Insertion of a Pre-SCOOP Transtracheal Oxygen Therapy Catheter with Use of a Raulerson Syringe

Abstract

To the Editor: Continuous oxygen therapy has become standard practice in managing cases of severe hypoxemia, and it has been proved beneficial in terms of survival.1Petty TL. Home oxygen therapy.Mayo Clin Proc. 1987; 62: 841-847Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 2Nocturnal Oxygen Therapy Trial GroupContinuous nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical trial.Ann Intern Med. 1980; 93: 391-398Crossref PubMed Scopus (2119) Google Scholar The advent of transtracheal oxygen therapy (TTOT) has improved efficiency of oxygen delivery and patients' compliance and functional status. However, TTOT is not without technical difficulties and complications.3Adamo JP Mehta AC Stelmach K Meeker D Rice T Stoller JK. The Cleveland Clinics initial experience with transtracheal oxygen therapy.Respir Care. 1990; 35: 153-160Google Scholar Between 1986 and 1991, we at the Cleveland Clinic Foundation performed 47 TTOT procedures with use of the SCOOP system, adhering strictly to the published guidelines.4Spofford B Christopher K. The ITOT manual for transtracheal oxygen therapy. Denver Institute for Transtracheal Oxygen Therapy, Denver1986Google Scholar Our initial experience has been previously published.3Adamo JP Mehta AC Stelmach K Meeker D Rice T Stoller JK. The Cleveland Clinics initial experience with transtracheal oxygen therapy.Respir Care. 1990; 35: 153-160Google Scholar All the procedures were performed by one of the two staff physicians or under their supervision by one of the pulmonary fellows. In our experience, one of the difficult steps in the procedure is the insertion of a 7-cm-long 18-gauge needle (Cook, Bloomington, Ind) into the trachea. Improper insertion of this needle can lead to misplacement of the pre-SCOOP catheter in either the anterior or the middle portion of the mediastinum.3Adamo JP Mehta AC Stelmach K Meeker D Rice T Stoller JK. The Cleveland Clinics initial experience with transtracheal oxygen therapy.Respir Care. 1990; 35: 153-160Google Scholar Accessing the tracheal lumen with use of the 20-gauge needle, which is used to inject lidocaine into the tracheal wall and the lumen, offers little difficulty. Recently, we performed TTOT procedures using a Raulerson syringe, which eliminated the step that required the use of an 18-gauge needle and added to the ease of the procedure. The Raulerson syringe is designed with a hollow piston that slides over a thin metal cannula, which extends between the ends of the barrel of the syringe. This metal cannula facilitates insertion of the guide wire through the hollow piston directly into the needle attached to the barrel and then into the site of interest. The syringe is supplied with Arrow double- and triple-lumen jugular catheterization kits (Arrow International, Reading, Pa). After 1 cm of vertical insertion has been achieved at the preferred site, a 1.5-inch 20-gauge needle attached to a Raulerson syringe containing 5 ml of 2 percent lidocaine is inserted into the trachea to infiltrate the intercartilagenous space. The bevel of the needle is kept facing caudally. Once tracheal penetration has been confirmed, a few milliliters of lidocaine is injected into the tracheal lumen. The soft straight end of a 0.025-inch-diameter guide wire is inserted through the channel of the piston and then through the needle into the tracheal lumen by using the Arrow advancer (Fig 1). Once an appropriate length of guide wire has been positioned inside the trachea, the Raulerson syringe and the needle are slowly removed. The remainder of the procedure is performed in the usual fashion without difficulty. Thus, the use of an 18-gauge needle is not required, and the placement of a guide wire is possible with a single tracheal penetration by a 20-gauge needle. We have used this method in six patients during the past four months, without any complications during either insertion or four months of follow-up. Even though the procedure of TTOT catheter placement is relatively simple, it is associated with a few complications.3Adamo JP Mehta AC Stelmach K Meeker D Rice T Stoller JK. The Cleveland Clinics initial experience with transtracheal oxygen therapy.Respir Care. 1990; 35: 153-160Google Scholar We feel that use of the Raulerson syringe adds to the ease of the procedure and may reduce potential complications. Of course, in selected patients, a 20-gauge needle longer than 1.5 inches and a guide wire longer than the commercially available length might be required. We hope that this report promotes the availability of the Raulerson syringe as a separate instrument.