Jet Ventilation: Traditional but Effective

Nirmal Kumar. S¹, S. Khaja Mohideen¹, Senthil Kumar. K², Ramasubramanian K³

¹Consultant Anaesthesiologists, Kauvery Hospital, Cantonment, Trichy

²HOD – Department of Anesthesiology, Kauvery Hospital, Cantonment, Trichy

³Consultant – Pulmonologist, Kauvery Hospital, Tennur, Trichy

Introduction

A young female presented with a mobile tracheal mass, which was successfully excised via rigid bronchoscopy under general anesthesia with jet ventilation. Airway surgery, particularly in cases involving dynamic tracheal lesions, poses unique challenges due to the critical need for maintaining oxygenation, securing the airway, and ensuring surgical precision. Anesthesia management in such scenarios is equally demanding, requiring meticulous ventilation strategies, careful hemodynamic monitoring, and close coordination between the surgical and anesthesia teams to minimize risks such as hypoxia, bleeding, or loss of airway control.

Case Presentation

A 25-year-old female presented with a 4-month history of chronic cough and occasional breathing difficulty, followed by stridor over the past week. She had no significant comorbidities. Contrast-enhanced CT of the chest revealed a pedunculated mass (2 cm × 1.5 cm) arising from the right lateral tracheal wall, approximately 1–2 cm above the carina. All routine hematological and biochemical investigations were within normal limits. Prior to definitive surgical intervention, a diagnostic bronchoscopy was performed to assess the lesion’s extent and facilitate anesthesia planning.

On the day of surgery, the patient was preoxygenated for 5 minutes. General anesthesia was induced with intravenous fentanyl (100 mcg), propofol (80 mg), and succinylcholine (100 mg). A rigid bronchoscope was inserted, and anesthesia was maintained under total intravenous anesthesia (TIVA) with propofol infusion, supplemental fentanyl boluses, and dexmedetomidine infusion. Jet ventilation was administered via the bronchoscope’s side port to maintain oxygenation and ventilation.

The surgical excision lasted approximately one hour. Serial intraoperative arterial blood gas (ABG) analyses confirmed normocarbia and adequate oxygenation throughout the procedure. At the conclusion of surgery, the patient was successfully awakened, resumed spontaneous breathing, and was extubated without complications.

Discussion

This case involved a 25-year-old female presenting with preoperative stridor secondary to a mobile tracheal mass, necessitating particularly cautious anesthetic planning due to the dual risks of tumor fragmentation and acute airway obstruction. Prior to definitive management, the patient underwent diagnostic bronchoscopy (Figure 1 & 2) by the pulmonology team to assess tumor characteristics, including precise measurements from the vocal cords to the lesion for potential emergency airway planning (1). Our team prepared for contingencies by having a microlaryngeal tube available for selective endobronchial intubation in case of bronchus obstruction occur during resection.

General anesthesia was maintained using Total Intravenous Anesthesia (TIVA), which offered distinct advantages for this airway procedure. By avoiding inhalational agents, we eliminated operating room pollution risks – a significant concern during open airway cases where traditional apnea-ventilation techniques are employed. Induction was achieved with intravenous agents and a depolarizing muscle relaxant to facilitate rigid bronchoscope placement, followed by maintenance with non-depolarizing neuromuscular blockade, propofol, fentanyl, and dexmedetomidine infusions for optimal surgical conditions.

Manual jet ventilation served as our primary ventilatory strategy, delivering oxygen through a high-pressure insufflator. This technique provided continuous respiratory cycles – a marked improvement over conventional intermittent apnea methods – while simultaneously improving surgical exposure through the rigid bronchoscope.

Jet Ventilation also provided an incidental yet valuable defogging effect on the bronchoscopic optics – a significant advantage during prolonged procedures requiring precise visualization. The jet system’s passive expiration phase and active, pressure-controlled inspiration (adjustable via a titratable pressure knob based on chest rise) required careful monitoring. Complications during jet ventilation for microlaryngoscopy, which is usually a relatively safe procedure, are rare. Those described have included hypoventilation, pneumothorax, pneumomediastinum, subcutaneous emphysema, pneumoperitoneum, and gastric distention ⁽²⁾.

To ensure adequate ventilation despite the passive exhalation, we performed serial arterial blood gas analyses every 30 min, maintaining PaCO2 below 40 mmHg throughout the hour-long procedure. Several critical safety measures were implemented. Given the 100% oxygen delivery inherent to jet ventilation, we instituted mandatory ventilation pauses during electrocautery use to mitigate fire risk.

Fig (3): Post Excision of Lesion

During tumor excision, the mass was carefully captured in a retrieval basket and removed en bloc via the bronchoscope to prevent airway obstruction. Following resection, the patient was orally intubated for final bronchoscopic hemostasis verification (Figure-3). Perioperative steroids were administered to minimize airway edema, and the patient was successfully extubated to face mask oxygen after demonstrating adequate spontaneous ventilation and awakening.

Fig (4): Jet ventilator equipment

Fig (5) – Jet ventilation malleable needle tip is shown in first picture. Fig (6) – The second picture shows how the airway is ventilated through jet ventilation while both endoscopy and bronchoscopy is done to identify trachea esophageal fistula

Conclusion

First described by Sanders in 1967 for emergency transtracheal oxygenation, jet ventilation remains valuable in elective airway surgery despite being deprioritized in modern difficult airway algorithms. Its ability to provide continuous oxygenation without obstructing the surgical field makes it ideal for managing mobile tracheal lesions, as demonstrated in this case. While no longer a primary rescue technique, it retains a role in specialized airway procedures where unobstructed visualization and stable ventilation are paramount.

References

Wahidi MM, Herth F, Yasufuku K, et al. Technical aspects of bronchoscopy: ACCP evidence-based clinical practice guidelines. Chest. 2021;160(2):e93-e126
Pacheco-Lopez PC, Berkow LC, Hillel AT, et Complications of jet ventilation during microlaryngeal surgery. Anesth Analg. 2019;129(5):1328-1332.
Daccache N, Wu Y, Jeffries SD, Zako J, Harutyunyan R, Pelletier ED, et al. Safety and recovery profile of patients after inhalational anaesthesia versus target- controlled or manual total intravenous anaesthesia: a systematic review and meta-analysis of randomized controlled British Journal of Anaesthesia. 2025 Mar 1.

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Jet Ventilation: Traditional but Effective