Interventional Pulmonary Procedures

Armin Ernst, MD, FCCP, Gerard A. Silvestri, MD, FCCP, David Johnstone, MD, FCCP

Disclosures

CHEST. 2003;123(5) 

In This Article

Transtracheal Oxygen Therapy

Transtracheal oxygen therapy (TTOT) is a minimally invasive procedure that is achieved through percutaneously placed devices that allow for long-term oxygen use. This procedure only deals with methods not employing surgically created stomas, and is usually a multistep procedure.

The procedure is usually performed on an outpatient basis. Dedicated procedure kits including needles, guidewire, dilators, stents, and oxygen delivery catheters are available.

A dedicated operator performs the procedure. Personnel required for this procedure include an RN or a respiratory therapist to administer and monitor conscious sedation if required, as well as a separate RN or a respiratory therapist to assist the dedicated operator. All supporting personnel should be familiar with the procedure being performed. This will maximize patient comfort and safety. As the long-term success of a TTOT procedure depends on careful teaching and follow-up and instructions on self-care, it is highly recommended to have a process in place dedicated to providing adequate patient education on the care of the device.

This procedure may be performed under local anesthesia with or without conscious sedation or under general anesthesia. Specific monitoring and documentation guidelines vary from hospital to hospital and from state to state. We recommend that the dedicated operator inquire about the applicable anesthesia and monitoring guidelines in their particular practice environment.

Before establishing TTOT, patients and their caregivers need to undergo appropriate teaching and preparation and demonstrate motivation to return for multiple postprocedure visits. The first step for the procedure is placement of the percutaneous stent. A small, 1.0- to 1.5-cm vertical incision is made over the insertion site and a guidewire introduced via Seldinger technique. The opening is then dilated and a stent is placed. After 1 week of tract maturation, the stent is removed and the oxygen delivery catheter placed. Until the tract is completely mature, all exchanges have to occur over the wire. Regular frequent follow-up is needed for several weeks postprocedure to allow for patient teaching and early recognition of complications.

Long-term oxygen has been shown to be beneficial in a variety of disorders. TTOT provides an additional means of delivering oxygen. Advantages are longer life of oxygen sources and cosmetic issues. Additionally, there is some evidence that patients experience improvement of dyspnea and exercise tolerance. TTOT can be considered for any patient receiving long-term oxygen. It is a good option in the patient intolerant of nasal cannula oxygen delivery, refractory hypoxemia, and limited mobility due to high oxygen demands.

Contraindications are uncorrectable coagulopathy, terminal illnesses, lack of motivation or support, inability to return for follow-up, pleural herniation over the trachea, and upper airway obstruction.

Complications of TTOT placement are very uncommon and include mucous ball formation, pneumothorax, and subcutaneous emphysema. Mortality is exceedingly low, and the most common morbidity is catheter-induced coughing.

Trainees should perform at least 10 procedures in a supervised setting to establish basic competency. To maintain competency, dedicated operators should perform at least five procedures per year.

Christopher KL, Spofford BT, Petrun MD, et al. A program for transtracheal oxygen delivery: assessment of safety and efficacy. Ann Intern Med 1987; 107:802-808

Couser JL, Make BJ. Transtracheal oxygen decreases inspired minute ventilation. Am Rev Respir Dis 1989; 139:627-631

Kampelmacher MJ, Deenstra M, van Kasteren RG, et al. Transtracheal oxygen therapy: an effective and safe alternative to nasal oxygen administration. Eur Respir J 1997; 10:828-833

Wesmiller SW, Hoffman LA, Sciurba FC, et al. Exercise tolerance during nasal cannula and transtracheal oxygen delivery. Am Rev Respir Dis 1990; 141:789-791

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