Transtracheal Oxygenation Research Articles

Use of Transtracheal Oxygen following Decannulation of Pediatric Tracheostomy

Purpose: Uninterrupted sustained oxygenation is paramount in neonates and infants with cyanotic/acyanotic congenital heart diseases (CHD) undergoing closed or open heart surgeries and tracheostomy tube decannulation to avoid hypoxic events. Description: We describe here-in a new device, permitting uninterrupted delivery of oxygen through the tracheostomy stoma, allowing continuation of enteral feeds and suctioning of the endotracheal secretions through the tracheostomy stoma. Evaluation: Eighty-four neonates and infants with a median age of four months (IQR:23 days-9 months) undergoing different closed and open heart surgeries for cyanotic/acyanotic CHD with or without pulmonary arterial hypertension were treated with a device permitting uninterrupted oxygenation following tracheostomy tube decannulation. There were 11 (13.1%) deaths due to multifactorial etiologies, and one was lost to follow-up. Seventy-two children were successfully decannulated using this protocol. At a median follow-up of 166(IQR:82.5-216) months, the actuarial survival was 86.61% (SE±0.04%; 95% CI: 77.1-92.3). Conclusions: Transtracheal oxygenation through the tracheostomy stoma via a thin catheter allows uninterrupted oxygenation following tracheostomy tube decannulation, continuation of enteral feeds, and allows intermittent endotracheal suctioning, thus avoiding post decannulation hypoxic events.

Perioperative Management of Patients with Hepatopulmonary Syndrome

Hepatopulmonary syndrome (HPS) is a syndrome of hypoxemia in patients with advanced liver disease, which results in significant mortality in the absence of liver transplantation. Management of HPS is complex both prior to and following liver transplantation as illustrated by a case presentation. This review considers the pathophysiology, diagnosis, assessment of severity, and treatment of HPS with a particular emphasis on perioperative management. Screening for HPS should be performed in all liver transplant candidates with room air saturation less than 97%. Diagnosis of HPS has been standardized with the use of agitated saline-enhanced echocardiography. Treatment modalities for profound hypoxemia include patient positioning, transtracheal oxygenation, nitric oxide therapy, intravenous methylene blue, and extracorporeal membrane oxygenation. Fortunately, patients with HPS who undergo successful liver transplantation will often have complete resolution of the symptoms related to HPS, although this may require weeks to months. Despite technical challenges, liver transplantation for HPS can be safely performed provided patients are identified and appropriately managed. Physicians caring for these patients should be prepared to use all available interventions including extracorporeal oxygenation to allow time for the HPS to resolve and oxygenation to improve. Further investigation is needed to identify effective medical treatments to mitigate HPS-related hypoxemia.

Training experts in difficult airway management: Evaluation of a continuous professional development program

ObjectiveThe Formation de référents aux techniques d’intubation difficile (FRTID) is a French continuing medical education program on difficult airway management. Its objectives are to train experts in the task of training other physicians in their hospitals for better guideline compliance. Our aim was to describe the curriculum of the experts and to evaluate the program's efficacy via a prospective survey. MethodsEach participant was asked to complete a questionnaire before (T0), immediately (T1), 6 (T6) and 12 (T12) months after the course. The main criterion was the proportion of the participants who declared that they had implemented at least one action to improve difficult airway management in their institution at 6 months. Other criteria included the proportion of participants who declared that they had modified their own clinical practice and the frequency of use of specific devices assessed on modified Likert numerical rating scales. ResultsTwo hundred and forty-four participants were included in the survey. One hundred and three, 91 and 62 participants responded to the T1 (immediately after the course), T6 (6 months later) and T12 (12 months later) questionnaires, respectively; 73 physicians (i.e. 30% of all participants and 80% of the survey responders) declared that they had implemented at least one action likely to optimize the management of difficult airways. On the T6 and T12 questionnaires, 91% and 97% of the responders respectively declared that they had changed their clinical practice. The course has resulted in increased use of transtracheal oxygenation with manual devices (Manujet®, Enk®) and Seldinger cricothyroidotomy as well as paediatric difficult airway techniques such as paediatric sized elastic gum and Airtraq™ or fibrescopic intubation under general anaesthesia with spontaneous ventilation (through a laryngeal mask). ConclusionThese data encourage the training of experts in difficult airways. This curriculum is contributing to the dissemination of the recommendations among a large number of practitioners.

