Barotrauma and Hypotension Resulting from Jet Ventilation in ...

Barotrauma and Hypotension Resulting 

from Jet Ventilation in Critically Ill Patients* 

Andrew Egol, D.O.; Judith A Culpepper, M. D.; and James V Snyder, M. D. 

We present the first reports of pneumoperitoneum secon- decrease the risk of such complications. We cannot, at 

dary to jet ventilation, bamtrauma secondary to jet ventila- present, recommend the use of hand-held jet ventilators 

tion thtough the suction port of a fiberoptic laryngoscope, unless both adequate exhalation space is guaranteed and 

and hypotension due to jet ventilation via nasotracheal and direct impingement of the catheter's tip on the mucosal 

omtracheal catheters. We suggest that minimizing airway surface is avoided. 

pressum and using jet catheters with side holes may help 

variety of techniques for jet ventilation have been 

A used in recent years as a means of delivering 

positive-pressure ventilation to patients during such 

procedures as bronchoscopy, laryngoscopy, tracheal 

suctioning, endotracheal tube change, and in other 

circumstances where positive-pressure ventilation is 

required during manipulation of the upper airway.14 

Several methods for hand-held jet ventilation during 

these procedures have been described previou~ly.~.~" 

Although jet ventilation can appear simple and effective 

in providing oxygenation and ventilation for patients, 

potentially life-threatening complications can 

occur. We report the findings in three patients who 

suffered significant complications during manually and 

mechanically regulated jet ventilation and suggest 

alterations in technique that may prevent such problems. 

A 66-year-old white woman was admitted to the intensive care unit 

(ICU) after fusion of the thoracic spine for osteoporotic vertebral 

compression fractures. The patient's postoperative problems included 

retmperitoneal hematoma (which required reexploration of 

the surgical site), pneumonia, sepsis with Pseudomonas, renal 

failure, and the need for prolonged mechanical ventilation. 

On the Uth postoperative day, laryngoscopic examination of the 

patienti upper airway was undertaken to evaluate whether any 

laryngeal injury was present due to prolonged orotracheal intubation. 

Since it seemed unlikely that the patient could soon be weaned 

from mechanical ventilation and then extubated, such damage, if 

present, would have been considered an indication for tracheostomy. 

It was planned to temporarily remove the orotracheal tube over a 

hollow flexible stylet, over which the orotracheal tube would be 

replaced at the end of the examination. The same stylet served to 

deliver jet ventilation during examination of the larynx. The handheld 

device for jet ventilation that was used (Instrumentation 

Industries) delivers oxygen at the available driving pressure. This is 

commonly 50 psi or 2,620 mm Hg. A ~ressure-reducing valve can be 

incorporated to lower the drivingpressure, but it was not used in this 

*From the Critical Care Medicine Training Program, University 

Health Center, Pittsburgh. 

Manuscript received January 26; revision accepted December 18. 

98 

Downloaded From: http://journal.publications.chestnet.org/ on 07/13/2013 

case. The device is manually operated by a spring-loaded valve and 

delivers gas via noncompliant tubing to a jetting stylet. The jetting 

stylet in this case was an 18 French tracheal suctioning catheter with 

two end holes. 

After the conventional mechanical ventilator was disconnected, 

the stylet was passed down the endotracheal tube into the trachea, 

and jet ventilation was initiated. The patient almost immediately 

became hypotensive and cyanotic, with obvious abdominal disten- 

tion. The jet stylet was withdrawn, and the patient was manually 

ventilated through the conventional endotracheal tube (which had 

not been removed) with aself-inflating bag using 100 percent oxygen. 

A chest roentgenogram confirmed the presence of a right-sided 

tension pneumothorax and pneumoperitoneum (Fig 1). A chest tube 

was immediately inserted, and the patient was returned to conven- 

tional mechanical ventilation. Her vital signs and arterial blood gas 

levels improved to their baseline levels. The pneumothorax and 

pneumoperitoneum resolved uneventfully. The patient survived this 

event and, after a prolonged stay in the hospital, was able to return to 

her home, ambulating with a walker. 

FIGURE 1. Chest roentgenogram showing tension pneumothorax 

and pneurnoperitoneum which occurred with jet ventilation during 

laryngoscopy (case 1). 

