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Transtracheal Oxygen Therapy FREE TO VIEW

Kent L. Christopher, MD, RRT, FCCP; Michael D. Schwartz, MD, FCCP
Author and Funding Information

From the Division of Pulmonary/Critical Care (Dr Christopher), University of Colorado Health Sciences Center; and the Department of Pulmonary/Critical Care (Dr Schwartz), National Jewish Health, Denver, CO.

Correspondence to: Kent L. Christopher, MD, RRT, FCCP, 9086 E Colorado Circle, Denver, CO 80231; e-mail: drkchristopher@comcast.net


For editorial comment see page 238.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;139(2):435-440. doi:10.1378/chest.10-1373
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Published online

Transtracheal oxygen therapy (TTO) has been used for long-term oxygen therapy for nearly 30 years. Numerous investigators have explored the potential benefits of TTO. Those results are reviewed in this article. TTO is best viewed not as a catheter but as a program for care. This article discusses patient selection for TTO. Publications evaluating complications are reviewed. In the past, a modified Seldinger technique (MST) was used for the creation of the tracheocutaneous fistula. The rather long program required for tract maturation with MST was labor-intensive and required substantial patient education and monitoring, particularly during the immature tract phase. Minor complications were not infrequent. More recently, the Lipkin method has been used to create a surgical tract under conscious sedation with topical anesthesia. The procedure is safe and well tolerated. Transtracheal oxygen is initiated the day following the procedure. Similarly, the tract matures in 7 to 10 days rather than the 6 to 8 weeks with MST. More rapid healing time and superior tract characteristics substantially reduce complications. The TTO program tailored for the Lipkin procedure is shortened, streamlined, and much less labor-intensive. Optimal outcomes with the TTO program require a committed pulmonologist, respiratory therapist, nurse, and surgeon (for the Lipkin procedure). This article discusses new directions in the use of transtracheal gas delivery, including the management of obstructive sleep apnea. Preliminary investigations regarding transtracheal augmented ventilation are presented. These include nocturnal use in severe chronic lung disease and liberation from prolonged mechanical ventilation.

Heimlich first described the use of a transtracheal catheter for long-term oxygen therapy (LTOT) in 1982. Transtracheal oxygen therapy (TTO) has subsequently been used in the treatment of chronic hypoxemia for nearly 30 years. Although potential benefits, safety, and efficacy have been established, the technology has only been used in a small portion of patients requiring LTOT. In short, some physicians have embraced TTO and have incorporated it into their practice. Perhaps most physicians have either forgotten about it or have not been exposed to the concept. They may not be familiar with the more recent method of creation of the catheter tract and streamlined care program. Others have either dismissed it as an impractical method of oxygen therapy or consider the technology of benefit to only a few patients with severe hypoxemia unresponsive (refractory) to maximum standard nasal oxygen flow.

Similarly, most patients are unaware of TTO as an alternative to the nasal cannula. Another subset of patients have taken the recommendation of their physicians or have sought out TTO through the internet or interactions with other patients using TTO. Others are aware of it but have either confused it with a standard tracheostomy or do not wish to commit to catheter care. The purpose of this article is to present a topic review of TTO. The potential benefits of TTO therapy, complications, patient selection, transtracheal procedures, and catheter care are discussed.

As an overview, subjects serve as their own control in most studies. In short-term physiologic studies, patients with an existing tracheocutaneous fistula usually received interventions related to tracheal gas delivery in a random order and then were compared with control evaluation with no tracheal flow. In the long-term clinical studies, data collected after initiation of TTO therapy were compared with data collected while the patient was receiving LTOT by nasal cannula. One investigation randomized 43 patients to receive LTOT by either TTO or nasal cannula control for the duration of the study. Assessment of complications, absolute contraindications, precautions, and general outcomes are based on longitudinal studies and clinical experience. These investigations are reviewed.

