Percutaneous Transtracheal Ventilation: Resuscitation Bags Do Not Provide Adequate Ventilation

Abstract

Introduction:Percutaneous, transtracheal jet ventilation (percutaneous transtracheal jet ventilation) is an effective way to ventilate both adults and children. However, some authors suggest that a resuscitation bag can be utilized to ventilate through a cannula placed into the trachea.Hypothesis:Percutaneous transtracheal ventilation (percutaneous transtracheal ventilation) through a 14-gauge catheter is ineffective when attempted using a resuscitation bag.Methods:Eight insufflation methods were studied. A 14-gauge intravenous catheter was attached to an adult resuscitation bag, a pediatric resuscitation bag, wall-source (wall) oxygen, portable-tank oxygen with a regulator, and a jet ventilator (JV) at two flow rates. The resuscitation bags were connected to the 14-gauge catheter using a 7 mm adult endotracheal tube adaptor connected to a 3 cc syringe barrel. The wall and tank oxygen were connected to he 14-gauge catheter using a three-way stopcock. The wall oxygen was tested with the regulator set at 15 liters per minute (LPM) and with the regulator wide open. The tank was tested with the regulator set at 15 and 25 LPM. The JV was connected directly to the 14-gauge catheter using JV tubing supplied by the manufacturer. Flow was measured using an Ohmeda 5420 Volume Monitor. A total of 30 measurements were taken, each during four seconds of insufflation, and the results averaged (milliliters (ml) per second (sec)) for each device.Results:Flow rates obtained using both resuscitation bags, tank oxygen, and regulated wall oxygen were extremely low (adult 215 ±20 ml/sec; pediatric 195 ±19 ml/sec; tank 358 ±13 ml/sec; wall at 15 l/min 346 ±20 ml/sec). Flow rates of 1,394 ±13 ml were obtained using wall oxygen with the regulator wide open. Using the JV with the regulator set at 50 pounds per square inch (psi), a flow rate of 1,759 ±40 was obtained.These were the only two methods that produced flow rates high enough to provide an adequate tidal volume to an adult.Conclusions:Resuscitation bags should not be used to ventilate adult patients through a 14-gauge, transtracheal catheter. Jet ventilation is needed when percutaneous transtracheal ventilation is attempted. If jet ventilation is attempted using oxygen supply tubing, it must be connected to an unregulated oxygen source of at least 50 psi.

The formulation and introduction of a ‘can't intubate, can't ventilate’ algorithm into clinical practice

“…It includes a 15‐mm connector for manual bag ventilation. Catheter flow rates are significantly higher with wall oxygen at both 10 and 15 l.min −1 administered through oxygen tubing as compared to bag ventilation [9], making this connection surplus to requirement in most clinical settings. The 15‐mm connector also has the added disadvantage of hiding any potential catheter kinks at the skin.…”

Ventilation through a straw

“…In the case of complete airway obstruction, up to 150 ml/s through a 14-G (ID: 1.55 mm) is difficult to achieve sufficient tidal volume, and it is also very difficult to manually compress the Ambu bag to deliver the insufflating volume through a 14-G cannula, resulting in severe hypercapnia due to hypoventilation. Therefore, a 14-G cannula is not recommended [ 6 ].…”

The great airway debate: is the scalpel mightier than the cannula?

“…Furthermore, the potential ventilation techniques following emergency cannula cricothyroidotomy can be dangerous in the case of TTJV and three-way taps; and inadequate in the case of ventilation bags attached to the cannula. [7][8][9] Other options remain untested in the emergency setting; there are no clinical reports of successful emergency use of the Enk oxygen flow modulator or the Rapid-O2 device. Both of these devices are T-piece variants with equivalent side-port diameter.…”