Barmuma and Hypdension hum Jet Ventilation (Em Culpepper, Snyder)

A man had his jaws wired closed following surgical duction of 

prognathism. Because of the risk of airway compromise secondary to 

postoperative swelling of soft tissue, he was extubated over a jetting 

stylet.= This stylet was a double-lumen nasogastric sump tube 

intended to be left in the trachea while the patient was observed for 

respiratory problems. Were ventilatory difficulty to occur, this stylet 

could deliver low-flow oxygen or jet ventilation; it could also function 

as a stylet over which a nasotracheal tube could again be inserted. 

Immediately after extubation, the patient breathed around the 

endotracheal stylet without difficulty. Upon initiation of a trial 

demonstration ofjet ventilation with aventilator set at approximately 

20 psi and 30 percent injection time (Instrument Development Corp 

vs 600), the patient remained comfortable until he tried to talk. At 

that time, his mean arterial blood pressure fell rapidly to 30 mm Hg, 

presumably due to closure of his vocal cords around the catheter. 

Blood pressure returned to normal promptly after the jet ventilator 

was turned off and the patient was positioned horizontally. No 

evidence ofbarotraumawas apparent on achest roentgenogram. The 

patient was stable with the stylet left in the trachea for the remaining 

period of observation after the initial extubation; remwal of the 

stylet resulted in no further problem. 

A 62-yearold white man presented to the ICU with the superior 

vena cava syndrome and respiratory failure secondary to atelectasis 

of the right upper and middle lobes from an endobronchial small cell 

carcinoma. Several days later, when he was stabilizd and ready for 

extubation, an examination of the upper airway with a flexible 

fiberoptic laryngompe was planned inorder to assess damage to the 

- - 

uDwr airway from the initial intubation. which had been traumatic. 

The fiberoptic laryngompe was passed through the nasotracheal 

tube without difficulty, after the patient was given a 100-mg 

intravenous bolus of lidocaine to diminish his cough reflex. The 

endotracheal tube was withdrawn from the larynx, over the 

laryngoscope, to facilitate the examination of the larynx. During the 

entire procedure, jetted oxygen at 40 psi via the suction port of the 

fiberoptic laryngompe provided ventilation. The jet ventilator was 

the same as that described in case 1. 

Three minutes into the examination, the patient developed 

significant abdominal distention and rigidity, with progressive 

cyanosis. Attempts to pass a nasogastric tube for decompression of 

the stomach were unsuccessful. Arterial blood gas analysis showed 

combined respiratory and metabolic acidosis with severe hypox- 

emia. Replacement of the endotracheal tube failed to impmve the 

movement of air, cyanosis persisted, and arterial hypotension 

ensued. Roentgenograms of the abdomen and chest revealed 

marked pneumoperitoneum, elevated hemidiaphragms, distention 

of the gastrointestinal tract, and resulting significant volume reduc 

tion of both lungs (Fig 2) without apparent pneumomediastinum or 

pneumothorax. Rapidly administered intravenous fluids partially 

corrected this patient's hypotension. Insertion of a 19-gauge catheter 

(Cook) into the peritoneal space caused prompt decompression of 

the pneurnoperitoneum and resolution of the hypotension, hypox- 

emia, and respiratory acidosis. A nasogastric tube was then success- 

fully passed to facilitate gastric decompression. 

Subsequent roentgenograms showed a resolving pneumoperito- 

neum but still no evidence of pneumomediastinum or pneu- 

mothorax. Instillation of water-soluble contrast material into the 

stomach through the patient's nasogastric tube failed to demonstrate 

perbration as the cause of the pneurnoperitoneum. The patient's 

family rehsed to grant permission for an exploratory laparotomy to 

exclude a perforated viscus. The peritoneal catheter was removed 

within five hours. The pneurnoperitoneum resolved completely over 

several days. 

The patient's subsequent course was complicated by severe 


pneumonia due to Cytomegalovirus and Pseudomonas aeroginosa, 

as well as renal failure and seizures. The patient died on the 57th day 

of hospitalization (51 days after developing the pneurnoperitoneum). 

