Jet Ventilation 

Jet Ventilation 

Key Points

  • Jet ventilation is a specialized ventilation technique using high-pressure gas delivered through a nozzle, allowing for unobstructed surgical fields and management of difficult airways
  • Jet ventilation can be categorized into high- or low-frequency types;3 both methods operate on similar basic principles
    • LFJV (low-frequency jet ventilation): uses hand-triggered devices for short procedures and emergency situations, relying on passive lung recoil for expiration
    • HFJV (high-frequency jet ventilation): employs specialized equipment for neonatal and pediatric care, using very high frequencies with small tidal volumes to enhance gas exchange through mechanisms such as laminar flow and cardiogenic mixing
  • Jet ventilation is a versatile technique used in various medical procedures; it is particularly beneficial in situations where conventional ventilation methods might interfere with surgical access or visibility or in a difficult airway scenario
  • Contraindications include severe airway obstruction above the cricothyroid membrane and significant lung disease (eg, pneumonia, acute exacerbation of chronic obstructive pulmonary disease or asthma)
  • Discuss airway management and anesthesia plan with the team
  • Monitor and adjust ventilator settings during the procedure
  • Provide continuous monitoring of oxygenation and ventilation parameters13
  • Identify and manage complications that arise
  • Maintain skill and familiarity with the technique through use of jet ventilation in routine practice13

Alarm Signs and Symptoms

  • Alarm signs and symptoms that require urgent attention or treatment in the context of difficult airway management include:
    • Absent or inadequate exhaled CO2
    • Absent or inadequate chest movement
    • Gastric air entry or distention
    • Decreasing or inadequate oxygen saturation
    • Hemodynamic changes associated with hypoxemia or hypercarbia (eg, hypertension, tachycardia, bradycardia, arrhythmia)
  • These signs and symptoms indicate inadequate ventilation and potential airway compromise, necessitating immediate intervention

Basic Information

Terminology

  • Jet ventilation is a specialized ventilation technique that uses a high-pressure stream of gas delivered through a nozzle1
    • This open system is characterized by positive pressure, pulsed breaths for inspiration via a jet nozzle, with passive exhalation occurring around the nozzle without a dedicated expiratory limb
    • This method can be applied supraglottically, infraglottically, or transtracheally, using either manual or automatic devices
    • Anesthesiologists employ jet ventilation in scenarios where the operative field must remain unobstructed or stationary, as well as in challenging “cannot intubate, cannot oxygenate” airway situations12

Background Information

  • Jet ventilation can be categorized into high- or low-frequency types3
    • Both methods operate on similar basic principles
      • High-pressure sources create jet streams that are intermittently interrupted by either pneumatic or electronic flow control devices
      • This process produces a tidal volume, which is further increased by the entrainment of gases at the jet nozzle
      • Expiration occurs because of the passive recoil of the lungs and chest wall
    • Each method’s effectiveness hinges on the proper setup and monitoring of equipment, as well as the clinician’s familiarity with the technique123
  • LFJV (low-frequency jet ventilation)
    • Uses hand-triggered devices for short procedures and emergencies, relying on passive lung recoil for expiration
    • Primarily used for short procedures such as laryngoscopy or bronchoscopy, as well as in emergency situations such as “can’t intubate, can’t ventilate” scenarios
    • Requires careful alignment of the nozzle or cannula to prevent complications such as gastric distention
  • HFJV (high-frequency jet ventilation)
    • Employs specialized equipment using very high frequencies with small tidal volumes to enhance gas exchange through mechanisms such as laminar flow and cardiogenic mixing
    • Primarily used for neonatal and pediatric care (uncommonly used in adults)
    • System allows for precise control of ventilator parameters, such as driving pressure and inspiratory time, and it features alarms and automatic shutdowns to prevent high airway pressures

Indications

  • Elective use: management of anticipated difficult airways, direct laryngoscopy, vocal cord surgery, and major surgical procedures of the airway such as tracheal reconstructions
    • Otolaryngology and surgical procedures of the airway: jet ventilation allows surgeons to operate without the obstruction of an endotracheal tube, facilitating procedures such as vocal cord surgery, tracheal resections, and other surgical procedures of the airway4
    • Rigid bronchoscopy: jet ventilation allows for adequate ventilation while maintaining an open airway for procedures in the tracheobronchial tree1
    • Stereotactic surgical procedures: HFJV is used in stereotactic surgical procedures, such as liver ablations, to minimize respiratory movements, improving the precision of surgical interventions5
  • Emergency use: in “cannot intubate, cannot oxygenate” scenarios, jet ventilation can be used as a lifesaving measure via a cricothyroid or transtracheal cannula2
  • Neonatal and pediatric care: HFJV is used as a rescue strategy in respiratory distress, particularly in neonates and pediatric patients3

