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Transtracheal Oxygen TTO Q & A

Answers from Our Professionals

More on Transtracheal Oxygen (TTO)

What Questions Should I Ask?

Q. I went to my pulmo doctor and asked if he would do an TTO. I asked if he would do Fast Track. He said yes. My question is what other questions should I have asked? I told him I couldn’t have it done until June. Now I am wondering if I should have gone to an ENT. I am on 3L O2 and I am sick of carrying 2 M6 or dragging E. Will the oxygen level drop with TTO. I wonder about the cannual getting caught and pulling out of the tract. I can hardly breathe through my nose, I really need TTO. Thank you for joining EFFORTS. Audrey UPNY

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A. The Fast Tract procedure is by far the preferred way to begin TTOT. It is the way most (but not all) hospitals are currently doing the procedure. It would be very unusual for a Pulmonologist to do the Fast Tract procedure as it is always done in the true operating room with an anesthesiologist in attendance. 99% of the Fast Tract procedures are done by an ENT surgeon. It is typically done with local anesthesia and conscious IV sedation (twilight sleep). By all our studies, and others as well, it is reasonable to expect your RESTING oxygen flow rate to drop about 50%. Your flow rate with increased activity will only be known after the catheter is in place and functioning optimally. It normally is reduced by about 30%. Virtually all TTO patients report that even though they may still get short of breath, they do recover quicker. You will “get your nose back” about 2 weeks after your procedure. It takes about that long for all the congestion to go away, and your nasal passages get back to their baseline configuration. You won’t have to worry so much about your tubing catching on everything, as the SCOOP oxygen tubing is designed to be worn under your upper body clothing.

In closing, please don’t misunderstand me, there is nothing wrong with doing the older outpatient Modified Seldinger approach to get you started on TTOT. There is just so much right with the Fast Tract. Ultimately, it is a decision that should be made between you and your pulmonologist. Having the right supportive personnel such as respiratory therapists, and nurses is also very important. I hope this helps. John R. Goodman
Not a Good Candidate?

Q. Who with emphysema and on 02 24/7, would NOT be good candidates for the TTO process? Warren

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A. There are only 4 absolute contraindications for SCOOP therapy that have been identified over the past 20 years. They are:
  1. Disabling anxiety. Patients who are so worried and anxious about the procedure and process that they are emotionally, mentally, and sometimes physically unable to properly maintain the catheter in good functioning order.
  2. Patients who have either one or both of their vocal cords dysfunctional. The problem here is an impaired ability to cough, which might become a problem with mucus management following the procedure.
  3. Significant anatomical deviation. This is rarely seen, but is easily ruled out by routine pre-procedure chest x–rays.
  4. Poor compliance with medical therapy. Patients who undergo this therapy must commit to following the pogrom as outlined by their physician.
Other issues such as lung function, blood gases, mucus problems, cough, cardiac problems, bleeding disorders, asthmatic components etc, are all managed on a case by case basis, and are more precautions than contraindications.

Our 20+ years of experience has held constant at about 80% of our patients presenting with the diagnosis of COPD. I hope this helps. Take care, John R. Goodman

Q. I recently had TTOT (8 weeks ago) and love it so far. My only problem is that I continue to cough up hard, black mucuos balls every time I clean. I change the catheter each morning and clean in place two more times a day. I sleep with a heated moisture machine and am taking Guaifenisen (600 mg) twice a day. I had four days last week without producing mucuos balls, but now — during the last 2 days — I am producing them again. Perhaps I am not fully healed yet, but would like any input you might have. My surgery was the overnight fast track system and I use the Scoop catheter. Larry CO

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A. Thanks for your e-mail, and I am glad you love your SCOOP. At 8 weeks, it is somewhat unusual to be coughing up hard, black mucus balls. I am glad you are already on a heated humidifier at night. Does it include a heated wire circuit? What temperature are you running the humidifier at? What is your oxygen liter flow at rest and with activity? What type of humidifier are you running during the day on your stationary oxygen unit?

What is your underlying lung pathology? Although we have tens of thousands of patients out there, I don’t know any two that clean their catheter EXACTLY the same way. Like water seeking it’s own level, most patients find the cleaning protocol that is best for them by trial and error over the first few weeks and months…just as you are doing.

