Abstract
Introduction: During upper airway surgery in a narrowed airway due to tumor or stenosis, safe ventilation, good laryngotracheal exposure, and preservation of an adequate surgical working space are of paramount importance. This can be achieved by small-lumen ventilation such as High Frequency Jet Ventilation (HFJV). However, this technique has major drawbacks, such as air-trapping and desaturation in patients with poor pulmonary reserve. Recently, an innovative ventilating system with flow-controlled ventilation (FCV) and a small-lumen endotracheal tube, the Evone® (Ventinova, Eindhoven, The Netherlands), was introduced, claiming to counter the drawbacks of HFJV.Objectives: To evaluate feasibility and safety of the Evone® FCV system in difficult upper airway surgery and to critically appraise this novel ventilation method.Patients and methods: Evone® is a FCV-device using a small-bore cuffed tube (Tritube®). This ventilator actively sucks air out of the lungs, rather than relying on the passive backflow of air like in HFJV. Data related to the medical history, surgery, and anesthesia of all consecutive patients undergoing upper airway surgery with Evone® FCV ventilation were included in a tertiary center retrospective observational study.Results: Fifteen Patients, with a median age of 54 years, were included. Surgical procedures and indications included laser-assisted endoscopic treatment of idiopathic subglottic stenosis (n = 3), tracheal stenosis (n = 1), and posterior glottic stenosis (n = 2), biopsy and/or Transoral Laser Microsurgery for laryngeal (pre)malignancy (n = 7) and resection of benign lesions with posterior (supra)glottic location (n = 2). Mean ventilation duration was 52.0 min (range 30–115 min, SD 19.6 min), mean surgery duration was 31.7 min (range 15–65 min, SD 13.2 min), mean minimal SaO2 was 96.3% (range 89–100%, SD 4.0%) and mean peak pCO2 was 41.4 mmHg (range 31–50 mmHg, SD = 5.5 mmHg). No anesthesia- or surgery-related complications, adverse events or intra-operative difficulties were reported during or after any of the 15 procedures. In all cases, compared to HFJV, Evone® FCV ventilation allowed a superior visualization and working space during the surgical procedure.Conclusion: The Evone® FCV ventilation system provides excellent conditions in patients undergoing upper airway surgery, as it combines excellent accessibility and visibility of the operation site with safe and stable ventilation.
Highlights
During upper airway surgery in a narrowed airway due to tumor or stenosis, safe ventilation, good laryngotracheal exposure, and preservation of an adequate surgical working space are of paramount importance
Compared to a conventional endotracheal tube, the small tube used during High Frequency Jet Ventilation (HFJV) results in superior intubation of narrowed airways and in improved surgical access, as it provides an unimpeded view of the larynx during ENT surgery
One last drawback of HFJV is the fact that the passive flow of air around the tube results in oscillation of the vocal cords, which can be hindering during phonosurgery or transoral laser microsurgery (TLM) [8]
Summary
During upper airway surgery in a narrowed airway due to tumor or stenosis, safe ventilation, good laryngotracheal exposure, and preservation of an adequate surgical working space are of paramount importance. The negative pressure is generated using jet-flow (Bernoulli’s principle) and was designed to be manually controlled It is typically used with a cuffed small lumen tube (e.g., Tritube R by Ventinova), which optimizes the ventilation while providing airway protection, with presumably less hypercapnia and hypoxia [10, 11]. This company launched the Evone R ventilator, a flow-controlled ventilator like the Ventrain R , but automatized This new equipment seems very promising, since it could potentially combine all benefits of other ventilation techniques, as it could provide the same stable, easy to monitor ventilation as a normal bore tube, with the benefits of increased visibility and improved working space for the surgeon related to the use of a small bore tube [3]. We evaluate the feasibility and safety of the Evone R system and deliver a critical appraisal of this novel method of ventilation
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