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Jet Ventilation for Airway Surgery: The Influence of Mode and Frequency on Ventilation Efficacy
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
2014 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Jet ventilation vid luftvägskirurgi : Betydelse av ventilationsmode och frekvens for ventilationens effektivitet (Swedish)
Abstract [en]

In surgery for airway obstruction, the anesthetist and the ear-nose-throat surgeon share the approach to the airway and jet ventilation (JV) is a mutually convenient ventilation technique for both parties. As a consequence of the open system jet ventilation is applied in, bedside measurements of lung volumes are cumbersome to perform and thus, there is a lack of studies comparing different modes of JV or investigating the influence of ventilator settings on lung volumes and gas exchange. In this thesis, single frequency jet ventilation and superimposed high frequency jet ventilation (SHFJV) at different frequencies are systematically compared with respect to lung volume changes, underlying airway pressure variations and the resulting gas exchange.

We compared three single-frequency JV modalities with SHFJV in patients. Moreover, we performed a systematic investigation of single frequency JV and SHFJV in a porcine model. Single frequency JV and SHFJV were compared frequency-wise in intact airways and in a newly developed model of tracheal obstruction. This model was also used to assess the influence of variable airway diameter on ventilation effectiveness during SHFJV. We measured chest wall volume variations with opto-electronic plethysmography and obtained airway pressures as well as gas exchange parameters.

In unobstructed airways, both single-frequency JV and SHFJV provided adequate oxygenation, despite differences in lung volumes. Carbon dioxide removal was most effective using single frequency JV at a frequency of 150 min-1. During SHFJV, for both intact and obstructed airways, the choice of frequency for the high frequency component had little influence on lung volumes, airway pressures and gas exchange. With decreasing airway diameter and SHFJV, we observed air trapping and lower tidal volumes and acceptable oxygenation. Carbon dioxide removal, however, was insufficient at the narrowest airway diameter. In single frequency JV, very high frequencies resulted in negligible tidal volume and inacceptable gas exchange. Airway obstruction potentiated this frequency dependence.

In conclusion, in intact airways, single frequency JV at sufficiently low frequencies provided adequate oxygenation and better CO2 removal than SHFJV. With decreasing airway diameter, SHFJV provided better oxygenation and CO2 removal and may therefore be the mode of choice in more complicated cases.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2014. , 62 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1014
Keyword [en]
jet ventilation, airway obstruction, tracheal stenosis, HFJV, SHFJV
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:uu:diva-229033ISBN: 978-91-554-8984-7 (print)OAI: oai:DiVA.org:uu-229033DiVA: diva2:735634
Public defence
2014-09-12, Gunnesalen, Psykiatrins hus, Akademiska sjukhuset, Uppsala, 13:00 (English)
Opponent
Supervisors
Funder
Swedish Heart Lung FoundationSwedish Research Council
Available from: 2014-08-20 Created: 2014-07-28 Last updated: 2014-09-10
List of papers
1. Comparison of superimposed high-frequency jet ventilation with conventional jet ventilation for laryngeal surgery
Open this publication in new window or tab >>Comparison of superimposed high-frequency jet ventilation with conventional jet ventilation for laryngeal surgery
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2012 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 108, no 4, 690-697 p.Article in journal (Refereed) Published
Abstract [en]

Background

New ventilators have simplified the use of supraglottic superimposed high-frequency jet ventilation (SHFJVSG), but it has not been systematically compared with other modes of jet ventilation (JV) in humans. We sought to investigate whether SHFJVSG would provide more effective ventilation compared with single-frequency JV techniques.

Methods

A total of 16 patients undergoing minor laryngeal surgery under general anaesthesia were included. In each patient, four different JV techniques were applied in random order for 10-min periods: SHFJVSG, supraglottic normal frequency (NFJVSG), supraglottic high frequency (HFJVSG), and infraglottic high-frequency jet ventilation (HFJVIG).

Chest wall volume variations were continuously measured with opto-electronic plethysmography (OEP), intratracheal pressure was recorded and blood gases were measured.

