The use of an endotracheal ventilation catheter for jet ventilation during a difficult intubation

This case report describes the use of an endotracheal ventilation catheter (ETVC) to provide prolonged intraoperative jet ventilation, reintubation and the maintenance of tracheal access following extubation. It emphasizes that excellent oxygenation and ventilation can be achieved but such management can be complicated by a pneumothorax even when the risks are minimized. A 43-yr-old man presented for possible pulmonary sleeve resection. Placement of a double lumen endotracheal tube (DLT) by direct laryngoscopy was unsuccessful due to the inability to visualize the glottis. A 7.5 mm endotracheal tube (ETT) was successfully introduced over a fibreoptic bronchoscope (FOB). An ETVC was passed, permitting manually cycled jet ventilation while general intravenous anaesthesia and muscle relaxation were maintained. The ETT was then withdrawn over the ETVC and jet ventilation continued for approximately 90 min, while attempts at placing a DLT over a now malfunctioning FOB continued. These attempts were eventually abandoned and the patient was returned to the post-anaesthesia care unit (PACU) haemodynamically stable. The trachea was extubated over the ETVC, which remained in situ. A pneumothorax was noted on the postoperative chest x-ray. This case illustrates prolonged intraoperative jet injection via a "jet stylet" with satisfactory ventilation and oxygenation but complicated by a pneumothorax. Also it illustrates a strategy for the management of a "difficult extubation."