end-expiratory collapse leading to lung injury, and may also carry the risk of severe injury.
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Affiliation(s)
- A Ziebart
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - A Garcia-Bardon
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - J Kamuf
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - R Thomas
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - T Liu
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - A Schad
- Institute of Pathology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - B Duenges
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - M David
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
| | - E K Hartmann
- Department of Anaesthesiology, Medical Centre of the Johannes Gutenberg-University, Mainz, Germany
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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; 115:308-16. [PMID: 26115955 DOI: 10.1093/bja/aev200] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Transtracheal access and subsequent jet ventilation are among the last options in a 'cannot intubate-cannot oxygenate' scenario. These interventions may lead to hypercapnia, barotrauma, and haemodynamic failure in the event of an obstructed upper airway. The aim of the present study was to evaluate the efficacy and the haemodynamic effects of the Ventrain, a manually operated ventilation device that provides expiratory ventilation assistance. Transtracheal ventilation was carried out with the Ventrain in different airway scenarios in live pigs, and its performance was compared with a conventional jet ventilator. METHODS Pigs with open, partly obstructed, or completely closed upper airways were transtracheally ventilated either with the Ventrain or by conventional jet ventilation. Airway pressures, haemodynamic parameters, and blood gases obtained in the different settings were compared. RESULTS Mean (SD) alveolar minute ventilation as reflected by arterial partial pressure of CO2 was superior with the Ventrain in partly obstructed airways after 6 min in comparison with traditional manual jet ventilation [4.7 (0.19) compared with 7.1 (0.37) kPa], and this was also the case in all simulated airway conditions. At the same time, peak airway pressures were significantly lower and haemodynamic parameters were altered to a lesser extent with the Ventrain. CONCLUSIONS The results of this study suggest that the Ventrain device can ensure sufficient oxygenation and ventilation through a small-bore transtracheal catheter when the airway is open, partly obstructed, or completely closed. Minute ventilation and avoidance of high airway pressures were superior in comparison with traditional hand-triggered jet ventilation, particularly in the event of complete upper airway obstruction.
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Affiliation(s)
- M Paxian
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - N P Preussler
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - T Reinz
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - A Schlueter
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
| | - R Gottschall
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Erlanger Allee 101, 07747 Jena, Germany
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