Anesth Analg 2000;90:1436-1440
© 2000 International Anesthesia Research Society
GENERAL ARTICLES
High Frequency Jet Ventilation in Interventional Fiberoptic Bronchoscopy
Hubert Hautmann, MD*,
Fernando Gamarra, MD*,
Markus Henke, MD*,
Stephanie Diehm, MD
, and
Rudolf M. Huber, MD*
*Medizinische Klinik, Klinikum Innenstadt,
Klinikum Großhadern/Klinikum Innenstadt, Klinik für Anästhesie, Ludwig-Maximilians-University, Munich, Germany
Address correspondence and reprint requests to Dr.med. Hubert Hautmann, MD, Klinikum Innenstadt, Medizinische Klinik, Ziemssenstr.1, D-80336 München, Germany. Address e-mail to hautmann{at}medinn.med.uni-muenchen.de
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Abstract
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High frequency jet ventilation (HFJV) is a well accepted method for securing ventilation in rigid and interventional bronchoscopy. We describe a technique of HFJV using a 14F nylon insufflation catheter placed in the trachea to support stent implantation or endobronchial balloon dilation in endobronchial stenoses with the flexible fiberscope. One hundred sixty-one cases were treated with either a metal wire stent (n = 105) or with balloon dilation (n = 56). In addition to HFJV, IV anesthesia was applied in 132 cases. Driving pressure was 1125–1275 mm Hg, frequency 80–100/min, and inspiratory:expiratory ratio of 1:2. Fraction of inspired oxygen ranged from 0.3–1.0. The effects on alveolar ventilation were assessed by using blood-gas analysis and continuous monitoring of transcutaneous oxygen and carbon dioxide tension (PtcCO2). Complications consisted of hypertension (n = 8), hypotension (n = 6), bronchospasm (n = 5), and hypoxia (n = 6). In 52% of the cases, mild hypercarbia (PtcCO2 50–60mm Hg) was observed. In two cases, a PtcCO2 > 80mm Hg resolved spontaneously when the patients returned to normal breathing after intermittent superimposed ventilation with a face mask. During placement of stents in the proximal trachea, the jet catheter had to be withdrawn, resulting in displacement of the catheter into the pharynx in one case, which was managed safely with the bronchoscope. In conclusion, HFJV achieves satisfactory operating conditions and provides adequate gas exchange for interventional bronchoscopic procedures with the fiberscope.
Implications: Safe ventilation is desired when performing tracheobronchial stent implantation and balloon dilation with the fiberscope. High frequency jet ventilation, applied with a 14F insufflation catheter through the nasotracheal route, offers safe ventilatory support with minimal complications. This was evaluated in 161 procedures treating benign and malignant airway stenoses.
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Introduction
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High frequency jet ventilation (HFJV) provides adequate pulmonary gas exchange. The advantage of this method of ventilation is that it can allow effective gas transport without high airway pressure or depression of hemodynamic function and thus avoid barotrauma or decreased cardiac output (1). Aspiration of gastric contents is prevented by causing a continuous gas flow outward through the larynx (2). HFJV has increasingly been used since its introduction in 1977 (3). It is applied in rigid bronchoscopy (4,5) with a specially designed jet valve and in fiberscopes in which the jet injector is attached to the suction channel without intervening tubing (6–8). HFJV for rigid bronchoscopy has also been delivered through thin nylon catheters (9), which can be introduced via the nasotracheal route (10–12). The advantage is the uninterrupted ventilatory support during the introduction of the rigid endoscope. This technique seems also very suitable for use in fiberoptic bronchoscopy, specifically for interventional procedures such as stent placement or endobronchial balloon dilation.
We report on our experience with 161 interventional fiberoptic bronchoscopic procedures performed with HFJV applied through a 14F catheter via the nasotracheal route.
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Methods
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For the present study, approval by the local investigation committee was granted, and informed consent was obtained in each case. One hundred sixty-one elective endobronchial procedures (105 stent implantations and 56 balloon dilatations) with HFJV were performed in 123 patients. Only expandable metal wire stents were used because most other stent types require rigid bronchoscopy (Table 1). The patients’ age ranged from 24 to 84 yr (mean ± SD: 60.7 ± 11.2 yr). Indications were endotracheal or endobronchial stenoses of different origin (Table 1). Specific symptoms were dyspnea or stridor, retention pneumonia, retention of secretions, or lung abscess. Means of therapy (stent insertion or balloon dilation) were considered a reasonable choice at the particular stage of the disease. Quantification of the stenoses was performed semiquantitatively. The stenosis was specified "subtotal" when it could only be passed with a 0.035-inch guidewire (0.9 mm); a "high-grade" stenosis was passed with a closed biopsy forceps (2.1 mm). "Medium-grade" stenoses could be passed with the bronchoscope (5.8 mm). In 41 cases, additional bronchography was performed to assess the grade of the stenosis and to evaluate the poststenotic situation.
