No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The Micro-Trach: a seven-year experience with transtracheal oxygen therapy
Abstract
Over a six-year period, 200 patients requiring long-term oxygen therapy for hypoxemic lung disease underwent insertion of the micro-trach transtracheal catheter and were evaluated for one to seven years. The catheter requires no removal for cleaning; it is designed to function undisturbed within the trachea for six months between replacements. Transtracheal oxygen delivery and saline instillation were instituted immediately after inserting the device. Oxygen administration at a rate of 0.25 to 3 L/min was equivalent to 1 to 8 L/min delivered nasally. By the end of one year of follow-up, 12.5 percent of patients had dropped out of the study. Most patients comply with prescribed 24-hour-a-day oxygen use; in keeping with the NOTT study, life expectancy of emphysema patients may therefore be increased.
... Since the initial description of TT oxygen delivery by Heimlich (1), a number of studies have been conducted to identify benefits of this therapy (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). TT oxygen delivery has been associated with decreased oxygen flow rates (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12), improved patient compliance (2)(3)(4), decreased oxygen costs (1,6), decreased hospitalization (1,3,4,7), and improved exercise tolerance (4,8). ...
... Since the initial description of TT oxygen delivery by Heimlich (1), a number of studies have been conducted to identify benefits of this therapy (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). TT oxygen delivery has been associated with decreased oxygen flow rates (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12), improved patient compliance (2)(3)(4), decreased oxygen costs (1,6), decreased hospitalization (1,3,4,7), and improved exercise tolerance (4,8). Quality of life may also improve (4,6). ...
... Since the initial description of TT oxygen delivery by Heimlich (1), a number of studies have been conducted to identify benefits of this therapy (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). TT oxygen delivery has been associated with decreased oxygen flow rates (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12), improved patient compliance (2)(3)(4), decreased oxygen costs (1,6), decreased hospitalization (1,3,4,7), and improved exercise tolerance (4,8). Quality of life may also improve (4,6). ...
The purpose of this study was to compare the efficacy of transtracheal (TT) oxygen delivery to that of nasal cannula delivery in subjects with chronic obstructive pulmonary disease (COPD). Twenty subjects (14 men, 6 women) were followed for 6 months during nasal cannula delivery. A TT catheter was then inserted, and measurements were repeated during TT use. With TT delivery, subjects required 45% less oxygen at rest and 39% less during exercise (p less than 0.0001). Oxygen use, measured by pounds of oxygen delivered to the home, also decreased, but the magnitude of change was less than anticipated (mean, 14%; range, +4% to -32%). Hospital days decreased from 12 +/- 10 during nasal cannula use to 4 +/- 6 during TT use (p less than 0.002). Exercise tolerance, as measured by a 12-min walk distance, was greater during TT use (p less than 0.0001). No change was seen in spirometry or acid-base balance. Also, no change was seen in Profile of Mood States, Sickness Impact Profile or Katz Adjustment Scale scores. Some problems were encountered relating to use of the catheter (displacement, mucus balls), but they were minor, and most were confined to the initial 2 months of TT use when the tract was immature. Our experience suggests that, in addition to decreasing oxygen flow rate, use of TT delivery may confer benefits that result in improved exercise tolerance and decreased hospitalization in patients with COPD.
... The transtracheal catheter was developed in the early 1980s, as an alternative to nasal cannula oxygen. [12][13][14] More recent surgical techniques have simplified the procedure. 15,16 Many benefits of transtracheal catheter oxygen have been described. ...
... 18 These oxygen savings should extend the use of portable oxygen devices by ambulatory patients, and thereby facilitate greater independence. In addition, patients on transtracheal catheter oxygen have improved oxygenation from the reduced oxygen cost of breathing 3 because of the reduced inspired minute volume and inspiratory work of breathing, 2 which may reduce the energy expenditure from breathing. 2 Other published benefits include reduced hematocrit, 12 increased exercise tolerance, 4,20 and improved arterial oxygenation during sleep. 21 Transtracheal oxygen has even been suggested as an alternative to other therapies for patients with refractory obstructive sleep apnea. ...
The fraction of inspired oxygen (F(IO(2))) is quoted for different oxygen delivery systems, but variations in inspiratory flow and tidal volume make precise measurement difficult. We developed a reliable method of measuring the effective F(IO(2)) in patients receiving supplemental oxygen.
Ten subjects with chronic hypoxemia breathed through a mouthpiece with a sampling probe connected to a mass spectrometer. Four of the 10 subjects had transtracheal catheters that allowed direct sampling of tracheal gas. We used oxygen concentrations of 47% and 97%, and flow rates between 1 L/min and 8 L/min. We also compared oxygen delivery via nasal cannula and transtracheal catheter. Effective F(IO(2)) was derived from plots of the fractional concentrations of carbon dioxide versus oxygen.
We found excellent correlation between the effective F(IO(2)) values from tracheal and oral sampling (r = 0.960, P < .001). With 97% oxygen via nasal cannula, effective F(IO(2)) increased by 2.5% per liter of increased flow (P < .001); effective F(IO(2)) reached 32.7% at 5 L/min while P(aO(2)) increased by 12 mm Hg per liter of increased flow. In 4 subjects with a transtracheal catheter, effective F(IO(2)) increased 5.0% (P < .001) per liter of increased flow, and P(aO(2)) increased by 13 mm Hg per liter of increased flow, whereas in the same 4 subjects using nasal cannula for oxygen delivery, P(aO(2)) increased by only 6 mm Hg per liter of increased flow.
Exhaled gas sampled at the mouth accurately reflected the effective F(IO(2)) in the trachea. In relation to inspired oxygen flow, the effective F(IO(2)) was lower than is conventionally thought. Compared to nasal cannula, transtracheal catheter approximately doubled the effective F(IO(2)) at a given flow rate. Accurate knowledge of F(IO(2)) should aid clinicians in managing patients with acute and chronic lung diseases.
... Transtracheal oxygen therapy (TTOT) improves the efficiency of oxygen delivery by creating an oxygen reservoir in the trachea and larynx. Consequently, mean oxygen savings amount to 50% at rest and 30% during exercise [4][5][6][7]. TTOT reduces dead space ventilation and inspired minute ventilation, while increasing alveolar ventilation slightly, which may result in a reduction of the oxygen cost of breathing [8][9][10][11]. As a result, patients using TTOT may experience improved exercise tolerance and reduced dyspnoea [12,13]. ...
... Secondly, the type of catheter is important. Compared to more flexible catheters, like the SCOOP, stiffer ones, like the Angiocath and Oxycath, may cause less mucous balls, but they seem to crack and break off sooner [4,26,31]. The standard internal length of 11 cm may prove to be too long in shorter patients and in patients whose lungs are retracted. ...
