Flow-controlled ventilation – a new and promising method of ventilation presented with a review of the literature

Canbaz

et al. 2023

Preprint

Background While actual figures are still lacking, this incidence of laryngotracheal stenosis (LTS) is expected to increase because of the high COVID-19 patient numbers requiring (prolonged) invasive mechanical ventilation. While prolonged intubation is a known risk factor of LTS, LTS related to COVID-19 may be result in a different phenotype: pronation affects the location of stenosis and COVID-19 pneumonia can decline lung mechanics. Therefore, airway management in patients with COVID-19 related LTS has unique challenges for both anesthesiologists and surgeons for its location and severity. This prospective observational feasibility trial aims to evaluate the use of a novel thin, cuffed, endotracheal tube (Tritube) in combination with flow_controlled ventilation (FCV) in the management of patients with LTS secondary to COVID-19 related LTS undergoing laryngeal surgery. Methods 20 patients suffering from COVID-19 related LTS, as diagnosed by CT, requiring endolaryngeal surgery were included. Ultrathin endotracheal tube Tritube, together with FCV was used for airway management and ventilation. Feasibility, ventilation efficiency and surgical exposure were evaluated. Results Median duration of mechanical ventilation during their ICU stay was 17 days, [range (7-27] and the prone position was used in all patients. In 18/20 patients endoscopic diagnosis, confirmed the initial CT diagnosis: posterior subglottic stenosis. Visual Analogue Scale (VAS) score was 9 out of 10 (range 7-10). FCV ventilation was performed with or without CO2 laser. All hemodynamic and respiratory variables were within the normal clinical range. In 1 patient a respiratory complication occurred, meaning that the SpO2 temporarily dropped to 89 %. Note that this patient had SpO2 of 90 % before induction of anesthesia. Conclusion This study shows that it is feasible to use Tritube with FCV in patients with unusual location of tracheal stenosis, namely a subglottic posterior location, undergoing laryngotracheal surgery. Tritube provides a good surgical field and FCV provided highly adequate ventilation especially in patients with compromised lung mechanics. Trial registration Clinical trial registration was done prospectively (NCT05317923) on 08/04/2022.

Section: Discussionsupporting

confidence: 61%

“…The bene ts of Tritube in upper airway surgery, a.o. improving surgical exposure and working conditions, have been described [7][8][9][29][30][31][32][33][34][35]. We con rm the great surgical exposure as the VAS was ranked 9 out of 10 (7-10).…”

Section: Discussionmentioning

confidence: 60%

Airway management during unusual tracheal stenosis: A Clinical Feasibility Trial

Canbaz

et al. 2023

Preprint

Journal of Health Sciences and Medicine

“…Although we had some reservations concerning the use of a ventilator and ventilation mode that we were not accustomed to when we first started the study, we did not encounter any ventilation problems in the patients. For the Tritube™ intubation tube, the higher cost compared to standard intubation tubes can be considered as a drawback (3,21).…”

Section: Discussionmentioning

confidence: 99%

Comparison of Tritube™ tube and Evone® ventilator use with traditional narrow-lumen tube use in microlaryngeal surgery cases

Kart

Hokenek

2023

Comparison of TritubeTM Tube and Evone® Ventilator Use with Traditional Narrow-Lumen Tube Use in Microlaryngeal Surgery Cases ABSTRACT Introduction: Upper airway surgery involves certain difficulties, such as tumors located in the endotracheal area, narrowing of the tracheal lumen by the tumor, the use of a narrow lumen tube constantly increasing pressure. In the literature, difficult airway management has been successfully performed in patients intubated with Tritube™ and ventilated with Evone® (Ventinova Medical, Eindhoven, The Netherlands), and the benefits of these tools during laryngeal surgery have been reported. Objectives: To evaluate the feasibility and safety of the Tritube™ tube and Evone® ventilator and compare patients intubated using Tritube™ and ventilated with flow-controlled ventilation (FCV) using Evone® (TT–FCV group) to those intubated using a traditional microlaryngeal intubation tube and ventilated with volume-controlled ventilation (MLT-VCV group) in terms of perioperative parameters and outcomes during microlaryngeal surgery (MLS). Materials and Methods: After receiving their informed consent, 18 patients were randomly assigned to two groups. Patients older than 18 years, who were scheduled for elective MLS were included in the study. The patients’ demographic parameters, American Society of Anesthesiology physical status (ASA), Mallampati and Cormack-Lehane scores, duration of ventilation, duration of surgery, hemodynamic parameters, ventilation parameters, and complications were recorded. Results: When the intraoperative respiratory and hemodynamic parameters of the patients were compared between the two groups, the intraoperative cerebral oxygen saturation (SpO₂) (p=0.020), tidal volume (p=0.005), compliance of the respiratory system (p=0.001), and post-extubation SpO₂ (p=0.001) values were statistically significantly higher in the TT-FVC group compared to the MLT-VCV group. Right SpO₂ (p=0.038), left SpO₂ (p=0.047), and time to extubation (p=0.021) were statistically significantly lower in the TT-FVC group compared to the MLT-VCV group. Discussion: Low airway peak pressure and stable hemodynamics were achieved with Tritube™, and no complications were encountered in the perioperative period. At the end of the surgery, the cuff was lowered, high-frequency jet ventilation was applied, and extubation was safe performed (3). Although the literature on TritubeTM and Evone® is still limited, the use of these tools in MLS appears to be advantageous to achieve safe airway management. Keywords: Microlaryngeal surgery, Ventilation, Hemodynamics

“…7 In the future, it may prove beneficial for tracheal resection surgery, but currently only limited clinical experience has been published. 8 The main observations and conclusions from currently available literature are summarized in Supplemental Data Table 1 (Supplemental Digital Content, Table 1, http://links.lww.com/AACR/A516).…”

Section: Discussionmentioning

confidence: 99%

The Tritube: Facilitating Upper Airway Surgery With an Ultrathin Cuffed Airway Device

et al. 2023

The Tritube is a narrow-bore cuffed tracheal tube (outer diameter 4.4 mm and inner diameter ~2.4 mm) that permits effective alveolar gas exchange using flow-controlled ventilation. Constant gas flow delivers physiological minute volumes, within preset pressure limits, and applies suction to the airway during expiration. The technique has attracted interest for laryngotracheal microsurgery as it provides superior surgical exposure and avoids many of the complications associated with high-frequency jet ventilation. Cuff inflation protects the lower airway and produces a motionless operating field. We describe the structure of the device, discuss its benefits, and suggest how it should be used clinically.