Transtracheal oxygen therapy
- Michael D Schwartz, MD, FACP, FCCP, FCCM
Michael D Schwartz, MD, FACP, FCCP, FCCM
- Associate Professor of Medicine
- National Jewish Medical and Research Center
- Kent L Christopher, MD, RRT, FCCP, FAARC
Kent L Christopher, MD, RRT, FCCP, FAARC
- Clinical Professor of Medicine
- University of Colorado Denver, School of Medicine
- Section Editors
- James K Stoller, MD, MS
James K Stoller, MD, MS
- Section Editor — Chronic Obstructive Pulmonary Disease
- Jean Wall Bennett Professor of Medicine, Samson Global Leadership Academy Endowed Chair
- Cleveland Clinic Lerner College of Medicine
- Chairman, Education Institute, Cleveland Clinic
- Praveen N Mathur, MB, BS
Praveen N Mathur, MB, BS
- Section Editor — Interventional Pulmonology
- Professor of Clinical Medicine
- Indiana University School of Medicine
Transtracheal oxygen (TTO) therapy refers to the delivery of long-term oxygen therapy (LTOT) through a transtracheal catheter (picture 1). It is an alternative to conventional LTOT, which is delivered through a nasal cannula.
The benefits of TTO therapy, patient selection, complications, and reimbursement are discussed in this topic review. Other issues related to LTOT are discussed separately. (See "Long-term supplemental oxygen therapy" and "Traveling with oxygen aboard commercial air carriers" and "Oxygen conserving devices" and "Use of oxygen in patients with hypercapnia".)
TTO therapy offers several potential benefits . Most studies that have examined the efficacy of TTO have used the subject as his or her own control. In the short-term physiologic studies, patients with an existing transtracheocutaneous fistula usually received interventions related to tracheal gas delivery in a random order, and then were compared to controls with no tracheal flow [2,3]. In the long-term clinical studies, data collected after initiation of TTO therapy were compared to data collected while the patient was receiving LTOT by nasal cannula [4-8]. One trial randomized 43 patients to receive TTO or LTOT via nasal cannula for the duration of the trial .
TTO was found to have the following effects when compared to LTOT delivered via nasal cannula (table 1):
- Reduces the oxygen flow that is required to achieve the same arterial oxyhemoglobin saturation, both at rest (55 percent reduction) and during exercise (30 percent reduction) 
- Improved exercise capacity was observed in two studies; however a third study found no increase in exercise capacity with TTO compared to nasal cannula, when controlled for oxygen saturation [3,5,9]
- Improves the room air alveolar to arterial oxygen tension gradient (ie, A-a gradient) [6,9]
- Reduces erythrocytosis and improves cor pulmonale [4,7,9]
- Reduces or maintains arterial carbon dioxide tension (PaCO2) 
- Corrects hypoxemia that was refractory to LTOT delivered by nasal cannula 
- Improves activity and mobility 
- Improves physical, social, and psychological function 
- Improves compliance (daily duration of oxygen use) 
- Reduces days of hospitalization 
- Christopher KL. Transtracheal oxygen catheter placement and management. In: Principles and Practice of Interventional Pulmonology, Ernst A, Herth F. (Eds), Springer, New York 2013. p.705.
- Bergofsky EH, Hurewitz AN. Airway insufflation: physiologic effects on acute and chronic gas exchange in humans. Am Rev Respir Dis 1989; 140:885.
- Dewan NA, Bell CW. Effect of low flow and high flow oxygen delivery on exercise tolerance and sensation of dyspnea. A study comparing the transtracheal catheter and nasal prongs. Chest 1994; 105:1061.
- 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.
- 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; 145:827.
- 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; 100:968.
- Christopher KL, Spofford BT, Brannin PK, Petty TL. Transtracheal oxygen therapy for refractory hypoxemia. JAMA 1986; 256:494.
- Kampelmacher MJ, Deenstra M, van Kesteren RG, et al. Transtracheal oxygen therapy: an effective and safe alternative to nasal oxygen administration. Eur Respir J 1997; 10:828.
- Bloom BS, Daniel JM, Wiseman M, et al. Transtracheal oxygen delivery and patients with chronic obstructive pulmonary disease. Respir Med 1989; 83:281.
- Benditt J, Pollock M, Roa J, Celli B. Transtracheal delivery of gas decreases the oxygen cost of breathing. Am Rev Respir Dis 1993; 147:1207.
- Couser JI Jr, Make BJ. Transtracheal oxygen decreases inspired minute ventilation. Am Rev Respir Dis 1989; 139:627.