Transtracheal oxygen therapy (TTOT) improves the efficiency of oxygen delivery and overcomes the discomfort associated with nasal oxygen delivery in patients on long-term oxygen therapy (LTOT). In addition, TTOT improves compliance and quality of life, and may reduce morbidity. Experience with TTOT in Europe is, however, scarce and the safety of TTOT has not yet been completely determined. These were reasons for testing the acceptance, efficacy and safety of TTOT. Patients were selected on the basis of the accepted indications and contraindications for TTOT. In 75 patients (48 males and 27 females) the mean follow-up time was 16 (range 0.5-51.5) months. Compared to nasal cannulae, TTOT caused a reduction in the oxygen flow rate of 47 (33-60)% at rest and a significant increase in the number of hours that oxygen was used. All patients on TTOT used oxygen for at least 20 h x day(-1). Most patients saw the procedure as a minor intervention. It was usually performed on an out-patient basis. In 34 patients, 51 mainly minor complications were seen, and most of these occurred in the first 10 patients. After precautions had been taken, complications occurred less frequently. No patient needed to be hospitalized because of a complication. TTOT had to be stopped in two patients; nevertheless, all patients preferred TTOT to the nasal cannulae. We conclude that transtracheal oxygen therapy is an effective and safe alternative to nasal oxygen administration, provided that it is restricted to a well-defined group of patients and applied by a motivated and experienced group of physicians.
... Given these benefits, TTOT became a useful tool for rehabilitating primarily chronic obstructive pulmonary disease (COPD) patients in the early 80s. [10][11][12] A growing body of evidence supported its use in several other conditions such as ILD, [2,13] OSA, [7,[14][15][16] and in patients with overlap syndrome. [7] While initially used to conserve oxygen (allowing increased oxygen delivery time with the same size reservoirs) in ambulatory COPD patients, more recently it was proven to be effective in treating severe refractory hypoxemia in patients with advanced lung diseases, including pulmonary fibrosis. ...
Transtracheal oxygen therapy is a well-established modality for improving oxygenation in patients with chronic obstructive pulmonary disease, sleep apnea, pulmonary fibrosis, and other conditions causing hypoxic respiratory failure. In spite of its proven track record, the device remains underutilized. This article reviews benefits and complications related to the use of this modality with an illustrative case presentation.
... Transtracheal oxygen (TTO) is delivered through a small stoma in the neck into the trachea [52,53]. Oxygen flows down the trachea toward the carina. ...
Oxygen is commonly prescribed for lung cancer patients with advancing disease. Indications include hypoxemia and dyspnea. Reversal of hypoxemia in some cases will alleviate dyspnea. Oxygen is sometimes prescribed for non-hypoxemic patients to relieve dyspnea. While some patients may derive symptomatic benefit, recent studies demonstrate that compressed room air is just as effective. This raises the question as to whether to continue their oxygen. The most efficacious treatment for dyspnea is pharmacotherapy-particularly opioids. Adjunctive therapies include pursed lips breathing and a fan blowing toward the patient. Some patients may come to require high-flow oxygen. High-flow delivery devices include masks, high-flow nasal oxygen and reservoir cannulas. Each device has advantages and drawbacks. Eventually, it may be impossible or impractical to maintain a SpO2 > 90%. The overall goal in these patients is comfort rather than a target SpO2. It may eventually be advisable to remove continuous oximetry and transition focus to pharmacological management to achieve patient comfort.
... En los últimos años se concibió una tunelización subcutánea, ingresándose por la región subxifoidea, desplazándose la tubuladura por la región preesternal hasta llegar la punto del ostoma traqueal donde ingresa el catéter a la vía aérea. Algunas series demuestran que el O 2 tt mejora la compliance al tratamiento, disminuye el trabajo respiratorio, y aumenta la tolerancia al ejercicio 64 . Por otro lado es el sistema mas estético, dado que su ingreso a nivel cutáneo puede ser disimulado por la vestimenta, siendo su índice de aceptación del 97% en pacientes seleccionados 65 . ...
Pathophysiology, diagnosis and treatment of severe chronic hypoxemia. Role of long-term oxygen therapy. The purpose of this article is to review the etiological and pathophysiological aspects of chronic severe hypoxemia (CSH) and to determine the indications of long-term oxygen therapy (LTOT). Three hypothesis are presented and analyzed: 1) CSH is harmful to the economy; 2) LTOT is therefore useful; 3) LTOT is not toxic and does not imply major risks than the benefits that it offers. Changes are produced by prolonged exposure to low levels of O2 leading to a sustained increase in pulmonary artery pressure. Secondary pulmonary hypertension (SPH) due to chronic hypoxemia is much more subtle and less symptomatic than that produced by other pathologies. Chronic obstructive pulmonary disease is the most common cause of CSH; these patients have a poor prognosis associated to the hypoxemia and its effects, being a PaO2 below 60 mmHg one of the most precise factors of mortality. Patients selection criteria for LTOT different sources for home oxygen therapy, methods of administration and finally an update of LTOT situation in our country and abroad are discussed.
Los riesgos de la administracion aguda de oxigeno se refieren a los efectos secundarios precoces, como la hipercapnia o las atelectasias por absorcion y al dano tisular, como la citotoxicidad pulmonar o la retinopatia de los prematuros. No se han demostrado riesgos relacionados con la administracion cronica de oxigeno en pacientes estables. La oxigenoterapia cronica no incrementa significativamente la PaC0 2 ni se reconocen lesiones tisulares atribuibles al tratamiento. El riesgo de explosion puede minimizarse con unas precauciones elementales. El mal funcionamiento de las fuentes de oxigeno pueden condicionar la efectividad del tratamiento, especialmente en el caso del concentrador si no se somete a revisiones periodicas. Los accesorios utilizados para recibir oxigeno pueden producir irritacion local, especialmente si se administran flujos elevados. Pueden producirse fugas en los tubos acodados o con multiples conexiones. El uso de humidificadores no esta justificado en la mayoria de pacientes, siendo ademas otra fuente de fugas. El cateter transtraqueal (CTT) es una forma invasiva de administrar oxigeno muy eficaz pero que plantea problemas en el momento de la insercison (enfisema subcutaneo, hematoma, broncoespasmo), o a largo plazo (tapones de moco alrededor del CTT o las infecciones locales).
Correspondencia: Servicio de Neumología. Planta 12. Residencia General. Hospital La Paz. P. ° de la Castellana, 261.28046 Madrid.