Postmortem examination revealed small cell carcinoma of the right 

upper lobe with superior vena caval obstruction. Metastases were 

present in the cerebral cortex, cerebellum, para-aortic and para- 

tracheal lymph nodes, liver, and adrenal glands. No evidence was 

present for an esophageal, gastric, tracheal, or pleural perforation. 

Mechanism of Injuries 

Theoretically, barotrauma from jet ventilation may 

be due to injection injury (analagous to grease-gun 

injury) or to overdistention of lung. Injection injury 

can occur when a high-pressure stream of gas is 

directed against mucosa and penetrates into sub- 

mucosal tissue or even perforates the wall altogether. 

This injury is more likely when the jetting catheter has 

only a terminal port, ensuring excessive pressure (as 

high as the pressure of the gas source used) when that 

port is pressed against mucosa. This injury is unrelated 

to airway pressure and does not require a high volume 

of gas. The second form of jet-induced barotrauma, 

that which is due to overdistention, may also occur 

without complete obstruction of the airway. If there is 

insufficient time or space for jetted gas to be exhaled, 

pressure will build up within the tracheobronchial 

tree, resulting in rupture at some point not necessarily 

close to the jet catheter. Oliverio et ale described one 

such case of pneumothorax during laryngoscopic jet 

FIGURE 2. Film documenting pneurnoperitoneum at time of jet 

ventilation through fiberoptic laryngoscope (case 3). 

CHEST 1 88 I 1 I JULY. 11985

ventilation. In this case, prolapse of a large vocal cord 

papilloma apparently prevented an adequate outlet for 

exhalation, causing high intratracheal pressures and 

the resulting pneumothorax. 

Chang et all0 reported the findings in a patient who 

developed left-sided pneumothorax during jet venti- 

lation for laryngoscopy in the operating room; the 

pneumothorax was probably secondary to the jet 

catheter having been inadvertently pushed beyond the 

, carina and possibly wedged in a bronchus when the 

patient was moved. In our first patient, we think that 

the pneumothorax was similarly due to accidental en- 

dobronchial positioning of the jet catheter. Such mal- 

positioning could have resulted in either an injection 

injury or local pulmonary distention and rupture. 

Since the suction catheter that was used has holes only 

at its end, gas exits from the catheter tip under high 

pressure. When the tip is wedged into a small airway, 

the distal pulmonary tissue may be quickly subjected 

to high pressure equal to the driving pressure (10 to 50 

psi) of the system. Dissection of gas through soft tissue 

planes, as discussed subsequently, presumbly resulted 

in pneumoperitoneum. 

Inadequate space and time for exhalation is probably 

also the etiologic mechanism when a patient being 

ventilated with a jet catheter through the larynx closes 

his cords around the catheter in laryngospasm or to 

talk. We believe the hypotension in our second patient 

to be due to high pleural pressure from this mecha- 

nism, with subsequent drop in venous return and 

cardiac output. 

Pneumoperitoneum as a barotraumatic complication 

of ventilatory support usually occurs through disrup- 

tion of either alveoli or small airways. Air, once out of 

the bronchial tree, dissects along the perivascular 

space back to the mediastinum and, from there, 

through soft tissue planes to result in pneumomediasti- 

num, retroperitoneal air, and subcutaneous emphy- 

sema." Subsequent rupture of pleura or peritoneum 

will lead to pneumothorax and pneumoperitoneum, 

respectively. In conventional mechanical ventilation, 

these complications are related to peak inspiratory 

pressures, end-expiratory pressures, duration of in- 

spiratory time, and the presence of underlying pulmo- 

nary disease."" Although pneumoperitoneum is a 

recognized complication of conventional mechanical 

ventilation, it has not been described previously as a 

complication of jet ventilation. 

In our first patient, pneumoperitoneum was pre- 

sumably secondary to pneumomediastinum, with fur- 

ther dissection of respiratory gas through soft tissue 

planes. In our third patient the mechanism is not so 

clear. Pneumoperitoneum associated with mechanical 

ventilation is usually associated with either pneu- 

mothorax or pneumomediastinum, and its occurrence 

in their absence suggests possible perforation of an 


abdominal viscus.14 In our third patient, pneumothorax 

or pneumomediastinum never became clinically 

or roentgenographically apparent. There was 

also no radiographic evidence of gas in the wall of the 

large bowel. Although the patient did not have a 

readily apparent gastric perforation on contrast examination, 

a lower esophageal perforation was not 

ruled out, as this area was not examined during the 

contrast study, and no esophagoscopy was performed. 

