Superimposed high-frequency jet ventilation for laryngeal and tracheal surgery

OBJECTIVE: To describe our experience with superimposed high-frequency jet ventilation (SHFJV), which does not require any endotracheal tubes or catheters, for performing laryngeal and tracheal surgery. DESIGN: A case series of 500 patients. SETTING: A university medical center. PATIENTS: Four hundred sixty adult patients and 40 children in a consecutive sample who required laryngeal or tracheal surgery under SHFJV. INTERVENTIONS: The SHFJV uses 2 jet streams with different frequencies simultaneously and is applied using a jet laryngoscope. Ventilation was performed with an air-oxygen mixture, and intravenous agents were used for anesthesia. Arterial blood gas values were analyzed. MAIN OUTCOME MEASURES: Reported values of oxygenation and ventilation during the application of SHFJV and laryngotracheal surgery. RESULTS: In 497 patients, adequate oxygenation with a mean +/- SD PaO2 of 91.8 +/- 22.9 mm Hg and ventilation with a PaCO2 of 29.7 +/- 5.5 mm Hg were achieved using SHFJV. The average duration of the application of ventilation was 27 minutes, and the longest duration was 118 minutes. No complications due to the ventilation technique were observed. Laser surgery was performed in 150 patients. CONCLUSIONS: The use of SHFJV in combination with the jet laryngoscope provides patients with sufficient ventilation during laryngotracheal surgery. Even in patients at high risk because of pulmonary or cardiac disease, this technique can be applied safely. In patients with stenosis, the ventilation is applied from above the stenosis, reducing the risk of barotrauma. The SHFJV can be used for tracheobronchial stent insertion, and laser can be used without any additional protective measures.     

Development of a jet tracheoscope. Value and possible uses in superimposed high frequency jet ventilation in endoscopic surgery of the respiratory tract

BACKGROUND AND OBJECTIVE: Tubeless jet-ventilation offers the surgeon an unimpaired surgical field and is therefore widely used in endolaryngeal surgery. In order to permit endotracheal surgery using the same devices and instruments as those used for the larynx, we have developed special jet-tracheoscopes. Here, we report on our experience with superimposed high-frequency jet-ventilation (SHFJV) together with total intravenous anaesthesia (TIVA) in endolaryngeal and especially endotracheal surgery. PATIENTS AND METHODS: The medical reports of 172 patients (91 females, 81 males) who had undergone endolaryngeal or endotracheal surgery in SHFJV were analysed retrospectively. RESULTS: Sufficient ventilation was possible in all cases and no vitally critical situation occurred. The main indication was laryngotracheal stenosis of different origins. No significant advantages could be observed in phonosurgery. There was no difficulty in exposing the endolarynx and subglottis with the currently available laryngoscopes (five sizes). The newly developed jet-tracheoscopes (two sizes) allowed a quick and safe extension of the operating field onto the tracheal bifurcation. CONCLUSIONS: SHFJV together with TIVA enlarges the diagnostic and therapeutic options in endoscopic surgery of the respiratory tract and is in many cases the precondition for endoscopic treatment without tracheotomy. In particular, the newly developed jet-tracheoscopes widen the spectrum of endoscopic surgery and allow the use of the micromanipulator guided CO2-laser in the trachea.     

Proximal large-bore jet ventilation for laryngeal laser surgery

The carbon dioxide surgical laser has made many open upper airway operations obsolete. However, new laser-related hazards have been encountered, the most serious of which is fire in the airway. Venturi jet ventilation removes that risk and provides an unobstructed surgical field. Indications and techniques for the use of jet ventilation with carbon dioxide laser surgery remain controversial, particularly whether jet ventilation should be used in papillomatosis or in the severely obstructed airway, and whether proximal and distal catheter techniques are equally safe and effective. We report the successful use of proximal large-bore Venturi jet ventilation in 327 consecutive patients undergoing microlaryngeal laser surgery. The technique is ideal for pediatric patients with subglottic stenosis or recurrent respiratory papillomas and has not caused distal seeding in the latter group. We recommend the use of low-pressure ventilation, even in relatively obstructed airways. The experimental evidence reported here corroborates the clinical viewpoint expressed; the technique is safe, simple, and uncomplicated if used with care.     