This chapter reviews the known effects of chronic oxygen therapy, its indications, and the various delivery systems now available. Oxygen therapy has become very important in the treatment of severe chronic obstructive pulmonary disease (COPD). Long-term oxygen improves survival in hypoxemic COPD. Other benefits of oxygen include better exercise tolerance, decreased dyspnea, and improvements in neuropsychological performance. In addition, there appear to be beneficial effects on pulmonary hemodynamics, sleep quality, reduced minute ventilation, and WOB. Hypoxemia is defined as an abnormally low arterial oxygen tension PaO2. The physiologic causes of hypoxemia include a low inspired partial pressure of oxygen, abnormal ventilation-perfusion relationship, decreased diffusion capacity, alveolar hypoventilation, and right to left shunt. Oxygen therapy increases the FiO2 and is the primary treatment for hypoxemia resulting from the first three causes. The hypoxemia of alveolar hypoventilation is best treated by increased ventilation while a true shunt is by definition unresponsive to hyperoxia. Although the reason for increased survival with oxygen is not clear, there is evidence that O2 can improve pulmonary hemodynamics and leads to reduced cardiac work and greater oxygen delivery. The consequences of exercise induced and nocturnal desaturation are not absolutely known. Clinicians should be aware of air travel-induced hypoxemia in COPD and be able to identify those who need oxygen in flight. Once a patient meets the criteria for oxygen prescription, the physician must complete the certificate of Medical Necessity Form specifying the indication for oxygen, type of system and liter flow at rest, exercise and sleep.
Respiratory symptoms such as breathlessness and cough are common in patients with advancing and incurable disease. For example, cancer, chronic cardiac and pulmonary disease, progressive neuromuscular disorders and degenerative disorders all give rise to varying degrees of respiratory distress, which adversely affects the patient's quality of life. In recent years, there has been significant growth in the palliation of respiratory symptoms, leading to practical ways of giving relief in hospices, hospitals, and at home. This book includes non-malignant respiratory diseases, such as tuberculosis in AIDS patients and cystic fibrosis, and focuses on aetiology and diagnosis and management, emphasising symptoms, quality of life, and psychosocial support. Its underlying theme is the application of modern research-based knowledge, in a humane way, for patients with advancing disease.
Cardiovascular diseaseDiabetes mellitusCachexiaPeptic ulcer diseaseOsteoporosisConclusions
References
In a patient with a transtracheal oxygen catheter (ITO 2 C), a nearly fatal complication occurred due to the formation of a mucous plug on the tip, which almost totally obstructed the tracheal lumen. To our knowledge, this complication has not been reported before with the use of this type of transtracheal oxygen catheter.
Ten patients with chronic lung disease received an implanted ITOC. Seven patients continue to use their catheters after a mean period of 14.75 months. Four catheters were removed, 2 at 1 month, 1 after 10 months and 1 after 13 months. One patient requested a second catheter. Three patients experienced mucus plug formation; this was transient in two patients, but led to removal of the catheter in the third. To determine the degree of oxygen-saving afforded by the ITOC, SaO2 was measured at rest and during exercise for eight of the ten subjects using a double-blind technique. The calculated oxygen savings were around 40 percent both at rest and during exercise. The ITOCs were well received by the majority of our patients and were shown to produce a useful saving of oxygen which is of benefit to patients using portable systems and those who require high oxygen flow rates. (Chest 1992; 102:1413-18)
Transtracheal oxygen (TTO) delivery for patients with chronic hypoxemia has been used increasingly since its introduction in 1982. Most complications have been relatively minor and usually occur in conjunction with catheter placement. This report describes two patients with long-term catheter use who developed increasing respiratory failure and cor pulmonale, at least in part, due to a large tracheal mucus plug.
Transtracheal oxygen catheters are being increasingly used because of savings in oxygen usage and patient preference. The complications of the catheter are believed to be minor and easily managed. Inspissated mucous collections that form at the tip of the SCOOP 1 (Transtracheal Systems, Denver, Colorado) catheter have been reported but are usually easily expectorated by the patient. This report describes a patient who had development of acute respiratory compromise from crusted mucoid impaction of the trachea secondary to transtracheal catheter use. General anesthesia and rigid bronchoscopy were required for removal of the obstructing impaction. Unexplained worsening of respiratory symptoms in patients with transtracheal oxygen catheters should be addressed by prompt stripping of the catheter.
A patient with acquired immunodeficiency syndrome (AIDS) was admitted to a hospital with cough and fever and after 29 days was transferred to a hospice. He was eventually shown to have active pulmonary tuberculosis. This diagnosis was obscured clinically by simultaneous infection with Pneumocystis carinii and Mycobacterium avium complex (MAC). Laboratory recognition of Mycobacterium tuberculosis was delayed because of overgrowth of cultures by MAC but was later established using DNA probe techniques. Thirty (19 percent) of 158 health care workers who had been exposed to this patient had conversion of their tuberculin skin tests. Diagnostic difficulties and nosocomial transmission of tuberculosis may occur when patients with AIDS have mixed mycobacterial infections.
Chronic obstructive pulmonary disease is a major cause of death and disability in the United States. The most important risk factor for COPD is cigarette smoking. Thus, COPD is largely a preventable condition. Other risk factors may include air pollution, childhood infections, heredity, advanced age, airway hyperresponsiveness, and occupational exposures. Some risk factors, including male sex and socioeconomic status, may gain their influence through associations with cigarette smoking or living conditions. More attention to primary, secondary, and tertiary prevention of COPD is required.
In order to reduce the burden of illness associated with COPD, greater efforts in smoking prevention and smoking cessation are required. Other measures include reductions in air pollution, influenza vaccination programs, and augmentation therapy for those with severe alpha-antitrypsin deficiencies. Once persons are afflicted with COPD, high quality medical care is essential.
Improved efforts in the prevention and management of COPD will require education directed toward patients, the general public, and health care providers. Considerably more research in education and prevention is necessary; this includes epidemiologic research to clarify the risk factors for dysfunction, biomedical research to substantiate information on the chemical markers of lung injury, expansion of the protease-inhibitor hypothesis, and evaluation of genetic predisposition toward the disease. Health services research will be required in order to create improved measures of health outcome, evaluate the cost-effectiveness of treatment programs, and improve the efficiency and effectiveness of both preventive and tertiary treatment programs. More research is necessary on cigarette use, access to care, and occupational exposures among members of underrepresented minority groups. Finally, it will be necessary to conduct more research to identify methods to help the general public adhere to preventive measures and to help COPD patients adhere to prescribed therapies.