I would recommend a couple of things. First, you should increase your Mucinex dosage to 1200mg, twice a day. If you underdose with your Mucinex, it is the same as not taking it. Number two, I would suggest that you increase your removal and reinsertion of the catheter to twice a day. You need to "strip" the catheter more frequently in order to "get ahead" of the mucus that is building up at the catheter tip. I would also continue with the cleaning in place regimen, but would also increase that to 4 times a day. I know this is a lot to ask of you, but it is only temporary. I’d suggest trying this new cleaning protocol for about 2 weeks, and then we can reevaluate. The black color can be due to almost anything from environmental factors to old blood that is still down there. This should begin clearing up as the days go by. Remember, if you’ve got a little Bronchitis or cold going on, your sputum production will necessarily increase as well. Finally, it is easy for all of us to get behind on our systemic hydration. Taking or drinking fluid is a big component of mucus management, as our mucus gets it water supply from the sub mucosal blood vessels that line the trachea. Normally mucus is 95% water, which is why it is normally thin, clear, and easy to cough up. Stay the course for now with the suggestions I have give, and I fell confident you’ll get through this episode. Take care, John R. Goodman
Age Limit for TTO

Q. Could you tell me what the cut off age is to have a TTOT. Thanks, Ione..WI

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A. This is a good question. The youngest SCOOP patient that I am personally aware of is 41 ½ years old. She came down to Denver from her home in Canada, and we very successfully placed a small (5cm) SCOOP catheter in her trachea. She has done very well for the past several years. With a little luck, her lungs will grow as she does, and the new functioning lung tissue will allow her to get off oxygen permanently. The oldest patient I am aware of is 94 years old, so you can see we have quite a range of ages. I can tell you that the average age of all of our patients for the past 20 years is 66.5 years old. Age, in and of itself, is not normally a contributing factor in the decision making process of patient selection. As Frank Sinatra sang, “Fairy tales can come true, it can happen to you, if your young at heart.”…Take care John

Q. I wonder if you could tell us what the name of the heated humidifier is that you are referring to. I’d like to talk to my O2 provider about one since I am so dry at night with my TTO. Sometimes when I wake up in the night, I can’t even swallow. ;o) Pat/MO

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A. I have had tremendous success with the Fisher–Paykel heated humidifier with heated wire circuit. I have used both the older model 730, and the newer model 850. Fisher–Paykel is a very good company with excellent clinical support provided both by the company, and their distributors. It is especially helpful when flow rates get up around 5–6 L/min at rest. Take care, John R. Goodman BS RRT
Using a Humidifier

Q. I have a DeVilliss Humidfier for night time. I haven’t used it since last year. If you get a chance would you please email me the reason for using the humidfier. You can email me private if that would be better, but I figured someone else might not know why, like me. I didn’t mention the itching to you when I talked to you, I thought I had taken enough of your time. I started to use water, and a Q–tip to clean at the opening, you’re right, the itching stopped. Thanks again for your help. Patricia

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A. The reason humidification is of paramount importance with SCOOP, is due to the fact that when you have a SCOOP catheter in your neck, you have bypassed the normal humidification process of the upper airway. Normally, when we breath in, the air is warmed (by the blood vessels in the nose), filtered (by the hairs in our nose) and humidified (by being exposed to the lining of the nose, mouth, and throat. By the time that "single: breath of air gets to the lungs it is already at body temperature (98.6 F, or 37C.) It is also 100 percent humidified at body temperature. These are the conditions necessary for all to go along well within the lungs.

Dropping in a SCOOP catheter bypasses all of the above, and so we have to artificially add back the humidity to compensate for it’s loss. We have never changed our policy towards humidification being absolutely necessary for all patients at all flow rates.

Patients who are approach 5–6 L/min might have special humidification requirements that would include heated humidification. This is due to the fact that heated water has a much higher capacity to carry water in molecular form, and therefore produce much higher relative humidity values than the standard bubble humidifiers. A stand bubble humidifier may at best provide from 25–40% RH on the best day of it’s life. And in any event, it is subject to environmental factors, and the total flow rate through the device.

Adequate humidification provides the ideal conditions in the lung for both mucus management, and mucus mobilization…both important considerations in oxygen dependent patients with COPD. I'll get off the soapbox now, but will be happy to answer any other questions regarding SCOOP. John R. Goodman BS, RRT
TTO and Flow Rate

Q. Why would it necessarily need to be someone with a high flow to get TTO? I use a fairly low flow when I am sitting but when I am moving around it has to be increased to probably 3.5. Now, I really don’t consider that to be a "high flow" but would still be interested in the TTO mainly to give my poor nose a rest.