Characteristics and surgical outcome of 98 infants and children surgically treated for a laryngotracheal stenosis after endotracheal intubation: Excellent outcome for higher grades of stenosis after SS-LTR

Introduction

To describe the characteristics and surgical outcome of 98 infants and children treated for an acquired laryngeal stenosis after intubation for respiratory support.

Material and methods

We retrospectively reviewed our data from the last 18 years (1994–2013) concerning infants and children with an acquired laryngotracheal stenosis who were treated in our hospital with a laryngotracheal reconstruction or a cricotracheal resection. Outcome was defined by decannulation ratio.

Results

Of the 98 infants and children who were studied, 54% were preterm, 18% neonates, 13% infants and 14% children. Ninety-one SS-LTR’s, two DS-LTR’s and five CTR’s were performed as primary surgery; three revision operations were performed (DS-LTR). Seventy-seven children had a tracheostomy prior to surgery; decannulation ratio was 93% after primary surgery and 95% after inclusion of revision surgery. For SS-LTR, the decannulation ratio was 93%, including grade III stenosis with comorbidities. Male sex and glottic involvement of the stenosis are correlated to failure of decannulation. Intubation in the term neonatal period is correlated to complicated post-operative course after SS-LTR.

Conclusions

Excellent results of surgery for acquired laryngotracheal stenosis can be obtained with a high decannulation rate. Even for higher grades of stenosis with comorbidities and glottic involvement, an SS-LTR is an effective surgical treatment for acquired laryngeal stenosis.     

Cricotracheal resection for pediatric subglottic stenosis

Until recently, cricotracheal resection (CTR) has not been commonly accepted as a treatment modality for severe subglottic stenosis in the pediatric age group. The reasons have included the risk of a possible dehiscence at the site of the anastomosis, the likelihood of injury to the recurrent laryngeal nerves, and the interference with normal growth of the larynx. Thirty-eight infants and children with a severe subglottic stenosis underwent a partial cricoid resection with primary thyrotracheal anastomosis. Thirty-three patients were tracheotomy-dependent at the time of surgery and 34 were referred cases; 27 were classified as grade III, and 10 as grade IV stenoses according to new Cotton's classification. Nineteen patients were younger than 3 years of age at the time of surgery. The tracheotomy was resected during the surgical procedure in 21 cases. Decannulation was achieved in 36/38 cases after an open procedure. There is one complete restenosis and one good result awaiting decannulation after further surgery for a Pierre Robin syndrome. The authors experienced no lesion of the recurrent laryngeal nerves and no fatality. Thirty-one patients show no exertional dyspnea, three a slight stridor while exercising, and two patients are not decannulated. The postoperative follow-up in longer than 10 years in eight cases. All patients show a normal growth of the larynx and trachea. Compared to laryngotracheoplasties, CTR gives better results for severe subglottic stenosis. This operation should become the treatment of choice for severe (grade III and IV) subglottic stenosis in infants and children.     

Anästhesiologische Besonderheiten bei der laryngotrachealen Chirurgie

During surgical procedures of the upper respiratory tract anesthesiologists and surgeons are in a kind of competition situation because of the close spatial relationship between the airway of the patient and the surgical area. Especially in laryngeal surgery the use of high-frequency jet ventilation (HFJV) offers an alternative to the endotracheal tube. During HFJV the ventilation gas is intermittently administered by an injector with a high frequency into the airway which is open to the outside. Exhalation occurs passively in the area nearby the wall of the airway cross-section. According to the availability of the technique and the indications jet ventilation can be implemented in an infraglottic, supraglottic, transtracheal or transluminal manner. To exert influence on gas exchange of the patient the respiratory rate, driving pressure, oxygen concentration and inspiration time can be changed according to the needs. Severe tracheal stenosis, risk of excessive bleeding during the procedure, patients at risk for aspiration and exacerbation of lung diseases are depicted as contraindications for HFJV. Complications under HFJV are rare despite the limited conditions for monitoring gas exchange and mechanics of ventilation in contrast to conventional ventilation. A particular challenge for the anesthesiologist is the use of HFJV during laryngeal laser surgery.     