The following potential benefits of TTO compared with nasal oxygen delivery are summarized in Table 1.1-10 A number of physiologic benefits have been described in the literature. Christopher et al1 reported a marked reduction in erythrocytosis and cor pulmonale with successful treatment of hypoxemia that was unresponsive (refractory) to maximal flows of standard nasal oxygen therapy. Significant reductions in hematocrit were also seen in patients who were believed to be adequately treated with nasal cannula therapy.2 Oxygen flow requirements were reduced by 55% with rest and 30% during exercise.2 Domingo and Domingo3 reported reduced pulmonary vascular resistance in patients requiring LTOT. Optimal oxygenation was demonstrated during sleep.

Table Graphic Jump Location
Table 1 —Potential Benefits of TTO

A-aDo2 = alveolar to arterial oxygen tension gradient; Ti/Ttot = time of inspiration relative to time of inspiration and expiration (respiratory duty cycle); TTO = transtracheal oxygen therapy.

O’Donohue4 evaluated room air arterial blood gases in patients who received nasal oxygen therapy during a control period and following administration of TTO. The room air alveolar to arterial oxygen tension gradient was significantly less after receiving transtracheal oxygen delivery. In addition, Hoffman et al5 and Bloom et al6 demonstrated that exercise capacity was significantly increased with TTO. Couser and Make7 showed that TTO decreases the inspired minute ventilation as a result of a reduction in tidal volume, and Bergofsky and Hurewitz9 and Hurewitz and colleagues10 documented reduced physiologic dead space with transtracheal gas delivery. In addition, Paco2 was maintained or reduced over time. Benditt et al8 reported reduced oxygen cost of breathing and shortened respiratory duty cycle with TTO. Other studies demonstrated that a number of potential physiologic benefits of transtracheal gas delivery are directly related to air and/or oxygen flows in ranges up to 6 to 8 L/min.7-10 These potential benefits can be achieved within standard transtracheal oxygen flow rates. As with nasal oxygen, TTO flow rates should be titrated to the level of oxygenation prescribed by the physician using either pulse oximetry or arterial blood gas analysis.

Greater activity3,6 may also result from improved physical, psychologic, and social function.6 Oxygen flow requirements with TTO are reduced by 55% at rest and approximately 30% during exercise.2 Consequently, portable oxygen delivery systems last longer, and patients can take advantage of smaller and lighter units. Activity may also be facilitated by improved exercise tolerance.5,6 Some patients have reported reduced dyspnea.7 Improvement in exercise capacity and dyspnea may result from the previously described reduced physiologic dead space,9,10 decreased inspired minute ventilatory requirements,7 and reduced oxygen cost of breathing.8

True 24 h/d compliance can be achieved with TTO therapy.3 Most patients conclude that TTO is more comfortable than the nasal cannula. Consequently, they are more likely to use TTO continuously. The most common reason for patients to seek TTO was the need for improved comfort. Patients receiving nasal oxygen may have suboptimal compliance because of discomfort from chronic irritation around the nose and ears or from more significant complications, such as contact dermatitis, chondritis, or skin ulceration. Although cosmesis is not a significant concern for many patients, some individuals may be more compliant with TTO because of improved self-image; the delivery device is entirely off the face and can easily be hidden from view.

Recent years have brought increasing concern for cost containment. Prolonged hospitalizations are much more costly than LTOT in the home. Compared with a nasal cannula control period, Hoffman et al5 showed that hospital days were significantly reduced with TTO. Bloom et al6 also demonstrated that hospital days for patients receiving TTO were significantly less than the hospital days during a period when they had received nasal oxygen. Likewise, the TTO group’s hospital days were fewer than seen in a separate nasal cannula control population. The prospective randomized controlled study by Bloom et al6 also demonstrated improved physical, psychologic, and social function with TTO.

Presently, TTO is administered using the Spofford Christopher Oxygen Optimizing Program, which is extensively described elsewhere.11-13 The program is composed of four clinical phases of care:

  • Phase I: Patient evaluation, selection, and procedure preparation

  • Phase II: Creation of the tracheocutaneous fistula

  • Phase III: Tract maturation management

  • Phase IV: Mature tract management

Complications and sequelae are influenced by the experience of the team providing care and the technique selected in phase II for creation of the tracheocutaneous fistula. The two methods are a modified Seldinger technique (MST)11-13 and the more recently developed and preferred surgical technique (the Lipkin procedure),12-14 which has a lower complication rate and shorter time for tract maturation. Phases I and IV are similar for both methods. There is more reported experience with MST.