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A. Ideally—according to the manufacturer—TTO should be considered when the amount of oxygen flow required exceeds 3 L/min AT REST. Folks with that sort of requirement, will usually have trouble saturating adequately with 6 L/min—the maximum flow of most all portable oxygen systems that are not “high–flow” systems. TTO is for the purpose of stretching the coverage of mid to high range flow needs. It is NOT intended to be for “cosmetic” purposes as a primary requirement. That cosmetically they are advantageous is a secondary and coincidental benefit, NEVER a primary objective! Make better sense now? Mark
Why Don’t More People Have It?

Q. If this procedure is so good, sounds great, why don’t more people have it?

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A. You ask a very valid question. My experience here in south Texas is that physicians are very poorly educated about TTO. Further, they are prejudiced without basis (IMHO), since their exposure and experience are so sorely lacking. I have queried M–A––Y about TTO and have received responses that, were they not so maddening, would be laughable. By far, the most frequent response I’ve received is that TTO causes over–secretion of mucus and has BIG problems with plugging. Therefore, it is dangerous for patients, as they might not get their oxygen delivery, yada, yada, yada. Of course, our few folks here on the list will dispell that fallacy. Also, it is next to impossible for the tube to plug up since air pressure would “blow” the plug out of the end, OR, the pop–off on the humidifier would sound, OR the tubings would blow apart because of the pressure build up, in the event that the plug didn’t blow loose. Another is that they are subject to frequent infections. Again, another fallacy. When I have asked those clinicians what/how many they’ve placed or dealt with I have been appalled with the fact that those who had the negative comments and attitudes about TTO had little or NO experience with it. Two of the loudest critics here in San Antonio, have never dealt directly with TTO.

On the other side of the coin, unfortunately, the Transtracheal folks have NOT had an “aggressive” approach to marketing TTO. Theirs is a difficult position in which to be. A lot of information gets disseminated through our professional seminars. Speakers are invited, or contracted, but rarely can walk in and say "I want to give a lecture". Many companies market and inform professionals about their products by soliciting small gourps of professionals and doing an inservice in their hospitals or clinics, with lunch or something similar, that costs lots and Transtracheal hasn’t spent the money to cover that kind of ground. Further, to be effective at marketing, you must have speakers/sales reps who are dynamic and have some degree of charisma in addition to proper knowledge of the product and process. I have heard several presentations over the years by folks from Transtracheal, and frankly, I’ve had difficulty staying awake and focused. Of perhaps ten speakers over the years, one has been able to capture audience attention. So, the technique has gone poorly promoted for a lot of years — — — at least in my neck of the woods.

Nevertheless, I opine that TTO has a very valid place and offers advantages not achievable through other means. So, I continue to push the concept — — — in those patients who use more than 3 liters/min. most of the time — — — hoping that some day, a few patients will have been insistent and provided the experience for their doctors to be able to (or should I say, HAVE TO) deal with it first hand — — — so that they can see that their fears and dislikes were, for the most part erroneous and ill–spent. I can only hope! Regards, Mark
Pulse Portable with TTO?

Q. Another question…with TTO, a pulse portable won’t work so what do you use? Sure wouldn’t want to go back to those big, ole tanks. Pat/MO

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A. Pat, There are several smaller portable options with TTO. First, with TTO, your O2 flow needs are usually quite a bit lower, so it is like a conserving device. Caire makes the Sprint, which is about 6 lbs full, and holds about 500 liters (4 hrs at 2 lpm, 8hrs at 1). Any of the smaller (M6, M9) cylinders might work ok also.

Pulse type (single lumen) conservers should also work. The only one I’ve tested with TTO is Spirit, but others (Escort, DeVilbiss, Chad) may work. Dual lumen (Helios, CR–50 etc) won’t work. Peter B
Are You Limited to Continuous Flow with TTO?

Q. Peter, happen to read your post and was surprised that you say a person isn’t limited to continuous oxygen flow with the Transtracheal. Am I missing something? I talked to my oxygen supplier and pulm doctor and they say as far as they know nothing new has came out and I must stay on continuous. Do you have the TTO? If so are you using pulse flow? Interesting. Louise, Idaho

