High-frequency jet ventilation is beneficial during shock wave lithotripsy utilizing a newer unit with a narrower focal zone

Recovery and safety with prolonged high-frequency jet ventilation for catheter ablation of atrial fibrillation: A hospital registry study from a New England healthcare network

STUDY OBJECTIVE

To investigate post-procedural recovery as well as peri-procedural respiratory and hemodynamic safety parameters with prolonged use of high-frequency jet ventilation (HFJV) versus conventional ventilation in patients undergoing catheter ablation for atrial fibrillation.

DESIGN

Hospital registry study.

SETTING

Tertiary academic teaching hospital in New England.

PATIENTS

1822 patients aged 18 years and older undergoing catheter ablation between January 2013 and June 2020.

INTERVENTIONS

HFJV versus conventional mechanical ventilation.

MEASUREMENTS

The primary outcome was post-anesthesia care unit (PACU) length of stay. In secondary analyses we assessed the effect of HFJV on intra-procedural hypoxemia, defined as the occurrence of peripheral hemoglobin oxygen saturation (SpO2) <90%, post-procedural respiratory complications (PRC) as well as intra-procedural hypocarbia and hypotension. Multivariable negative binomial and logistic regression analyses, adjusted for patient and procedural characteristics, were applied.

MAIN RESULTS

1157 patients (63%) received HFJV for a median (interquartile range [IQR]) duration of 307 (253-360) minutes. The median (IQR) length of stay in the PACU was 244 (172-370) minutes in patients who underwent ablation with conventional mechanical ventilation and 226 (163-361) minutes in patients receiving HFJV. In adjusted analyses, patients undergoing HFJV had a longer PACU length of stay (adjusted absolute difference: 37.7 min; 95% confidence interval [CI] 9.7-65.8; p = 0.008). There was a higher risk of intra-procedural hypocarbia (adjusted odds ratio [ORadj] 5.90; 95%CI 2.63-13.23; p < 0.001) and hypotension (ORadj 1.88; 95%CI 1.31-2.72; p = 0.001) in patients undergoing HFJV. No association was found between the use of HFJV and intra-procedural hypoxemia or PRC (p = 0.51, and p = 0.97, respectively).

CONCLUSION

After confounder adjustment, HFJV for catheter ablation procedures for treatment of atrial fibrillation was associated with a longer length of stay in the PACU. It was further associated with an increased risk of intra-procedural abnormalities including abnormal carbon dioxide homeostasis, as well as intra-procedural arterial hypotension.

Extracorporeal shockwave lithotripsy in the management of urinary stones: New concepts and techniques to improve outcomes

Objective

Extracorporeal shockwave lithotripsy (SWL) currently plays an important role in the treatment of urinary tract lithiasis. The purpose of this article was to describe new concepts and procedural strategies that would improve results using SWL as a treatment for urolithiasis, thereby achieving better clinical practice.

Methods

A systematic review process was carried in PubMed/PMC from January 2003 to March 2023. A narrative synthesis of the most important aspects has been made.

Results

The important recommendations for the adequate selection of the candidate patient for treatment with SWL are summarized, as well as the new strategies for a better application of the technique. Aspects about intraoperative position, stone localization and monitoring, analgesic control, machine and energy settings, and measures aiming at reduced risk of complications are described.

Conclusion

To achieve the therapeutic goal of efficient stone disintegration without increasing the risk of complications, it is necessary to make an adequate selection of patients and to pay special attention to several important factors in the application of treatment. Technological development in later generation devices will help to improve current SWL results.

Safety of High-Frequency Jet Ventilation During Image-Guided Thermal Ablation Procedures

RATIONALE AND OBJECTIVE

Percutaneous thermal ablative technique is a common radiological procedure for malignant lesions treatment. Controlled assisted ventilation during general anesthesia is the usual mode of ventilation, but high-frequency jet ventilation (HFJV) can be a helpful alternative for the operator. The objective was to evaluate the safety of HFJV during thermal ablation procedures.

MATERIALS AND METHODS

This monocentric prospective analysis included adult patients undergoing percutaneous thermal ablation procedures for abdominal tumor performed under HFJV. Procedures with a transpulmonary path were excluded. The primary outcome was the incidence of respiratory complications. Secondary outcomes included gas exchange modifications (hypercapnia, hypoxemia, pulmonary atelectasis) and the incidence of barotrauma.

