Near total intrathoracic airway obstruction managed with a Tritube (R) and flow‐controlled ventilation: a reply.

We would like to thank the Editor for the opportunity to respond to the report by Dr Mallam and colleagues. The ultrathin Tritube (R) in combination with both mechanical ventilator Evone (R) and manual ventilator Ventrain (R) (all Ventinova Medical BV, Eindhoven, The Netherlands) were chosen for airway management and ventilation in a patient with acute, near total airway obstruction. The authors describe unexpected complications related to the use of the devices, which we address in this correspondence.

We would like to acknowledge the stressful situation encountered by the authors during this case. Following this case an immediate correspondence was initiated by the hospital’s senior airway surgeon and the hospital’s senior airway lead. Thanks to a clear and open communication to the manufacturer, appropriate measures were expedited. A field safety notice was filed, and all affected Evone devices were temporarily placed under quarantine. Upon identification of the root cause, a solution was implemented through a software upgrade which addressed the challenges described in this publication. Competent authorities, including the Medicines and Healthcare Products Regulatory Agency were subsequently satisfied with the handling of the problem and the solution provided, and all Evone devices were released from quarantine. To date, no comparable incidences have been reported to the manufacturer. Ventinova is aware of frequent use of Evone and Tritube for various indications in many countries.

Apart from the technical issues related to Evone the authors describe sudden ventilatory problems, which could not directly be linked to an obvious obstruction of Tritube. Based on the description provided, such issues might occur due to an altered positioning of Tritube, such as upon surgical manipulation too close to the carina with the mucous membrane and/or viscous secretions (that are likely with described pathology) causing a valve mechanism occlusion. However, as more data are lacking, the exact reason remains unclear.

Additionally, questions were raised on the suitability of Ventrain as a backup tool for ventilation in obstructed airways. We agree with the authors that proper use of Ventrain and Tritube requires careful monitoring of intra‐tracheal pressures, which can be easily done by connecting a manometer to the pressure lumen of the Tritube [1]. Alternatively, in a sealed or (nearly) obstructed airway, it is recommended to include a sufficiently long equilibration period every five ventilation cycles to avoid excessive positive or negative pressure in the lungs (Fig. 1).

Figure 1.

Cross section of Ventrain. 1: Gas inlet connected to oxygen source. 2: Jet nozzle accelerating the velocity of oxygen flow. 3: Exhaust pipe facilitating the exit of gas during expiration and equilibration. 4: Side‐port connected to patient. 5: Bypass allowing air to enter the ejector (on/off switch). (a) Equilibration position with open bypass. No clinically‐relevant flow to and from the patient (= equilibration with atmosphere). (b) Inspiration position with both exhaust pipe and bypass closed. (c) Expiration position with exhaust pipe open and bypass closed. Used with permission of Ventinova Medical BV, Eindhoven, the Netherlands

The clinical application of Ventrain, including its potential advantages over alternative techniques, has been described in detail [2]. Several studies have demonstrated that Ventrain is the safest and most efficient device for ventilation in a (near) complete airway obstruction [3, 4, 5], and its successful use in emergency situations has been published [6, 7]. However, we would like to emphasise that Ventinova strongly advises users to complete the required training before device use to assure safe application of Ventrain in emergencies.

Finally, we agree with the authors that flow‐controlled ventilation using Evone in combination with Tritube represents a valuable solution for managing complex difficult airway cases, as it has been successfully used by others for this purpose [8, 9, 10].