Guidelines for TTOT Patient Selection

Introduction

Transtracheal oxygen (TTO) therapy must be viewed as a complete program of care, which is easy and highly successful when followed properly. We recommend that the physician who offers TTO therapy start with predictably easy candidates.  This will promote initial success for the entire team and offer a smooth transition from novice to expert.   Our knowledge, gained from thousands of patient months of experience, has shown your experience with your first 10 patients should be viewed as a learning curve, after which you should steadily reduce morbidity and time commitments to this program.

General Indications

Patients must meet Medicare (NOTT) criteria for continuous oxygen therapy (i.e. PO2 less than 55 mm Hg on room air), and CMS criteria for long term oxygen therapy.

Specific Indications

  • Currently using 1-6 liters per minute via nasal cannula.
  • Have FEV1's between 500 and 1000 cc's.
  • Have PO2's on supplemental oxygen greater than 55 mm Hg.
  • Have PCO2's on supplemental oxygen less than 45 mm Hg.
  • Live less than 1 hour from their physician.
  • Have dependable transportation.
  • Have strong significant other support.
  • Spend less than 12 hours per day in bed.
  • Leave the house routinely for activities such as shopping, socializing or work.
  • Be highly motivated to improve their quality of life.
  • Experience non-compliance related to the nasal cannula.
  • Have need or desire for improved mobility.
  • Experience complications of the nasal cannula that make the patient non-compliant with their O2 therapy.
  • Have cor pulmonale or erythrocythemia on nasal oxygen.
  • Have hypoxemia that is refractory to nasal cannula or mask therapy.
  • Patient preference

Contraindications

  • Patient Selection
  • Severe anxiety neurosis.
  • Mental or physical incompetence.
  • Upper airway obstruction.
  • Pleura herniated over puncture site.
  • Vocal cord paralysis.
  • Acute respiratory failure.

Precautions

Experience has proven that patients with one or more of the following precautions may have successful TTO2 experiences once the learning curve has been established.

  • Refractory to nasal cannula or mask oxygen therapy, i.e. PO2 of less than 55 mm Hg at a flow rate greater than 6-8 liters per minute. This is a very difficult group of patients to treat with transtracheal oxygen and should not be attempted until sufficient experience with easier patients is acquired.
  • Poor mechanical reserve (e.g. FEV1 less than 500 ml).
  • Hypercapnia without acidemia (e.g. PaCO2 greater than 45 mm Hg).
  • End-stage in their disease process, with significantly elevated PCO2 and/or profound hypoxemia despite supplemental oxygen.
  • Display symptoms of severe disabling anxiety.
  • Have very serious arrhythmia or other significant medical problems, i.e. insulin dependent diabetes.
  • Bronchial hyperreactivity.
  • Copious or viscous sputum.
  • Bleeding disorder.
  • Very fat neck or other anatomic abnormality.
  • Mild to moderate anxiety neurosis.
  • Live alone or so far away from the transtracheal support unit that they cannot be adequately monitored.