RESULTS

Sixty patients were included during the study period. The mean duration time was 88 min. All procedures went according to the protocol and there was no respiratory complication. There was no barotrauma event. Three patients had an exhaled capnia above 45 mmHg at the end of the procedure which normalized within 10 min of conventional ventilation.

CONCLUSION

HFJV during thermal ablation procedures is safe regarding gas exchange and barotrauma. This technique could be an interesting alternative to conventional ventilation during image-guided thermal ablation procedures. Clinical Trials database This study was registered in Clinical Trials database (NCT04209608).

Jet Ventilation Reduces Coronary Sinus Movement in Patients Undergoing Atrial Fibrillation Ablation: An Observational Crossover Study

BACKGROUND

One of the reasons that high-frequency jet ventilation (HFJV) is used is due to the near immobility of thoracic structures. However, no study has quantified the movements of cardiac structures during HFJV compared with normal mechanical ventilation.

METHODS

After ethical approval and written informed consent, we included 21 patients scheduled for atrial fibrillation ablation in this prospective crossover study. Each patient was ventilated with both normal mechanical ventilation and HFJV. During each ventilation mode, displacements of the cardiac structure were measured by the EnSite Precision mapping system using a catheter placed in the coronary sinus.

RESULTS

The median [Q1-Q4] displacement was 2.0 [0.6-2.8] mm during HFJV and 10.5 [9.3-13.0] mm during conventional ventilation (p < 0.000001).

CONCLUSION

This study quantifies the minimal movement of cardiac structures during HFJV compared to standard mechanical ventilation.

Embolisation of pulmonary arteriovenous malformations using high-frequency jet ventilation: benefits of minimising respiratory motion

Background

To evaluate patient radiation dose and procedural duration recorded during pulmonary arteriovenous malformation (PAVM) embolisation performed using high-frequency jet ventilation (HFJV) as compared with conventional intermittent positive pressure ventilation (IPPV)

Methods

Patients undergoing PAVM embolisation with HFJV assistance after April 2017 were retrospectively identified as group A, and those treated with IPPV before April 2017 as group B. Primary outcomes were patient radiation dose and procedural duration between groups A and B. Secondary outcomes were difference in diaphragmatic excursion between groups A and B, in group A with/without HFJ assistance, technical/clinical success, and complications.

Results

Twelve PAVMs were embolised in 5 patients from group A, and 15 PAVMs in 10 patients from group B. Mean patient radiation was significantly lower in group A than in group B (54,307 ± 33,823 mGy cm² [mean ± standard deviation] versus 100,704 ± 43,930 mGy cm²; p = 0.022). Procedural duration was 33.4 ± 16.1 min in group A versus 57.4 ± 14.9 min in group B (p = 0.062). Diaphragmatic excursion was significantly lower in group A (1.3 ± 0.4 mm) than in group B (19.7 ± 5.2 mm; p < 0.001) and lower with near statistical significance in group A with HFJV than without HFJV (1.3 ± 0.4 mm versus 10.9 ± 3.1 mm; p = 0.062). Technical and clinical success was 100% in both groups, without relevant complications.

Conclusion

HFJV-assisted PAVM embolisation is a safe, feasible technique resulting in reduced patient radiation doses and procedural time.

Reducing kidney motion: optimizing anesthesia and combining respiratory support for retrograde intrarenal surgery: a pilot study

BACKGROUND

One of the greatest challenges presented with RIRS is the potential for movement of the stone within the operative field associated with diaphragm and chest respiratory excursions due to mechanical ventilation. To overcome this challenge, we propose in this pilot study a new general anesthesia technique combining high frequency jet ventilation (HFJV) with small volume mechanical ventilation (SVMV). Data regarding safety, feasibility and surgeons' impression was assessed.

METHODS

Patients undergoing RIRS for kidney stones from November 2017 to May 2018 were prospectively recruited to participate in the study. In each case after the beginning of general anesthesia (GA) with mechanical ventilation (MV) surgeons were asked to assess the mobility of the operative field and conditions for laser lithotripsy according to the developed questionnaire scale. The questionnaire consisted of 5 degrees of assessment of kidney mobility and each question was scored from 1 to 5, 1 being very mobile (extremely poor conditions for dusting) and 5 completely immobile (Ideal conditions for dusting). After the assessment GA was modified with combined respiratory support (CRS), reducing tidal volume and respiratory rate (small volume mechanical ventilation, SVMV) and applying in the same time transcatheter high frequency jet ventilation (HFJV) inside the closed circuit. After beginning of CRS, surgeons were once again asked to assess the mobility of the operative field and the conditions for laser lithotripsy. Main ventilation parameters were recorded and compared in both regimens.