Contraindications

  • Absolute contraindications
    • Severe obstruction of the airway above the cricothyroid membrane (significant risk of pneumothorax as the patient would be unable to exhale)3
    • Pneumonia and of chronic obstructive pulmonary disease or asthma (significant risk of overdistention and/or hypoventilation in the presence of increased respiratory compliance or elevated bronchial resistance)16
  • Relative contraindications (in these situations, the risks and benefits of jet ventilation must be carefully weighed against alternative airway management strategies1)
    • Morbid obesity in patients with poor baseline oxygenation, because they may not tolerate apneic periods well
    • Uncontrolled coagulopathy due to the increased risk of bleeding from the jet ventilation site
    • Tracheal obstruction may also be considered a relative contraindication for less experienced operators, because it can make proper catheter placement and ventilation more challenging

Treatment

Approach to Treatment

  • Identify the need for jet ventilation
  • Discuss airway management and anesthesia plan with the team
  • Monitor and adjust ventilator settings during the procedure
  • Provide continuous monitoring of oxygenation and ventilation parameters13
    • Perform frequent clinical assessments, including vital signs monitoring, physical examination, and airway pressure monitoring
    • Maintain continuous pulse oximetry and CO2 monitoring
  • Manage complications that arise
    • Awareness and management of potential complications are critical13
  • General principles
    • Maintain skill and familiarity with the technique through use of jet ventilation in routine practice13
    • Ensure the safe and effective use of jet ventilation through collaboration between anesthesiologists and pulmonologists during procedures such as rigid bronchoscopy1

Description

  • Jet ventilation is a versatile technique used in various medical procedures
    • Use in situations where conventional ventilation methods might interfere with surgical access or visibility
      • Short procedures, such as laryngoscopy or bronchoscopy
      • Maxillofacial and laryngotracheal surgery
    • Use via cricothyroidotomy cannula in emergency scenarios or management of a difficult airway
      • “Cannot intubate, cannot oxygenate”
    • See Table 1 for general characteristics of jet ventilation methods
    • Evaluate for absolute and relative contraindications

Table

Table 1. Jet ventilation methods.

TypeFrequencyDescriptionApplication
LFJV10-30 breaths per minuteA jet frequency of 8-10 per minute allows adequate time for exhalation via passive recoil of the lung and chest wall and prevents air trapping and buildup of pressure in small airwaysAlso called normofrequent jet ventilationOften applied via hand-triggered devicesEffective FiO2 in the trachea is 0.8-0.9 because of dilution by entrainment of ambient airSidearm attachment to a bronchoscope or laryngoscope may allow oxygen entrainment instead of ambient airShort investigative procedures, such as laryngoscopy or bronchoscopyManagement of a difficult airway or the “cannot intubate, cannot oxygenate” scenario via a cricothyroidotomy cannula
HFJVMore than 60 breaths per minute (1-10 Hz)Uses specialized equipmentCombines very high respiratory rates with tidal volumes smaller than the anatomical dead space volumeDelivers heated, humidified jetsTreatment of perinatal respiratory failure in premature and term neonates7Used for severe pediatric respiratory failure from multiple etiologies7HFJV is not a first line mechanical ventilation mode and is rarely used in adults
Superimposed HFJVCombination of LFJV and HFJVA double-jet technique combining low and high frequenciesSpecialized cases (eg, endoscopic laryngotracheal surgery8)Laryngotracheal surgerySevere tracheal stenosis
Transtracheal jet ventilationHigh frequencyProvided via a laryngeal catheterLow tidal volumeAnticipated difficult airwaysSpecific surgical procedures (eg, high-risk pharyngolaryngeal surgery9)

Caption: FiO2, fraction of inspired oxygen; HFJL, high-frequency jet ventilation; LFJV, low-frequency jet ventilation.

