1. An Innovative Technique to Oxygenate and Ventilate
Dr Ayush Gupta
DTCD, DNB, DM Fellow
Department of Pulmonary, Critical Care and Sleep Medicine
Safdarjang Hospital

2. Case Summary 19 year old female Normal milestones, no co-morbidities
Presented with chief complaints of:-
progressively increasing breathlessness – 7 years
cough, sputum, hemoptysis on and off – 7 years
History of ATT intake 3 times – 2006, 2011, 2014
Sputum for AFB stain – Negative all three times
Diagnosed as having post tubercular bilateral bronchiectasis with type 2 respiratory failure by private practioner
Referred to Safdarjang hospital for further management

3. Case summary – Xray Chest

4. CT Chest – mediastinal window

5. CT Chest – Mediastinal window

6. CT chest – Mediastinal window

7. CT Chest – Mediastinal window

8. CT Chest- Lung window

9. CT Chest – Lung window

10. CT Chest – Lung window lower cuts

11. Case Summary - investigations
Hb-10.6gm/dl; TLC-5600; KFT, LFT- WNL
Sputum for AFB stain and culture – Negative
Gene Xpert Mtb – Negative
Total Serum IgE – 104
Specific IgE/ IgG against aspergillus – Negative
Cystic fibrosis work up – Negative (CFTR; Sweat Chloride)
Mantoux test 1 TU – 7mm induration
Serum ACE – 86 units/ml (elevated); S Ca2+ - Norm
ABG on 21% FiO2–
ph – 7.331; pCO2 – 73; pO2 – 35; HCO3 – 33

12. Case Summary
No biopsy or TBNA was possible in view of type 2 respiratory failure
Vitals – Temp – 98 degree F
Pulse – 132/min
RR – 36/min
BP- 120/60 mm of hg
SpO2 – 66% on room air and 89% on 6l via
nasal prongs
Provisional diagnosis - ?Stage 4 Sarcoidosis / Bilateral bronchiectasis/ Chronic type 2 respiratory failure was made (Negative Mantoux, Bilateral mediastinal adenopathy; Extensive fibrocystic lung lesions; Sputum for AFB negative; Elevated ACE)

13. Treatment
Patient had received 3 courses of ATT – good compliance; persistent symptoms
Received multiple courses of systemic steroids in view of obstructive airway disease – no response
Steroids were discontinued on presentation to our unit; started on inhaled bronchodilators + ICS
In view of type 2 RF, tachypnea and tachycardia, patient was put on non invasive mechanical ventilation
Ipap- 22; Epap- 6; Fio2- 40%

14. NIV machine – with in built oxygen air blender to deliver desired FiO2

15. ABG – Pre and Post NIV Pre NIV Post NIV Fio2- 21% 21% pH – 7.331 7.382
pCO
58.2
pO2- 35 40
HCO3 – 33.3
29.5
So2- 65%
71%

16. Symptomatic improvement
Patient was gradually weaned to nocturnal NIV (8-10 hrs) with daytime oxygen therapy
Her dyspnea improved, tachycardia and tachypnea reduced (HR-110; RR – 25 at rest on oxygen)
Patient was planned for home nocturnal NIV and domiciliary oxygen therapy
Was also given option of lung transplantation

17. The issues
Patient required 5-6 litres/min flow rate via nasal prongs at rest to keep SpO2 of 88-90% - difficult to manage at home and will result in limitation of physical activity
Patient bought Respironics Bipap machine with ST mode and when oxygen supplementation was added via cannula through full face mask, flow requirements were 10-11L/min to maintain SpO2 of 90% on NIV – due to dilution of oxygen flow in the NIV mask as a result of high NIV pressures

18. The issues
Patient remained hypercapnic at maximal tolerable pressures – PaC02 was mm of Hg

19. Methods to add oxygen in the NIV circuit when not using NIV machine with blender

20. What next?? Not able to oxygenate at rest
Not able to mix adequate oxygen in the NIV circuit
Persistent hypercapnea at maximal tolerable pressures