Modified Seldinger Technique

In phase II, under local anesthesia in conjunction with a mild oral narcotic analgesic, a needle-guidewire single dilator is used to insert a nonfunctioning, open-ended stent through a vertical skin incision, which is sutured in place. The stent remains for 1 week. In phase III, the stent is removed over a wire guide and a functioning catheter is inserted. Transtracheal oxygen delivery begins and the patient learns to clean the catheter daily through instilled saline followed by insertion of a cleaning rod. The catheter is periodically removed for cleaning over a wire guide by the physician. A wire guide is used to ensure access to the tract for reinsertion, which, like a tracheostomy tube removal, can quickly occur when the tract is still immature. Tract maturation with MST requires 6 to 8 weeks. Phase IV begins when the tract is a mature tracheocutaneous fistula, and the patient is trained to remove and reinsert the catheter (without a wire guide) during the routine cleaning process. Phase IV is designed to teach the patient catheter and LTOT self-care with periodic health maintenance visits intended for collaborative care with the physician.

Complications With the MST Procedure

Potential complications from the study by Kampelmacher et al15 of 75 patients who underwent MST are illustrated in Table 2. An initial experience with 10 patients was compared with subsequent care with the next 65 subjects. Complications were minor. There was a substantial overall reduction in percent complications as the investigators gained experience. Subcutaneous emphysema (3%) was the only complication during the procedure and stent week (phase II). In general, during the immature and mature tract periods (phase III and IV) complications reduced in frequency as experience with the procedure was gained. However, assuming no patient had more than one complication, the prevalence of complications was 34%. The most prevalent complications were keloids (11%), chondritis (3%), and inadvertent dislodgement of the catheter with successful reinsertion by clinical staff (9%). These accounted for 23% of complications. In another two series, catheter dislodgement occurred in 38%16 and 44%.17 These issues were likely precipitated by inflammation of exposed cartilage during the MST procedure.

Table Graphic Jump Location
Table 2 —Complications of TTO With the Modified Seldinger Technique

Adapted from Kampelmacher et al.15 See Table 1 for expansion of abbreviation.

A minor complication encountered in only one of 75 patients in the Kampelmacher et al15 study was the formation of symptomatic mucus balls, which are accumulations of inspissated mucus on the outer aspect of the catheter tip. They generally occur during the 6 to 8 weeks when the tract is immature (phase III) and the patient cannot routinely remove the catheter for cleaning. Mucus balls cause cough and dyspnea, which resolve when the mucus is removed by the physician. Reported incidence in three series was 14%,16 25%,17 and 38%.18 As with any technology, outcomes can vary substantially among caregivers. A variety of factors, such as team experience, modifications in the program of care, and the characteristics of the patients selected, can all play a role.

Published cases report rare incidents of one death19 and five life-threatening events due to airway obstruction from mucus balls.20-24 In addition, there is one case report of tracheal perforation25 and one report of death due to catheter misplacement.26

The Lipkin Surgical Procedure

The Lipkin surgical procedure is the method of choice.14 Alan Lipkin, an otolaryngologist, designed a surgical technique in an effort to reduce the number of minor complications with TTO. The procedure and modified Spofford Christopher Oxygen Optimizing Program are thoroughly described elsewhere.12,13 Under conscious sedation and topical anesthesia, a skin incision is made, cervical fat is removed, and the strap muscles are exposed. The sternothyroid muscles are dissected away from the anterior tracheal wall in the midline, and the full-thickness skin flap is sutured to the underbelly of the muscles. A specialized tracheal punch or scalpel is used to remove a window of cartilage at the level of the second or third tracheal interspace. A nonfunctioning stent is then inserted into the surgically created tracheocutaneous fistula.

Unlike MST, wherein administration of TTO is delayed for 1 week, the functioning catheter is inserted the next morning, and TTO is initiated. Rather than the phase III tract maturation time of 6 to 8 weeks, the tract is mature within 10 to 14 days. The patient can then be taught to remove the catheter for cleaning. With the MST, phase III is the most labor-intensive and educationally intense portion of the program. Physician training can be streamlined and patient education can be markedly simplified when the Lipkin procedure is used. The combination of the decrease in unscheduled or emergent visits due to complications and the shortened program results in reduced demands on physician time and resources. Finally, the shortened and streamlined program facilitates referral center treatment of out-of-town patients who otherwise might not have access to TTO.