BACKGROUND: The Nocturnal oxygen therapy trial and Medical Research Council studies have shown that home oxygen therapy increases survival and offers hemodynamic benefits to hypoxemic chronic obstructive pulmonary disease. In recent years, research has been aimed at improving patients' quality of life by introducing portable sources of liquid oxygen and oxygen-saving systems, such as the oxymizer and transtracheal catheters. PURPOSE: To identify the acute and long-term hemodynamic response to different methods of oxygen saving devices, oxymizer and transtracheal catheter, in chronic obstructive pulmonary disease patients previously oxygenated via nasal prongs. METHODS: Acute response. A minimum of 3 nocturnal pulse-oximetries were performed with each device (nasal prongs, oxymizer and transtracheal catheter) to find the minimum oxygen flow required to maintain a Sao2 % > 88% during 95% of the night. With the preset oxygen flow, a radionuclide ventriculography was performed at rest and during exercise to calculate the right and left ventricular ejection fraction. Long-term response to transtracheal catheter: Arterial gasometries, hemoglobin determinations, Pulmonary function testing, echocardiography, radionuclide ventriculography (right and left ventricular ejection fractions, and ventricular volumes), right heart catheterization, 6 minute walking test, and a visual analogue scale score were performed at the beginning of the study and 1 year later in 10 hypoxemic chronic obstructive pulmonary disease. RESULTS: Acute response. The increment of the left ventricular ejection fraction during maximal exercise with the oxymizer was significantly lower than with nasal prongs or transtracheal catheter and the right ventricular ejection fraction showed a tendency to decrease (P=0.06). Long-term response to transtracheal catheter. At the end of follow-up, decreases were found in hemoglobin (15.2 to 12.9 g/dL) and forced expiratory volume in the first second (0.78 L to 0.62 L) and the Pao2 (determined with the same oxygen flow via transtracheal catheter) increased (66.8 to 71.0 mm Hg), (P<0.05), but the cardiac work, the 6 minute walking test and the visual analogic scale did not deteriorate. Cardiac index, pulmonary capillary wedge pressure, right and left ventricular ejection fraction did not change. Mean pulmonary arterial pressure did not improve but the pulmonary arteriolar vascular resistances and the right ventricle free wall stress index significantly improved at the end of the study. The end-systolic and end-diastolic volumes of the right ventricle determined at rest showed a tendency to decrease (P=0.06). CONCLUSIONS: For patients on home oxygen therapy, who wish to maintain maximal physical activity, the oxymizer is not recommended as an oxygen saving device. Long-term oxygenation, 24 hours per day with liquid oxygen via transtracheal catheter in hypoxemic patients previously on home oxygen therapy with nasal prongs, who maintained physical activity showed improved oxygenation (hemoglobin values decreased), improved Pao2. and showed hemodynamic benefits (decrease of the post-load). All these results occurred despite the forced expiratory volume in the first second deterioration, maintaining the same degree of dyspnea (unchanged visual analogue scale score) and exercise capacity (no changes in 6 minute walking test).
vdsfgsdlfgTranstracheal oxygenPercutaneous tracheotomy
Los pacientes con insuficiencia respiratoria crónica incluidos en programas de oxigenoterapia y ventilación mecánica domiciliaria refieren tener habitualmente grandes dificultades para realizar viajes complejos que impliquen diferentes destinos y permanencias prolongadas fuera de su domicilio habitual. Todos ellos tienen en común la necesidad de disponer de un equipamiento tecnológico más o menos sofisticado en casa que limita su libertad de movimientos. Hablamos de los sistemas de oxigenoterapia y respiradores mecánicos. Dadas las dificultades para viajar en avión que tienen este tipo de pacientes, nos planteamos que un crucero sería una alternativa ideal al ser el hotel el que se desplaza. Ello facilitaría la logística del viaje, pues sólo tendríamos que realizar la instalación de los equipos en un único emplazamiento. Con estas premisas hemos organizado hasta la fecha 2 cruceros para enfermos respiratorios crónicos, la Expedición RESpIRA y el Crucero de la EPOC. En nuestra experiencia, los problemas a los que debemos enfrentarnos a la hora de organizar un crucero para pacientes con insuficiencia respiratoria crónica se relacionan con el reclutamiento de pacientes, la financiación del viaje y la elección del itinerario que vamos a realizar. Una vez aclarados estos aspectos, hay que conseguir la autorización de la compañía naviera correspondiente, con el visto bueno de los servicios médicos y de seguridad de a bordo. Tras obtener el permiso para poder realizar el crucero y una vez que sepamos cuántos pacientes van a viajar, es necesario conocer qué material vamos a necesitar en términos de número de equipos de oxigenoterapia, respiradores y material fungible y, finalmente, dónde lo vamos a conseguir. Después sólo quedará disfrutar de la excursión. La participación de los médicos responsables de los programas de oxigenoterapia y ventilación mecánica domiciliaria es fundamental para transmitir seguridad a los pacientes y garantizar la solución de los problemas técnicos y médicos que pueden presentarse durante el viaje.
Ten patients with chronic lung disease received an implanted ITOC. Seven patients continue to use their catheters after a mean period of 14.75 months. Four catheters were removed, 2 at 1 month, 1 after 10 months and 1 after 13 months. One patient requested a second catheter. Three patients experienced mucus plug formation; this was transient in two patients, but led to removal of the catheter in the third. To determine the degree of oxygen-saving afforded by the ITOC, SaO2 was measured at rest and during exercise for eight of the ten subjects using a double-blind technique. The calculated oxygen savings were around 40 percent both at rest and during exercise. The ITOCs were well received by the majority of our patients and were shown to produce a useful saving of oxygen which is of benefit to patients using portable systems and those who require high oxygen flow rates.
Transtracheal oxygen is generally well tolerated in patients with chronic hypoxemia. Minor complications are common, but there are few reports of serious respiratory tract infections associated with transtracheal oxygen therapy. We describe four patients with interstitial lung disease who had frequent lower respiratory tract infections requiring hospitalization after initiation of transtracheal oxygen therapy.
Oxygen therapy through a transtracheal catheter has been used increasingly for the long-term delivery of continuous oxygen. Compared to nasal cannula it results in significant reduction in oxygen flow requirements. This form of therapy has gained patient acceptance because of several advantages including improved convenience, aesthetics, compliance, and mobility. Reported complications generally have been minor, including subcutaneous emphysema, cough, "mucous ball" formation and mild hemoptysis. In this report, we describe a case of granulation tissue formation at the transtracheal catheter puncture site which was treated with Nd:YAG laser bronchoscopy to reestablish patency of the upper airway. No recurrence was noted after two years of follow-up.
Transtracheal (TT) oxygen delivery involves administration of oxygen percutaneously through a catheter inserted in the suprasternal trachea. Transtracheal oxygen delivery has been proposed as a means of overcoming the high visibility, inconvenience, and discomfort associated with nasal cannula use. This report describes our experience using TT delivery in 40 patients with chronic obstructive pulmonary disease (n = 32) and other types of lung disease (n = 8). Overall acceptance of TT catheter use was high and only 5 subjects elected to discontinue use. We believe the TT route is a relatively safe approach for oxygen administration and a promising method of improving patient compliance. It also offers the potential of more adequately oxygenating patients with refractory hypoxemia.
