Jet ventilation for maxillofacial and laryngotracheal anaesthesia: a narrative review

Introduction

Jet ventilation is a commonly used modality for the oxygenation of patients undergoing maxillofacial and laryngotracheal surgery. It is a highly versatile way of providing oxygenation, enabling gas delivery at multiple points along the airway. This includes but is not limited to alongside bronchoscopes, supraglotically, subglotically via catheters or transtracheal via percutaneous cannulas.

Jet ventilation is defined as the use of a high-pressure air source pneumatically cut or electronically controlled to generate a tidal volume which is applied to the patient (1). There is entrainment of gases possible at the jet nozzle and expiration is dependent on passive lung and chest wall recoil. Jet ventilation can be high or low frequency.

The use of ventilating bronchoscopes also played a role in the evolution of jet ventilation during shared airway surgery. This was first described by Douglas Saunders, who designed a connector to the rigid bronchoscope which allowed the delivery of oxygen at jet pressures of 3 bar via a 0.035-inch diameter nozzle (1) This technique allows the use of a hand-held operated valve to inject short bursts of high-pressure gas via a nozzle connected to a 100% oxygen and a pressure limiting valve. This overcame the prior need to pause surgery and remove the surgical instruments to oxygenate the patient instead of providing continuous oxygenation; pauses provided passive expiration.

The advent of jet ventilation dates to the 1970s when Klain and Smith (2) described the experimental use of intermittent ventilation via a fluidic logic-controlled oxygen jet ventilator at rates of 20–200/min in dogs through a transtracheal catheter. This allowed surgical access to the airway via an open, rigid bronchoscope with concurrent oxygenation via a separate tracheal cannula. Their results showed that intermittent high-pressure jet ventilation was able to maintain adequate oxygenation using ventilation rates of 200/min. It was later applied to patients undergoing laryngoscopy under general anaesthesia with the benefit of an undisturbed surgical field whilst allowing adequate oxygenation at a ventilatory rate of 100/min and driving pressure (DP) of 2.2–3.6 bar (3).

Jet ventilation has since become a commonly employed technique for patients undergoing microlaryngoscopy, laryngeal surgery and cervicofacial cancer pan endoscopies. It has proved beneficial by improving surgical conditions and providing a means of ongoing oxygenation should an airway compromise or emergency occur. It may also be required in cases of severe maxillofacial trauma when oral or nasal intubation is not feasible (4).

However, a UK-based national survey conducted in 2006 showed that only 67% of departments offered a form of jet ventilation (5). At this time jet ventilation was part of the Difficult Airway Society (DAS) ‘Intubation Guidelines-Cannot Intubate, Cannot Ventilate’ algorithms (6). In the updated 2015 guidance from DAS (7) jet ventilation has been removed. No similar surveys have been repeated since 2006 but given jet ventilation is no longer recommended as the final lifesaving step in front of neck access, jet ventilation is restricted to Ear Nose and Throat and Oral Maxillo-Facial centres in the UK.

Currently, there are no consensus agreements on the mode of oxygenation, transtracheal or subglottic catheter or cricothyroid cannula nor the mode of ventilation high or low frequency ventilation and the various pressure and time settings. As such, the aim of this article is to give an overview of the current evidence and uses of jet ventilation in maxillofacial and laryngotracheal anaesthesia from the available literature and guidance. We present this article in accordance with the Narrative Review reporting checklist (available at https://joma.amegroups.com/article/view/10.21037/joma-23-24/rc).

Methods

A literature search was conducted, and key published articles were identified using Embase, Ovid, PubMed and Google Scholar published in English up until July 2023. Papers not published in English, those with non-human subjects, paediatric patients (aged <18 years) and front-of-neck access in Intensive Care Units and pre-hospital were excluded. Published titles and abstracts were reviewed and those deemed clinically relevant were included (Table 1). This narrative review did not include a full critical appraisal of the literature.

Indications, advantages and disadvantages of jet ventilation

Jet ventilation can be used electively in the airway management of maxillofacial and laryngotracheal surgery. It can also be used in the emergency setting in a ‘Can’t intubate, Can’t oxygenate’ (CICO) airway scenario via a cricothyroid or transtracheal cannula. The high-flow oscillating component of jet ventilation is used in neonatal and paediatric critical care as a rescue ventilatory strategy in respiratory distress though it is normally administered in normal bore endotracheal tubes (ETTs). Further discussion on paediatric populations is beyond the scope of this review.