Results

Chest wall volumes were normalized to NFJVSG end-expiratory level. The increase in end-expiratory chest wall volume (EEVCW) was 239 (196) ml during SHFJVSG (P<0.05 compared with NFJVSG). EEVCW was 148 (145) and 44 (106) ml during HFJVSG and HFJVIG, respectively (P<0.05 compared with SHFJVSG). Tidal volume (VT) during SHFJVSG was 269 (149) ml. VT was 229 (169) ml (P=1.00 compared with SHFJVSG), 145 (50) ml (P<0.05), and 110 (33) ml (P<0.01) during NFJVSG, HFJVSG, and HFJVIG, respectively.

Intratracheal pressures corresponded well to changes in both EEVCW and VT. All JV modes resulted in adequate oxygenation. However, PACO2was lowest during HFJVSG [4.3 (1.3) kPa; P<0.01 compared with SHFJVSG].

Conclusion

SHFJVSG was associated with increased EEVCW and VT compared with the three other investigated JV modes. All four modes provided adequate ventilation and oxygenation, and thus can be used for uncomplicated laryngeal surgery in healthy patients with limited airway obstruction.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-168896 (URN)10.1093/bja/aer460 (DOI)000302016600021 ()22258205 (PubMedID)
Available from: 2012-02-17 Created: 2012-02-17 Last updated: 2017-12-07Bibliographically approved
2. Frequency dependence of lung volume changes during superimposed high-frequency jet ventilation and high-frequency jet ventilation
Open this publication in new window or tab >>Frequency dependence of lung volume changes during superimposed high-frequency jet ventilation and high-frequency jet ventilation
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2014 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 112, no 1, 141-149 p.Article in journal (Refereed) Published
Abstract [en]

Background. Superimposed high-frequency jet ventilation (SHFJV) has proved to be safe and effective in clinical practice. However, it is unclear which frequency range optimizes ventilation and gas exchange. The aim of this study was to systematically compare high-frequency jet ventilation (HFJV) with HFJV by assessing chest wall volume variations (Delta EEVCW) and gas exchange in relation to variable high frequency. 

Methods. SHFJV or HFJV were used alternatively to ventilate the lungs of 10 anaesthetized pigs (21-25 kg). The low-frequency component was kept at 16 min(-1) in SHFJV. In both modes, high frequencies ranging from 100 to 1000 min(-1) were applied in random order and ventilation was maintained for 5 min in all modalities. Chest wall volume variations were obtained using opto-electronic plethysmography. Airway pressures and arterial blood gases were measured repeatedly. 

Results. SHFJV increased Delta EEVCW compared with HFJV; the difference ranged from 43 to 68 ml. Tidal volume (V-T) was always >240 ml during SHFJV whereas during HFJV ranged from 92 ml at theventilation frequency of 100 min(-1) to negligible values at frequencies >300 min(-1). We observed similar patterns for Pa-O2 and Pa-CO2. SHFJV provided generally higher, frequency-independent oxygenation (Pa-O2 at least 32.0 kPa) and CO2 removal (Pa-CO2 similar to 5.5 kPa), whereas HFJV led to hypoxia and hypercarbia at higher rates (Pa-O2 < 10 kPa and Pa-CO2 > 10 kPa at f(HF) > 300 min(-1)). 

Conclusions. In a porcine model, SHFJV was more effective in increasing end-expiratory volume than single-frequency HFJV, but both modes may provide adequate ventilation in the absence of airway obstruction and respiratory disease, except for HFJV at frequencies >= 300 min(-1).

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-212347 (URN)10.1093/bja/aet260 (DOI)000328404700021 ()23963714 (PubMedID)
Available from: 2013-12-09 Created: 2013-12-09 Last updated: 2017-12-06Bibliographically approved
3. Efficacy of Superimposed High Frequency Jet Ventilation and High Frequency Jet Ventilation in an Animal Model of Tracheal Obstruction
Open this publication in new window or tab >>Efficacy of Superimposed High Frequency Jet Ventilation and High Frequency Jet Ventilation in an Animal Model of Tracheal Obstruction
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2014 (English)In: Anesthesiology, ISSN 0003-3022, E-ISSN 1528-1175Article in journal (Refereed) Submitted
Abstract [en]

Background

Superimposed high frequency jet ventilation (SHFJV) and high-frequency jet ventilation (HJFV) are widely used for airway interventions using rigid bronchoscopy. SHFJV was found to provide higher lung volume and better gas exchange than HFJV in unobstructed airways.

We hypothesized that, also in the presence of airway obstruction, SHFJV would provide higher lung volumes, better oxygenation and more effective CO2 removal than HFJV.