- Hurewitz AN, Bergofsky EH, Vomero E. Airway insufflation. Increasing flow rates progressively reduce dead space in respiratory failure. Am Rev Respir Dis 1991; 144:1229.
- Spofford B, Christopher KL, Goodman JR. Transtracheal Oxygen Therapy. In: Problems in Respiratory Care - The Current Status of Oxygen Therapy, Christopher KL (Ed), J.B. Lippincott Company, Philadelphia 1990. p.600.
- Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann Intern Med 1980; 93:391.
- Reinke, LF, Hoffman, LA. Transtracheal oxygen: Patient management strategies. Respir Care Prac 1992; 5:66.
- Christopher KL, VanHooser DT, Jorgenson SJ, et al. Preliminary observations of transtracheal augmented ventilation for chronic severe respiratory disease. Respir Care 2001; 46:15.
- Brack T, Senn O, Russi EW, Bloch KE. Transtracheal high-flow insufflation supports spontaneous respiration in chronic respiratory failure. Chest 2005; 127:98.
- Christopher KL, Schwartz MD. Transtracheal oxygen therapy. Chest 2011; 139:435.
- Harris RJ. Transtracheal oxygen therapy success. Chest 2011; 140:563.
- Schwartz MD, Make B. Long-term oxygen therapy: whatever happened to transtracheal oxygen? COPD 2009; 6:226.
- 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; 100:108.
- Hoffman LA, Wesmiller SW. Transtracheal oxygen. In: Portable Oxygen Therapy Including Oxygen Conserving Methodology, Tiep BL (Ed), Futura Publishing Co, Mount Kisco, NY 1991.
- Wesmiller SW, Hoffman LA, Wiseman M. Understanding transtracheal oxygen delivery. Nursing 1989; 19:43.
- SCOOP Transtracheal Oxygen Therapy. Clinical Guide for the Fast Tract Insertion Technique. Transtracheal Systems, Inc., Englewood, CO, 1997.
- Lipkin AF, Christopher KL, Diehl S, et al. Otolaryngologist's role in transtracheal oxygen therapy: the minitrach procedure. Otolaryngol Head Neck Surg 1996; 115:447.
- Tiep BL, Christopher KL, Spofford BT, et al. Pulsed nasal and transtracheal oxygen delivery. Chest 1990; 97:364.
- Yaeger ES, Goodman S, Hoddes E, Christopher KL. Oxygen therapy using pulse and continuous flow with a transtracheal catheter and a nasal cannula. Chest 1994; 106:854.
- Orvidas LJ, Kasperbauer JL, Staats BA, Olsen KD. Long-term clinical experience with transtracheal oxygen catheters. Mayo Clin Proc 1998; 73:739.
- Heimlich HJ, Carr GC. The micro-trach. A seven-year experience with transtracheal oxygen therapy. Chest 1989; 95:1008.
- Couser JI Jr, Make BJ. Respiratory tract infection complicating transtracheal oxygen therapy. Chest 1992; 101:273.
- Fletcher EC, Nickeson D, Costarangos-Galarza C. Endotracheal mass resulting from a transtracheal oxygen catheter. Chest 1988; 93:438.
- Burton GG, Wagshul FA, Henderson D, Kime SW. Fatal airway obstruction caused by a mucous ball from a transtracheal oxygen catheter. Chest 1991; 99:1520.
- 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; 101:580.
- Roth BJ, Irvine TW, Liening DA, et al. Acute respiratory compromise resulting from tracheal mucous impaction secondary to a transtracheal oxygen catheter. Chest 1992; 101:1465.
- de Groot RE, Dik H, de Groot HG, Bakker W. A nearly fatal tracheal obstruction resulting from a transtracheal oxygen catheter. Chest 1993; 104:1634.
- Ulstad DR, Koppin J. Massive atelectasis with respiratory arrest due to transtracheal oxygen catheter-related mass formation. Chest 1994; 106:982.
- Menon AS, Carlin BW, Kaplan PD. Tracheal perforation. A complication associated with transtracheal oxygen therapy. Chest 1993; 104:636.
- Kristo DA, Turner JF, Hugler R. Transtracheal oxygen catheterization with pneumomediastinum and sudden death. Chest 1996; 110:844.
- PATIENT SELECTION
- GENERAL APPROACH
- Phase I
- - Preprocedure evaluation
- - Patient education
- Phase II
- - Modified Seldinger technique
- - Lipkin procedure
- - Comparison
- Phase III
- - Tract loss
- - Mucus accumulation
- Phase IV
- GENERAL COMPLICATIONS
- SUMMARY AND RECOMMENDATIONS