ENT/HEAD & NECK
Transtracheal jet
ventilation
Shubhranshu Gupta
Rob O’Donnell
Abstract
Transtracheal jet ventilation (TTJV) is a method of lung ventilation via a
narrow-bore catheter placed percutaneously into the trachea, bypass-
ing the upper airway and glottis. A pressurized jet of oxygen that en-
trains air is delivered to the lungs. This technique can be utilized in
both elective and emergency situations. The Difficult Airway Society
(DAS) recommend that the use of TTJV in ‘can’t intubate, can’t
oxygenate’ (CICO) situations be limited to experienced clinicians
who regularly use the technique in routine clinical practice, advocating
that a surgical approach be the default technique for most in this sit-
uation. Prophylactic insertion of a transtracheal catheter in situations
where airway management is anticipated to be difficult is also well
described. If successful, this technique allows for continued oxygena-
tion of the patient while attempts are made to secure a definitive
airway. This article will examine the indications for TTJV and the phys-
iology behind its mechanism of action. We will also describe the
equipment required, technique and potential complications.
Keywords Difficult airway; failed intubation; jet ventilation; Ravussin
needle; transtracheal
Royal College of Anaesthetists CPD Matrix: 1B02; 2A01; 3A01; 3A02
Transtracheal jet ventilation (TTJV) is a method of lung venti-
lation via a percutaneously placed narrow-bore (usually an in-
ternal diameter of
2 mm, or 14 gauge) catheter into the trachea,
bypassing the upper airway and glottis. Jet ventilation involves
the delivery of a pressurized jet of oxygen that entrains air. Jet
ventilation can be low frequency or high frequency.
High-pressure jet ventilators are able to generate an adequate
inspiratory flow through a small bore catheter. The tidal volume
is composed of the jet volume plus the volume of entrained gas.
Adequacy of ventilation is assessed by chest expansion. Upper
airway patency must be maintained in order to allow passive
expiration from elastic recoil of the lungs and chest wall. Without
this, a narrow diameter catheter would not allow adequate
expiration due to the high resistance to flow. In ‘can’t intubate,
can’t oxygenate’ (CICO) emergencies the upper airway may be
partially or completely obstructed e this may be the underlying
Shubhranshu Gupta MBBS FRCA is a Consultant Anaesthetist at the
Queen Elizabeth University Hospital, Glasgow, UK. Conflicts of
interest: none declared.
Rob O’Donnell MBChB MSc FRCA is an ST7 in Anaesthetics at the
Queen Elizabeth University Hospital and an Honorary Clinical
Lecturer at the University of Glasgow, UK. Conflicts of interest: none
declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 21:4
Learning objectives
After reading this article, you should be able to:
C explain the indications for transtracheal jet ventilation
C describe the methods for carrying out transtracheal jet
ventilation
C discuss the potential complications of transtracheal jet
ventilation
cause of the failure to intubate and oxygenate, or may be present
in combination with other factors.
Ventilation may be more effective when some degree of
airway obstruction is present, as this may prevent some backflow
of gas.1 The priority, however, is to maintain some degree of
airway patency in order to avoid barotrauma.
High-frequency ventilation utilizes a rapid respiratory rate
and low tidal volumes. Transtracheal high-frequency jet venti-
lation (HFJV) with an automated ventilator may offer some
protection against pressure related complications by means of
pressure monitoring and alarms, and an automatic cut-off trig-
gered by high peak or plateau airway pressures. Reduction in
airway driving pressure and frequency of ventilation are used to
lower airway pressures.2
History
Reed et al. and Jacoby et al. published studies on transtracheal
catheterization in the 1950s. Sanders described jet ventilation via
a rigid bronchoscope in 1967. Spoerel was the first to combine
percutaneous access to the trachea via the cricothyroid mem-
brane with jet ventilation e this allowed not only adequate
oxygenation but also CO2 excretion.
The early use of transtracheal catheters focused on their use in
resuscitation and in the management of unanticipated difficult
airways. From the 1980s onwards, publications also described
the technique for use in elective ENT surgery. In 2003, trans-
tracheal catheterization was included in the American Society of
Anaesthesiologists guidelines for management of the difficult
airway.
Physiology
Gas exchange in low-frequency TTJV occurs mainly via
convective ventilation or bulk flow, i.e. mass flow of gas into and
out of the lung. The alveolar ventilation is calculated using the
formula:
VA ¼ f  ðVT  VDÞ
where VA is alveolar ventilation, f is rate of ventilation, VT is
tidal volume and VD is dead space volume.
