The importance of transtracheal jet ventilation in the management of the difficult airway

Abstract

Inadequate oxygenation and ventilation is responsible for 50-75% of cardiac arrests following the administration of anesthesia. A majority (55-93%) of these intraoperative ventilatory cardiac arrests have resulted in death or brain death. The recent introduction of preanesthesia equipment checklists, inspired oxygen analyzers, disconnect alarms, pulse oximetry and end-tidal capnography should allow the earlier detection (and, therefore, usually rectification) of inadequate oxygenation and/or ventilation. The response to the detection of inadequate oxygenation and/or ventilation is to ventilate the lungs with oxygen via mask or endotracheal tube. However, when one cannot ventilate via mask, or intubate the trachea (hereafter referred to as cannot ventilate/intubate), even if one is aware of a life-threatening gas exchange problem, and has no immediately available alternative plan, then death is inevitable. For the purpose of this paper, cannot ventilate via mask means that a fully trained and/or reasonably experienced anesthetist cannot cause a life-sustaining amount of gas exchange to occur despite the fact that anterior jaw thrust and/or oropharyngeal and/or nasopharyngeal airways are being used, and cannot intubate means that the same anesthetizing individual cannot pass an endotracheal tube through the vocal cords within a life-sustaining period of time. There is widespread agreement in the literature that percutaneous transtracheal jet ventilation (TTJV) using a large iv catheter inserted through the cricothyroid membrane is a simple, relatively safe, extremely effective treatment of choice for the desperate cannot ventilate/intubate situation. Compared with percutaneous cricothyroidotomy and tracheostomy, establishment of percutaneous TTJV is much quicker and simpler. Unfortunately, TTJV is not immediately available in the majority of anesthetizing locations in the United States; 'immediately available' means that there is already present a dedicated high pressure oxygen source and the necessary preassembled materials to connect the high pressure source to the hub of an iv catheter. The purpose of this article is to show that TTJV is indeed an effective, simple, and inexpensive solution to the cannot ventilate/intubate problem, and, therefore, can be and should be immediately available in every anesthetizing location.