Methods

In a porcine model, we used a stent with ID 4 mm to create tracheal obstruction. The anesthetized animals (25-31.5kg) were alternately ventilated with SHFJV (low frequency 16min-1, combined with a high frequency fHF) and HFJV (solely fHF) at a set of different fHF from 50-600min-1. Chest wall volume changes were measured with opto-electronic plethysmography, airway pressures were registered continuously and arterial blood gases were obtained repeatedly.

Results

SHFJV provided higher ∆EEVCW than HFJV with a difference between both modes of 129 ml (fHF=50min-1) to 62 ml (fHF=400min-1). Tidal volume (VT) was always greater than 213 ml with SHFJV, but with HFJV, increasing fHF reduced VT from 112 (97-130) ml at fHF=50 min-1 to negligible values at fHF>150 min-1.

In analogy, SHFJV provided paO2 of >30 kPa and acceptable CO2 removal for all fHF, whereas fHF>150 min-1 resulted in severe hypoxia and hypercarbia during HFJV.

Conclusion

SHFJV effectively increased lung volumes and maintained gas exchange compared with HFJV. SHFJV may be a safer option than HFJV in laser surgery, where low FiO2 is required. HFJV with frequencies >100-150 min-1 should not be used in severe airway obstruction.

Keyword
jet ventilation, airway obstruction, tracheal stenosis, HFJV, SHFJV
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-229060 (URN)
Funder
Swedish Research CouncilSwedish Heart Lung Foundation
Available from: 2014-07-28 Created: 2014-07-28 Last updated: 2017-12-05Bibliographically approved
4. Influence of Tracheal Obstruction on the Efficacy of Superimposed High-frequency Jet Ventilation and Single-frequency Jet Ventilation
Open this publication in new window or tab >>Influence of Tracheal Obstruction on the Efficacy of Superimposed High-frequency Jet Ventilation and Single-frequency Jet Ventilation
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2015 (English)In: Anesthesiology, ISSN 0003-3022, E-ISSN 1528-1175, Vol. 123, no 10, 799-809 p., doi:10.1097/ALN.0000000000000818Article in journal (Refereed) Published
Abstract [en]

Background

Superimposed high frequency jet ventilation (SHFJV) has been used successfully in selected patients with severe central airway obstruction undergoing airway interventions.

We sought to systematically describe the efficacy of SHFJV in relation to obstruction and the high frequency component (fHF) in a model of tracheal stenosis.

Methods

Ten anesthetized animals (25-31.5kg) were alternately ventilated with SHFJV (low frequency 16min-1, random fHF) at a set of different fHF from 50-600min-1. Tracheal obstruction was created using exchangeable stents with different inner diameter (2, 4, 6, 8mm) that were inserted into the trachea. Chest wall volume was measured using optoelectronic plethysmography, airway pressures were recorded and blood gases were analyzed repeatedly.

Results

Stent ID reduction from 8 to 2mm resulted in an increase of ∆EEVCW by up to 3x (e.g. 323 [255 - 410] ml vs 106 [81 - 138] ml at fHF=100 min-1). At the same time, VT decreased by up to 4.2x (e.g. 477 [434 – 524] ml vs 114 [79 – 165] ml). PaO2 and paCO2 remained at acceptable levels for 4-8 mm stent ID but CO2 removal became suddenly impaired at 2mm stent ID (paCO2>12 kPa). Pre-stenotic airway pressure monitoring was accurate at 8mm stent ID, but overestimation of peak inspiratory pressure (PIP) up to 2x and underestimation of PEEP up to 19x was observed at 2mm stent ID.

Conclusion

SHFJV was able to maintain oxygenation and carbon dioxide removal over a wide range of obstructions, despite decreasing VT and successive air trapping. At 2 mm stent ID, only carbon dioxide removal became insufficient.

Keyword
jet ventilation, airway obstruction, tracheal stenosis, HFJV, SHFJV
National Category
Anesthesiology and Intensive Care
Research subject
Anaesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-229061 (URN)
Funder
Swedish Research CouncilSwedish Heart Lung Foundation
Available from: 2014-07-28 Created: 2014-07-28 Last updated: 2017-12-05

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Citation style
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  • modern-language-association-8th-edition
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  • Other locale
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Output format
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