Partial cricoid resection with primary tracheal anastomosis for subglottic stenosis in infants and children

Fifteen infants and children with a severe subglottic stenosis underwent a partial cricoid resection with primary tracheal anastomosis. The etiology of the stenosis was congenital in 3 cases and was acquired after prolonged intubation in 12. Fourteen patients were tracheotomy dependent at the time of surgery, and 13 (87%) of the 15 were classified grade III (7 cases) and IV (6 cases) according to Cotton. The resection included the cricoid only in 5 cases and the cricoid and a segment of trachea (1 to 4 rings) in 10 cases. Decannulation was achieved after a single open procedure in 14 (93%) of the cases. The authors encountered no lesion of the recurrent laryngeal nerves and no fatalities. There was, however, 1 restenosis. Twelve cases were decannulated within 6 months, most of them at 2 months. The postoperative voice is normal in 10 cases, and a slight dysphonia is present in 4 cases. Twelve patients show no exertional dyspnea, and 2 exhibit a slight stridor while practicing sports. Ten of 14 cases have been followed for more than 5 years, with the longest follow-up now being 14 years. In all cases, the laryngotracheal development is normal. The results of this small series compare favorably with those of laryngotracheoplasty procedures usually performed for subglottic stenosis in infants and children. In the future, partial cricoid resection with primary tracheal anastomosis should be considered as an important treatment option for severe subglottic stenoses in infants and children.     

Evaluation of neonatal subglottic stenosis: a 3-year prospective study

Subglottic stenosis is the most common cause of chronic airway obstruction. It results in prolonged tracheal cannulation of infants and children. Following the widespread adoption over the past 20 years of prolonged intubation for respiratory support in neonates, the incidence of acquired subglottic stenosis increased dramatically. On January 1, 1987, we began a 3-year prospective study to delineate potential etiologic factors involved in the development of subglottic stenosis in neonates. The present study analyzes data from 289 infants. Relationships between birth weight, gestational age, endotracheal tube size, duration of intubation and ventilation, number and difficulty of intubations, and the subsequent need for medical and surgical therapy are discussed. Whole organ larynges from autopsy specimens provide histological correlation.     

Prolonged endotracheal intubation in neonates with hyaline membrane disease

It is well documented that prolonged endotracheal intubation can lead to subglottic trauma and stenosis. Newborn infants with hyaline membrane disease often require assisted ventilation for prolonged periods of time. We examined 11 such children ranging in age from four months to 4.25 years by endoscopy. Some abnormality was found in every child, and in nine there was minor narrowing of the airway.     

Low frequency jet ventilation for tracheal resection

Low frequency jet ventilation was used successfully for maintaining normal ventilation during tracheal resection for stenosis. Following resection of the stenosis around the endotracheal tube, the tube was withdrawn and the proximal end of a sterile double lumen nasogastric tube with the distal end removed passed over the ether screen. The larger lumen was connected to a Saunders jet apparatus and the smaller to a CO2 analyzer. With the distal end held in the lumen of the distal tracheal stump, jet ventilation was initiated at a rate of 20/min at a pressure sufficient to obtain adequate chest rise and fall. Adequate CO2 removal was verified by monitoring the expired level and blood gases. We obtained normal arterial and end tidal gas tensions by this method which allowed the surgeon complete freedom to anastomose the posterior and lateral tracheal walls.     

Acquired subglottic cysts in premature infants

Advances in the management of premature infants have resulted in improved survival. However, long-term intubation may produce associated laryngeal complications. We report 12 infants and children who developed subglottic cysts following long-term intubation as newborns. The majority of the cysts were in the posterior subglottic larynx. Laser excision of the cysts was undertaken in 8 patients and 3 underwent removal with cupped forceps. Recurrent cysts in 3 patients required more than one endoscopic procedure. The differential diagnosis of stridor in infants who have required long-term intubation includes subglottic cysts. The cysts are not always obvious at endoscopy and indeed may be buried below the mucosa within a soft tissue subglottic stenosis. Their presence may be suspected when tiny beads of mucus are released when laser surgery of a soft tissue stenosis is applied. Successful management of these cysts includes early precise diagnosis, with careful identification of these cysts to differentiate them from other types of subglottic stenosis. An initial attempt of conservative management with endoscopic excision is made. If this fails, an anterior cricoid split may be indicated in cases where the cysts are associated with soft tissue subglottic stenosis. Tracheostomy may be unavoidable in some cases.     