We speculate that he may have had inadvertent direction 

of gas flow under high pressure into the esophagus, 

resulting in either a high esophagogastric pressure 

with distension and rupture or a local injection injury 

to the wall of the esophagus. The gas distention seen in 

his gastrointestinal tract on roentgenograms supports 

either hypothesis. Either of these two mechanisms 

could result in tension pneumoperitoneum." Chang et 

alW described a case of severe abdominal distension 

during jet ventilation which was believed to be secondary 

to displacement of the jet catheter, allowing part 

of the jet ventilator stream to be introduced into the 

patient's digestive tract. While this did not result in 

pneumoperitoneum, the gastrointestinal distension, 

noted on abdominal roentgenograms, impaired spontaneous 

breathing to such a degree that the patient 

required reintubation for mechanical ventilation. 

Another possible explanation for our third patient's 

barotrauma is that rupture occurred at the catheter tip 

within the trachea due to injection injury, with air 

dissection into the esophagus and through the lower 

mediastinum into the peritoneal cavity. An additional 

possible mechanism is that gas jetted into the trachea 

had inadequate room for exhalation, with increased 

overall airway pressure resulting in rupture of the 

tracheobronchial tree at a site distant from the catheter 

tip, with dissection of gas through soft tissue planes to 

the peritoneum; however, there was no roentgenographically 

demonstrated free mediastinal or pleural 

air to support this hypothesis. 

Several authors have described the use ofjet ventilation 

during fiberoptic bronchoscopy and laryngos- 

A variety of methods have been used which 

include ventilation through the bronchoscope (via the 

suction port of a flexible bronchoscope or an attached 

channel of a rigid bronchoscope) or through a 14-gauge 

catheter placed inside an endotracheal tube with an 

inner diameter of 3 to 5 mm that was placed along the 

outside of the bronchoscope. While complications 

have been described with translaryngeal and percuta- 

neous transtracheal catheter jet ventilati~n,'~~~~~~" no 

complications previously have been reported second- 

ary to jet ventilation through the suction port of a 

fiberoptic bronchoscope or laryngoscope. We believe 

that both mechanisms of trauma discussed previously 

are inherent with this maneuver; however, direct visu- 

alization throughout the procedure should minimize 

mutrauma and W(HISiOn trOm Jet Ver~uiatbr~ (€go/, cupepper; snyw

the risk of injection injury. 

Preuentwn of Znju y 

With either of the two methods of damage (injection 

injury and impaired exhalation), trauma is related to 

pressure. Pressure can be limited by avoiding the 

factors which increase it and by development and use 

of pressure-sensing and cutoff devices. The amount of 

pressure in the airway is determined by multiple 

interrelating factors. Resistance to exhalation, time of 

exhalation, and minute ventilation determine positive 

end-expiratory pressure (PEEP). Peak airway pressure 

is determined by PEEP, compliance of the lungs, and 

tidal volume (VT) (ie, gas flow and inspiratory time). 

Gas flow is determined by driving pressure and the 

radius and length of the jet catheter. Manipulating 

these factors may decrease the risk of injury, as shown 

in the following tabulation giving suggestions for 

decreasing the risk with a hand-held jet: 

1. Be continually aware of location of catheter tips: 

A. Avoid direct pressure against mucosa. 

B. Avoid insertion into orifices from which exhalation 

may be restricted. 

C. Secure catheter to minimize risk of migration. 

D. Use tracheal tubes with fixed-position jet catheter. 

2. Use catheters with side holes. 

3. Minimize resistance to exhalation: 

A. Use a smaller-diameter jet catheter and a larger 

endotracheal tube. Deflate the endotracheal tube 

cuff. 

4. Use suction: applying a negative pressure to the ex- 

piratory port will diminish entrainment and VT, but 

also lower peak and mean pressure and PEEP. 

