Cephalad Transtracheal Oxygen Therapy Catheter

Abstract

A 66-year-old man, previously employed as a belt and brick plant operator, and a 25 pack-year ex-smoker, was referred with refractory hypoxia to oxygen delivered via standard nasal cannula. Spirometry revealed moderate restrictive lung disease. Chest films revealed end-stage pulmonary fibrosis with honeycombing and emphysematous blebs in the upper lobes. He had diagnoses of idiopathic pulmonary fibrosis and chronic obstructive pulmonary disease. His oxygen requirements were not being met with standard methods. Transtracheal oxygen therapy was subsequently initiated. Four weeks into the transtracheal oxygen therapy, the patient complained of increasing cough, shortness of breath, and hoarseness of voice. He also felt that the treatment was not as effective as it was previously. Bronchoscopy was performed to rule out a large mucus plug at the end of the catheter. A cephalad catheter was visualized. DISCUSSION It has been shown that continuous oxygen therapy in chronically hypoxemic patients reduces morbidity and mortality. 1 Oxygen delivery is usually initiated via nasal cannula in a majority of patients. Other methods include reservoir cannulas and demand–flow devices. These devices reduce oxygen consumption considerably. Heimlich 2 first introduced the transtracheal oxygen delivery system in 1982. A reduction in oxygen flow rate requirements, nasopharynx irritation, respiratory effort, improved nutrition, and earlier return to activities of daily living were clearly demonstrated. These conclusions have been verified by various other studies. 3–6 Although not completely elucidated, Benditt et al. 7 postulated that transtracheal oxygen results in decreased total inspired minute ventilation and induces a less energy-demanding respiratory pattern. This may be the mechanism behind improved subjective feelings in patients using transtracheal oxygen therapy. Despite the varied benefits of transtracheal oxygen delivery, a number of complications can occur. Mucus plugging, immature tract formation, and accidental dislodgment are among the most frequent complications. 8 Most difficulties can be classified as early or late. 9 Early complications are predominantly technical or procedure related. Late complications are likely infectious, symptomatic, or mechanical in nature. Mehta et al. 10 and Lipkin et al. 11 have revealed techniques to reduce the incidence of complications. However, certain problems cannot be avoided with transtracheal oxygen delivery systems. Often, meticulous catheter maintenance is the only means of evading future dilemmas. Cephalad catheter displacement can be an early or late complication. Cephalad retroversion of a transtracheal catheter has been described. 4,6,12Fig. 1 shows a cephalad catheter displaced to the level of the vocal cords and beyond. Displacement on insertion is the typical basis of catheter retroversion. Occasionally, forceful cough is the culprit.FIG. 1.: Distal end of the transtracheal catheter protruding through the glottis.CONCLUSION Transtracheal oxygen therapy is a novel approach to oxygen delivery in the chronically hypoxemic patient. Although complications can be expected, most are nonlife-threatening. 2–4,8,9 Several, if not all, potential complications can be managed and even prevented by a team trained in follow-up and maintenance. Cephalad catheter displacement is an extremely uncommon complication. We document catheter retroversion through the vocal cords in a patient with a forceful cough response.