21. Options
Ask patient to buy home oxygen concentrator with 11L/min flow rate capacity – tried but did not work with NIV as it was not 100% pure oxygen; costly
Ask patient to buy home NIV machine with in built blender – extremely costly; requires pressurised oxygen source through cylinders; cannot be used with O2 concentrators
Oxygen conserving devices such as pendant device – solved the issue of daytime high oxygen requirement with nasal prongs but the problem with NIV remained; patient found it obtrusive

22. Not able to discharge patient home
Patient was in stable, chronic type 2 respiratory failure but required NIV machine with in built blender
She was bed bound with exertional desaturation limiting her physical activity
Bilateral extensive bronchiectasis limited her long term survival

23. The final solution – Transtracheal oxygen using Minitrach catheter

24. Transtracheal oxygen (TTO)
Transtracheal oxygen is delivered via a catheter inserted through cricothyroid membrane or between 1st and 2nd tracheal rings
Usual technique is a surgically created tract between the first and the second tracheal rings in OT by a surgeon (T10 Fast Tract procedure kit; SCOOP system; USA; TTO2.com)
SCOOP transtracheal catheters are placed in the tract to deliver oxygen directly into trachea; Tract matures; SCOOP catheters changed monthly
Costly; Patented; Surgical procedure; Not available

25. Minitrach transtracheal catheter
Inserted through cricothyroid membrane using Seldinger technique bedside by Pulmonologist/ Critical care specialist
Easy to insert; no guidance required; voice preserved
No major complications; well accepted by the patient
Either 100% oxygen or air oxygen mixture can be insufflated through transtracheal catheter
OD of 4mm and length of 6 cms; 10 french suction catheter can pass through lumen
Not routinely used for TTO delivery

26. TTO - Advantages
Acts as oxygen conserving device with the trachea acting as reservoir – reduces oxygen demand from the source by 40-50%
Reduces the anatomical dead space compartment by flushing out CO2 proximal to the tip of catheter in the trachea – changes Vd/Vt ratio and reduces PaCO2
Reduces minute ventilation requirement by 20-30%
Minute ventilation sparing effect of TGI reduces work of breathing
O2 does not get diluted with the NIV flows in the face mask

27. Status of the patient post TTO
Daytime – O2 inhalation at 2 l/min via TTC at rest; 3l/min while walking; able to do all her routine activities and walk for about 500 metres at a stretch
Nocturnal NIV – Ipap- 22, Epap- 6, O2 inhalation via TTC at 3l/min with NIV
Pulse- 110/min, RR- 24/min
ABG – pH ; PaCO2- 50; PaO2- 42; HCO3- 28
Vocalising and communicating
Discharged home safely
Awaiting lung transplant

28. Transtracheal catheter in situ

29. O2 inhalation via TTC at 2-3L/min

30. Case report Accepted for publication in IJCDAS in 2015
2 patients with chronic type 2 RF on high intensity NIV with high pressure requirements
Required high flow rates of supplemental oxygen with NIV
Had persistent hypercapnia on maximal tolerated pressures
NIV with TTO using minitrach catheter
Both patients had significant reduction in O2 requirement from source, reduced PaCO2 levels and were made ambulatory at home

31. Newer potential indications
Early weaning of ARDS patients – successfully tried in one patient of H1N1 severe ARDS
Acute exacerbation of COPD with hypercapnea – as an adjunct to NIV
Acute exacerbation of IPF with high FiO2 requirements - tried in one patient while awaiting response to high dose steroids
Traumatic brain injury with COPD – tried in one patient to maintain normocapnea and reduce WOB
Neuromuscular disorders with type 2 RF - with NIV

32. Complications
Bronchial mucosal damage – due to impact of the jet stream as well as physical impact of the catheter tip on the tracheal wall
Inadequate humidification of the inspired gas -catheter blocks due to thick, retained secretions
Hemoptysis- tracheal wall injury or faulty insertion technique
Usually minor; Catheter well tolerated

33. Summary
Transtracheal oxygen therapy via minitrach catheter is an innovative technique to oxygenate and ventilate the patient
Acts as an oxygen conserving device with trachea as the reservoir; reduces oxygen demand from source
Reduces anatomical dead space, changes Vd/Vt ratio, reduces minute ventilation requirement, WOB and PaCO2
Easy to insert; Good compliance; Speech preservation
Potential use in a variety of clinical situations
NIV with TTO is an experimental modality with promising results and sound physiological basis

34. Thank You