A total of 33 consecutive patients who underwent the Lipkin procedure were compared with 64 consecutive patients who underwent MST and were followed for a similar period.14 Chondritis occurred in 12% relative to 25% in the MST cohort, and the incidence of symptomatic mucus balls was 15% compared with 44%, respectively. Of note, keloids, temporarily dislodged catheters, and lost tracts were not encountered, compared with 2%, 41%, and 14% in the MST group. No operative complications were experienced. In view of the previously stated advantages over MST, the Lipkin procedure is the preferred method for creation of the TTO tracheocutaneous fistula.

Indications, absolute contraindications, and precautions are presented in Table 3. The indications for TTO are based on the potential benefits summarized in Table 1. Absolute contraindications are driven by the complications discussed previously and what could be a predictably bad outcome. The defined precautions are intended to assist in avoiding complications as well but have also been driven by years of experience managing severely ill patients with chronic hypoxemia. The ideal candidate is not the patient with severe uncorrected (refractory) hypoxemia but the patient who is adequately oxygenated with 2 to 4 L/min cannula flows. Individuals who are highly motivated, desire to be active, and can manage their catheter care are likely to do very well. A supportive significant other is of great benefit. The Lipkin procedure certainly requires a surgeon well versed in tracheostomy, but the involvement of the pulmonologist throughout the program is critical for success. Involvement of other team members (eg, respiratory therapist, nurse) also optimizes outcomes.

Table Graphic Jump Location
Table 3 —TTO: Indications, Absolute Contraindications, and Precautions

The pulmonologist is reimbursed for patient care under standard current procedural technology (CPT) evaluation and management codes. The CPT for the MST procedure is 31730: “Transtracheal (percutaneous) introduction of needle wire dilator/stent or indwelling tube for oxygen therapy.” Additionally, the MST code with a modifier has been used by pulmonologists for removal of the stent over a guidewire and insertion of the transtracheal catheter. The coding is 31730 with modifier 58: “Staged or related procedure or service by the same physician during the postoperative period.” There presently is no dedicated code for clinician removal and reinsertion of the catheter during cleaning and tract evaluation. This is a periodic necessity, particularly in phase III when the fistulous tract is not mature. Some have used CPT code 31502: “Tracheostomy tube change prior to establishment of fistula tract.”

The Lipkin procedure has no dedicated code, but surgeons often use 31610: “Tracheostomy, fenestration procedure with skin flaps.” Since 31610 is not bundled, some surgeons also elect to use 15838: “Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad.”

Coding is the responsibility of the physician, and reimbursement is clearly subject to payor policy and regional variations in payment amount. The catheters and supplies are presently bundled under the monthly oxygen reimbursement structure. This topic is covered elsewhere.27

As noted previously, transtracheal oxygen delivery has a variety of potential physiologic benefits that are directly related to standard TTO flows in ranges up to 6 to 8 L/min.7-10 Administration of higher flows beyond what is necessary to achieve adequate oxygenation has additional potential benefits. Transtracheal delivery of a high flow of heated and humidified oxygen/air mixture has been termed transtracheal augmented ventilation (TTAV).28 TTAV decreases inspired minute volume and decreases oxygen cost of breathing. TTAV at 10 L/min has been successfully used over extended periods for nocturnal augmented ventilation in subjects on TTO with hypoxemia due to severe chronic lung disease.28 Improved exercise capacity occurred following a 3-month intervention with nocturnal TTAV.28 TTAV is also used for spontaneous breathing trials in liberation from prolonged mechanical ventilation.12 Finally, Brack et al29 have shown additional physiologic benefits at 15 L/min compared with 10 L/min delivery. High flows of 15 L/min, when compared with TTO at 1.5 L/min, resulted in reduced respiratory rate and Paco2 with reduced end-expiratory lung volume.

