Transtracheal Oxygen Therapy and COPD

Less commonly used procedure has its benefits

Indian doctor talking with patient
LWA/Dann Tardif / Getty Images

People with chronic obstructive pulmonary disease (COPD) often need supplemental oxygen in the later stages of the disease. More often than not, it will be delivered through a tube, called a nasal cannula, that rests on the face directly under the nose.

In some cases, a cannula will not be sufficient, and a person will require a more direct method of delivery.

To this end, a doctor may choose to use transtracheal oxygen therapy (TTOT) in which a narrow tube, called a catheter, is inserted through a hole in the neck to feed oxygen directly to the lungs.

Pros and Cons of TTOT

TTOT was first used in 1982 but has since been largely dismissed by those who consider it to be impractical other than in cases of extreme oxygen deprivation (hypoxia).

Clearly, the procedure has its limitations. The insertion of a catheter into the neck can be distressing and/or unsightly to some (although it is generally not considered uncomfortable). Moreover, the tube is prone to clogging and may sometimes require unwieldy adjustments.

However, in recent years, a number of doctors have endorsed its use in people who they believe can benefit greatly from the procedure.

This includes individuals who are achieving less-than-optimal results with a cannula, oftentimes because they are not using it enough and/or properly.

The simple fact is that the prolonged use of a cannula can lead to chronic irritation around the nose and ears and the development of contact dermatitis, chondritis, and skin ulcers. This alone can discourage use, leading to a deterioration of physical activity and exercise tolerance.

By contrast, TTOT can actually improve a person's quality of life rather than diminish it.

TTOT requires far less oxygen than a cannula, meaning that a portable oxygen concentrator can be smaller, lighter, and longer lasting, allowing a person to be out and about for longer periods of time.

TTOT also requires 55 percent less oxygen during rest and 35 percent during exercise compared to a cannula. These numbers can translate to improved physiological function and an increase in exercise tolerance. While these facts don't entirely overcome the obstacles to TTOT, they do advocate for its use in persons are not responding to standard oxygen therapy as well as they should.

If considering TTOT, there are two common procedures that are used by surgeons:

Modified Seldinger Technique

The modified Seldinger technique is the best-known TTOT procedure, although its popularity has declined since most insurance companies won't cover it. The procedure itself is performed under anesthesia on an outpatient basis and involves the following steps:

  1. A small incision is made into the neck into which a needle is inserted.
  2. A wire guide is then passed over the needle, and the needle is extracted.
  3. A smooth tube called a dilator is then passed over the wire and begins the process of gently stretching the neck tissue.
  1. Once the opening is large enough, the dilator is removed and a stent is passed over the wire into the opening. This will keep the incision from closing.
  2. After the wire guide is removed, the stent is sutured into place.
  3. After a week, a return visit would be scheduled to remove the stent. The catheter would then be inserted into the trachea to complete the procedure.

The Fast Tract Technique

A newer method, called the Fast Tract technique, was developed to streamline the TTOT process. The procedure is performed in the operating room under light sedation and usually involves an overnight stay.

To create the transtracheal opening, the surgeon will create tiny skin flaps on the neck, exposing the inside of the trachea.

The skin flaps would then be tacked to the underlying muscle on the inside of the neck, creating a permanent pathway.

With the Fast Tract procedure, TTOT can begin the following day rather than a week later.

Source:

Christopher, K. and Schwartz, M. "Transtracheal Oxygen Therapy." Chest Journal. 2011; 139(2):435-40. DOI: 10.1378/chest.10-1373.