High frequency jet ventilation in the management of intra‐operative tracheal injury

Abstract

SummaryA patient undergoing pharyngo-oesphagectomy with gastric transposition sustained a large tracheal fear during the blind oesophageal dissection. High frequency jet ventilation was successfully employed in the acute airway management and continued postoperatively. Key words Surgery; oesophagectomy.Complications; tracheal injury. Ventilation; high frequency jet.Intra-operative tracheal injury is a recognised complication of total oesophagectomy with gastric transposition [ 1-31, The incidence of this complication was 16% in the early series of patients reported by Condon [l], but has more recently been estimated as 0.6% [4]. Prompt action is needed to avert profound respiratory and cardiovascular embarrassment.We are unaware of any previous reports in which high frequency jet ventilation has been successfully used in such circumstances. Case historyA 65-year-old man with a carcinoma of the upper oesophagus presented for total pharyngo-oesophagectomy with gastric pull-up.Induction and maintenance of anaesthesia was initially uneventful. The lungs were ventilated via a 9.0 mm cuffed orotracheal tube with a total fresh gas flow of 1.7 I.min-' delivered via a circle system. The tumour was found to extend from the cricoid cartilage to the level of TI. Dense adhesions to the trachea were present, although the tumour did not breach the wall of the oesophagus. During the difficult blunt dissection of the oesophagus, a 2 cm tear was created in the posterior wall of the trachea, approximately two rings above the level of the carina. Immediate inability to ventilate the patient was apparent. The fresh gas flow was increased to 12 Lmin-l of oxygen with isoflurane 2%, in an attempt to oxygenate and anaesthetise the patient by insufflation, assisted when possible by gentle manual ventilation.The Spo2 decreased from 99% to 93% and remained at this level. An attempt at rapid surgical closure of the tracheal tear failed because the suture line was unable to withstand the relatively high airway pressure.High frequency jet ventilation was instituted within 5 min by means of a system designed by one of the authors (S.M.). A 60cm long, reinforced polyvinyl chloride catheter of internal diameter 2.0 mm was passed through the rubber diaphragm of a swivel connector of the catheter mount and down the tracheal tube. The tip was positioned by the surgeons distal to the tracheal tear, but above the carina. The catheter was then taped to the mount to prevent its accidental movement. The proximal end of the catheter was connected by a Luer lock to a Sander's injector powered by pipeline oxygen. Ventilation was maintained at a rate of 10&125 min-I, tidal volume 80-100 ml and airway pressure < 10 cmHzO using the injector. Anaesthesia was maintained by a propofol infusion of 100 pg.kg-'.min-' and 66% NzO in oxygen and 2% isoflurane entrained via the circle system. Muscle relaxation was continued with an atracurium infusion at a rate of 0.5 mg.kg-'.h-'.The Spo2 increased promptly and remained > 97% for the remainder of the procedure. A left ...

Major Airway Injury During Esophagectomy: Experience at a Tertiary Care Center

“…The use of high-frequency jet ventilation has also been described in such a situation. 7 The treatment entails repair of the trachea. Conversion to a thoracotomy and direct visualization and suturing of the rent is an acceptable method of repair.…”

“…[6][7][8] The situation is life threatening and demands immediate attention. Delayed detection of the injury and consequent tension pneumothorax has also been described.…”

“…5 Tracheal laceration is associated with loss of airway compliance and the respiratory insufficiency. [6][7][8] This can lead to a life-threatening hypoxia. The condition mandates immediate attention to ventilate the patient and subsequent management of laceration.…”

“…The condition mandates immediate attention to ventilate the patient and subsequent management of laceration. [4][5][6][7][8] Various methods of tracheal repair have been described. 4,5,[9][10][11][12] We herein describe our experience of managing tracheal injuries in patients undergoing esophagectomy over a period of one decade.…”

Notfallversorgung einer durch scharfe Gewalt verursachten Halsweichteilverletzung infolge Selbstmordversuch

“…In der Literatur sind bei vergleichbaren trachealen Verletzungen die Versorgung mittels Notkonio-bzw. Tracheotomie [9] und weitere Verfahren beschrieben, die jedoch nicht auf die präklinische Versorgung zugeschnitten sind: Beispielsweise werden die fiberoptische (Wach-)Intubation [2,6,7], die Hochfrequenz-Jet-Ventilation [7,14] oder der femorale kardiopulmonale Bypass [7] diskutiert. Wie sich aus der vorliegenden Falldarstellung ergibt, kann die Atemwegssicherung über die offene Trachea als eine weitere Möglichkeit der Versorgung eines offenen Halstraumas in der Akutsituation lebensrettend sein.…”