Prior studies have evaluated TTO for treatment of obstructive sleep apnea. Flows of 2 to 6 L/min have improved sleep indices and improved oxygen saturation.30,31 Schneider et al32 used the TTAV concept with higher flows to resolve obstruction. Our anecdotal experience has shown effective treatment of obstructive sleep apnea with nocturnal TTAV in patients who also require daytime TTO for hypoxemia due to COPD.

In summary, TTO has a number of potential benefits and is both safe and effective. Compared with MST, the Lipkin surgical procedure is preferred because of the low complication rate and ability to shorten and streamline the clinical care program. The pulmonologist and other team members (surgeon, respiratory therapist, and nurse) allow the TTO program to provide high standards of care and quality of life for appropriately selected LTOT patients.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Christopher is a member of the National Association for Medical Direction of Respiratory Care board of directors and a member of the Board of Medical Advisors for the American Association for Respiratory Care. Dr Christopher has licensed patents to Transtracheal Systems, Inc and Phillips Respironics, Inc, and may receive a financial return in the future. At present, he has no professional relationship with either company. Dr Schwartz has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

CPT

current procedural terminology

LTOT

long-term oxygen therapy

MST

modified Seldinger technique

TTAV

transtracheal augmented ventilation

TTO

transtracheal oxygen therapy

Christopher KL, Spofford BT, Brannin PK, Petty TL. Transtracheal oxygen therapy for refractory hypoxemia. JAMA. 1986;2564:494-497. [CrossRef] [PubMed]
 
Christopher KL, Spofford BT, Petrun MD, McCarty DC, Goodman JR, Petty TL. A program for transtracheal oxygen delivery. Assessment of safety and efficacy. Ann Intern Med. 1987;1076:802-808. [PubMed]
 
Domingo C, Domingo E.Pinsky MR, Dhainault F, Artigas A. Cardiopulmonary response to home oxygen therapy: nasal prongs versus oxygen-saving devices. The Pulmonary Circulation: Moving from Passive to Active Control. 1991; Philadelphia, PA WB Saunders Co Ltd:157-169
 
O’Donohue WJ Jr. Effect of oxygen therapy on increasing arterial oxygen tension in hypoxemic patients with stable chronic obstructive pulmonary disease while breathing ambient air. Chest. 1991;1004:968-972. [CrossRef] [PubMed]
 
Hoffman LA, Wesmiller SW, Sciurba FC, et al. Nasal cannula and transtracheal oxygen delivery. A comparison of patient response after 6 months of each technique. Am Rev Respir Dis. 1992;1454 pt 1:827-831. [PubMed]
 
Bloom BS, Daniel JM, Wiseman M, Knorr RS, Cebul R, Kissick WL. Transtracheal oxygen delivery and patients with chronic obstructive pulmonary disease. Respir Med. 1989;834:281-288. [CrossRef] [PubMed]
 
Couser JI Jr, Make BJ. Transtracheal oxygen decreases inspired minute ventilation. Am Rev Respir Dis. 1989;1393:627-631. [PubMed]
 
Benditt J, Pollock M, Roa J, Celli B. Transtracheal delivery of gas decreases the oxygen cost of breathing. Am Rev Respir Dis. 1993;1475:1207-1210. [PubMed]
 
Bergofsky EH, Hurewitz AN. Airway insufflation: physiologic effects on acute and chronic gas exchange in humans. Am Rev Respir Dis. 1989;1404:885-890. [PubMed]
 
Hurewitz AN, Bergofsky EH, Vomero E. Airway insufflation. Increasing flow rates progressively reduce dead space in respiratory failure. Am Rev Respir Dis. 1991;1446:1229-1233. [PubMed]
 
Spofford B, Christopher KL, Goodman JR.Christopher KL. Transtracheal oxygen therapy. Problems in Respiratory Care– The Current Status of Oxygen Therapy. 1990; Philadelphia, PA JB Lippincott Company:600-621
 
Christopher KL.Beamis J, Mathur P, Mehta A. Transtracheal oxygen therapy. Interventional Pulmonary Medicine. 2004; New York, NY Marcel Dekker:503-543
 