Tracheostomy

The most common indications for modern tracheostomy are prolonged ventilation for respiratory failure and airway protection following traumatic brain injury with neurologic dysfunction. For background purposes, history and facts related to early tracheostomy are provided. Thereafter, anatomy and physiology are discussed, as are other anatomical considerations, including the site of the procedures, anesthesia, and patient positioning. Counseling and informed consent are also discussed. The operative techniques are provided for emergent surgical airway (cricothyroidotomy and transtracheal needle ventilation and oxygenation) and open and percutaneous tracheostomy. Tracheostomy management is described. Complications are listed and described. Early complications include displacement, pneumomediastinum/pneumothorax, bleeding, infection, acute obstruction, and negative pressure pulmonary edema. Late complications include subglottic tracheal stenosis, tracheal granulation, vocal cord dysfunction, tracheoesophageal fistula, tracheoinnominate fistula, and tracheocutaneous fistula. This review contains 13 figures, 1 video, 2 tables, and 38 references.

Intubation difficile : évaluation des connaissances et de l’expérience des internes en anesthésie-réanimation

ObjectivesAssessment of knowledge and experience in anaesthesiology residents on alternative techniques for difficult airway management. MethodDescriptive study using an anonymous electronic questionnaire, with 20 multiple-choice questions of 59 4th- and 5th-year residents in anaesthesiology of Amiens, Rouen and Caen University Hospitals (France). ResultsFourty-three (73%) answered to the questionnaire. Thirteen residents (30%) admitted to know last expert conference of the French Anaesthesiology Society partially, 19 (44%) didn’t train on mannequin or simulator. Twelve residents (28%) admitted to be insufficient trained to set up a Fastrach in an emergency context, and 39 (91%) to set up a transtracheal oxygenation technique. The rates of residents reaching the educational objectives on patients were 4% for the Fastrach, 21% for fiberoptic intubation, 12% for cricothyroidotomy. ConclusionFour years after the expert conference of the French Anaesthesiology Society, the educational objectives are not achieved during the resident training, both on mannequins or patients.

An Algorithm for Difficult Airway Management, Modified for Modern Optical Devices (Airtraq Laryngoscope; LMA CTrach ™)

Because algorithms for difficult airway management, including the use of new optical tracheal intubation devices, require prospective evaluation in routine practice, we prospectively assessed an algorithm for difficult airway management that included two new airway devices. After 6 months of instruction, training, and clinical testing, 15 senior anesthesiologists were asked to use an established algorithm for difficult airway management in anesthetized and paralyzed patients. Abdominal, gynecologic, and thyroid surgery patients were enrolled. Emergency, obstetric, and patients considered at risk of aspiration were excluded. If tracheal intubation using a Macintosh laryngoscope was impossible, the Airtraq laryngoscope (VYGON, Ecouen, France) was recommended as a first step and the LMA CTrach™ (SEBAC, Pantin, France) as a second. A gum elastic bougie was advocated to facilitate tracheal access with the Macintosh and Airtraq laryngoscopes. If ventilation with a facemask was impossible, the LMA CTrach™ was to be used, followed, if necessary, by transtracheal oxygenation. Patient characteristics, adherence to the algorithm, efficacy, and early complications were recorded. Overall, 12,225 patients were included during 2 yr. Intubation was achieved using the Macintosh laryngoscope in 98% cases. In the remainder of the cases (236), a gum elastic bougie was used with the Macintosh laryngoscope in 207 (84%). The Airtraq laryngoscope success rate was 97% (27 of 28). The LMA CTrach™ allowed rescue ventilation (n = 2) and visually directed tracheal intubation (n = 3). In one patient, ventilation by facemask was impossible, and the LMA CTrach™ was used successfully. Tracheal intubation can be achieved successfully in a large cohort of patients with a new management algorithm incorporating the use of gum elastic bougie, Airtraq, and LMA CTrach™ devices.

Oxygen Delivery During Transtracheal Oxygenation

The Manujet™ and the ENK Oxygen Flow Modulator™ (ENK) deliver oxygen during transtracheal oxygenation. We sought to describe the ventilation characteristics of these 2 devices. The study was conducted in an artificial lung model consisting of a 15-cm ringed tube, simulating the trachea, connected via a flow analyzer and an artificial lung. A 15-gauge transtracheal wire reinforced catheter was used for transtracheal oxygenation. The ENK and Manujet were studied for 3 minutes at respiratory rates of 0, 4, and 12 breaths/min, with and without the artificial lung, in a totally and a partially occluded airway. Statistical analysis was performed using analysis of variance followed by a Fisher exact test; P < 0.05 was considered significant. Gas flow and tidal volume were 3 times greater with the Manujet than the ENK (approximately 37 vs 14 L · min(-1) and 700 vs 250 mL, respectively) and were not dependent on the respiratory rate. In the absence of ventilation, the ENK delivered a 0.6 ± 0.1 L · min(-1) constant gas flow. In the totally occluded airway, lung pressures increased to 136 cm H(2)O after 3 insufflations with the Manujet, whereas the ENK, which has a pressure release vent, generated acceptable pressures at a low respiratory rate (4 breaths/min) (peak pressure at 27.7 ± 0.7 and end-expiratory pressure at 18.8 ± 3.8 cm H(2)O). When used at a respiratory rate of 12 breaths/min, the ENK generated higher pressures (peak pressure at 95.9 ± 21.2 and end-expiratory pressure at 51.4 ± 21.4 cm H(2)O). In the partially occluded airway, lung pressures were significantly greater with the Manujet compared with the ENK, and pressures increased with the respiratory rate with both devices. Finally, the gas flow and tidal volume generated by the Manujet varied proportionally with the driving pressure. This study confirms the absolute necessity of allowing gas exhalation between 2 insufflations and maintaining low respiratory rates during transtracheal oxygenation. In the case of total airway obstruction, the ENK may be less deleterious because it has a pressure release vent. Using a Manujet at lower driving pressures may decrease the risk of barotrauma and allow the safe use of higher respiratory rates.