Paediatric tracheostomy: Sheffield experience 1979-1999

We have reviewed our experience of tracheostomy in children over the past 20 years at Sheffield Children's Hospital. One hundred and forty-eight tracheostomies were performed in 143 children aged one day to 13 years old (average 27 months). Sixty-five per cent of patients were < one year old. The indications for tracheostomy were upper airways' obstruction in 72 per cent, and assisted ventilation/ bronchopulmonary toilet in 28 per cent. The commonest single reason was acquired subglottic stenosis (SGS) in infants, accounting for 25 per cent of tracheostomies (36/143). The complication rate of tracheostomy was 46 per cent, most commonly granulation tissue formation. There were four deaths directly due to the tracheostomy: two accidental decannulations and two obstructions. Eighty-nine children were decannulated under our care. The average time until decannulation was 25 months.     

Tubeless translaryngeal superimposed jet ventilation

Summary Microsurgical endoscopic interventions of the larynx offer an optimal approach to the surgeon by providing an unrestricted operative field. During such operations, ventilating the patient should in no way be impaired. For this reason we have developed a new type of tubeless jet ventilation which consists of both low-frequency and superimposed high-frequency jet ventilation. In addition, we have integrated two specifically sized jets into a Kleinsasser laryngoscope, placing them at different sites. This technique guarantees adequate ventilation with an oxygen-air blend. Due to the Venturi effect, air and tidal volumes are also enhanced when passing through the external open end of the laryngoscope. This type of tubeless jet ventilation was applied to more than 60 patients, using a prototype jet. Anesthesia consisted of a continuous intravenous administration of propofol, with sufentanil and vecuronium given as needed. Clinical results revealed optimal ventilation of all patients without hypercapnia or other complications. Operative conditions for the surgeon were also very satisfactory. Findings demonstrated that this type of tubeless jet ventilation is also particularly suited for laryngeal laser surgery, thus avoiding flammable tubes and noxious anesthetics.     

Risk stratification in endoscopic airway surgery: is inpatient observation necessary?

PurposeTo compare post-operative complication rates between inpatient and outpatient endoscopic airway surgery in patients with laryngotracheal stenosis. Secondary objectives included characterization of a cohort of patients with this disease.MethodsRetrospective review of patients with laryngotracheal stenosis in a tertiary care laryngology practice over a 5-year period.ResultsNinety-one patients underwent 223 endoscopic airway surgeries. Of 114 outpatient interventions, 1 patient (0.8%) sought emergent medical care following discharge for respiratory distress. Of 109 procedures resulting in admission, no patients required transfer to a higher level of care, endotracheal intubation or placement of a surgical airway. There was no statistically significant difference in complication rates between patients treated as outpatients or inpatients (p = 0.33, chi square). There were no cardiopulmonary events. There were no pneumothoraces despite frequent use of jet ventilation. The most common etiologic category was idiopathic (58%), followed by granulomatosis with polyangiitis (16%) and history of tracheotomy (12%). Most patients with idiopathic disease were female (p < 0.001, Fisher's exact test).ConclusionPatients undergoing endoscopic surgery for airway stenosis rarely have post-operative complications, and outpatient surgery appears to be a safe alternative to post-operative admission and observation.     

Estenosis subglótica postintubación en niños. Diagnóstico,tratamiento y prevención de las estenosis moderadas y severas

Introduction and objectivesSubglottic stenosis is one of the most common causes of upper airway obstruction. Almost 90% of them result from endotracheal intubation. Therapy depends on the degree of stenosis, among other factors. Therapeutic approaches range from watchful waiting, in mild stenosis, to complex surgery for severe cases. We report our experience on the surgical management of post-intubation subglottic stenosis in children, emphasising the need for recognition and prevention of predisposing factors of post-intubation stenosis.MethodsWe retrospectively evaluated 71 patients with moderate to severe post-intubation subglottic stenosis, operated in the Respiratory Endoscopy Service in a period of eight years. The clinical variables analysed were age at surgery, degree of stenosis, surgical technique, complications and outcome.ResultsIn 84.5% of patients, only 1 surgical approach was required to achieve decannulation. Three surgical techniques were implemented as therapy: laryngotracheal reconstruction, partial cricotracheal resection and anterior cricoid split. Decannulation was achieved in 70 cases. In 71.8%, ventilation, swallowing and voice qualities were good; 23.9% presented dysphonia; and 2.8% presented a mild respiratory distress. One patient died.ConclusionIn patients with subglottic stenosis, selection of the most accurate treatment is the key to success, reducing the number of surgeries and preventing complications.     