Christopher KL, Schwartz M.Rose BD. Transtracheal oxygen therapy. UpToDate. 2009; Waltham, MA UpToDate
 
Lipkin AF, Christopher KL, Diehl S, Yaeger ES, Jorgenson S. Otolaryngologist’s role in transtracheal oxygen therapy: the minitrach procedure. Otolaryngol Head Neck Surg. 1996;1155:447-453. [CrossRef] [PubMed]
 
Kampelmacher MJ, Deenstra M, van Kesteren RG, Melissant CF, Douze JM, Lammers JW. Transtracheal oxygen therapy: an effective and safe alternative to nasal oxygen administration. Eur Respir J. 1997;104:828-833. [CrossRef] [PubMed]
 
Adamo JP, Mehta AC, Stelmach K, et al. The Cleveland Clinic’s initial experience with transtracheal oxygen therapy. Respir Care. 1990;352:153-160
 
Hoffman LA, Johnson JT, Wesmiller SW, et al. Transtracheal delivery of oxygen: efficacy and safety for long-term continuous therapy. Ann Otol Rhinol Laryngol. 1991;1002:108-115. [PubMed]
 
Orvidas LJ, Kasperbauer JL, Staats BA, Olsen KD. Long-term clinical experience with transtracheal oxygen catheters. Mayo Clin Proc. 1998;738:739-744. [CrossRef] [PubMed]
 
Burton GG, Wagshul FA, Henderson D, Kime SW. Fatal airway obstruction caused by a mucous ball from a transtracheal oxygen catheter. Chest. 1991;996:1520-1523. [CrossRef] [PubMed]
 
Fletcher EC, Nickeson D, Costarangos-Galarza C. Endotracheal mass resulting from a transtracheal oxygen catheter. Chest. 1988;932:438-439. [CrossRef] [PubMed]
 
Harrow EM, Oldenburg FA, Lingenfelter MS, Leonard J. Respiratory failure and cor pulmonale associated with tracheal mucoid accumulation from a SCOOP transtracheal oxygen catheter. Chest. 1992;1012:580-581. [CrossRef] [PubMed]
 
Roth BJ, Irvine TW, Liening DA, Duncan NO, Cragun WH. Acute respiratory compromise resulting from a tracheal mucous impaction secondary to a transtracheal oxygen catheter. Chest. 1992;1015:1465-1466. [CrossRef] [PubMed]
 
de Groot RE, Dik H, de Groot HG, Bakker W. A nearly fatal tracheal obstruction resulting from a transtracheal oxygen catheter. Chest. 1993;1045:1634-1635. [CrossRef] [PubMed]
 
Ulstad DR, Koppin J. Massive atelectasis with respiratory arrest due to transtracheal oxygen catheter-related mass formation. Chest. 1994;1063:982. [CrossRef] [PubMed]
 
Menon AS, Carlin BW, Kaplan PD. Tracheal perforation. A complication associated with transtracheal oxygen therapy. Chest. 1993;1042:636-637. [CrossRef] [PubMed]
 
Kristo DA, Turner JF, Hugler R. Transtracheal oxygen catheterization with pneumomediastinum and sudden death. Chest. 1996;1103:844-846. [CrossRef] [PubMed]
 
Christopher KL, Porte P. Long-term oxygen therapy. Chest. 2011;139(2):430-434.
 
Christopher KL, VanHooser DT, Jorgenson SJ, et al. Preliminary observations of transtracheal augmented ventilation for chronic severe respiratory disease. Respir Care. 2001;461:15-25. [PubMed]
 
Brack T, Senn O, Russi EW, Bloch KE. Transtracheal high-flow insufflation supports spontaneous respiration in chronic respiratory failure. Chest. 2005;1271:98-104. [CrossRef] [PubMed]
 
Farney RJ, Walker JM, Elmer JC, Viscomi VA, Ord RJ. Transtracheal oxygen, nasal CPAP and nasal oxygen in five patients with obstructive sleep apnea. Chest. 1992;1015:1228-1235. [CrossRef] [PubMed]
 
Sériès F, Forge JL, Lampron N, Cormier Y. Transtracheal air in the treatment of obstructive sleep apnoea hypopnoea syndrome. Thorax. 2000;551:86-87. [CrossRef] [PubMed]
 
Schneider H, O’Hearn DJ, Leblanc K, et al. High-flow transtracheal insufflation treats obstructive sleep apnea. A pilot study. Am J Respir Crit Care Med. 2000;1616:1869-1876. [PubMed]
 

Figures

Tables

Table Graphic Jump Location
Table 1 —Potential Benefits of TTO

A-aDo2 = alveolar to arterial oxygen tension gradient; Ti/Ttot = time of inspiration relative to time of inspiration and expiration (respiratory duty cycle); TTO = transtracheal oxygen therapy.