In the elective setting commonly encountered operations that benefit from a jet ventilation airway approach are: microlaryngoscopy procedures, laser airway ablations, tracheal dilatations, vocal cord surgery and cervicofacial cancer pan endoscopies. Emergency use of jet ventilation is more commonly encountered during maxillofacial surgery in cases such as severe trismus, infection or trauma requiring transtracheal ventilation.

As with all invasive techniques, it is not without issue. The advantages and disadvantages of jet ventilation for maxillofacial and laryngotracheal surgery are explored in Table 2.

Physiology of jet ventilation

Gas exchange and transport during jet ventilation is a complex process combining a multitude of mechanisms. Low-frequency jet ventilation (LFJV) is facilitated by the bulk flow of gases like awake spontaneous respiration. Thus, using tidal volumes greater than the dead space to ventilate the alveolar space. The basis of its physiology stems from the Bernoulli concept first described in 1738, demonstrating that the velocity of a fluid is greatest when the pressure is least. It refers to the changes in increased flow together with a drop in pressure and energy at the point of a restriction (8). This allows the entrainment of oxygen into the catheter.

High-frequency jet ventilation (HFJV) uses tidal volumes smaller than the dead space. Therefore, there is a reliance on several other physiological mechanisms (9) of gas transport other than bulk flow. Laminar flow (10) facilitates the movement of gases between the lungs and the outside during HFJV due to the differences in the speed of gas moving on the inside versus the outside of a tube. As such, bidirectional flow is facilitated. In the centre of the airway, there is a fast-moving channel of air entering the lungs, whilst at the peripheries the gas moves out of the lung thus facilitating oxygenation and hypocarbia.

Taylor type dispersion also plays a part (10). This is the diffusion of high-velocity gases from the centre to the margins of the alveolus facilitating oxygenation by moving it to the alveolar membrane and removing carbon dioxide from the alveolus back into the connecting airways. Pendelluft or collateral ventilation (10) is the movement of gases between the lungs due to changes in compliance and resistance. Therefore, some areas of the lung fill more rapidly or empty quicker than others. This can enable gas flow from one alveolus to another in separate lung units locally recirculating the oxygen rich gas. Molecular diffusion contributes to HFJV all be it minimally. This is the movement of molecules from an area of high to low concentration thus facilitating oxygen entry to low oxygen concentration in the alveolus from the high concentration of oxygen in entrained air. Cardiogenic mixing occurs due to agitation of the lung units by the cardiac ventricular walls. In classical HFJV, expiration was a passive process assisted by the elastic recoil of the lungs and chest wall. In modern ventilators, they account for expiration thus minimising carbon dioxide accumulation thus increasing the potential surgical time.

Types of jet ventilation

HFJV

HFJV is a form of time-cycled pressure-limited ventilation (1). The underlying principle of HFJV is the artificial application of intermittent pulses of high-pressure gas using supra-physiological frequencies (11). High-frequency ventilation also covers the techniques of high-frequency positive pressure ventilation (HFPPV), now obsolete, and high-frequency oscillation ventilation (HFOV) used in neonatal and paediatric medicine.

HFJV allows the intermittent application of a high-pressure gas through a small-bore needle or cannula which may be placed supraglottic, subglottic or transtracheal. It commonly uses frequencies of 110–140/min and uses a fresh stream of gas allowing entrainment of a second gas during its use. Parameters adjustable during HFJV include the rate/frequency of breaths per minute (f), the DP, inspiratory time (I time) and the fractional inspired oxygen content (FiO₂).

The ‘Monsoon’ (Acutronic Medical Systems AG, 8816 Hirzel, Switzerland) (Figure 1) and ‘Twinstream’ (Figure 2) (Carl Reiner GmbH, Vienna, Austria) ventilators are currently the two leading the market ranging from 4–600/min. The monsoon delivers heated, humidified jets of air that are interrupted by an electrical solenoid valve adjusting the respiratory rate and creating a square pressure waveform.