The quantification and location of the various airway stenoses are displayed in Table 2. In the trachea, 73% of the stenoses were malignant. Sixty-four percent of these stenoses were quantified "high grade," 34% "medium grade, " and 1 stenosis was subtotal. The patient was placed in supine position. Premedication consisted of 1–3 mg IV midazolam and atropine 0.5 mg IV. Topical anesthesia was achieved by instillation of 10–15 mL 2% oxybuprocaine nebulized in the spontaneously breathing patient. With the aid of a fiberbronchoscope, a 14F nylon catheter with a length of 44 cm (Rüsch, Kernen, Germany) was introduced transnasally over a guide wire with the tip positioned in the distal trachea. When the lesion was located within the trachea, the catheter was positioned either proximal to the lesion or passed through the lesion (Figure 1 ). In the latter case, end-expiratory pressure was not to exceed 15 mm Hg. The catheter was normally passed through the lesion when a dilation was performed; however, ventilation was stopped while the balloon was inflated, which lasted 10–30 s. In stent implantations, the catheter was always drawn back proximal to the stenosis when the prosthesis was positioned. In case of high tracheal lesions, the tip of the catheter came to lie directly distal to the glottis. After the stent was expanded, the catheter was immediately forwarded through the lumen of the prosthesis. A jet injector (AMS1000; Acutronic Medical Systems, Jona, Switzerland), together with a humidification roller pump (HH812, Accutronic Medical Systems) was connected to an oxygen regulator and directly attached to the catheter (frequency 80–100/min, inspiratory:expiratory ratio 1:3, driving pressure 1125–1275 mm Hg). Fraction of inspired oxygen (FIO2) (0.3–1.0) was adjusted according to the actual oxygenation to achieve a normal percutaneous oxygen tension.
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Figure 1. Diagram of the general setup and a close view of the high frequency jet ventilation catheter in tracheal position with the tip distal to a tracheal stenosis. The motion of the fiberscope is not limited by the presence of the jet ventilation catheter.
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General anesthesia was induced only when cough or respiratory excursions disturbed the accuracy of the intervention, or when the patient was in a poor condition. Then IV propofol was given by continuous infusion of 6 to 10 mg · kg-1 · h-1 after a bolus of 2 mg/kg and alfentanil in a dosage of 1 mg followed by 0.5 mg, as needed. Muscle relaxants were not administered. In every patient, SaO2, arterial blood pressure, and an electrocardiogram were continuously monitored. Percutaneous oxygen and carbon dioxide tension (PtcCO2) were measured by using a transcutaneous electrode heated to 42°C and placed on the thorax below the clavicle. Measurements were verified by using arterial blood gas analysis.
Preoperative measurements included forced expiratory volume in one second, peak expiratory flow rate, forced vital capacity, airway resistance (Bodyscreen; Jaeger, Würzburg, Germany), and arterial blood gas tensions. Lung function data obtained within 72 h before the procedure were available in 115 cases.
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Results
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In 132 cases (82%), IV anesthesia was administered in addition to jet ventilation. Mean duration of jet ventilation was 72 min (range 20–210). The time of anesthesia when applied ranged from 10 to 210 min (mean 59). Pretreatment lung function was moderately impaired within the study cohort (Table 3). Seventy-nine percent of the patients had a long history of cigarette smoking, 61% showed symptoms of chronic bronchitis, and 39% were taking regular antiobstructive medication. During jet ventilation, mean percutaneous oxygen tension was 129 ± 31 mm Hg (mean ± SD). Maximum PtcCO2 was 52.4 ± 11.4 mm Hg. Hypercapnia was the most common adverse effect. In two cases, PtcCO2 exceeded 80 mm Hg. It was successfully diminished with intermittent superimposed face mask ventilation. In all cases jet ventilation induced hypercapnia resolved spontaneously when the patients returned to normal breathing. Other complications are summarized in Table 4.
