Chest

Chest

Volume 139, Issue 2, February 2011, Pages 435-440
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Topics in Practice Management
Transtracheal Oxygen Therapy

https://doi.org/10.1378/chest.10-1373Get rights and content

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.

Section snippets

Prior TTO Study Designs

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

Potential Benefits of TTO

The following potential benefits of TTO compared with nasal oxygen delivery are summarized in Table 1.1, 2, 3, 4, 5, 6, 7, 8, 9, 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

The TTO Program

Presently, TTO is administered using the Spofford Christopher Oxygen Optimizing Program, which is extensively described elsewhere.11, 12, 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

Procedures, Complications, and Sequelae

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, 12, 13 and the more recently developed and preferred surgical technique (the Lipkin procedure),12, 13, 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

Complications With the Lipkin Surgical Procedure

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

Indications, Absolute Contraindications, and Precautions

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

Reimbursement

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

New Directions

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, 8, 9, 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

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    For editorial comment see page 238.

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    Copyright © 2011 The American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.