A 50-year-old man with pulmonary fibrosis and COPD presented with worsening cough, dyspnea, chest pain, and hypoxemia of no readily apparent etiology, approximately four weeks after insertion of a transtracheal oxygen therapy catheter. Despite vigorous bronchial hygiene therapy, the patient died. Autopsy revealed obstruction of the trachea by a large mucous ball. We point out the nonspecificity of physical and radiologic findings associated with this condition and suggest that serial flow-volume loop analysis or earlier use of fiberoptic bronchoscopy might have been of assistance in premortem diagnosis of the mucous plug.
Long term continuous oxygen therapy improves prognosis in patients with hypoxaemic chronic airflow limitation. Transtracheal delivery of oxygen permits adequate oxygenation of such patients at lower flow rates than are required for delivery by nasal cannulas, thus increasing the time for which portable oxygen cylinders can be used and improving the efficacy of domiciliary oxygen concentrators in patients with refractory hypoxaemia. In a study of the long term acceptability and risks of transtracheal oxygen in 37 patients, with a total follow up of 595 patient-months, most patients reported symptomatic benefit and four have used transtracheal oxygen successfully for more than four years. Problems have included surgical emphysema (4 patients), catheter fracture (9), local infection (34), and catheter dislodgement (21); but these have been relatively infrequent and in general have not caused important clinical problems. Transtracheal oxygen therapy was discontinued in 10 patients before death for various reasons, including infection (2 patients), catheter fracture (1), and surgical emphysema (1). Accumulation of mucus balls has not been a problem. It is concluded that transtracheal oxygen therapy is a safe and acceptable alternative to nasal cannulas in well motivated patients with hypoxaemia due to chronic airflow limitation who are keen to pursue an active life.
Oxygen therapy improves mortality and morbidity in hypoxemic patients with COPD. For best results, oxygen should be administered continuously. The general guidelines that qualify a patient for long-term home oxygen therapy are rather explicit, although there are some gray areas, such as increasing exercise performance in normoxemic COPD patients and the treatment of dyspnea in certain patients.
The physiologic goals of oxygen therapy are to reverse or prevent tissue hypoxia under the various conditions of life. Patients often experience a fall in oxygen saturation during REM sleep and during exercise. Thus, the oxygen preemption should specify the oxygen setting during wakeful rest, sleep, and exertion.
Pulmonary rehabilitation is the definitive long-term management for patients with chronic lung diseases by building endurance, strength, and coping skills. Patients undergoing pulmonary rehabilitation are taught to become active and mobile. The rehabilitation programs have a special role in helping patients to accept and properly administer their own oxygen therapy.
Oxygen therapy should be based on mobility and portability. Improvements in the weight and bulk of oxygen containers and the introduction of oxygen-conserving devices have rendered oxygen systems more portable and less costly.
The prescription initiates a clinical triad relationship between the patient, physician, and home oxygen vendor. Prescribing home oxygen is now more time-consuming, and the prescription process requires the careful attention of the physician. The prescription must include patient data, the diagnostic reasons for oxygen, the blood gases, the type of system, and the liter-flow for the various living conditions such as rest, sleep, and exertion. Reimbursement for oxygen via Medicare and other carriers will depend upon the physiologic data as well as the successful completion of a rather complex form.
Oxygen therapy should be monitored by regular arterial blood gases or pulse oximetry where appropriate. Patients should have a blood gas sample taken upon any change of condition or adjustment of the oxygen flow setting. Successful oxygen therapy should be physician directed, based on a solid understanding of the physiologic processes involved.
In summary, we find that long term oxygen therapy is practical, that it can lower both pulmonary arterial pressure and the red cell mass, and also reduce the time spent in hospital. It is yet to be ascertained by a controlled trial if these improvements are significant when compared with those obtained in similar patients treated without oxygen. The Union Carbide Walker system is a convenient and relatively cheap way of giving oxygen over this long period. Although oxygen on exercise improves these patients' exercise tolerants, it would appear that weight of the Oxygen Walker might prevent much advantage to be taken of this in these severely disabled patients if the patient actually carries the Walker himself, but this portable system greatly increases the patient's social mobility.
This article has discussed drug therapy in the elderly and included a discussion of optimal inhaled bronchodilator therapy; issues relating to tracheostomy, a frequent requirement after ventilatory failure in the elderly; oxygen administration, emphasizing its effects on exercise in COPD, and forced oscillation, a new technique that may have utility in the measurement of lung function in the geriatric population.
Previous studies have shown transtracheal delivery of low-flow oxygen (TTO) decreases inspired minute ventilation (Veinsp) and have postulated that this would result in a decrease in the work of breathing (WOB). We hypothesized that a fall in central inspiratory neuromuscular drive (CIND) with TTO would reflect a fall in WOB. We measured resting ventilatory parameters (RVP) and CIND by the mouth occlusion pressure technique (MOP) at different gas flow rates through the catheter in 21 subjects (13 men, 8 women; mean age, 60 +/- 10.6 years) with severe COPD with a mature intratracheal oxygen catheter (ITOC). We also constructed a lung/chest wall analog (LCA) to determine if flow through the catheter would alter pressure changes during inspiration. Inspiratory tidal volume (Vtinsp) and minute ventilation (Veinsp) decreased proportionally to the gas flow rate through the catheter. However, with increasing flow through the catheter, P0.1 increased in the LCA, presumably due to the Bernoulli effect. The lack of a similar change in the subject group suggests that CIND does, in fact, fall, and that possibly there is a decrease in WOB. This effect may be of benefit to patients with severe COPD.
The available evidence indicates that pulmonary rehabilitation benefits patients with symptomatic COPD. The effect of pulmonary rehabilitation programs on health care use is promising but requires further investigation. In contrast, aerobic lower extremity training is of benefit in several areas of importance to patients with COPD. These areas include exercise endurance, perception of dyspnea, quality of life, and self-efficacy. The exact role of upper extremity exercise training programs requires further studies but should be used in patients who develop symptoms with arm activities. Psychological support improves the awareness of the patient and increases his or her understanding of the disease, but when used alone it is of limited value. Pulmonary rehabilitation when coupled with smoking cessation, optimization of blood gases, and medications offers the best treatment option for patients with symptomatic airflow obstruction.
A 69-year-old man with hypoxemic COPD underwent placement of a transtracheal oxygen (TTO) catheter. At 3 months, the catheter tract appeared mature with minimal erythema and no evidence of infection at the catheter site. The patient and his spouse were taught to remove and reinsert the catheter but were told to delay beginning the procedure due to erythema at the stoma site. Despite instructions not to remove the catheter for cleaning, the spouse removed the TTO catheter and attempted to reinsert it using the flexible metal cleaning rod. Subsequently, the patient suffered an acute episode of subcutaneous air and hemodynamic collapse resulting in death. Necropsy revealed a false catheter tract occluded by clotted blood and a defect in the platysma muscle where oxygen had dissected into the mediastinum. The patient died due to pneumomediastinum and cardiac tamponade.