Arterial hypotension occurred exclusively in the anesthesia group and required IV adrenergic treatment with dopamine. Hypoxemia was predominantly caused by bronchospasm and was treated with an increase in FIO2, inhaled ß-agonists, and IV corticosteroids (prednisolone 100 mg). In two cases, supraventricular tachycardia was reversible with verapamil. Minor bleeding was observed in 36 cases, but did not necessitate specific therapy. In eight cases of tracheal stenoses, the jet catheter was placed through the lesion. In one of these cases, end-expiratory pressure exceeded 15 cm H2O and was corrected by reducing driving pressure and frequency without impairing oxygenation. The positioning of the jet catheter when deploying a stent within the proximal portion of the trachea was the only technical difficulty encountered. The tip of the jet catheter had to be placed at the very proximal end of the trachea, because it was not desirable to place the stent over the catheter. In 10 cases of stent placement in the proximal trachea, the catheter slipped out of the trachea in one case. It was then immediately reintroduced over a guide wire, which was placed by using the bronchoscope. To avoid respiratory disturbances in these cases, patients were oxygenated with a FIO2 of 1.0 before stent deployment. In the 29 cases in which HFJV was performed without anesthesia, patients did not experience any discomfort as a result of catheter ventilation.
After the procedure, all patients had satisfactory spontaneous breathing. Oxygen was supplied via nasal canula or Venturi mask. Two patients were held in the postoperative care unit overnight for observation and SaO2-monitoring because of prolonged bronchospasm with impaired respiratory function. However, patients were readmitted to the general ward the following day. In all other cases, patients stayed in the postoperative care unit for 30 to 240 min (mean 134 min) until postoperative SaO2 reached the preinduction value.
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Discussion
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High frequency positive pressure ventilation through a nylon catheter has been used successfully not only in complex thoracic surgery (13), but also for application in bronchoscopy. It has, however, not been described for the use in fiberoptic bronchoscopy. Beside laser therapy, bronchoplastic procedures, such as stent implantations and balloon dilatations are increasingly performed with the fiberscope (14–16). Although these procedures have in rare cases been done by using local anesthesia alone, safe oxygenation is highly desired, because most of these patients present with impaired respiratory function. This applies especially to our study cohort. Most of the patients suffered from malignant disease and showed symptoms of chronic, often obstructive, lung disease, which was confirmed by using lung function analysis. In addition, ventilation of depending lung areas is further impaired by endobronchial stenoses.
The jet catheter is easy to insert transnasally with the aid of a fiberscope. Medici et al. (12) placed it in a mainstem bronchus contralateral to the lesion 3 cm distal to the carina while performing laser therapy. In this manner, an adequate ventilation of the nonaffected lung was achieved. We positioned the catheter within the trachea with the idea of partially utilizing the ventilatory capacity of the affected lung. In the case of tracheal lesions, the catheter was placed beyond the stenosis. In only one case did end-expiratory pressure exceed the predetermined limit. This was easily corrected by reducing driving pressure and frequency to avoid the risk of over-distending restricted lung areas and causing barotrauma. Even if the catheter would have to be positioned proximal to a stenosis, adequate ventilation is still likely to be provided. With proper adjustment of the respirator, it is possible to overcome the high inspiratory resistance and to ventilate the patient, even with a laryngeal stenosis of 90% above the stenosis (17). When dilating within the trachea, the jet catheter will remain in place because it does not disturb the dilation process. However, ventilation has to be stopped while the balloon is inflated, which takes no more than 30 seconds. When tracheal stents were implanted, the jet catheter had to be withdrawn because the stent cannot be placed over the catheter. The risk of stent dislocation would be considerable when the catheter is eventually removed. However, in very proximal lesions, the jet catheter may slip through the vocal cords into the pharynx with the consequence of impeding ventilation. Although we observed this complication in one case, it did not complicate the procedure, because the jet catheter could immediately be repositioned with the bronchoscope. For safety reasons, however, we recommend the placement of a guide wire in the trachea before the jet catheter is drawn back. A thin (0.035-inch) guide wire most likely will not interfere with a deployed stent. When the catheter leaves the trachea, it can easily be put back in place by simply pushing it over the guide wire.
Hypercapnia in HFJV is a well described phenomenon and often observed in clinical studies (12,18–20). When PtcCO2 exceeded 80 mm Hg, we used a face mask to eliminate CO2. This was a prophylactic maneuver with no evidence of clinical deterioration. PtcCO2 would presumably have resolved spontaneously after the restoration of normal breathing. Nevertheless, transcutaneous capnography during HFJV proved a useful addition to standard monitoring. It can indicate and, thus, reduce the danger of hypoventilation. Klein et al. (21) even recommended it for routine use in interventional bronchoscopy. With HFJV already established, switching to rigid bronchoscopy during the procedure is safe, and the rigid endoscope can be unhurriedly introduced.
In conclusion, interventional fiberoptic bronchoscopy with HFJV by using a nylon catheter may offer a practical alternative to rigid bronchoscopy for optimal ventilatory support with minimal complications. HFJV can also be performed without the use of narcotics if anesthesia is not considered necessary, but when safe ventilation is still desired.
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Acknowledgments
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We thank Astrid Borgmeier for her illustrative assistance with this report.
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Accepted for publication March 3, 2000.
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Abstract
Introduction
