Paul B. Comer

Emergency percutaneous transtracheal ventilation during anesthesia using readily available equipment.

Percutaneous transtracheal ventilation has been described as a possible technique for use during anesthesia in the management of acute upper airway obstruction. This study described a modified percutaneous transtracheal ventilation device for use with standard anesthesia machines. Unlike previously reported devices, this device does not require specialized equipment or prior assembly. The efficacy of this device was tested on anesthetized dogs. Adequate ventilation was easily maintained as documented by serial arterial blood gas determinations, and the device also proved capable of reversing severe hypercapnea such as might result from upper airway obstruction. Extrapolation of the data obtained from these experiments indicates that this device, if used properly, should provide adequate ventilation and oxygenation in adult humans.

Cessation of pulmonary artery catheter-induced endobronchial hemorrhage associated with the use of PEEP.

Endobronchial hemorrhage is an uncommon, potentially lethal complication of pulmonary artery catheterization. Pulmonary hypertension and advanced age are risk factors for pulmonary arterial rupture (1,2). Although abnormal coagulation increases mortality from catheter-induced pulmonary hemorrhage, it may not be the only reason for a fatal outcome (1,3-5). Appropriate therapy for pulmonary hemorrhage due to pulmonary artery catheterization has not been defined. Thoracotomy for resection of the affected lung has not been uniformly successful (4,6,7). Endobronchial intubation has been effective in some (8), but not all, cases (9). Resumption of cardiopulmonary bypass has terminated hemorrhage in patients undergoing open-heart surgery (10). Dependent positioning of the affected lobe was attempted in one fatality (3), while in six other reported fatalities no specific therapy was mentioned (1,5). Spontaneous resolution may occur and has been reported in several cases in which up to 500 ml of blood was lost (5,ll15). No therapy other than oxygen and endotracheal suctioning was employed in these cases. Positive end-expiratory pressure (PEEP) has been successfully employed in a case of endobronchial hemorrhage during cardiopulmonary bypass (10). We present a case that occurred in the intensive care unit. Massive hemoptysis after inflation of the balloon of a pulmonary artery catheter was resolved when PEEP was applied.

Evaluation of catheter placement in the treatment of venous air embolism.

: Venous air embolism is a potential complication of many surgical, therapeutic, and diagnostic procedures. Aspiration of air via a catheter placed in the superior vena cava or right atrium or placed in the pulmonary outflow tract and pulled through the right heart chambers had been advocated for the treatment of venous air embolism. In this study, three catheter positions were analyzed to determine which was best for removal of gas after induction of massive venous air embolism in dogs. In 18 dogs, 9 of which were suspended by their forelegs to simulate the sitting position used in posterior fossa exploration and 9 of which were supine, a Swan-Ganz catheter was placed in the right atrium, right ventricle, or pulmonary artery. A measured amount of air was injected into the left jugular vein and syringe aspiration of the air was attempted through the catheter. In the group with the catheter in the pulmonary artery, aspiration was continuous while the catheter was withdrawn through the right heart chambers. The amount of air aspirated varied widely among the three catheter positions, and no one catheter position proved superior to the other two.

Emergency percutaneous transtracheal ventilation (PTV).

Ventilation through a percutaneous needle catheter inserted into the trachea has been advocated for resuscitation in acute upper airway obstruction. However, the customized, prefabricated equipment proposed by others for that use is not always available. We describe a device for percutaneous transtracheal ventilation (PTV) that can be rapidly assembled using available, inexpensive hospital supplies. With this device, moderate inflation pressures and flow rates of oxygen resulted in arterial PaO2 of greater than 300 torr and PaCO2 values of approximately 40 torr in dogs. PTV may be used as a life-saving measure in cases of acute upper airway obstruction when conventional airway management is unsuccessful.

Airway maintenance in patients with long-term endotracheal intubation.

Long-term endotracheal intubation in seriously ill patients is frequently complicated by nosocomial infection of the tracheobronchial tree, especially with aerobic gram negative bacilli. A further complication is drying of pulmonary secretions unless the medical gases given are humidified. The performance characteristics of humidifying system used in spontaneously breathing, intubated patients is described. This system possesses the potential to decrease infection, provides physiologic humidification without nebulization, and, by avoiding air dilution, allows the administration of a precisely regulated FIO2.

Pulmonary angiography via an indwelling four-channel Swan-Ganz catheter.

An indwelling Swan-Ganz catheter was utilized for pulmonary angiography in an extremely ill patient without the necessity for a further invasive procedure. The procedure allowed prompt exclusion of pulmonary embolism as a cause of her deteriorating condition, and confirmed the diagnosis of adult respiratory distress syndrome (ARDS).