Full text of DOI:10.1007/BF03020385

NEUROANESTHESIA AND INTENSIVE CARE
1161
Translaryngeal open ventilation to treat acute
respiratory failure in acute exacerbation of chronic
obstructive pulmonary disease. A preliminary report
[La ventilation ouverte, translaryngée, pour traiter l’insuffisance respiratoire aiguë
d’une maladie pulmonaire obstructive chronique : un compte rendu préliminaire]
Yoanna Skrobik MD FRCPC,* Cesare Gregoretti MD†
Purpose: To describe a minimally invasive alternative to conven-
tional mechanical ventilation, using a small size uncuffed nasotra-
cheal tube (translaryngeal open ventilation) paired with pressure
control ventilation, in acute respiratory failure complicating chronic
obstructive pulmonary disease (COPD).
Objectif : Décrire une variante, avec effraction minimale, de la ven-
tilation mécanique traditionnelle qui utilise un petit tube nasotrachéal
sans ballonnet (ventilation ouverte translaryngée) jumelé à la ventila-
tion limitée par la pression, dans un cas d’insuffisance respiratoire
aiguë compliquant une maladie pulmonaire obstructive chronique
(MPOC).
Clinical features: Two cooperative COPD patients, who failed
noninvasive mechanical ventilation, were intubated nasotracheally.
Mechanical ventilation was initiated in pressure control mode via an
uncuffed 6 mm tube.
Éléments cliniques : Deux patients souffrant de MPOC, chez qui
la ventilation mécanique non effractive avait échoué, ont subi une
intubation nasotrachéale. La ventilation mécanique a été amorcée en
mode limité par la pression au moyen d’un tube de 6 mm sans bal-
lonnet.
Results: Respiratory rate improved after 1 hour (from 44 to 28
–1
–1
breaths·min in case 1 and from 32 to 25 breaths·min in case 2);
PaC02 decreased (from 120 to 62 mmHg in case 1 and from 69 to
51 mmHg in case 2); with pressure control mode levels of 45 cm
H2O and 55 cm H2O respectively. PaO2 increased from 40 mmHg
(with FIO2 0.3) to 55 mmHg (with FIO2 0.3) in the first patient and
from 55 mmHg (with FIO2 0.4) to 60 mmHg (with F IO2 0.4 ) in the
second patient; pH improved from 7.18 to 7.31 in case 1 and from
7.22 to 7.39 in case 2. Patients were able to trigger the ventilator,
speak, swallow and to clear secretions spontaneously. Both patients
were ventilated for three days in this manner without any adverse
effects. Both survived and were discharged home after 20 and 18
days in hospital respectively.
Résultats : La fréquence respiratoire s’est améliorée après une heure
(de 44 à 28 respirations·min–1 dans le premier cas et de 32 à 25 res-
pirations·min–1 dans le cas 2) ; la PaC02 a diminué (de 120 à 62
mmHg dans le cas 1 et de 69 à 51 mmHg dans le cas 2) ; en mode
limité par la pression, les niveaux ont été de 45 cm H2O et 55 cm
H2O respectivement. La PaO2 a augmenté, passant de 40 mmHg
(avec FIO2 0,3) à 55 mmHg (avec FIO2 0,3) chez le premier patient
et de 55 mmHg (avec FIO2 0,4) à 60 mmHg (avec FIO2 0,4 ) chez
le second ; le pH s’est amélioré de 7,18 à 7,31 dans le premier cas
et de 7,22 à 7,39 dans le second. Les patients pouvaient déclencher
le ventilateur, parler, avaler et expectorer spontanément. La ventila-
tion s’est poursuivie ainsi pendant trois jours sans effets secondaires
pour les deux patients. Ces derniers ont survécu et ont quitté l’hôpital
après 20 et 18 jours respectivement.
Conclusion: This very preliminary report suggests that, in careful-
ly selected patients who fail mask ventilation, mechanical support
with translaryngeal open ventilation can improve gas exchange,
breathing pattern and tachypnea, without hindering glottic function.