The delivered FiO2 depends on the volume of the main jet
flow (FiO2 of 1.0) and the volume of entrained air in the side flow
due to the Venturi effect (FiO2 of 0.21).
Inspired flow may be lost to the upper airway if it is patent,
resulting in insufficient tidal volume.3 Increasing upper airway
obstruction may divert more flow to the lungs and result in
increased tidal volume (TV) but result in a longer expiratory
185 Ó 2020 Elsevier Ltd. All rights reserved.
 ENT/HEAD & NECK
time, whereas a lesser degree of upper airway obstruction may
result in lower TV, but preserved minute volume (MV) due to a
shorter expiratory time.
HFJV delivers tidal volumes that are lower than the combined
anatomical plus equipment dead space. Some bulk flow may be
possible in the alveoli close to the conducting airways but this
does not account for adequate ventilation. The above equation
does not therefore explain gas exchange in this situation, as other
mechanisms are involved.4
Laminar flow occurs in the smaller airways where Reynolds
number is low, which results in a parabolic airflow: the centre of
the airflow has a higher velocity than that around it. Jet venti-
lation amplifies the difference in velocities of gas such that gas at
the centre of the airflow moves into, and that at the margins
tends to move out of, the lung.
Taylor-type dispersion describes the interaction between axial
parabolic velocity and the radial concentration gradient and ex-
plains further mixing of gases in smaller airways. In larger air-
ways, turbulent flow eddy currents in combination with bulk
flow result in a similar radial mixing effect.4
Pendelluft or collateral ventilation results from variable time
constants of alveoli and leads to flow of gas from one alveolus to
another. This is more pronounced in high-frequency breaths and
facilitated by higher mean airway pressures seen in HFJV leading
to extensive recirculation of gas between regions. Smaller vol-
umes of gases reach more respiratory units as compared to the
tidal volumes used in conventional ventilation.4
Jet ventilation is effectively a form of time-cycled, pressure-
limited ventilation. A decrease in compliance of the system re-
sults in a reduction in minute ventilation and it is the driving
pressure rather than the frequency of ventilation that determines
CO2 elimination.
Indications
The use of TTJV in both the elective and emergency settings is
well described. Within the elective setting it is most commonly
used for airway management during ENT procedures, in partic-
ular laryngeal and tracheal surgery, where it offers the advantage
of providing the surgeon with an unobstructed view of the
larynx.
TTJV is recommended in the management of CICO emergen-
cies by numerous airway guidelines and was previously advo-
cated in the Difficult Airway Society (DAS) guidelines on the
management of the unanticipated difficult airway, until the most
recent edition published in 2015.5 DAS now recommends a sur-
gical cricothyroidotomy using a scalpel/bougie/endotracheal
tube technique, with TTJV reserved for use only by those clini-
cians experienced with the technique in their routine clinical
practice. This is due to the number of adverse events noted with
TTJV in the emergency situation, particularly CICO. A systematic
review of 428 procedures by Duggan et al. in the British Journal
of Anaesthesia in 2016 found a statistically significant higher risk
of adverse events with the use of TTJV in CICO emergencies in
comparison with non-CICO emergencies and elective use.6 De-
vice failure occurred in 42% of CICO emergencies versus 0% of
non-CICO emergencies and 0.3% of elective procedures. Baro-
trauma occurred in 32% of CICO emergencies versus 7% non-
CICO emergencies and 8% elective procedures. The occurrence
ANAESTHESIA AND INTENSIVE CARE MEDICINE 21:4
of more than one complication was also higher in CICO
emergencies.
The National Audit Project 4 (NAP4) Major Complications of
Airway Management in the United Kingdom reported a high
failure rate with emergency cannula cricothyroidotomy of
approximately 60%, whereas a surgical technique was almost
always successful.7
In the urgent non-CICO situation, lung ventilation via a pro-
phylactically inserted transtracheal catheter can maintain
oxygenation and may allow time to attempt to secure a definitive
airway. TTJV may also be a useful aid for intubation where the
larynx is obscured by swelling or tumour, with intubation guided
by visualization of expiratory gas bubbles in the pharynx. It also
serves as a potential alternative to primary tracheostomy, which
may place considerable stress on the awake patient.8
THRIVE (transnasal humidified rapid insufflation ventilatory
exchange) is a method of apnoeic oxygenation, delivered by
systems such as OptiflowÔ Nasal High Flow by Fisher and
Paykel Healthcare. It offers the ability to preoxygenate the patient
and may afford time to prepare equipment prior to commencing
jet ventilation. It may also allow maintenance of oxygenation and
ventilation throughout surgery without the need for transtracheal
jet ventilation. Its mechanism of action is via the triad of apnoeic
oxygenation, apnoeic ventilation and continuous positive airway
pressure (CPAP), which prevents atelectasis. One major limita-
tion to this method, however, is its reliance on a patent airway in
order to be successful. A jet ventilator should be available in case
of failure of the nasal high-flow system.
