Percutaneous Transtracheal Jet Ventilation
Marzieh Beigom Khezri
Department of Anesthesiology, Medical School, Qazvin University of Medical Science, Qazvin,
Iran. E-mail: mkhezri@qums.ac.ir
Learning objective:
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Describes a method of PTJV and oxygen delivery for needle cricothyroidotomy that
is easily accessible, simple to assemble, easy to use, and readily available in every
emergency setting.
Introduction
In a minority of patients, rotine air way management fail, and a surgical airway is required in
order to secure the airway.[1] Two important benefits for the patients who underwent successful
PTJV. First, PTJV provided effective oxygenation while allowing adequate time for upper
airway visualization and possible suctioning of oropharyngeal secretions. Second, the subsequent
tracheal intubation was easier, possibly because the high tracheal pressure from the gas
insufflation opened the collapsed glottis and allowed for better visualization of the glottic
aperture. [2]
Some reports have recommended PTJV only as a transient resuscitative measure for emergent
situations in which endotracheal intubation or other ventilation methods are not feasible.[3,4]
PTJV is widely thought of as a temporizing procedure to be maintained for only 30 minutes at
best. The use of PTJV was not widely accepted at first because of initial reports of high
complication rates.[5,6] Also, PTJV does not provide definitive airway protection against copious
secretions or aspiration. However, animal experiments and clinical studies have demonstrated
that transtracheal ventilation is an effective, quick, fairly simple, and safe way to obtain and
maintain an airway for a prolonged period of time.[7] Transtracheal jet ventilation has been used
extensively as a means of ventilation during surgery and procedures of the upper airway.[8] PTJV
is a rapid procedure for obtaining airway control in both elective and emergency situations for
patients of all ages and in many clinical situations.[ 9,10, 11] However, in a life-threatening
situation in which tracheal intubation and bag-mask-valve ventilation cannot be performed to
restore adequate gas exchange during acute respiratory failure, PTJV must be entertained as a
viable interim maneuver. Under such circumstances, PTJV with a large bore needle provides
immediate oxygenation and ventilation by providing adequate gas exchange and ensuring the
patency of the airway until a definitive procedure such as oral intubation with bronchoscopy
followed by surgical tracheostomy can be performed. It requires fewer instruments and can be
performed more quickly than surgical cricothyrotomy. Transtracheal jet ventilation may be used
even with partial airway obstruction.[12]PTJV can force oropharyngeal secretions out of the
proximal trachea and may force a foreign body out of the proximal trachea (in cases of partial
airway obstruction). However, upper airway patency is required for exhalation during PTJV, and
an open cricothyrotomy is preferred if significant obstruction exists. PTJV is the surgical airway
of choice for children younger than 12 years because of the small tracheal diameter on which an
open cricothyrotomy is often impossible. Although rarely performed, needle cricothyroidotomy
is a potentially life-saving procedure. The range of adapted equipment presently used for needle
cricothyroidotomy is diverse.
A surgical airway can be obtained in the emergency setting in 1 of 2 principal methods:
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surgical cricothyroidotomy
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Needle cricothyroidotomy.[1, 13] ( provides the simplest, fastest, and safest access.)[2, 5]
Cricothyrotomy creates a percutaneous airway through the cricothyroid membrane. Its
advantages over tracheotomy are that the membrane is superficial and relatively
avascular and cartilage incision is not necessary because the height of the membrane is
greater than the distance between the tracheal rings. Cricothyrotomy can be performed
with a surgical or cannula (needle) technique, and appropriate use can prevent anestheticrelated deaths. It is a core skill for the anesthesiologist.
Indications
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Complete upper airway obstruction(surgical cricothyrotomy is preferred over PTJV)
Temporary measure to establish oxygenation until tracheostomy can be done
PTJV is indicated in any situation in which intubation is contraindicated or cannot be
achieved.[14]
The failure or inability to secure a definitive airway by endotracheal intubation in a
timely fashion, and a subsequent inordinate delay in definitive airway control and
oxygenation
PTJV has also been used electively in patients of all ages and as a rescue procedure.
PTJV is the surgical airway of choice for children younger than 12 years of age.
Contraindications
Absolute contraindications
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
If a definitive airway can easily and rapidly be secured with endotracheal intubation,
percutaneous transtracheal jet ventilation (PTJV) is not used.