5. Use minimal effective driving pressure. 

6. Encourage development and use of effective pressure- 

sensor and pressure-cutoff device. 

For example, the use of more side holes, a lower 

driving pressure, or a smaller catheter, or not advanc- 

ing the catheter as far, all might have prevented 

pulmonary rupture in the first case. Avoiding contact 

with the mucosal surfice might have prevented injury 

in the third case. When a jet catheter is inserted 

through the larynx, safe use requires that the patient 

not close his or her cords or lips and that expiratory 

obstruction is absent. Development of an effective 

pressure sensor and pressure cutoff would enhance 

safety in all applications. We recognize that these 

recommendations are contradictory-one must hope 

to achieve a balance among them to minimize risk and 

maximize benefit to the patient. 

These cases demonstrate the necessity of continued 

awareness of the position of the jet catheter tip during 

the entire procedure of jet ventilation. If a jet catheter 

is used that is long enough to slip past the carina into 

smaller airways, it may be safer to use a catheter with 

large proximal side holes so that gas can escape above 

the potentially wedged tip of the catheter. Such side 


Table 1-Effect qfcatheter Vatidled on Preusum 

Delioetad by the Jet* 

Pressure at 

Catheter's 

Jet Catheter Tip, psi? 

3%-in 14gauge Deseret catheter No. 012-010 

(with open tip) 

With 4 side holes open 30 



16 French Argyle double-lumen Salem sump tube 

All holes are side holes; tip is closed 

With 11 holes open 0 

If tip is cut to open it 






With 1 side hole open 5 


14 French Superior suction catheter (with 

open tip) 

With 2 side holes open 

With 1 side hole open 

With 0 side holes open --- 

*Hand-held jet ventilator (Instrumentation Laboratories). 

tAs measured by pressure gauge (US Gauge 13400-1). 

holes can markedly decrease pressure delivered at the 

tip but still function smoothly when used clinically for 

jet ventilation. A catheter with a closed tip and side 

holes appears to be even safer (Table 1). Inadvertent 

wedging of the catheter can be prevented by measuring 

its length and marking the appropriate depth of 

insertion before beginning the procedure and securing 

the catheter h m further advance once it is properly 

positioned in the patient's trachea. Despite these 

precautions, the use of blindly placed jet catheters may 

result in a higher incidence of direct injury than if the 

procedure were performed under constant direct visualization. 

A catheter appropriate in some clinicd 

situations is the HiLo Jet tracheal tube (No. 86613; 

Mallinckrodt, Inc.). This tube consists of a conventional 

endotracheal tube with a separate lumen for the 

jet which is one-tenth the lumen provided for exhalation, 

thus ensuring adequate space for exhalation. 

Furthermore, this catheter is short enough that inadvertent 

wedging into small airways is unlikely. 

Pressure-cutoff devices for jet ventilation remain a 

problem. The use of a separate catheter to sense 

pressure and activate a cutoff entails risk of occlusion of 

the sensing catheter (eg, by condensed water) and is 

thus inherently inadequate to protect the patient from 

injection injuries. Incorporation of the sensing device 

within the jet catheter is desirable but requires tolerance 

of the high pressures during inspiration (eg, 40 to 

50 psi) while retaining sensitivity to significant changes 

in expiratory pressure. The system must also be easily 

CHEST 1 88 I 1 1 JULY, 1198 101

adjustable. No system for jet ventilation that is com- 

mercially available at this time has all of these features. 

In summary, although jet ventilation is potentially 

useful in many circumstances in the intensive care 

unit, it carries sigdcant risks of complications, in- 

cluding barotrauma and hypotension. We believe that 

such complications can be minimized with appropriate 

attention to details of technique, as noted previously. 

Development and use of additional safety devices is 

crucial to the safety of this procedure. The routine use 

of techniques for hand-held jet ventilation cannot, at 

the present time, be recommended unless adequate 

space hr exhalation is guaranteed and impingement of 

the catheter on mucosal surfaces is avoided. 

ACKNOWLEDGMENT: We thank Ms. Michele Macom for secre- 

tarial assistance and ME James Roth, Mr. Charles Kern, and Mr 

James O'Leary for their technical assistance. 

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