Épiglottite aiguë obstructive en réanimation : stratégie pour une intubation à haut risque

Acute epiglottitis is an infection of supraglottic structures, with a high risk of life-threatening respiratory obstruction. We report a case of a 52-year-old patient who presented with a prehospital hypoxic respiratory arrest caused by obstructive oedema with a successful resuscitation. Laryngoscopy after a sudden unplanned extubation permits diagnosis of acute obstructive epiglottitis. The growing threat of laryngeal dyspnea prompts emergency tracheal airway protection, by means of the combined preparation of transtracheal oxygenation access and the use of fiber-optic laryngoscopy. This case report emphasises the airway management strategy successfully used in this patient.

Transtracheal Oxygenation: An Alternative to Endotracheal Intubation During Cardiac Arrest

Because efforts to secure adequate arterial oxygenation during cardiac resuscitation are more important than efforts to promote CO(2) elimination, we investigated whether continuous transtracheal oxygenation (TTO) could represent a potentially simpler alternative to conventional positive-pressure ventilation with 100% O(2) through an endotracheal tube. Controlled and randomized. Animal laboratory. Thirty male Sprague-Dawley rats. The technique for TTO was initially developed and tested in five rats. A model of ventricular fibrillation (VF) was then used to compare the effects of TTO (n = 5) with the effects of O(2) delivery through an endotracheal tube as part of positive-pressure ventilation (n = 5) or through a mask without additional airway intervention (n = 5). VF was induced and left untreated for 4 min, after which chest compression and one of the three oxygenation interventions was started. Defibrillation was attempted after 6 min of chest compression. In a subsequent series, defibrillation was attempted after 10 min of chest compression in rats treated with either TTO (n = 5) or endotracheal intubation (ET; n = 5). TTO and ET secured adequate arterial PO(2) during chest compression (213 +/- 77 mm Hg and 154 +/- 36 mm Hg; not significant), whereas the mask yielded an arterial PO(2) of only 49 +/- 38 mm Hg (p < 0.05). Each rat treated with TTO or ET was successfully resuscitated and survived the postresuscitation interval, but none of the rats treated with the mask survived. TTO maintained its efficacy after increased duration of chest compression. TTO was as effective as conventional positive-pressure ventilation with 100% O(2) for securing oxygenation, resuscitation, and short-term survival and more effective than O(2) delivered through a mask.

Assisted pressure control ventilation via a mini-tracheostomy tube for postoperative respiratory management of lung cancer patients

Assisted pressure control ventilation (PCV) via a min-tracheostomy tube (MTT) was conducted to improve gas exchange and reduce the work of breathing of lung cancer patients after surgery.Thirty-two patients with lung cancer underwent lobectomy and were managed postoperatively by assisted PCV via an MTT. On the basis of a simulation study using a lung model for clinical use, we set the inspiratory pressure to 20 cmH2O and inspiratory time to 1.0 sec to produce a 450-ml supported volume via the MTT per breath. The blood gases and respiratory rate of each patient were measured under three sets of conditions: PCV via an MTT transtracheal oxygenation (TTO) via an MTT and a Venturi face mask with the same FiO2. After PCV via an MTT overnight, the blood gases in the room air were measured 2.5 h after withdrawing PCV. In order to determine the effect of PCV via an MTT on gas exchange after PCV withdrawal, 32 other age and sex-matched lung cancer patients, who had undergone lobectomy and oxygenation via a face mask alone after surgery, were used as historical controls.The simulation study showed that the ventilated volume provided by assisted PCV via an MTT was about half that provided via a conventional endotracheal tube, even in the presence of air leakage. The clinical application showed that the ventilated volume obtained with the PCV via an MTT was significantly higher than that with spontaneous breathing (P<0.001). PCV via an MTT increased the P aO2and reduced both the P aCO2and respiratory rate significantly in comparison with TTO via an MTT and a face mask (P<0.001). After PCV withdrawal the morning after surgery, the P aO2of the PCV group was significantly higher than that of the historical controls (P<0.001). No postoperative pulmonary complications were observed in either the PCV or the control groups, however. In addition, no complications or morbidity were seen related to either MTT insertion or PCV via an MTT.Assisted PVC via an MTT increased the tidal volume, improved the gas exchange, reduced the respiratory rate by providing adequate ventilatory support and increased the P aO2, even after withdrawal following lung surgery. Even though we did not observe any benefit of clinical outcome with PCV via an MTT in the present study, this procedure appears to be a potentially useful respiratory management modality for patients with high risk of postoperative pulmonary complications.