PTJV is not used in the presence of known significant direct damage to the cricoid
cartilage or larynx.[14]
Relative contraindications
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If complete upper airway obstruction is present, surgical cricothyrotomy is preferred over
PTJV.[15]
PTJV can be used in the presence of partial airway obstruction provided that appropriatesized catheters are used.[15]
Airway obstruction below the vocal cords that renders exhalation difficult or impossible
is a relative contraindication.
Equipment
Equipment for needle cricothyrotomy and percutaneous transtracheal jet ventilation (PTJV)
consists of the following:[4]
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High-pressure noncollapsible oxygen tubing
Needle catheter, 13 or 14 gauge
Oxygen source with a flow at 10-15 L/min
Manual jet ventilator/insufflator device
If a manual jet ventilator/insufflator device is not available, needle cricothyrotomy and PTJV can
be performed with equipment that is readily accessible in emergency settings, is simple to
assemble, and is easy to use. This equipment includes the following:
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
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Oxygen source with a flow at 10-15 L/min(Oxygen could be provided by flashing
oxygen at a rate of 15/L/min)16
Commercial bag-valve-mask device (Ambu bag) that includes noncollapsible oxygen
tubing and a reservoir bag
Large-bore, over-the-needle intravenous catheter (14 ga; 2 in) Plastic syringe, 3 mL, with
Luer lock tip, that fits tightly into a 7.5-mm inner diameter endotracheal tube adapte
Inner adapter of 7.5 mm endotracheal tube
Click here to see video
Equipment assembly
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Connect the intravenous catheter to a 3-mL syringe barrel (with its plunger removed).
Connect the 3-mL syringe barrel to a 7.5-mm inner diameter endotracheal tube adapter.
Lock the valve of the bag-valve-mask device and connect its oxygen tubing to an oxygen
source with a flow at 10-15 L/min. (Oxygen could be provided by flashing oxygen at a
rate of 15/L/min)16
Connect the endotracheal tube adapter to the bag-valve-mask device.
Manually ventilate at a rate of 1-second compression with 4-second relaxation
(ventilations are guided with chest rise).
Positioning
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The patient ideally should be positioned to expose the neck and its landmarks (see image
below). If no contraindications are present (eg, known or suspected cervical spine injury),
place the patient's head in a hyperextended or "sniffing" position. Extension of the neck
aids identification of the anatomy and control of the cricoid space.
The cricothyroid membrane is located by identifying the dip or notch in the neck below
the laryngeal prominence. The cricothyroid membrane is bounded by the thyroid cartilage
superiorly and the cricoid cartilage inferiorly. The landmarks are most easily found by
placing the index finger on the prominence of the thyroid cartilage and slowly palpating
downward until the finger "drops off" the thyroid cartilage and onto the cricoid
membrane.
Airway protection during percutaneous transtracheal jet ventilation (PTJV) is attained by
positioning the patient to allow drainage of secretions away from the larynx during
expiration, so upward gas flow through the larynx causes secretions and blood, for
example, to be blown away from the larynx.
Technique
Before percutaneous transtracheal jet ventilation (PTJV) can begin, a needle cricothyrotomy
must be performed.
Needle cricothyrotomy
Description: Catheter passed through cricothyroid membrane allowing for jet ventilation
(oxygenation through small transtracheal catheters) via specialized ventilator.
Anesthesia
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Lidocaine 1-2% at a dose of 2-3 mL is generally sufficient for local skin anesthesia via
infiltrative administration in patients who are alert and awake. Injection of a small
amount of anesthetic percutaneously into the trachea itself will blunt the cough response
as well.( If the patient is alert or concern exists about the cough reflex, prepare another 5mL syringe containing 4 mL of 1% lidocaine with a 25-ga needle).
Some advocate that 2 mL of lidocaine be sprayed into the larynx/trachea percutaneously
to suppress the cough reflex.
o
o
Attach a small (3-5 mL) syringe containing 1-2 mL of sterile normal saline or
water to a large-bore needle (13 or 14 ga). A small bend in the distal 2.5 cm
segment of the needle can facilitate advancing the catheter once the trachea has
been cannulated. There are also commercially available catheters with a slight
bend at the tip specifically for PTJV.