RESULTS

A total of 38 patients were included in the study. The mean age was 49 (range 45-53) with a mean stone size of 10 mm (range 10-14) and Hounsfield unit of 1060 (range 930-1190). All patients underwent successful RIRS and no intraoperative complications occurred throughout the duration of the study. A statistically significant difference between ventilation parameters prior to and after CRS institution was detected in all cases, however their clinical impact was negligible. Despite this, assessment via the questionnaire scale point values varied significantly before and after the application of CRS and were 2.3 (2.1; 2.6) and 3.8 (3.7; 4.0) respectively (p < 0.001).

CONCLUSIONS

The novel combined respiratory approach consisting of HFJV and SVMV appears to provide better conditions for stone dusting through reduced respiratory kidney motion and is not associated with adverse health effects or complications.

TRIAL REGISTRATION

NCT03999255 , date of registration: 25th June 2019 (retrospectively registered).

Toward Respiratory-Gated Retrograde Intrarenal Surgery: A Prospective Controlled Randomized Study

INTRODUCTION

We set out to investigate whether general anesthesia with low ventilation (LV, respiratory rate ≤8/minute and tidal volume <500 mL) could reduce renal mobility and thereby facilitate improved retrograde intrarenal surgery (RIRS) compared with general anesthesia with standard ventilation (SV).

MATERIALS AND METHODS

All 60 consecutive patients who presented for RIRS in our department from September 1, 2017 to December 31, 2017 were prospectively randomized 1:1 into one group that was selected to receive SV and another that received LV. Significant factors influencing the study endpoints considered fragmentation rate (FR), removal rate (RR), processing rate (PR), and operating rate (OR), were statistically analyzed for the whole group as well as for comparison by level of surgeon expertise.

RESULTS

Univariate analysis revealed that LV was a significant factor in improving all endpoints. Some endpoints were also affected by the stone's volume, number, and density as well as the surgeon expertise. LV remained the single independent factor for FR, RR, and PR in the multivariate analysis. LV significantly improved all four of the fellows' endpoints (p < 0.05 for each) and positively influenced the expert's RR (p = 0.04), PR (p = 0.02) and OR (p = 0.04). The performance gap between the fellows and the experts narrowed under LV. The end-tidal CO₂ was significantly higher in the LV group (50 vs 36 mm Hg; p < 0.0001), however, without any clinical significance. The overall stone-free rate (97%) and complication rate (5%) were not significantly different between the two groups. The patient's anesthesia-related safety was not affected by the mode of ventilation as evidenced by no need to convert from LV to SV during the procedures.

CONCLUSIONS

LV during RIRS has a significant positive impact on the overall improvement of surgical performance and effectiveness. It does not negatively affect the patient's anesthesia-related safety and may contribute to considerably improving the performance of in-training endourologists.

High frequency jet ventilation for motion management during ablation procedures, a narrative review

BACKGROUND

High frequency jet ventilation (HFJV) is a method of ventilation that has gained renewed interest over the recent years as it can reduce organ movement to near static conditions, thus enhancing surgical precision in minimal invasive procedures, for example, ablation procedures for atrial fibrillation and solid organ tumours. The aim of this review was to create a summary of the current evidence concerning the clinical use of HFJV for ablative procedures.

METHOD

PubMed was searched for the key words high frequency ventilation and ablation January 1990-December 2016.

RESULT

The search initially identified 34 papers, 14 met the inclusion criteria. Articles in other languages than English (n = 1), comments regarding other articles (n = 4) and articles that did not include HFJV or ablative procedures (n = 15) were excluded. Two articles were added from references in papers included from the primary search. Sixteen studies were finally included in the review; four updates/reviews and 12 papers with results from studies of HFJV on humans, with a total of 889 patients; 498 patients ventilated with HFJV and 391 controls. There were no randomised studies. The overall scientific quality of the studies was low.

CONCLUSION

There is a lack of well-designed studies evaluating HFJV during ablation procedures. The available information, while sparse, supports the effect of less tissue movement, resulting in better surgical precision and outcome; such as shorter procedural time, fewer shock waves (ESWL) and less recurrence of atrial fibrillation. Randomised controlled studies are needed in this promising area of research to prove its superiority to standard ventilation.