Figure 1 Monsoon jet ventilator (Acutronic Medical Systems AG, 8816 Hirzel, Switzerland).

Figure 2 Twinstream jet ventilator (Carl Reiner GmbH, Vienna, Austria) (12).

The Twinstream ventilator has the added advantage of being able to provide high- and LFJV simultaneously or alternatively, resulting in a bi-level mode of ventilation. It is currently the only device on the market, which uses a microprocessor to allow for this multifunction, and therefore can control the positive end-expiratory pressure (PEEP) and plateau pressure.

LFJV

LFJV delivers high-pressure gases via a narrow cannula commonly using a hand-held device at frequencies of 10–20 breaths/min for short procedures e.g., laryngoscopy. Oxygenation can be achieved either via a needle, suspension laryngoscope or bronchoscope. Entrainment of air occurs during this process, and it remains of high importance to maintain an open airway to allow for passive expiration, especially at the level of the larynx to avoid any complications by baro- or volutrauma. Similarly, to HFJV, this technique allows for a motionless operating field but is more commonly used during shorter procedures. The adequacy of ventilation can’t be assessed via capnography so meticulous observation of clinical signs of a patent airway and consideration of hypercapnia is important in these cases (13).

The currently available manually driven low-frequency jet ventilators include the Sanders (VBM Medizintechnik GmbH-Germany, Sulz a. N. Germany), the ManuJet III (VBM Medizintechnik GmbH-Germany, Sulz a. N. Germany) and the Ventrain (Ventinova Medical B.V., Eindhoven, the Netherlands). The Sanders jet ventilator (Figure 3) is a manually operated pressure regulating valve connected to a high-pressure oxygen source. It is squeezed to deliver the jet at the selected pressure, 0.5–3 Bar, and usually held for one second before being released for 4–5 seconds to facilitate passive exhalation.

Figure 3 Sanders jet ventilator (14).

The Ventrain handheld ventilation device was developed based on the concept of allowing active positive inspiratory pressure whilst also performing active expiration using suction and the Bernoulli effect. This gives it the greatest advantage in comparison to the other manual jet ventilation systems available as it allows for safe expiration reducing the risk of barotrauma. It was initially designed to be used via the transtracheal route using a narrow bore cannula such as Cricath and to be part of the CICO algorithms (15). Duggan et al. showed that the use of transtracheal jet ventilation had improved success rates if used during elective cases, but high complication rates (51%) in addition to device failure and barotrauma were reported in CICV cases (15). However, limited experience meant that whilst its use remains available in some hospitals, not many British anaesthetists have experience with it (16).

Jet ventilation delivery systems

Supraglottic delivery systems

All supraglottic delivery systems avoid the use of an ETT facilitating surgical access. Supraglottic jet ventilation may be provided using a fine bore needle attached to the surgical suspension laryngoscope or by using a narrow bore catheter. Whilst this allows for a tubeless surgical field it may come at the expense of movement at the vocal cords and the inability to monitor capnography.

Subglottic delivery systems

Subglottic jet ventilation can be achieved by using the Hunsaker Mon-Jet Catheter (Medtronic Xomed, Jacksonville, USA) or LaserJet Catheter (Acutronic Medical Systems AG, Hirzel, Switzerland). The Hunsaker Mon-Jet Catheter (Figure 4) is made from a non-flammable, laser-safe fluoroplastic material with a basket-shaped distal part allowing for central alignment within the airway (18). The largest review to date examining the use of the Hunsaker Mon-Jet Catheter reviewed 837 cases of its use and showed a complication rate of 5.8% (19). This review highlighted the importance of correct patient selection before application and knowledge of the use of jet ventilation and troubleshooting. Similarly, the LaserJet Catheter (Figure 5) is made from non-flammable polytetrafluoroethylene and is now more widely used for laryngeal laser surgery (20). Both catheters allow for side-stream capnography monitoring via a second proximal port.

Figure 4 Hunsaker Mon-Jet catheter (Medtronic Xomed, Jacksonville, USA) (17).

Figure 5 The LaserJet catheter (Acutronic Medical Systems AG, Hirzel, Switzerland).