While the dominant hand holds the syringe and needle containing saline, with the needle
directed caudally at 30-45° to the skin, hold and stabilize the larynx with the nondominant
hand. Stabilize the cricoid cartilage with the thumb and middle fingers of the nondominant
hand, and palpate the cricothyroid membrane with the nondominant index finger.

Insert the needle through soft tissues, the skin, and the cricothyroid membrane. The
cricothyroid membrane should be punctured in the inferior aspect (ie, nearer the cricoid
Cartilage than the thyroid cartilage) to avoid puncturing the cricothyroid arteries.
While exerting negative pressure on the barrel of the syringe, insert the needle through the
cricothyroid membrane into the larynx. Air bubbles in the fluid-filled syringe signify entry
into the larynx.
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After entering the larynx, advance the cannula into the larynx and trachea, and then
remove the needle.
If much resistance is encountered when the needle or catheter is passing through the skin,
subcutaneous tissue, or cricothyroid membrane, kinking or bending of the catheter may
occur unless a stiffer catheter is used. A small nick in the skin may be needed to facilitate
passage through the dermis into the subcutaneous tissue. A percutaneous dilational or
Seldinger guidewire technique may result in fewer complications.[ 17,18]
Secure the cannula by suturing it to the skin or by placing a circumferential tie around the
neck. The proximal end of the cannula must be snug or tightly fitting and securely held
around the puncture wound opening. If the cannula is not securely held in place,
subcutaneous emphysema may result, the cannula may be dislodged from the larynx, or
both.
Connect the oxygen source to the cannula.
Percutaneous transtracheal jet ventilation
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A trial of several bursts of oxygen flow is recommended to make certain that the cannula
is correctly placed and that the setup is working and ventilating properly.
The hypoxic patient should receive 100% oxygen in intermittent bursts < 50 psi at a rate
of 20 bursts per minute. For this, an oxygen source capable of 50 psi is needed, along
with a regulator to ensure delivery of no more than 50 psi.For children, 30 psi has been
recommended. The percentage of inspired oxygen concentration can then be adjusted,
depending on blood gas laboratory results.
The inspiratory phase or insufflation with the burst of oxygen should last approximately 1
second, and the expiratory phase should last long enough to allow for adequate
exhalation, typically 3-4 seconds.[3,19]( slow intermittent rate of 6 breath /min and an
inspiratory –expiratory ratio of 1/4) .16 An adequate expiratory phase is important to
minimize the risk of barotrauma. Ventilation was controlled by manually opening and
closing the valve approximately 12 to 20 times per minute. A successful PTJV was
defined as the insertion of an angiocath through the cricothyroid membrane into the
trachea and restoration of the pulse O2 saturation to > 90% while using high-pressurized
oxygen. An unsuccessful PTJV was defined as the inability to insert the angiocath
through the cricothyroid membrane or the inability to insufflate oxygen with the jet
ventilator.
Pearls
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
To avoid subcutaneous emphysema or a dislodged cannula, be sure to snugly secure the
cannula after insertion.
A small nick in the skin may be needed to facilitate passage through the dermis into the
subcutaneous tissue. Thin catheters may kink or bend in the presence of too much
resistance during insertion.
Percutaneous transtracheal jet ventilation (PTJV) can be performed in patients of all ages.
and it is the surgical airway of choice for children younger than 12 years.
Complications
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Complications with this technique include aspiration, bleeding, pneumothorax,
subcutaneous emphysema, barotrauma (eg, pneumothorax, pneumomediastinum),
catheter-related problems (eg, obstruction or blockage of the catheter, kinking of the
catheter, catheter displacement, misplaced or unsuccessful needle or catheter
placement),[7] and inadequate ventilation.[ 17,20]
The exact incidence of complications with percutaneous transtracheal jet ventilation
(PTJV) is not known, but it is thought to be low, considering that the complication rate of
translaryngeal puncture alone is in the range of 0.03-0.8%.[13]
Disadvantages of PTJV include the following:
o
o
Incomplete control of the airway with subsequent greater potential for aspiration
than with a cuffed endotracheal tube
Potential for barotrauma (subcutaneous emphysema or pneumothorax) if
exhalation is inadequate and airway pressure is elevated
References
1. European Resuscitation Council. Guidelines for the advanced management of the
airway and ventilation during resuscitation. A statement by the Airway and Ventilation
Management of the Working Group of the European Resuscitation Council.