Transtracheal oxygenation and ventilation.

Transtracheal oxygenation and ventilation.

Airway Insufflation: Increasing Flow Rates Progressively Reduce Dead Space in Respiratory Failure

We have previously shown that airway insufflation (AI) reduces dead space (VD) and minute ventilation (VL) in patients with respiratory failure, and when used chronically leads to lowered and more stable arterial PCO2. The present study was designed to measure the effect of increasing AI flow rate on VD and other aspects of gas exchange in respiratory failure in order to examine the hypothesis that AI exerts its main physiologic effect by progressive reductions of VD. Five patients with varying degrees of respiratory failure caused by either restrictive or obstructive lung disease were studied by means of the specialized techniques we developed to analyze gas exchange during AI. At 1 L/min (as in transtracheal oxygenation), at 5 L/min, and 8 L/min, AI produced progressive reductions in VD, tidal volume, and VL. Contrary to our previous study, some of these patients accompanied the decrease in VD with not only decreases in VL but with slight rises in alveolar ventilation (VA) and decrements in arterial PCO2. The greatest percentile decreases in VD and VL occurred in those with the smallest initial control values for each of these parameters. In summary, AI exerts its main effects on gas exchange through the reductions in VD that it produces, and the accompanying decreases in VL and/or slight increases in VA seem to stem from the latter.

Transtracheal oxygenation using simple equipment and a low-pressure oxygen source

Transtracheal oxygenation using simple equipment and a low-pressure oxygen source

A program for transtracheal oxygen delivery. Assessment of safety and efficacy.

Over a 2-year period, the safety and efficacy of a program specifically designed for transtracheal oxygen therapy were evaluated in 100 patients with chronic hypoxemia. The four clinically defined phases of the program included patient orientation, evaluation, and selection (phase I); a new needle-wire guide-dilator transtracheal procedure and stent week (phase II); transtracheal oxygen delivery with an immature tract (phase III); and transtracheal oxygen delivery with a mature tract (phase IV). Sequelae and complications were minor, and patient acceptance was high. As compared with the nasal cannula, the transtracheal catheter was associated with a significant reduction in oxygen flow requirement during both rest and exercise. Adequate oxygenation was maintained over time, and erythrocythemia was alleviated with transtracheal delivery. We conclude that transtracheal oxygenation by this method has a low, acceptable morbidity; it is more efficient than nasal cannula delivery and may be more effective in some patients.

A Problem with a Transtracheal Oxygenation System

A Problem with a Transtracheal Oxygenation System

An Easily Assembled Device for Transtracheal Oxygenation

An Easily Assembled Device for Transtracheal Oxygenation

Failed Intubation Protocol: Oxygenation Without Aspiration

The stimulus for the development of ‘failed intubation drill’ was a maternal death. The mother died from the consequences of silent pulmonary acid aspiration associated with a difficult endotracheal intubation. It occurred at a time when regional anaesthesia was rarely used for caesarean section in the locality. The purpose of the drill (or protocol) was to outline a safe plan of action following failure to intubate the trachea in a mother anaesthetized for an obstetric operation. It was necessary to take steps to effect oxygenation without aspiration. The details for enabling a safe changeover to a general anaesthetic without an endotracheal tube were given. The plan recognized that oxygenation would be difficult in some patients. Such cases were to be allowed to wake up before a decision on an alternative anaesthesia could be made. The maintenance of cricoid pressure and placing the patient in the left lateral head-down posture remains essential to the protocol. This chapter deals with some causes of unexpected difficulty with visualization of the larynx. Methods of improving the chance of successful intubation in problem cases are given. The factors which make intermittent positive pressure ventilation by face-mask difficult, or impossible, are reviewed, and the ways of clearing an obstructed airway when intubation has failed are outlined. The authors attach importance to the use of the triple airway manoeuvre, and forward displacement of the larynx by endo-oesophageal intubation in some cases. Where there is complete inability to ventilate by face-mask following a failed intubation, transtracheal oxygenation via a catheter inserted through the cricothyroid membrane is effective and life-saving. A failed intubation protocol is presented.