Monitoring and Adjustment of Ventilator Settings

  • Figure 1. Anesthesia for airway surgery.From Chitilian HV et al. Anesthesia for airway surgery. Thorac Surg Clin. 2018;28(3):249-255, Figure 3.
  • Figure 2. Manual jet ventilation during foreign body removal. A small catheter was inserted transnasally into the trachea and connected to Manujet III device during rigid bronchoscopy.From Shaoqing Li et al. Efficacy of manual jet ventilation using Manujet III for bronchoscopic airway foreign body removal in children. Int J Pediatr Otorhinolaryngol. 2010;74(12):1401-1404, Figure 1.
  • Figure 3. The jet laryngoscope. 2 cannulas are integrated apart from each other in the jet laryngoscope. A third cannula—placed at the top (not shown in this figure)—continuously measures the ventilation pressure at the tip. 2 metal cannulas of 1.5 mm internal diameter are welded to the proximal third of the rigid jet laryngoscope on the left side, without protruding into the lumen of the jet laryngoscope. The low-frequency jet stream (f = 1.67-15 Hz or 100-900 breaths per minute) passes through the distal cannula and the high-frequency jet stream (f = 0.167-0.2 Hz or 10-12 breaths per minute) through the proximal cannula. Driving pressures are 1 to 3 bar at both nozzles.From Bigenzahn et al. Superimposed high-frequency jet ventilation (SHFJV) for endoscopic laryngotracheal surgery in more than 1500 patients Br J Anaesth. 2006;96(5):650-659, Figure 2.
  • Figure 4. The application of jet ventilation.From Patel RG. Percutaneous Transtracheal jet ventilation: a safe, quick, and temporary way to provide oxygenation and ventilation when conventional methods are unsuccessful. Chest. 1999;116(6):1689-1694, Figure 2.
  • Carefully place the catheter to avoid trauma (may be placed supraglottically, infraglottically, or transtracheally, depending on the indication for jet ventilation) (Figure 1Figure 2Figure 3, and Figure 4)
  • Key variables in jet ventilation are frequency, driving pressure, inspiratory time, and FiO2 (fraction of inspired oxygen); tidal volume is not directly set but is a function of these parameters and respiratory system characteristics
  • Adjustments to these variables can have counterintuitive effects; for example, increasing frequency may induce hypercapnia by reducing tidal volume if other parameters remain constant
  • Intrinsic PEEP (positive end-expiratory pressure) is an important component of jet ventilation and increases with frequency
  • Careful adjustment of parameters (eg, rate, driving pressure, inspiratory time, FiO2) is crucial to maintaining adequate ventilation and oxygenation while avoiding complications such as gas trapping or CO2 retention13
    • Jet ventilation operates as a time-cycled, pressure-limited system where the driving pressure is more critical for CO2 elimination than respiratory frequency
      • This system can result in frequency-dependent PEEP, with mean and peak airway pressures lower than that of conventional ventilation
      • These properties are beneficial in reducing gas leaks in certain conditions, such as bronchopleural fistulas. However, inadequate air egress during expiration can quickly lead to pressure buildup, necessitating high-pressure alarms and automatic shutdown features for safety

Continuous Monitoring of Oxygenation and Ventilation Parameters13

  • Use a combination of clinical assessment, laboratory tests, and imaging studies to ensure the patient’s safety and the effectiveness of the ventilation strategy
    • Frequency of monitoring should be tailored to the individual patient’s condition and the specific clinical context
    • More frequent monitoring is required during the initial phases of jet ventilation and in critically ill patients; as the patient stabilizes, the frequency of monitoring can be adjusted accordingly
  • Clinical assessment
    • Vital signs: continuous monitoring of heart rate, blood pressure, oxygen saturation, and respiratory rate
    • Airway pressure monitoring: continuous monitoring of airway pressures, including peak inspiratory pressure and PEEP, to avoid barotrauma and ensure adequate ventilation
    • Chest wall movement and auscultation: regular assessment of chest wall movement and lung sounds to ensure bilateral ventilation and detect any signs of pneumothorax or other complications
  • CO2 monitoring and pulse oximetry
    • Continuous monitoring of oxygen saturation to ensure adequate oxygenation
    • Continuous or intermittent monitoring of CO2 levels is essential
      • Measuring CO2 level in jet ventilation systems, which use high gas flow, poses challenges due to the open nature of the system
      • Some jet ventilators allow intermittent end-tidal CO2 sampling by pausing high-frequency ventilation and delivering larger tidal volume breath
      • Employ alternative techniques, such as transcutaneous continuous CO2 monitoring, intermittent blood gas sampling, or continuous intra-arterial blood gas measurement3
        • Employ arterial blood gas sampling to monitor pH, PaCO2, and PaO2 levels
          • Frequency may vary depending on the patient’s condition but is typically done every 30 minutes to 1 hour initially and adjusted based on clinical stability
  • Imaging studies
    • Chest radiograph: baseline and periodic chest radiographs to assess lung expansion, detect any signs of barotrauma (eg, pneumothorax, pneumomediastinum), and verify the position of the jet ventilation catheter or endotracheal tube1

