Novel technique for safe tracheostomy during COVID-19 pandemic using Evone® flow-controlled ventilation system

The Tritube: Facilitating Upper Airway Surgery With an Ultrathin Cuffed Airway Device

The Tritube is a narrow-bore cuffed tracheal tube (outer diameter 4.4 mm and inner diameter ~2.4 mm) that permits effective alveolar gas exchange using flow-controlled ventilation. Constant gas flow delivers physiological minute volumes, within preset pressure limits, and applies suction to the airway during expiration. The technique has attracted interest for laryngotracheal microsurgery as it provides superior surgical exposure and avoids many of the complications associated with high-frequency jet ventilation. Cuff inflation protects the lower airway and produces a motionless operating field. We describe the structure of the device, discuss its benefits, and suggest how it should be used clinically.

Comparison of TritubeTM Tube and Evone® ventilator use with traditional narrow-lumen tube use in microlaryngeal surgery cases

Comparison of TritubeTM Tube and Evone® Ventilator Use with Traditional Narrow-Lumen Tube Use in Microlaryngeal Surgery Cases ABSTRACT Introduction: Upper airway surgery involves certain difficulties, such as tumors located in the endotracheal area, narrowing of the tracheal lumen by the tumor, the use of a narrow lumen tube constantly increasing pressure. In the literature, difficult airway management has been successfully performed in patients intubated with Tritube™ and ventilated with Evone® (Ventinova Medical, Eindhoven, The Netherlands), and the benefits of these tools during laryngeal surgery have been reported. Objectives: To evaluate the feasibility and safety of the Tritube™ tube and Evone® ventilator and compare patients intubated using Tritube™ and ventilated with flow-controlled ventilation (FCV) using Evone® (TT–FCV group) to those intubated using a traditional microlaryngeal intubation tube and ventilated with volume-controlled ventilation (MLT-VCV group) in terms of perioperative parameters and outcomes during microlaryngeal surgery (MLS). Materials and Methods: After receiving their informed consent, 18 patients were randomly assigned to two groups. Patients older than 18 years, who were scheduled for elective MLS were included in the study. The patients’ demographic parameters, American Society of Anesthesiology physical status (ASA), Mallampati and Cormack-Lehane scores, duration of ventilation, duration of surgery, hemodynamic parameters, ventilation parameters, and complications were recorded. Results: When the intraoperative respiratory and hemodynamic parameters of the patients were compared between the two groups, the intraoperative cerebral oxygen saturation (SpO₂) (p=0.020), tidal volume (p=0.005), compliance of the respiratory system (p=0.001), and post-extubation SpO₂ (p=0.001) values were statistically significantly higher in the TT-FVC group compared to the MLT-VCV group. Right SpO₂ (p=0.038), left SpO₂ (p=0.047), and time to extubation (p=0.021) were statistically significantly lower in the TT-FVC group compared to the MLT-VCV group. Discussion: Low airway peak pressure and stable hemodynamics were achieved with Tritube™, and no complications were encountered in the perioperative period. At the end of the surgery, the cuff was lowered, high-frequency jet ventilation was applied, and extubation was safe performed (3). Although the literature on TritubeTM and Evone® is still limited, the use of these tools in MLS appears to be advantageous to achieve safe airway management. Keywords: Microlaryngeal surgery, Ventilation, Hemodynamics

A new perspective during laryngo-tracheal surgery: the use of an ultra-thin endotracheal tube (Tritube®) and flow-controlled ventilation—a retrospective case series and a review of the literature

Background

Upper airway surgery often poses a challenge to both anesthesiologists and surgeons, as airway access, mechanical ventilation, and surgical difficulties may occur in a tricky combination. To fulfill the need for a tubeless surgery, techniques such as apneic oxygenation or jet ventilation may be used, which carry the risk of several complications. The ultrathin cuffed endotracheal tube Tritube can be used with flow-controlled ventilation (FCV) to provide adequate surgical field and ventilation. To assess the feasibility, safety, and effectiveness of this technique, we describe a series of 21 patients, with various lung conditions, undergoing laryngo-tracheal surgery with FCV delivered via Tritube. Moreover, we perform a narrative systematic review to summarize clinical data on the use of Tritube during upper airway surgery.

Results

All patients were successfully intubated in one attempt with Tritube. The median (interquartile range [IQR]) tidal volume was 6.7 (6.2–7.1) mL/kg of ideal body weight, the median end-expiratory pressure was 5.3 (5.0–6.4) cmH2O, and the median peak tracheal pressure was 16 (15–18) cmH2O. The median minute volume was 5.3 (5.0–6.4) L/min. Median global alveolar driving pressure was 8 (7–9) cmH2O. The median maximum level of end-tidal CO2 was 39 (35–41) mmHg. During procedures involving laser, the maximum fraction of inspired oxygen was 0.3, with the median lowest peripheral oxygen saturation of 96% (94–96%). No complications associated with intubation or extubation occurred. In one patient, the ventilator needed to be rebooted for a software issue. In two (10%) patients, Tritube needed to be flushed with saline to remove secretions. In all patients, optimal visualization and accessibility of the surgical site were obtained, according to the surgeon in charge. Thirteen studies (seven case reports, two case series, three prospective observational studies, and one randomized controlled trial) were included in the narrative systematic review and described.

Conclusions

Tritube in combination with FCV provided adequate surgical exposure and ventilation in patients undergoing laryngo-tracheal surgery. While training and experience with this new method is needed, FCV delivered with Tritube may represent an ideal approach that benefits surgeons, anesthesiologists, and patients with difficult airways and compromised lung mechanics.