© Borgis - New Medicine 2/2001, s. 26-27
Piotr Wójtowicz1, Barbara Lisowska2, Andrzej Kukwa1, Lechosław P. Chmielik1
The use of high frequency ventilation in the treatment of the larynx and upper
1 Department of Otolaryngology, Stomatology Division the Medical Academy School in Warsaw
Head of Department.: Prof. Andrzej Kukwa MD.
2 Department of Anaesthesia and Intensive Care Unit, Czerniakowski Hospital in Warsaw
Head of Department.: Dr hab. Henryk Kwiatkowski MD.
Summary
The authors discuss the application of high frequency ventilation in the endoscopic treatment of the larynx and upper tracheal stridors. The use of HFJV allows a reduction of any indication to perform tracheostomy and increases safety in laser operations in the larynx and trachea.
INTRODUCTION
Stridor of the larynx and the trachea, according to world statistics, are of iatrogenic origin in 90% to 95% of cases.The reasons are as follows: prolonged intubation, tracheotomy, removal of vocal cords (chordectomy). They are also an occasional result of laryngeal operations.
In spite of our exact knowledge of the causes of iatrogenic stridor there is no apparent tendency to reduce these alarming figures. Reconstruction of the constricted laryngeal lumen and tracheal opening is usually a multi – stage operational procedure, requiring knowledge of several techniques, advanced equipment allowing treatment to be adjusted to the age of the patient, the local state of health and the extent of the constriction.
The Dental Otholaryngological Hospital of A.M Warsaw has dealt with constrictive complications of the larynx and the upper trachea for 11 years. The experience gained in this time fully convinces us of the need to extend the use of endoscopic intervention procedures. The usage of high frequency ventilation increases the effectiveness of endoscopic procedures. High frequency ventilation (HFV) may be defined as ventilation where the frequency of the respiration used is four times higher than that of the patient in the resting state. The limit value for adults is set at 60 breaths/min (1 Hz) and the limit value for infants is 120 breaths/min (2 Hz) (1).
The aim of HFV is reduction of the average and the maximum pressures in the respiratory tract. This is achieved by using a much lower than normal respiratory volume (1-5 ml/kg). We should distinguish 3 different types of HFV:
– HFPPV high frequency positive pressure ventilation;
– HFJV high frequency jet ventilation;
– high frequency oscillation.
The above – named HFV types vary in the following aspects among others; the respiratory volume, ventilation frequency, and expiration where in HFPPV and in HFJV expiration is active and in HPO it is passive. The basic difference that exists between HFPPV and HFJV is the way in which the gases are supplied to the respiratory tract (1).
MATERIAL AND METHOD
In the period 1990 to 2000 in the Dental Otholaryngological Hospital of the Medical Academy in Warsaw, 115 patients with stridor of the larynx and trachea were treated. The constrictions were of an anatomical nature, and 160 patients had paralysis of both sides, that is functional stridor. For 5 years the treatment of stridor has been helped by HFJV. For this technique we qualified patients exceeding 17 years of age with first or second degree stridor according to Cotton, as well as patients with vocal cord paralysis on both sides, who had no earlier tracheotomy due to the local conditions and pressure in the vocal cords not allowing precise execution.
This ventilation method was used in 6 patients with anatomical stridor and in 5 patients with functional stridor. In all cases HFJV was used in conjunction with TIVA (total i.v. anaesthesia), using Propofol in a continous infusion together with fractioned doses of Fentanyl, an opiod and Tracrium, and Pavulon which is an anti – spasmic drug.
The respiratory gases were given through a catheter (in 9 patients) or through a needle directed through the skin to the opening of the trachea (2 patients). In all these cases an effort was made to stabilise the catheter so that the ends were visible throughout the whole operation and were kept a safe distance from the bifurcation of the trachea. Reconstruction of the lumen was done by using classical microsurgical – techniques as well as using Nd-Yag and Holm-Yag lasers. Usually these techniques were combined and applied depending on the effectiveness in the stipulated conditions. The result in 10 cases was satisfactory patency in a single stage procedure, and only in one case from the anatomical stridor group were we forced to use the next stage of surgical treatment. We observed only one complication, in the form of pneumothorax of the right lung of a patient. She had been ventilated by catheter. She needed several days observation and was treated conservatively.
DISCUSSION
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Piśmiennictwo
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