Complications

  • Barotrauma due to jet ventilation can manifest as pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum, or subcutaneous emphysema (the risk is higher in patients with severe obstructive airway diseases, such as asthma or chronic obstructive pulmonary disease)
  • Malposition of catheters may lead to gastric distention or, in severe cases, gastric rupture
  • Patients with severe lung pathology, particularly those with restrictive pulmonary diseases, may experience inadequate gas exchange resulting in hypoxemia or hypercapnia
  • Other complications include dysrhythmias, necrotizing tracheobronchitis, and an increased incidence of necrotizing enterocolitis in neonates
  • These potential complications underscore the importance of careful patient selection, proper technique, and vigilant monitoring when employing jet ventilation13

Efficacy

  • Efficacy of jet ventilation depends on the specific clinical context and the underlying condition being treated
    • Adult patients undergoing surgical procedures of the airway: jet ventilation has been used successfully in adult patients undergoing laryngotracheal surgery, carinal resection and reconstruction, and other airway procedures, providing adequate oxygenation and ventilation while minimizing interference with the surgical field189
    • Pediatric patients with acute respiratory failure: the current evidence base for HFJV in pediatric ICUs is limited, with most studies being small, single-center case series or physiologic studies lacking control groups. Although HFJV may be beneficial in managing refractory hypercapnia and air leak syndrome in pediatric patients, its effect on outcomes and oxygenation requires further investigation through rigorous randomized controlled trials10
    • Neonatal patients with severe respiratory failure: HFJV has been used in neonatal patients with severe respiratory failure, including those with respiratory distress syndrome and persistent pulmonary hypertension, although the evidence is limited and inconclusive11
    • Adult patients with ARDS (acute respiratory distress syndrome): the efficacy and safety of jet ventilation for adult ARDS patients have not been well studied in large randomized controlled trials, unlike other ventilation strategies that are recommended in guidelines. High-frequency oscillatory ventilation, which is similar in some ways to jet ventilation, is not recommended for routine use in moderate to severe ARDS12

Author Affiliations

Vikramjit Mukherjee, MD
Associate Professor, Department of Medicine at NYU Grossman School of Medicine
Director, Critical Care, Bellevue Hospital Center
Medical Director, Special Pathogens Program, Bellevue Hospital Center
Rudra Ramanathan, MD

Clinical Fellow Pulmonary Disease, Critical Care and Sleep Medicine

Department of Medicine

Division of Pulmonary Disease, Critical Care and Sleep Medicine

NYU

References

1.Putz L et al. Jet ventilation during rigid bronchoscopy in adults: a focused review. Biomed Res Int. 2016;2016:4234861.

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2.Jeffrey L et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology. 2022; 136:31-81.

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3.Evans E et al. Jet ventilation. BJA Educ. February 2007;7(1):2-5.

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4.Dow O et al. Jet ventilation for maxillofacial and laryngotracheal anaesthesia: a narrative review. J Oral Maxillofac Anaesth. March 30, 2024;3.

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5.Galmén K et al. Clinical application of high frequency jet ventilation in stereotactic liver ablations–a methodological study. F1000Res. June 19, 2018;7:773.

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6.Rouby JJ et al. Clinical use of high frequency ventilation. Acta Anaesthesiol Scand Suppl. 1989;90:134-139.

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7.Miller AG et al. High-frequency jet ventilation in pediatric acute respiratory failure. Respir Care. February 2021;66(2):191-198.

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8.Rezaie-Majd A et al. Superimposed high-frequency jet ventilation (SHFJV) for endoscopic laryngotracheal surgery in more than 1500 patients. Br J Anaesth. 2006;96(5):650-659.

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9.Barnes RK et al. Transtracheal jet ventilation in a general tertiary hospital: a 7-year audit. Anaesth Intensive Care. July 2021;49(4):316-321.

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10.Miller AG et al. High-frequency jet ventilation in neonatal and pediatric subjects: a narrative review. Respir Care. May 2021;66(5):845-856.

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11.Rojas-Reyes M et al. Rescue high-frequency jet ventilation versus conventional ventilation for severe pulmonary dysfunction in preterm infants. Cochrane Database Syst Rev. October 16, 2015;2015(10):CD000437.

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12.Fan E et al. An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. May 1, 2017;195(9):1253-1263.

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