To determine whether transtracheal catheter and reservoir nasal cannula contribute to maintaining adequate oxygen saturation during sleep, and to calculate the oxygen saving they allow compared to nasal prongs.
A prospective study in which patients were randomly assigned to either nasal prongs or oxymizer device prior to transtracheal oxygen delivery. Arterial oxygen saturation was then monitored by a finger pulse oximeter during 8 h of sleep.
Pulmonary ward of 'The Hospital Universitari Germans Trias i Pujol, Badalona (Barcelona/Spain)'.
Fourteen stable hypoxemic (PaO2 50 +/- 6.9 mm Hg; PaCO2 51.5 +/- 9.3 mm Hg) COPD patients (FVC 44 +/- 19%; FEV1 26.5 +/- 11.5%; FEV1/FVC 44.9 +/- 9.7%) already receiving oxygen therapy at home.
Pulmonary function test was performed. The lowest flow required to obtain an SaO2 at or above 88% for over 95% of the sleep time was determined for each type of oxygen delivery. Patients were not switched to the next type of oxygen delivery device until 3 reliable pulse oximetries had been obtained. The percentage of oxygen savings was calculated. Awake PaO2 was measured in patients using nasal prongs and transtracheal catheter while continuing to inspire oxygen at the same flow rate as when asleep.
As expected, no differences were found in SaO2 measurements for the three types of oxygen delivery. Oxygen savings were 48.65% for the oxymizer device and 52.87% for the transtracheal catheter. Awake PaO2 was significantly higher (p < 0.04) in patients with nasal prongs than in those with transtracheal catheter at the flow rate required when asleep.
The oxymizer device and transtracheal oxygen delivery benefit hypoxemic COPD patients reducing oxygen use during sleep by around 50%. Higher PaO2 levels were necessary to prevent nocturnal SaO2 decreases in patients with nasal prongs than in patients with transtracheal oxygen delivery. Oxygen-conserving devices are reliable and advisable methods for nocturnal oxygenation.
To evaluate and discuss the use of transtracheal oxygen catheters for the treatment of chronic hypoxemia and to discuss the complications associated with the placement and care of these devices.
We conducted a retrospective study at a tertiary medical center and reviewed the pertinent literature.
The medical records of 56 patients who received a transtracheal oxygen catheter between January 1987 and June 1992 at our institution were reviewed for demographic data, diagnosis leading to catheter placement, complications related to catheter use, reason for catheter removal, and duration of use. Follow-up results were established by documentation in the medical records or telephone interview.
During the study period, 39 men and 17 women received a transtracheal catheter. More than half the patients (52%) had chronic obstructive pulmonary disease. The duration of use of the catheter ranged from 2 days to more than 6 years, and the most frequent cause for removal of the catheter was death. Of the 56 patients, 42 died with the catheter in place, 24 within the first year after placement. Complications ranged from mucous plugging (38 % of patients) to pneumothorax (4%), and no patient died of a catheter-related complication. Overall, 55% of patients had their catheter for less than 1 year after placement.
In patients with transtracheal oxygen catheters, problems related to mucous plugging are common, but severe complications such as pneumothorax and pneumomediastinum are uncommon. Although selection factors that would identify ideal candidates for transtracheal oxygen therapy have not been established, such a catheter is best placed in highly motivated patients who can physically manage the daily care of this device.
The development of ultrathin fiberoptic bronchoscopy (FB) has made the examination of neonatal airways a practical possibility. The aim of this study was to assess the effects of intratracheal oxygen (ITO) administration on blood oxygenation and carbon dioxide (CO2) changes during FB in different body-weight infants.
Newborns suspected of having airway problems, but in a stable cardiopulmonary condition were studied. An ultrathin (outside diameter, 2.2 mm) fiberoptic bronchoscope that was modified by adding an external tube (internal diameter, 0.3 mm; outside diameter, 0.64 mm) to deliver oxygen was used. For ITO administration, a low oxygen flow rate of 0.1 l/kg/min was delivered directly into the trachea. Oxygenation and CO2 measurements were obtained at five different stages: 1) just before FB (baseline); 2) with the tip of the bronchoscope at the supralarynx; 3) with the tip at the carina without ITO; 4) with the tip at the carina with ITO; and 5) 15 minutes after FB. Forty infants were studied completely and divided into two groups according to their body weight: 1) the light-weight group (< 2,500 g), 21 infants; and 2) the heavy-weight group (> or = 2,500 g), 19 infants.
In both groups, arterial blood oxyhemoglobin saturation and oxygen tension decreased significantly (p < 0.05) when the tip of the bronchoscope advanced from the nostril to the supralarynx, and further decreased (p < 0.01) when at the carina level. Small infants had greater decrements of both oxygenation measurements (p < 0.05) than the large infants. After ITO administration, both oxygenation measurements increased significantly (p < 0.001) and returned to baseline following FB. Both end tidal pressure of CO2 (P(ET)CO2) and arterial CO2 tension (PaCO2) significantly increased from the baseline when the FB tip was advanced from the supralarynx to the carina (p < 0.05). During ITO administration, the PaCO2 increased (p < 0.01) but the P(ET)CO2 decreased (p < 0.001). After FB, both CO2 measurements returned to baseline. The pH only decreased during ITO administration.
We conclude that FB causes significant hypoxemia and hypercapnia in newborns, especially in underweight infants. Appropriate ITO can be considered a safe and beneficial technique for maintaining oxygenation during FB. P(ET)CO2 monitoring may mask true blood CO2 retention during ITO administration.
As an adjunct to mechanical ventilation, tracheal gas insufflation (TGI) injects gas flow into the trachea to flush carbon dioxide (CO2) from the anatomical and mechanical dead space, but the addition of TGI flow from a catheter may cause problems related to increased flow velocity at the catheter tip. Forward momentum and turbulence beyond the tip oppose expiratory flow and may cause or increase intrinsic positive end-expiratory pressure. If the catheter is placed within the endotracheal tube (ETT), the catheter itself acts as a resistive element to exhalation. Effects of the catheter presence (contact on or whipping against the airway) or local rapid gas flow effects on the tracheal mucosa are possible. Thus far, TGI has been delivered through a range of catheter sizes and styles. Two general design modifications have been incorporated in TGI systems to address the possible problems: embedding the catheter flow channel within the ETT, and directing the TGI flow cephalad. The LaBrune-Boussignac tube was designed with 6 or 8 channels embedded within the ETT, from which TGI flow exits laterally within the ETT at 1.5 cm from its tip. This avoids the use of a catheter and thus avoids local traumatic effects. A reverse-thrust catheter has been designed to direct flow within a sheath around the catheter tip; flow exits cephalad from a gap between the sheath and the catheter shaft. As part of a proposed ventilatory mode (intratracheal pulmonary ventilation) the reverse-thrust catheter delivers the tidal breath and, additionally, flushes CO2 and accelerates secretion removal during exhalation. A reverse-flow design ETT has been developed with two channels, one for tidal volume delivery and the other for TGI flow. The TGI channel is relatively large and flow is directed cephalad by a nozzle at the catheter tip. A recently developed bidirectional catheter allows the option of delivering TGI flow cephalad, towards the lungs or in both directions. Unfortunately, to be convenient, the use of specially designed catheters or ETTs requires the anticipation of TGI use. A complete system for the safe and convenient use of TGI in ventilated patients is not as yet available, but concerns about the safety and convenience of TGI delivery have been addressed with recent advances in catheter/tube design.
