Translaryngeal open ventilation to treat acute respiratory failure in acute exacerbation of chronic obstructive pulmonary disease. A preliminary report

Transtracheal Open Ventilation in Acute Respiratory Failure Secondary to Severe Chronic Obstructive Pulmonary Disease Exacerbation

RATIONALE

Patients who fail noninvasive ventilation are generally intubated and are then subjected to complications of invasive mechanical ventilation. With transtracheal open ventilation, ventilator support is delivered through an uncuffed small bore minitracheostomy tube, which eliminates pooling of secretions above the cuff and thus reduces the risk of tracheobronchial microbial colonization.

OBJECTIVE

To compare transtracheal open ventilation (treatment group) with conventional invasive ventilation (control group) in patients with exacerbation of chronic obstructive pulmonary disease who initially failed noninvasive ventilation.

METHODS

Patients were randomized to receive trans-tracheal open ventilation (n=19) or conventional invasive ventilation (n=20).

MEASUREMENTS AND MAIN RESULTS

There was no difference in arterial blood gases after 1 and 30 h between the two groups. Two patients receiving transtracheal open ventilation and 13 undergoing conventional ventilation had complications (p<0.0001). Compared with conventional ventilation, transtracheal open ventilation significantly decreased both the duration of mechanical ventilation (7.6+/-4.7 vs. 18.6+/-10.6 d, p<0.0001) and length of stay in the intensive care unit (10.2+/-4.5 vs. 21.3+/-9.7 d, p<0.0001).

CONCLUSIONS

Transtracheal open ventilation was as effective as conventional ventilation in maintaining adequate gas exchange and reducing complications, duration of mechanical ventilation, and intensive care unit length of stay.

Assessment of Ventilation During the Performance of Elective Endoscopic-Guided Percutaneous Tracheostomy

STUDY OBJECTIVES

To evaluate the feasibility of uninterrupted translaryngeal open ventilation delivered through a pediatric, uncuffed endotracheal tube during percutaneous endoscopic tracheostomy (PET).

DESIGN AND SETTING

Prospective, observational clinical study in a six-bed ICU of a university hospital.

PATIENTS

Forty consecutive adult patients requiring an elective tracheostomy.

INTERVENTIONS

We employed the basic Ciaglia technique with multiple dilators (n = 10), a single dilator (n = 15), and the Fantoni method (n = 15). During PET, pressure-controlled ventilation was maintained through an uncuffed, 4-mm inner-diameter pediatric tube. The fraction of inspired oxygen was 1.0. Ventilator settings were as follows: pressure-controlled ventilation, 40 cm H(2)O; respiratory rate, 25/min; inspiratory time, 1.2 s of inspiratory time (inspiratory/expiratory ratio, 1:1); and positive end-expiratory pressure, 0 cm H(2)O.

MEASUREMENTS AND RESULTS

Measurements of arterial blood gas (ABG) tensions were obtained before the start of each tracheostomy and every 3 min during the procedure. An average of 8.28 +/- 2.28 ABG measurements were obtained from each patient (+/- SD). All patients were successfully assisted during performance of the tracheostomy, and no patient required ventilation through a cuffed endotracheal tube. The maximum increase in PaCO(2) was 8.49 +/- 5.50 mm Hg, and the maximum decrease in pH related to hypercarbia was 0.04 +/- 0.04. The PaO(2) increased in all patients (maximum change, 69.75 +/- 57.00 mm Hg; p < 0.01), and no patient had desaturation during the procedure.

CONCLUSIONS

The technique that we propose for airway management during PET was safe and effective. A mild increase in PaCO(2) was not associated with significant metabolic and hemodynamic consequences, and an adequate PaO(2) was maintained throughout the study.