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A. There is nothing that precludes using TTO with a pulsed conserver. Each model may respond a bit differently, because the breathing “signal” it gets is much stronger than from a cannula. Several clinical studies have been done over the years with TTO and different pulse type systems. As Tom mentioned, TTO itself is a conserving system, the continuous flows you need are usually lower (about half). This means that the relative gain you get with a pulse conserving device is less than with a cannula. Say your needs with a cannula and continuous flow are 3 lpm when you’re walking. You want to use M6 (B) cylinders which are light (maybe 5–6 lbs with everything) Continuous flow +Cannula@ 3 lpm = <1 hour If you use a conserving device, you will extend that to approx 3 hours. If you use TTO, your flow rate might drop to 1.5, so the cylinder would last around 2 hours. If you use TTO AND the conserving device, you still get about 3 hours. As for the comfort or lack thereof from having the burst of O2 hit your trachea, that’s going to be a very personal thing. Might bother some and not others. Should be easy to try, as most O2 suppliers have some conserving devices in service. Ask to try one out. Make sure your sats are monitored to get the best settings during different activity levels. Peter B. PS — Louise, no, I’m not on TTO. I’m an engineer that works with O2 systems.
Advantages and Disadvantages

Q. I have seen a couple of you refer to using the TTO and would like to hear of any disadvantages you’ve experienced. I am seriously considering it for a number of reasons: mouth breathing at night, constant (it seems) nasal congestion, and trouble keeping my sats up if doing anything other than sitting or reclining (even at 4–5). In addition, I’m still working and it’s difficult to attend meetings with the irritating puff–puff–puff of my o–demand portable or to give training classes with tubing hanging off my face. My pulmo says I may be close to requiring the TTO instead of conventional delivery anyway. So if you have any encouragement or discouragement, please let me know what your experience has been like. Also, I can’t seem to get an answer to the question of whether or not it works with the on–demand or impulse systems versus continuous flow. Thanks! Barbara CO

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A. Joyce, Two things. 1. You are not limited to continuous flow oxygen. Many single lumen cannula conservers will work fine with TTO. Dual lumen models like Helios and CR–50 will not, however. 2. TTO is in itself an oxygen conserving device, because much of the gas that would otherwise be wasted when you exhale is pooled in your trachea, so you get it back when you inhale. This means that a lower continuous flow often works (maybe half what you used with a cannula). Peter Bliss
Itching at Trach Site

Q. Does anyone who has a TTO have a problem with the opening of the trach, itching and being very dry? I do, it’s driving me more crazy ,then I am. If so, what do you use or do for it? You can’t put any cream or lotion at that spot, can you? Thanks, Patricia

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A. Generally speaking, I do not recommend that any "lotions, potions, or notions" be put around the tract site. It is very easy to kill all the normal bacteria that normally reside in the area and allow ripe conditions for a superimposed fungal infection. I spoke to Patricia earlier today, but she didn’t mention her itching problem to me. It is quite unusual for a patient to report this problem. I have seen it occasionally in patients who "overkill" their cleaning by using peroxide to clean around the tract. This will cause the skin around the tract to tighten up a bit. It will become quite dry, red in appearance, and itch to boot. I continue to recommend nothing but water and a Q–tip. If you feel better using distilled or sterile water…be my guest. Keeping the area around the tract site clean and dry is most important during the first few months following the procedure. In due time the tract will “snug down” around the catheter and be no different than a pierced ear. Hope this helps Patricia and other patients who may be experiencing the same problem. John R. Goodman BS RRT
Liquid vsPortable Oxygen

Q. Do you like the liquid better than the M6? What kind of portable are you using? My suppliers haven’t had any luck finding a 550 and the 1000’s are so heavy. How long did the M6 last you? Pat/MO

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A. In theory, any single lumen cannula OCD should work with TTO, but theory is only that. Unfortunately, there is no published data on this. The people at Transtracheal have experience, and I would ask them.

Possibilities working with cylinders include:
  • Chad Oxymatic series
  • DeVilbiss PD1000, PD4000
  • AirSep Impulse Elite
With liquid, the Escort and Spirit should work well. I know the Spirit is in use by TTO patients with good results. Don’t know about Escort for sure. Experience shows that TTO is itself a good conserver of oxygen. Most patients seem to need about half the continuous flow rate, because your airway acts as a nice reservoir, storing up oxygen late in exhalation. But, a good conserver such as those listed above should do a bit better. For instance (completely hypothetical here), an M6 tank on 3 lpm continuous flow will last about 1 hour. With TTO, you may be able to use 1.5 lpm, and it would last you 2 hours. With an OCD, you may need about 40 mL/breath, and at 20 breaths per minute, the cylinder would last 3 hours. If you can’t find a 550, you might ask for a Caire Sprint. Same size, (continuous flow only) about 4 hours at 2 lpm continuous, 6 lbs. Works nicely for TTO patients on lower flows. Peter B