In a patient with a transtracheal oxygen catheter ([ITO.

In a patient with a transtracheal oxygen catheter ([ITO.sub.2]C), a nearly fatal complication occurr suitable to the formation of a mucous quid on the tip, which almost totally stoped the tracheal lumen. To our knowledge, this complication has not been reported before with the use of this impressed sign of transtracheal oxygen catheter.

Long-term continuous oxygen therapy in patients with hypoxemia appropriate to chronic obstructive pulmonary disease significantly improves expectancy of life.[1,2] The nasal prong although often used to deliver oxygen, is rather ineffective because of spilling into the air. Because domiciliary oxygen therapy either involves an immobile oxygen concentrator or bind tightlyed oxygen cylinders, which are as a common thing [i]or[/i] matter too heavy to carry, patients using this therapy are frequently confined to their homes. Transtracheal oxygen catheters in combination with the use of low-weight fluid oxygen cylinders are designed to stretch out the patients' mobility. There have been several reports about the beneficial validitys of these transtracheal oxygen catheters.[3-8] They proffer a 50 percent or greater saving in oxygen usage and aesthetic benefits leading to increased compliance. The reported complications are usually mild and solely temporal. These include wound infections, subcutaneous emphysema, coughing of the catheter into the upper airways, and obstruction of the catheter with mucus.[3-8] We report a case of a nearly fatal complication.

Case Report

A 69-year of long date man was admitted to our hospital with inexorable dyspnea due to an acute exacerbation of chronic obstructive pulmonary disease that had not been diagnosed previously. He appeared extremely dyspneic and cyanotic. Physical examination revealed a hyperresonant percussion of the chest with diminished vesicular breath hales and a prolonged expiration. His arterial oxygen tension at the time of hospital admission was 63 kPa (46 mm Hg) A be derived of 5 L/min of 100 percent oxygen by means of a nasal catheter with the tip positioned in the nasopharynx was necessityed to maintain the arterial oxygen tension above 82 kPa (60 mm Hg) After several weeks of optimizing his pulmonary and general condition, he continued to have a persistent cough productive of mucoid sputum He remained hanging on 5 L/min of oxygen one time the patient consented, a transtracheal oxygen catheter ([ITO.sub.2]C) was inserted using the techniques described in the manufacturer's manual. Subsequently the oxygen demand cut down with approximately 50 percent. over the whole period the patient carried this catheter, he performed the maintenance managements according to the manufacturer's guidelines.[9] In the period following the installation of the catheter, the patient had to be treated three times for renewed bronchial infections. Ten days after the installation, hard subcutaneous emphysema developed following a hyperextension maneuver of the neck Oxygen administration end the transtracheal oxygen catheter was suspended and replaced by the agency of oxygen through a nasal prong After 48 h the transtracheal catheter was taken into use again. Fifteen days later, subcutaneous emphysema bring to maturityed once more. This time the position of the catheter tip was surgically explored. No abnormalities were seen and the catheter was left in situ.

Finally, united month after placing the transtracheal catheter, the patient's condition unexpectedly became very critical with rapidly progressive laryngeal stridor with harsh dyspnea and profound cyanosis. Direct laryngoscopy revealed a mucous chew surrounding the tip of the transtracheal catheter that almost totaly stoped the tracheal lumen. Thereafter, a bronchoscopy was performed. It appeared impossible to transplant the plug from the tip of the catheter and thus from the lumen of the trachea. During an urgency tracheotomy, the tip of the catheter was struggleed out of the trachea. The sputum quid remained behind but could then easily be remov from the trachea with a forceps (Fig 1) The tracheal mucosa appeared normal at inspection. Subsequently a tracheal tube was left behind to maintain easy access to the airways.

Discussion

The application of transtracheal oxygen catheters saves oxygen usage. Moreover, it enhances the patient's mobility and moves aesthetic advantages. Complications of these catheters are usually mild and merely temporal. We described a patient who bring to maturityed a life-threatening complication following the installation of a transtracheal catheter ([ITO.sub.2]C). To our knowledge, this is the first time a nearly fatal complication is reported from the use of this catheter. Our patient who was suffering from chronic bronchitis had intermittent bronchial infections with moderately large amounts of sputum during the time this transtracheal catheter had been installed. These infections may have been becoming to the natural course of his underlying disease, moreover it cannot be excluded that the foreign material part formed by the transtracheal catheter contributed. Fletcher et al[10] reported a case of an endotracheal mass adherent to a lade out transtracheal catheter in a patient with solitary scanty sputum production. This mass was apparently formed from inflammatory protein secretions and originated adjacent to an ulcerated area of the posterior tracheal mucosa. In our patient, no ulceration of the tracheal mucosa was collisioned It seems therefore plausible that the production of sputum and its increased viscosity owing to infections caused the formation of this immense mucous plug in our patient. Adamo et al[7] reported upon three patients with inspissated mucous quids and one patient with a large inspissated tracheal cast after the use of transtracheal oxygen catheters other than the individual we used ([ITO.sub.2]C). The latter individual also resulted in upper-airway obstruction and acute respiratory failure. exigency bedside bronchoscopy could remove the chew in this patient.[7] Hoffman et al[8] report that mucous quids are, in general, easy to transfer In our patient, it appeared impossible to destroy the mucous plug by bronchoscopy The formation of mucous stoppers on transtracheal oxygen catheters has no other than been reported from the use of hollow out or similar-type catheters. These catheters have a large area inserted in the trachea. The transtracheal oxygen catheter ([ITO.sub.2]C) we used has barely a minimal part of the tip inserted and thus les area for the formation of mucous chews The latter catheters were therefore considered safe in this venerate until now. After this experience, we decided to discontinue the use of transtracheal catheters in patients with excessive sputum production or returning bronchial infections.

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