Evaluate the potential safety and efficacy of transtracheal augmented ventilation (TTAV), which is the transtracheal delivery of high flows of a humidified air-oxygen blend.
The first of 2 observational studies evaluated patients before and after a 3-month intervention with the nocturnal (Noc) administration of TTAV at 10 L/min. Resting physiologic studies evaluated standard low-flow transtracheal oxygen (LFTTO), TTAV, and breathing without transtracheal flow via mouthpiece (MP). Patients also underwent nocturnal polysomnography, bronchoscopy, ventilatory drive evaluation, and treadmill exercise. The second study assessed the safety of Noc TTAV for up to 60 months. Each study evaluated 15 different transtracheal patients with severe lung disease.
Pleural pressure-time index and respiratory duty cycle were significantly lower (p < 0.05) when comparing MP to TTAV. TTAV contributed more (p < 0.05) than LFTTO to the total volume delivered to the lung (V(L)). Arterial blood gases and (V(L)) were unaltered by TTAV. Sleep quality and nocturnal oxygenation with TTAV were similar to LFTTO, and Noc TTAV had no effect on ventilatory drive. Bronchoscopy showed no evidence of substantial injury. Treadmill exercise tests showed a longer exercise time (p < 0.005) and greater total work (p < 0.05) following Noc TTAV. During exercise, the changes in slope for heart rate and pH were less steep (p < 0.05) following Noc TTAV. The 3-month study and a long-term evaluation showed that Noc TTAV was well-tolerated and safe, with a reported high compliance.
Patients with chronic hypoxemia and severe respiratory insufficiency may benefit from Noc TTAV.
This is the first report to evaluate transtracheal oxygen catheter (TTOC) use in a pediatric patient series. Seven pediatric patients (4 boys and 3 girls) received TTOCs in 2 tertiary care medical centers. The medical indications included bronchopulmonary dysplasia in 4 patients and tracheomalacia in the other 3. The average age at the time of placement was 22 months (range, 2 weeks to 37 months). Catheter placement for 4 patients was through an open tracheotomy stoma. In 3, placement was through a percutaneous technique. The follow-up ranged from 2 weeks to 5 years. There were no long-term complications. Transient needs for supplemental oxygen were all met by the TTOC system. In 4 patients, the catheter has been removed because of resolution of the supplemental oxygen requirements. Minor complications included skin site infection and mucus plugging. In 1 patient, accidental dislodging of the catheter led to its replacement in the operating room. In 1 percutaneous placement, a pneumothorax occurred and resolved without any persistent morbidity. We conclude that transtracheal oxygen delivery can be a reasonable alternative to a nasal cannula or formal tracheotomy in selected pediatric patients in whom long-term oxygen delivery, but not an alternate airway, is required. In order to avoid complications, meticulous technique must be adhered to in using the percutaneous approach for placement.
Patients with chronic respiratory insufficiency who are receiving domiciliary oxygen therapy and mechanical ventilation report great difficulty in taking complex trips involving several destinations and prolonged stays away from home. Such patients share a common need for home equipment whose technology is relatively sophisticated, a condition that limits their freedom of movement. We are referring to systems for delivering oxygen therapy and mechanical respirators. Given that such patients have problems traveling by air, we hypothesized that a cruise would be an ideal alternative, given that travel would take place in the hotel itself. A cruise would facilitate the logistics of the journey, given that the equipment would have to be set up at only one setting. Working with these assumptions, we have thus far organized two cruises for chronic respiratory insufficiency patients: the "RESpIRA Expedition" and the "COPD Cruise". Our experience shows that the organizational problems to be coped with are patient recruitment, financing and choice of itinerary. With those aspects clear, organizers must then obtain the authorization of the cruise operator, including the approval of the medical and safety personnel on board. After obtaining permission for the cruise and as soon as the organizers know how many patients will travel, a list of oxygen therapy equipment (respirators and disposable supplies) must be compiled. Finally, equipment suppliers must be found. Afterwards, all that remains is to enjoy the trip. The participation of physicians responsible for domiciliary oxygen therapy and mechanical ventilation programs is essential for making patients feel safe and for assuring solutions for technical and medical problems that might arise.
In over 100 chronic obstructive pulmonary disease patients, continuous oxygen therapy has been provided for up to 4 years using Micro-Trach percutaneous transtracheal catheters less than 2.0 mm in diameter. Successful rehabilitation has been achieved. Advances in materials, insertion technique, and protocols have simplified patient management. Complications occasionally encountered are bleeding, infection, subcutaneous emphysema, increased mucus production, and catheter failure or displacement. Long-term delivery of supplemental oxygen directly into the tracheobronchial tree eliminates the oxygen loss through the oral and nasal orifices that occurs when a nasal cannula is used. This closed system permits maintenance of therapeutic arterial blood levels with improved efficiency, greater comfort, and increased activity. The elimination of nasal irritation and cosmetic objections caused by nasal cannulas increases patient compliance, resulting in uninterrupted 24-hour-a-day oxygen use as indicated. The technique of inserting a transtracheal catheter and postinsertion management are discussed in detail.
One hundred patients with chronic airway obstruction, 50 in Chicago and 50 in London, were studied by standardized techniques in 1961. The results of the initial studies, previously reported, showed that the patients in the two cities were similar; using clinical and physiological criteria based on pathological studies, the patients were divided into three types—emphysematous type A, bronchial type B, and an indeterminate type X. The patients were studied again in succeeding years, 1962-65. During this time 26 died, 19 due to their respiratory disease; these 19 patients were initially more breathless, had a higher incidence of cor pulmonale, and had more severe airway obstruction and higher carbon dioxide pressures than the remainder. Type B patients (mortality 36%) had a worse prognosis than either type A (15%) or type X (12%). Of the measurements made, high carbon dioxide pressures were most closely related (p<0·001) to mortality. During the period of follow-up about one-third of the patients who did not die became more short of breath and developed more severe airway obstruction and carbon dioxide retention: about 10% showed definite improvement in symptoms and pulmonary function. The F.E.V.1·0 declined on average by 46 ml./year, 4·8% of the initial value; V.C. declined by 120 ml./year, 4·0% of the initial value; mixed venous Pco2 increased 1 mm. Hg/year. The changes that occurred during this time confirmed the previously reported similarity between the patients attending the two clinics. Although the incidence of bronchitic exacerbations was similar in the two cities, such illnesses in the London patients led to more frequent and more prolonged incapacity.