Equipment
There are numerous different cannula types and sizes for use in
jet ventilation. A kink-resistant cannula should be used, such as
the Ravussin cannula (VBM Medizintechnik, Germany) or the
emergency transtracheal airway catheter (Cook Medical, Bloo-
mington, USA).
The Teflon-made VBM cannula (Figure 1) has a curved shaft
and angled connector that sits flush with the skin and is secured
with the Velcro strap provided. It is produced in three sizes: 13G
for use in adult patients and 14G and 18G for paediatric patients.
It has two connectors: a 15-mm diameter ISO (International Or-
ganization for Standardization) male connector that allows
connection with a standard anaesthetic system for oxygenation
insufflation, and a Luer lock connector for high-pressure jet
ventilation.
There are several methods for oxygenation via the catheter:
 Anaesthetic circuit, which will enable apnoeic oxygena-
tion. Other methods of connection to a low-pressure oxy-
gen outlet have been described. Cook produces oxygen
tubing designed for connection to a transtracheal catheter
and which allows manual control of oxygen flow and
ventilation via the transtracheal catheter.
 Sanders injector connects to a 4 bar oxygen source to
enable jet ventilation. There is a variable outlet pressure
version, the Manujet made by VBM (Figure 2), which in-
creases safety as driving pressure can be adjusted between
0 and 4 bar.
 Jet ventilator, for example the Mistral (Acutronic Medical
Systems, Switzerland) (Figure 3), is a high-frequency
186 Ó 2020 Elsevier Ltd. All rights reserved.
 ENT/HEAD & NECK
Figure 1 VBM transtracheal catheter.
Figure 2 Sanders injector.
Figure 3 Mistral jet ventilator.
ventilator and can ventilate at rates of 12e600 per minute,
with a driving pressure of 0e4 bar and a variable inspi-
ratory: expiratory (I:E) ratio. This ventilator also monitors
pause pressure and will cut out if intratracheal pressure is
above a set level (usually 10e30 mbar).
Technique
Open the cannula in a sterile fashion and draw 2.5 ml of saline
into a 5-ml syringe. Prepare a three-way tap with a short
ANAESTHESIA AND INTENSIVE CARE MEDICINE 21:4
extension and attach capnograph tubing to the side arm. All
equipment should be checked and in working order.
The cricothyroid membrane is the preferred puncture site due
to the ring-shaped cricoid cartilage protecting against puncture of
the posterior tracheal wall and potentially the oesophagus.
Optimal patient position is supine with the neck extended. This
may be difficult in a patient with respiratory distress but can-
nulation is possible in a patient with a flexed neck who is sitting
up. Identification of the anatomy and marking the position of the
thyroid cartilage, the cricoid cartilage and midline is useful
(Figure 4). Aseptic technique should be used, including cleaning
the skin with 2% chlorhexidine and donning sterile gloves.
In an awake patient, 2% lidocaine should be infiltrated sub-
cutaneously at the insertion site. Injection of lidocaine into the
trachea aids insertion and is also a useful method of confirming
needle position in the trachea. Ultrasound may be used to locate
the trachea if the anatomy is distorted by tumour, swelling or
trauma.9
For the right-handed technique, stand on the patient’s left side
and stabilize the larynx by placing the index and middle fingers
of the left hand on either side of the trachea at the level of
insertion; this will also help insertion into the midline (Figure 5).
Attach the 5 ml saline-filled syringe to the cannula and insert the
needle perpendicular to the skin, advancing until a ‘pop’ is felt.
There should be no resistance on aspiration and air is seen as
bubbles in the saline confirming placement in the trachea. Re-
angle the needle caudally at 45 degrees to the skin and
advance by a further 2 mm to ensure that the cannula is in the
trachea and then smoothly advance the cannula over the needle
(Figure 6).
Remove the needle from the cannula and attach the three-way
tap with a short extension. Re-attach the syringe and confirm air
aspiration. Capnography should always be used for further
confirmation of correct placement.7 Secure the cannula and
attach the Sanders injector or jet ventilator. A single jet can be
given to further confirm correct placement. Before commencing
jet ventilation, it is vital to ensure a clear upper airway for the
expiratory pathway (Figure 7), which may require opening the
mouth, performing airway manoeuvres or inserting airway
adjuncts.