Improvement of SWL Efficacy: Reduction of the Respiration-Induced Kidney Motion by Using an Abdominal Compression Plate

BACKGROUND AND PURPOSE

In extracorporeal shockwave lithotripsy (SWL), respiratory-induced motion of the upper urinary tract may hamper stone targeting and disintegration. The objective of this study is to analyze the effect of abdominal compression (AC) to kidney motion and to shock wave efficacy.

SUBJECTS AND METHODS

The study included 10 volunteers and 10 kidney stone patients. AC was achieved by a wedge-shaped compression plate. Patients underwent a routine ultrasound-guided SWL. For analgosedation, remifentanil (∼0.1 μg/kg/min) was administered. The respiratory-induced kidney motion, as well as with free breathing and AC, was quantitatively evaluated on basis of recorded ultrasound videos. By definition, shock wave efficacy was 100%, if the stone center was aligned with the shock wave focus. Its decrease depending on off-focus distance was obtained by model stone tests. On this basis, a mean shock wave efficacy value was attributed to the displacement function resulting from each measured kidney motion.

RESULTS

In volunteers, the amplitude of the displacement function with AC (mean: 8 mm; range: 3-11 mm) was significantly lower than with free breathing (mean: 12 mm; range: 5-19 mm) (paired samples t-test, p < 0.001). Correspondingly, the mean efficacy improved to 91% (range: 78%-99%) from 79% (range: 59%-94%) (p < 0.01). In the patient cohort, the amplitudes were similar and the efficacy even higher because of the respiratory depressant effect of remifentanil. By AC, the efficacy improved to 93% (range: 85%-98%) compared with 87% (range: 77%-96%) (p < 0.01).

CONCLUSIONS

AC with a compression plate is easy to perform and well tolerated by patients. It significantly reduces respiratory-induced kidney motion and improves shock wave efficacy.

High-frequency jet ventilation under general anesthesia facilitates CT-guided lung tumor thermal ablation compared with normal respiration under conscious analgesic sedation

PURPOSE

To determine whether technical difficulty of computed tomography (CT)-guided percutaneous lung tumor thermal ablations is altered with the use of high-frequency jet ventilation (HFJV) under general anesthesia (GA) compared with procedures performed with normal respiration (NR) under conscious sedation (CS).

MATERIALS AND METHODS

Thermal ablation treatment sessions performed with NR under CS or HFJV under GA with available anesthesia records and CT fluoroscopic images were retrospectively reviewed; 13 and 33 treatment sessions, respectively, were identified. One anesthesiologist determined the choice of anesthesiologic technique independently. Surrogate measures of procedure technical difficulty--time duration, number of CT fluoroscopic acquisitions, and radiation dose required for applicator placement for each tumor--were compared between anesthesiologic techniques. The anesthesiologist time and complications were also compared. Parametric and nonparametric data were compared by Student independent-samples t test and χ(2) test, respectively.

RESULTS

Patients treated with HFJV under GA had higher American Society of Anesthesiologists classifications (mean, 2.66 vs 2.23; P = .009) and smaller lung tumors (16.09 mm vs 27.38 mm; P = .001). The time duration (220.30 s vs 393.94 s; P = .008), number of CT fluoroscopic acquisitions (10.31 vs 19.13; P = .023), and radiation dose (60.22 mGy·cm vs 127.68 mGy·cm; P = .012) required for applicator placement were significantly lower in treatment sessions performed with HFJV under GA. There was no significant differences in anesthesiologist time (P = .20), rate of pneumothorax (P = .62), or number of pneumothoraces requiring active treatment (P = .19).

CONCLUSIONS

HFJV under GA appears to reduce technical difficulty of CT-guided percutaneous applicator placement for lung tumor thermal ablations, with similar complication rates compared with treatment sessions performed with NR under CS. The technique is safe and may facilitate treatment of technically challenging tumors.

Optimizing shock wave lithotripsy: a comprehensive review

Shock wave lithotripsy is a commonly used procedure for eradicating upper urinary tract stones in patients who require treatment. A number of methods have been proposed to improve the results of this procedure, including proper patient selection, modifications in technique, adjunctive therapy to facilitate elimination of fragments, and changes in lithotripter design. This article assesses the utility of these measures through an analysis of contemporary literature.