A system of transtracheal oxygen administration has been developed which is more effective for rehabilitating chronic obstructive pulmonary disease (COPD) patients than traditional systems for providing continuous oxygen therapy. The procedure involves administering oxygen continuously through a No. 16 intravenous catheter inserted transtracheally. Therapeutic PaO2 levels are attained with an oxygen flow of 0.25 to 1 liter per minute. Transtracheal oxygen administration has numerous advantages over nasal cannula or Venturi mask devices. With this system, the patient requires 3 to 4 times less oxygen; therefore, a 2.7-kg (6–1b) portable tank will last most of one day. Oxygen-enriched air via transtracheal catheter reaches the lungs directly with less respiratory effort. Delivery of oxygen is not impaired by sinusitis, mouth-breathing, displacement of nasal cannula or loss of oxygen into the room. Patients experience an immediate sensation of being able to breathe more easily, begin ambulating the day of the procedure, have improved nutrition and return to many normal activities.
At six centers, 203 patients with hypoxemic chronic obstructive lung disease were randomly allocated to either continuous oxygen (O2) therapy or 12-hour nocturnal O2 therapy and followed for at least 12 months (mean, 19.3 months). The two groups were initially well matched in terms of physiological and neuropsychological function. Compliance with each oxygen regimen was good. Overall mortality in the nocturnal O2 therapy group was 1.94 times that in the continuous O2 therapy group (P = 0.01). This trend was striking in patients with carbon dioxide retention and also present in patients with relatively poor lung function, low mean nocturnal oxygen saturation, more severe brain dysfunction, and prominent mood disturbances. Continuous O2 therapy also appeared to benefit patients with low mean pulmonary artery pressure and pulmonary vascular resistance and those with relatively well-preserved exercise capacity. We conclude that in hypoxemic chronic obstructive lung disease, continuous O2 therapy is associated with a lower mortality than is nocturnal O2 therapy. The reason for this difference is not clear.
A 50 percent or greater savings in oxygen usage and aesthetic benefits leading to increased compliance are reasons for increasing use of the transtracheal catheter for administration of home supplemental oxygen. Minor complications of the procedure are common and include catheter dislodgement, bronchospasm, subcutaneous emphysema, bleeding at the catheter site, as well as hemoptysis and wound infections. Rare complications include retroflexion of the catheter into the upper trachea from coughing, and fracture of the catheter with loss in the trachea. New, improved catheters and detailed descriptions for operator use may reduce the frequency of these complications. This report describes a potentially serious complication of a transtracheal catheter system which resulted despite appropriate use and care of the catheter.
Eight patients with chronic severe and refractory hypoxemia were treated with a new transtracheal oxygen catheter. All patients demonstrated an arterial oxygen partial pressure of less than 55 mm Hg on high-flow nasal cannula therapy. Refractory hypoxemia was successfully treated in all eight patients following initiation of transtracheal oxygen therapy at 2.5 to 6.0 L/min. Arterial oxygen partial pressure was 50% greater and oxygen flow requirements were 72% less with transtracheal oxygen. There were no complications related to the procedure and oxygen flow rates up to 6 L/min were well tolerated. Although four patients died, four remain clinically stable with adequate oxygenation at up to 20 months' follow-up. All eight patients experienced an improvement in quality of life with transtracheal oxygen.
(JAMA 1986;256:494-497)
Long-term survival data are presented for 200 patients with chronic airway obstruction of uncertain etiology who were enrolled in a prospective study approximately 14 years ago. Early death rates were closely related to the initial level of ventilatory impairment. Subjects with relatively mild impairment on entry to the study had a favorable prognosis for the first 5 to 7 years of follow-up but then began to show a higher death rate; there are few long-term survivors in the total series.
Transtracheal administration of oxygen is a new technique for long term treatment. Twenty patients with hypoxaemia due to chronic obstructive airways disease were studied while receiving oxygen through a microcatheter inserted percutaneously into the trachea. By bypassing most of the dead space and avoiding oxygen wastage at the face this method of delivery reduced oxygen requirements by roughly half compared with delivery through nasal cannulas, thus reducing costs and facilitating portable treatment. Twelve of these patients continued to use the system for up to 13 months in preference to using nasal cannulas. Two important complications were a staphylococcal infection and a fractured catheter. Transtracheal oxygen reduced breathlessness and helped patients with routine daily activities. Transtracheal administration of oxygen is a practical method of treatment which may have an important role in rehabilitating patients with chronic lung disease.
To investigate the mechanisms of CO2 transport during constant flow ventilation, we measured arterial blood gases using air, 80% He-20% O2 (He) or 80% SF6-20% O2 (SF6) as the insufflating gas. At any given flow rate (0.2 to 1.0 L/s), PaCO2 was greatest with He and lowest with SF6. Data for all gases could be described by the equation PaCO2/Pb = 0.044 V-0.64 v0.23, where Pb = barometric pressure, PaCO2 is in mm Hg, V = insufflated flow in L/s, and v = kinematic viscosity (cm2/s). At any given flow rate, the AaPO2 was greater using SF6 than using He. These results are consistent with a 2-zone model of gas transport in which the enhancement of gas transport as V increases may be due to an increase in the turbulent diffusivity in zone I (the region affected by the jet). The decreased gas transport with He compared to air and SF6 at any V may be due to either the decreased penetration depth of zone I caused by the greater kinematic viscosity of He, or the decreased rate of gas transport in the region affected by cardiogenic oscillations (zone II) secondary to the higher molecular diffusivity of He.
To document the course and prognosis of chronic obstructive lung disease, 200 patients with the disorder were enrolled in a prospective standardized study four to eight years ago. Their disease progressed in a more regular and more predictable fashion than had been anticipated from casual clinical observations. Reasonably precise predictions of longevity could be made on the basis of initial findings. Measurements of ventilatory capacity, resting heart rate and carbon dioxide levels were the best indicators of prognosis. Prediction of survival was further improved by consideration of the course of physiologic abnormalities over a two-year follow-up period. Most features of the disease showed a systematic tendency to worsen, but yearly changes were relatively small, often becoming evident only with long-term observation. Data are compatible with the concept that chronic obstructive lung disease is a slowly progressive disorder that begins many years before the onset of clinical symptoms.
Transtracheal oxygen therapy: a guide for the respiratory therapist
- Spofford
Type and frequency of complications of transtracheal oxygen therapy with the SCOOP system (Abstract)
- Stoller