Table Graphic Jump Location
Table 2 —Complications of TTO With the Modified Seldinger Technique

Adapted from Kampelmacher et al.15 See Table 1 for expansion of abbreviation.

Table Graphic Jump Location
Table 3 —TTO: Indications, Absolute Contraindications, and Precautions

References

Christopher KL, Spofford BT, Brannin PK, Petty TL. Transtracheal oxygen therapy for refractory hypoxemia. JAMA. 1986;2564:494-497. [CrossRef] [PubMed]
 
Christopher KL, Spofford BT, Petrun MD, McCarty DC, Goodman JR, Petty TL. A program for transtracheal oxygen delivery. Assessment of safety and efficacy. Ann Intern Med. 1987;1076:802-808. [PubMed]
 
Domingo C, Domingo E.Pinsky MR, Dhainault F, Artigas A. Cardiopulmonary response to home oxygen therapy: nasal prongs versus oxygen-saving devices. The Pulmonary Circulation: Moving from Passive to Active Control. 1991; Philadelphia, PA WB Saunders Co Ltd:157-169
 
O’Donohue WJ Jr. Effect of oxygen therapy on increasing arterial oxygen tension in hypoxemic patients with stable chronic obstructive pulmonary disease while breathing ambient air. Chest. 1991;1004:968-972. [CrossRef] [PubMed]
 
Hoffman LA, Wesmiller SW, Sciurba FC, et al. Nasal cannula and transtracheal oxygen delivery. A comparison of patient response after 6 months of each technique. Am Rev Respir Dis. 1992;1454 pt 1:827-831. [PubMed]
 
Bloom BS, Daniel JM, Wiseman M, Knorr RS, Cebul R, Kissick WL. Transtracheal oxygen delivery and patients with chronic obstructive pulmonary disease. Respir Med. 1989;834:281-288. [CrossRef] [PubMed]
 
Couser JI Jr, Make BJ. Transtracheal oxygen decreases inspired minute ventilation. Am Rev Respir Dis. 1989;1393:627-631. [PubMed]
 
Benditt J, Pollock M, Roa J, Celli B. Transtracheal delivery of gas decreases the oxygen cost of breathing. Am Rev Respir Dis. 1993;1475:1207-1210. [PubMed]
 
Bergofsky EH, Hurewitz AN. Airway insufflation: physiologic effects on acute and chronic gas exchange in humans. Am Rev Respir Dis. 1989;1404:885-890. [PubMed]
 
Hurewitz AN, Bergofsky EH, Vomero E. Airway insufflation. Increasing flow rates progressively reduce dead space in respiratory failure. Am Rev Respir Dis. 1991;1446:1229-1233. [PubMed]
 
Spofford B, Christopher KL, Goodman JR.Christopher KL. Transtracheal oxygen therapy. Problems in Respiratory Care– The Current Status of Oxygen Therapy. 1990; Philadelphia, PA JB Lippincott Company:600-621
 
Christopher KL.Beamis J, Mathur P, Mehta A. Transtracheal oxygen therapy. Interventional Pulmonary Medicine. 2004; New York, NY Marcel Dekker:503-543
 
Christopher KL, Schwartz M.Rose BD. Transtracheal oxygen therapy. UpToDate. 2009; Waltham, MA UpToDate
 
Lipkin AF, Christopher KL, Diehl S, Yaeger ES, Jorgenson S. Otolaryngologist’s role in transtracheal oxygen therapy: the minitrach procedure. Otolaryngol Head Neck Surg. 1996;1155:447-453. [CrossRef] [PubMed]
 