Transtracheal delivery systems

The transtracheal route may be used as a strategy for oxygenation in cases with difficult airway or surgical access. In those patients with pharyngeal and laryngeal pathology caused by malignancy, surgery or radiotherapy managing the airway is particularly challenging. Tracheal intubation is often impractical and historically a primary tracheostomy has been the chosen technique (21). However, this is not without risk. Transtracheal catheters have the advantage of a minimally invasive technique, with a clear surgical field that can be initiated before the induction of general anaesthesia and maintained after emergence (22). The Ravussins cannula (VBM Medizintechnik GmbH-Germany, Sulz a. N. Germany) is a commonly used transtracheal cannula for microlaryngoscopies. However, complications from barotrauma have occurred because of airway outflow obstruction during jet ventilation (23). The use of automated HFJV has been shown to reduce the risk of complications if operated by an experienced anaesthetist in these transtracheal delivery systems (24).

Role of jet ventilation in difficult intubation

In the 2004 DAS guidelines for the management of the unanticipated difficult intubation (6), jet ventilation was considered an appropriate management in the ‘can’t intubate, can’t ventilate’ scenario. It was later taken out of 2015 DAS guidance (7) in favour of the simplified scalpel-bougie-tube technique to streamline and simplify guidance in these high-pressure scenarios. The evidence suggests that in technically demanding, stressful CICO scenarios with notoriously challenging human factors jet ventilation is associated with a high risk of device failure and barotrauma (15). Resultantly the authors recommend following the DAS guidance of scalpel-bougie-tube in the first instance in a CICO scenario.

Discussion

Complications arising from the use of jet ventilation include barotrauma, catheter malposition and inadequate gas exchange (Table 2). Equipment failures and technical complications may occur due to catheter blockage, kinking, malpositioning or dislodgment/disconnection during use. For this reason, an allocated staff member should be continuously visualising and ensuring a good jet catheter position, usually done by a second anaesthetist or trained nurse. Poor gas exchange during jet ventilation commonly leads to hypercapnia and/or hypoxia. Subglottic jet catheters such as the LaserJet catheter now have a sidestream capnography port and the Monsoon ventilator provides warmed humidified gas jets.

Barotrauma and air entrapment have been reported in case studies (25,26), but remain a rare complication (5,18). A 10-year review of jet ventilation complications showed that the use of subglottic jet ventilation catheters was the single independent factor leading to barotrauma (23).

Several studies have tried to determine predictive factors for complications and adverse events in these cases. A review showed an association between obesity and previous airway surgery and the occurrence of adverse events (27). Similarly, Tang et al. showed that a BMI greater than 25 was linked to hypercapnia in patients undergoing HFJV (28).

Complications and adverse events can be avoided by regular training and meticulous attention and care during use, ensuring safe settings are used and alarms are engaged. There are no set standards or guidelines for the use of jet ventilation, but most departments rely on their own standard operating procedure and experienced staff. The volume of gas delivered is set by three main parameters including the DP, the frequency (f) and inspiratory time (IT), normally set as a percentage. Table 3 gives suggestions for commonly used settings.

To ensure safe use and avoid the occurrence of barotrauma, alarms should be set for the pause pressure and peak inspiratory pressure. The pause pressure is measured at the distal jet ventilation catheter and reflects the mean airway pressure. Once the alarm is engaged any further inspiration is stopped. The fractional-inspired oxygen (FiO₂) can also be altered and is commonly reduced to 0.4 during laser surgery. Several automated devices now contain a laser setting which automatically reduces the FiO₂ and signals a message when it is safe to use the laser.

Hypercapnia can be overcome by increasing the DP and thus tidal volume and by decreasing the frequency or inspiratory time to increase the exhalatory time. An increase in the frequency without a change of the other parameters may inadvertently lead to hypercapnia. Hypoxia can be managed by increasing the DP, and inspiratory time of FiO₂. Supplemental oxygen can be provided via high-flow nasal cannulas (e.g., Optiflow).