Resuscitation. Jun 1996;31(3):201-30. [Medline].
2. Patel RG. Percutaneous Transtracheal Jet Ventilation A Safe, Quick, and Temporary
Way To Provide Oxygenation and Ventilation When Conventional Methods Are
Unsuccessful. chest 1689;116(6):1689-1694.
3. Stothert JC Jr, Stout MJ, Lewis LM, Keltner RM Jr. High pressure percutaneous
transtracheal ventilation: the use of large gauge intravenous-type catheters in the
totally obstructed airway. Am J Emerg Med. May 1990;8(3):184-9. [Medline].
4. Walls RM. Management of the difficult airway in the trauma patient. Emerg Med Clin
North Am. Feb 1998;16(1):45-61. [Medline].
5. Benumof JL, Scheller MS. The importance of transtracheal jet ventilation in the
management of the difficult airway. Anesthesiology. Nov 1989;71(5):769-78.
[Medline].
6. Patel RG. Percutaneous transtracheal jet ventilation: a safe, quick, and temporary way
to provide oxygenation and ventilation when conventional methods are unsuccessful.
Chest. Dec 1999;116(6):1689-94. [Medline].
7. Jorden RC. Percutaneous transtracheal ventilation. Emerg Med Clin North Am. Nov
1988;6(4):745-52. [Medline].
8. Smith RB, MacMillan BB, Petruscak J, Pfaeffle HH. Transtracheal ventilation for
laryngoscopy. A case report. Ann Otol Rhinol Laryngol. May-Jun 1973;82(3):347-50.
[Medline].
9. O'Connor JV, Reddy K, Ergin MA, Griepp RB. Cricothyroidotomy for prolonged
ventilatory support after cardiac operations. Ann Thorac Surg. Apr 1985;39(4):353-4.
10. Carden E, Ferguson GB. A new technique for micro-laryngeal surgery in infants.
Laryngoscope. May 1973;83(5):691-9. [Medline].
11. Chong CF, Wang TL, Chang H. Percutaneous transtracheal ventilation without a jet
ventilator. Am J Emerg Med. Oct 2003;21(6):507-8. [Medline].
12. Ward KR, Menegazzi JJ, Yealy DM, Klain MM, Molner RL, Goode JS.
Translaryngeal jet ventilation and end-tidal PCO2 monitoring during varying degrees
of upper airway obstruction. Ann Emerg Med. Nov 1991;20(11):1193-7. [Medline].
13. Leibovici D, Fredman B, Gofrit ON, Shemer J, Blumenfeld A, Shapira SC. Prehospital
cricothyroidotomy by physicians. Am J Emerg Med. Jan 1997;15(1):91-3. [Medline].
14. Yealy DM, Stewart RD, Kaplan RM. Myths and pitfalls in emergency translaryngeal
ventilation: correcting misimpressions. Ann Emerg Med. Jul 1988;17(7):690-2.
[Medline].
15. Yealy DM, Menegazzi JJ, Ward KR. Transtracheal jet ventilation and airway
obstruction. Am J Emerg Med. Mar 1991;9(2):200. [Medline].
16. Donlon JV,Doyle JD,Feldman A M.Anesthesia for eye ,ear,,nose, and throat surgery in
miller anesthesia ,2005 ,Chichill levingstone , 2547.
17. Ciaglia P, Brady C, Graniero KD. Emergency percutaneous dilatational
cricothyroidostomy: use of modified nasal speculum. Am J Emerg Med. Mar
1992;10(2):152-5. [Medline].
18. Ophir D, Konichezky S. Minicricothyrotomy for tracheobronchial toilet. Ann Otol
Rhinol Laryngol. May 1990;99(5 Pt 1):337-9. [Medline].
19. Spencer CD, Beaty HN. Complications of transtracheal aspiration. N Engl J Med. Feb
10 1972;286(6):304-6. [Medline].
20. Flory FA, Hamelberg W, Jacoby JJ, Jones JR, Ziegler CH. Transtracheal resuscitation.
J Am Med Assoc. Oct 13 1956;162(7):625-8. [Medline].