Kampelmacher MJ, Deenstra M, van Kesteren RG, Melissant CF, Douze JM, Lammers JW. Transtracheal oxygen therapy: an effective and safe alternative to nasal oxygen administration. Eur Respir J. 1997;104:828-833. [CrossRef] [PubMed]
 
Adamo JP, Mehta AC, Stelmach K, et al. The Cleveland Clinic’s initial experience with transtracheal oxygen therapy. Respir Care. 1990;352:153-160
 
Hoffman LA, Johnson JT, Wesmiller SW, et al. Transtracheal delivery of oxygen: efficacy and safety for long-term continuous therapy. Ann Otol Rhinol Laryngol. 1991;1002:108-115. [PubMed]
 
Orvidas LJ, Kasperbauer JL, Staats BA, Olsen KD. Long-term clinical experience with transtracheal oxygen catheters. Mayo Clin Proc. 1998;738:739-744. [CrossRef] [PubMed]
 
Burton GG, Wagshul FA, Henderson D, Kime SW. Fatal airway obstruction caused by a mucous ball from a transtracheal oxygen catheter. Chest. 1991;996:1520-1523. [CrossRef] [PubMed]
 
Fletcher EC, Nickeson D, Costarangos-Galarza C. Endotracheal mass resulting from a transtracheal oxygen catheter. Chest. 1988;932:438-439. [CrossRef] [PubMed]
 
Harrow EM, Oldenburg FA, Lingenfelter MS, Leonard J. Respiratory failure and cor pulmonale associated with tracheal mucoid accumulation from a SCOOP transtracheal oxygen catheter. Chest. 1992;1012:580-581. [CrossRef] [PubMed]
 
Roth BJ, Irvine TW, Liening DA, Duncan NO, Cragun WH. Acute respiratory compromise resulting from a tracheal mucous impaction secondary to a transtracheal oxygen catheter. Chest. 1992;1015:1465-1466. [CrossRef] [PubMed]
 
de Groot RE, Dik H, de Groot HG, Bakker W. A nearly fatal tracheal obstruction resulting from a transtracheal oxygen catheter. Chest. 1993;1045:1634-1635. [CrossRef] [PubMed]
 
Ulstad DR, Koppin J. Massive atelectasis with respiratory arrest due to transtracheal oxygen catheter-related mass formation. Chest. 1994;1063:982. [CrossRef] [PubMed]
 
Menon AS, Carlin BW, Kaplan PD. Tracheal perforation. A complication associated with transtracheal oxygen therapy. Chest. 1993;1042:636-637. [CrossRef] [PubMed]
 
Kristo DA, Turner JF, Hugler R. Transtracheal oxygen catheterization with pneumomediastinum and sudden death. Chest. 1996;1103:844-846. [CrossRef] [PubMed]
 
Christopher KL, Porte P. Long-term oxygen therapy. Chest. 2011;139(2):430-434.
 
Christopher KL, VanHooser DT, Jorgenson SJ, et al. Preliminary observations of transtracheal augmented ventilation for chronic severe respiratory disease. Respir Care. 2001;461:15-25. [PubMed]
 
Brack T, Senn O, Russi EW, Bloch KE. Transtracheal high-flow insufflation supports spontaneous respiration in chronic respiratory failure. Chest. 2005;1271:98-104. [CrossRef] [PubMed]
 
Farney RJ, Walker JM, Elmer JC, Viscomi VA, Ord RJ. Transtracheal oxygen, nasal CPAP and nasal oxygen in five patients with obstructive sleep apnea. Chest. 1992;1015:1228-1235. [CrossRef] [PubMed]
 
Sériès F, Forge JL, Lampron N, Cormier Y. Transtracheal air in the treatment of obstructive sleep apnoea hypopnoea syndrome. Thorax. 2000;551:86-87. [CrossRef] [PubMed]
 
Schneider H, O’Hearn DJ, Leblanc K, et al. High-flow transtracheal insufflation treats obstructive sleep apnea. A pilot study. Am J Respir Crit Care Med. 2000;1616:1869-1876. [PubMed]
 
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    Print ISSN: 0012-3692
    Online ISSN: 1931-3543