Congenital nasal pyriform aperture stenosis: diagnosis and management of 20 cases

The objective of this study was to review the characteristics of congenital nasal pyriform aperture stenosis (CNPAS) in a series of 20 children seen between 1993 and 1996. The diagnosis was made by physical examination and computed tomography scan. A single central maxillary incisor was detected in 12 cases (60%). Three children had morphological abnormalities of the pituitary gland shown on magnetic resonance imaging. One child had an antidiuretic hormone deficiency, and another child had a growth hormone deficiency. Two children had craniosynostoses, 1 of which was Apert's syndrome. All patients underwent operation by a sublabial approach, and 1 was referred for a columellar necrosis after nasal stenting. After surgery, all patients showed improvement, and the nasal stenting was usually removed 1 week after surgery. Follow-up revealed normal breathing. In conclusion, CNPAS was previously considered to be an unusual cause of nasal obstruction in neonates and infants. The number of cases treated recently in our department suggests that this newly recognized entity is more common than expected.     

The utility of routine chest radiography following jet ventilation in elective laryngotracheal surgery

OBJECTIVES/HYPOTHESIS: Jet ventilation is a useful mode of airway management for laryngotracheal surgery. The objective of this study is to evaluate the utility of routine chest radiography following jet ventilation for these cases. STUDY DESIGN: Retrospective chart review. METHODS: Thirty-four elective surgical procedures performed from 1998 to 2002 are reviewed for postoperative airway and pulmonary complications. Data were collected from clinical notes as well as from the results of chest radiographs. This included the need for tracheotomy, reintubation, pneumothorax, pneumomediastinum, and atelectasis. RESULTS: A retrospective chart examination revealed no major complications. Twenty-nine of the 34 cases had postoperative chest radiography (CXR) performed on a routine basis. Atelectasis was present in 12 of 29 CXR (41%); no intervention was required in these cases. CONCLUSIONS: Routine postoperative CXR may not be useful following jet ventilation for elective laryngotracheal surgery. The safety of jet ventilation is discussed.     

Die Jet-Ventilation in der operativen Laryngologie

Conventional endotracheal intubation can be a limiting factor in endolaryngeal and endotracheal surgery. Tubeless jet ventilation can overcome this problem and provides an unlimited operation field to the surgeon. Since the development of first jet ventilation systems, many modifications have been performed and are used permanently in daily clinical routine. The aim of this work is to provide an overview of widely used jet ventilation systems and furthermore to list all advantages, as well as disadvantages of this technique in laryngotracheal surgery.     

Complications of Venturi jet ventilation during microlaryngeal surgery

Microlaryngoscopy for the diagnosis and treatment of laryngeal pathology is a commonly performed procedure in otolaryngology. The use of this technique continues to increase in frequency due to the availability of laser surgery for the management of laryngeal disease. Ventilation during microlaryngoscopy, however, poses a problem as the airway must be shared by the anesthesiologist and the otolaryngologist. Although many techniques of ventilation during microlaryngoscopy are used, the use of high-pressure Venturi jet ventilation, especially during laser surgery, is most frequent. Complications during high-pressure Venturi jet ventilation are uncommon but may occur suddenly and present the surgeon with a life-threatening emergency. Hypoventilation, pneumomediastinum, pneumothorax, severe abdominal distention, and death (directly attributable to various methods of jet ventilation) have been described.     

Prevention of subglottic stenosis in neonatal ventilation

Mechanical ventilation of the newborn is now widely used in neonatal intensive care. The oro-tracheal route of intubation is simpler, but for long-term ventilation has been considered unstable. A method of fixation of oro-tracheal tubes is described which overcomes this instability. Five hundred consecutive ventilated infants were intubated by the oro-tracheal route and the tube was fixed by the method described. Of the 500 ventilated infants, 213 died without being extubated. Of the 287 survivors, 44 developed a degree of post-extubation stridor. No surviving infant developed clinical evidence of subglottic stenosis and in almost 200 postmortem examinations laryngeal narrowing was not identified. The method of oro-tracheal fixation described is stable and may reduce the incidence of subglottic stenosis.