Awareness of human factors and communication are paramount for patient safety, especially during shared airway surgery. As highlighted in previous major reviews such as the Fourth National Audit Project in the United Kingdom and Closed Loop Analysis in the United States, failures in communication can lead to complications in airway management (5,29). A single-centre study introduced a jet-ventilation communication protocol including a surgical-led debrief, and staff and equipment checklists and showed that manual jet ventilation can be performed safely even with inexperienced staff (30). This study emphasised the importance of a detailed theatre team discussion before the start of the list, discussing the type of jet ventilation used and the rescue plans available. The recently published human factors guideline for anaesthesia also encourages the use of focused team debriefs encouraging all theatre team members to participate and plan through possible challenges and complications of the planned procedure (31). Consequently, clear team communication and pre-procedural planning are required when using jet ventilation to ensure optimal patient outcomes.

Further applications of vet ventilation

In recent years, the use of jet ventilation in head and neck surgery and intensive care has expanded to other specialities including hepatobiliary surgery, cardiac interventions, thoracic surgery, and extracorporeal lithotripsy for urological procedures. The use of HFJV was described in percutaneous radiofrequency ablation of liver tumours due to its ability to reduce ventilation-related liver movement. Thermal ablation is used as a curative therapy for liver tumours and precise use of the ablation device is key. A case report by Biro et al. reports the use of a subglottic HFJV via a disconnected ETT using a DP of 1.8 bar and a frequency of 150 cycles/min. Spiral computed tomography (CT) images were taken before and post-HFJV and showed a clear reduction in the cranio-caudal swinging of the liver from 20 to 5 mm (32).

A case series using a 3D marker shield and CT imaging to analyse the ventilation-associated movement for patients undergoing stereotactic liver ablation under general anaesthesia showed similar results. In the mentioned case, the jet catheter was placed through an ETT which was left open to air to allow the escape of gases (33). However, an ETT adapter such as the ‘LifePort’ by Bunnell allows for easy switching between conventional and jet ventilation, as its triple port system allows for jet injection and pressure monitoring. Similarly, the Evone ventilator (Ventinova Medical B.V., Eindhoven, The Netherlands) in Figure 6 allows for multifunction ventilation, allowing not only ventilation via an ETT or Trilumen tube by controlling inspiration and expiration flow from a set PEEP to a set peak pressure and vice versa (34) but also HFJV when an open airway is present.

Figure 6 The Evone ventilator (Ventinova Medical B.V., Eindhoven, The Netherlands).

Similarly, HFJV has been used as a method of ventilation for patients undergoing cardiac ablation for atrial fibrillation and other arrhythmias. A retrospective study comparing its use to standard ventilation showed reduced procedural times and a higher success rate secondary to less atrial motion (35). Whilst the number of randomised controlled trials comparing its use to standard ventilation in cardiac intervention remains limited, there is evidence of improved outcomes. Moreover, the use of HFJV is expanding further, recently being used in a case report of a patient undergoing a Mitraclip insertion for valve repair (36).

Extracorporeal shockwave lithotripsy is another procedure in which the use of HFJV has been investigated to reduce kidney movement intra-operatively and case series and studies have shown improved surgical conditions and reduced operative times (37,38). Whilst additional uses of HFJV to minimise movement from ventilation are expanding across other specialties further studies are required to precisely evaluate its advantages and risk profile.

Conclusions

Jet ventilation is a commonly used technique to ventilate patients during maxillofacial and laryngotracheal surgery. Alongside apnoeic nasal oxygenation, THRIVE and percutaneous tracheostomies, jet ventilation provides another effective technique in the arsenal of the maxillofacial and laryngotracheal anaesthetist. Here we have shown modern advancements have made jet ventilation safe, operational, and an appropriate technique for patients and clinicians alike. Future recommendations include national standardised operating procedures and the continued investment and multidisciplinary participation in jet ventilation training for all anaesthetists for both the difficult and elective airway.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Chris Jones & Bhavesh Patel) for the series “Anaesthesia for Maxillofacial Surgery” published in Journal of Oral and Maxillofacial Anesthesia. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://joma.amegroups.com/article/view/10.21037/joma-23-24/rc

Peer Review File: Available at https://joma.amegroups.com/article/view/10.21037/joma-23-24/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-23-24/coif). The series “Anaesthesia for Maxillofacial Surgery” was commissioned by the editorial office without any funding or sponsorship. O.D. is an active member of the European Society of Anaesthesiology and Intensive Care (ESAIC) and European Society of Airway Management and sits on both boards. These are unpaid roles and do not conflict with this article. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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