Ventilation is initiated using 100% oxygen at a low driving
pressure, typically 1 bar if using a Sanders injector with a
reducing valve or an automatic ventilator. It can then be gradu-
ally increased until adequate ventilation is achieved. Chest
movement should be closely observed to ensure complete expi-
ration prior to the next jet of air. Slow expiration due to partial
upper airway obstruction is common and constant vigilance is
vital to prevent barotrauma.
Complete obstruction of the upper airway is rare. Insertion of
a second cannula into the trachea to create an expiratory
pathway has been suggested but would allow only very slow
expiration. If the chest does fail to deflate, do not give another jet.
Once the chest is inflated with oxygen, oxygen tubing may be
attached with a flow rate of 300 ml/min. This has the potential to
maintain oxygenation in a pre-oxygenated patient while attempts
are made to obtain a definitive airway by tracheostomy or intu-
bation via the upper airway.
The Ventrain (Dolphys Medical, Netherlands) is a jet venti-
lator that may be beneficial in an obstructed upper airway, and
187 Ó 2020 Elsevier Ltd. All rights reserved.
 ENT/HEAD & NECK
Figure 4 Patient positioned, with cricoid cartilage, thyroid cartilage
and first tracheal ring anatomy marked.
Figure 5 Insertion of the transtracheal catheter.
Figure 6 VBM catheter advanced over the needle.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 21:4
Figure 7 Jaw lift to maintain patent upper airway.
certainly in complete airway obstruction, as it allows active
expiration by generating suction using the Venturi effect, aug-
menting expiration and functioning as a bidirectional airway.10
This results in better PaO2, significantly lower airway pressures
and less risk of hyperinflation with consequent barotrauma and
cardiovascular depression.
Oxygenation may be difficult in obese patients; increasing the
I:E ratio and driving pressure as well as positioning the patient
head-up may help.
Transtracheal jet ventilation provides excellent gas exchange
in most patients and there is no time limit on the duration of
ventilation. However, during long procedures, the oxygen will
cause drying of the tracheal mucosa that can be prevented by
using a humidification system or regular irrigation with saline.
End-tidal CO2 levels cannot be continuously monitored. A
three-way tap can be attached and intermittently opened to the
CO2 analysis port during expiration, or blood gas analysis can be
performed to establish the arterial PaCO2.
Postoperatively, the cannula can be left in situ for up to 72
hours if felt necessary, for example, due to potential for airway
swelling postoperatively. Such patients must be nursed in an area
with the appropriate expertise and clear instructions should be
provided regarding the cannula’s use and removal.
The VBM cannula is not laser safe, although may have some
resistance to damage from a laser strike as it is made from Teflon.
Complications
Hypoxia
This can be from hypoventilation, misplacement of the cannula
or barotrauma. Inadequate oxygenation during TTJV is more
common in obese patients.
Misplacement
There may be failure to place the cannula in the airway; this may
be due to technical difficulty or due to incorrect technique.
Subcutaneous emphysema has also been described and is more
common with repeated attempts at cannulation.
188 Ó 2020 Elsevier Ltd. All rights reserved.
 ENT/HEAD & NECK
Equipment failure
The cannula may kink or break, and can dislodge from the
airway if not secured prior to commencement of jet ventilation.
The cannula hub can also dislodge from the oxygenation device.
Barotrauma
Pneumothorax and pneumomediastinum usually occur only if
the expiratory pathway is obstructed. Constant observation of
chest movement to ensure complete expiration prior to the next
jet, or use of an automatic, pressure limited jet ventilator will
reduce this. If severe, the effects of barotrauma can lead to
distortion of the anatomy, making a definitive surgical airway or
oral intubation impossible. Cardiovascular instability and
collapse may also occur due to impairment of cardiac output
secondary to barotrauma.
Haemorrhage/trauma
There are no reports of major haemorrhage, but minor haemor-
rhage or bruising may occur at the insertion site. If a major vessel
is inadvertently punctured, remove the cannula and apply pres-
sure until cessation of bleeding.
Infection
Aseptic technique should be employed during cannula insertion
as infection at the insertion site has been reported.
Human factors
Lack of training and familiarity may result in incorrect use of
equipment and ventilation technique. Regular training and drills
should be undertaken in order to reduce the impact of human
factors and improve crisis resource management. A
ANAESTHESIA AND INTENSIVE CARE MEDICINE 21:4
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189 Ó 2020 Elsevier Ltd. All rights reserved.