Conclusion : Ce compte rendu très préliminaire signale que, chez
des patients attentivement sélectionnés ne pouvant recevoir une ven-
tilation au masque, l’assistance mécanique avec la ventilation ouverte
translaryngée peut améliorer l’échange gazeux, le mode de respiration
et la tachypnée, sans gêner la fonction glottique.
Form the Critical Care Division,* Maisonneuve Rosemont Hospital, Montréal, Québec Canada; and the Intensive Care Unit,† CTO,CRF,
ICORMA, Torino, Italy.
Address correspondence to: Dr. Yoanna Skrobik, Critical Care Division, Hôpital Maisonneuve-Rosemont, 5415, boul. de l’Assomption,
Montréal, Québec H1T 2M4, Canada. Phone: 514-252-3400; Fax: 514-252-3806; E-mail: skrobiky@total.net
Accepted for publication June 5, 2001.
Revision accepted September 10, 2001.
This article is accompanied by additional audiovisual material that can be consulted at www.cja-jca.org
CAN J ANESTH 2001 / 48: 11 / pp 1161–1164

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CANADIANJOURNAL OF ANESTHESIA
ENTILATORY support in respiratory fail-
ure using facial or nasal masks offers many
advantages.1 Clinical reports including
multicentre, randomized controlled trials
hyperinflation and diffuse inspiratory and expiratory
wheezing with a prolonged expiratory phase. Chest x-
ray showed no infiltrates; electrocardiogram was
unchanged from his baseline (right atrial hypertrophy
and right axis deviation) except for sinus tachycardia.
His arterial blood gas analysis on admission (with
nasal cannulae delivering 6 L of oxygen a minute)
V
indicate that noninvasive ventilation can decrease ven-
tilator days, length of the intensive care unit (ICU)
stay and the incidence of ventilator associated pneu-
monia.1–3 The reasons for this remain to be fully elu-
cidated. Proposed explanations include preservation
of glottic function, the elimination of accumulated
secretions above the endotracheal tube cuff,4 and
improved patient comfort with a decrease in the
amount of sedation required. Mechanical ventilation
with endotracheal intubation remains, however, the
standard of care in patients with severe acute respira-
tory insufficiency, particularly those who have failed4
or are considered ineligible for mask ventilation.
Recent publications5,6 also suggest that mask ventila-
tion may not be safe for all patients.
Transtracheal open ventilation has recently been
described in COPD.7–9 Patients with acute respiratory
failure who failed mask ventilation were randomized
to either conventional mechanical ventilation through
a cuffed orotracheal tube, or transtracheal open venti-
lation, defined as ventilatory support through an
uncuffed mini-tracheostomy tube. Mechanical ventila-
tion was delivered using a pressure control mode.
Patients with transtracheal open ventilation main-
tained glottic function and were able to swallow, eat,
and speak. They required far less sedation and had a
dramatically decreased incidence of ventilator associat-
ed pneumonia.8
showed a pH of 7.23, PaCO of 95 mmHg, HCO of
3
34, PaO 48 mmHg. Face ma2sk ventilation was attempt-
2
ed but was not tolerated by the patient despite reassur-
ance. With mild sedation (propofol infusion at 0.8
mg·kg– 1·hr– 1 ) his PaCO rose to 120 mmHg, Pa02
2
dropped to 40 and he became more acidemic (pH 7.18).
The patient was still able to communicate and
expressed anxiety at being unable to speak with an
endotracheal tube in place. He accepted a trial with a
small uncuffed endotracheal tube with the under-
standing that the treatment was experimental, might
not work and require subsequent conventional endo-
tracheal intubation with a full sized cuffed tube.
A 6-mm ID (Mallinckrodt Co) orotracheal 280-
mm long tube was inserted into the patient’s nose and
advanced blindly into the trachea after topical anes-
thesia. The cuff was inflated briefly to measure intrin-
sic positive end expiratory pressure (PEEP) while
initiating mechanical ventilation in assisted pressure
control mode with a standard ICU ventilator (Servo
300, Siemens Elema, Uppsala, Sweden). Static intrin-
sic PEEP was obtained with the patient as relaxed as
possible. PEEP was set at 80% of the intrinsic PEEP (8
cm H2O).10 The cuff was then deflated and expiratory
volume measured via the ventilator. The inspiratory
pressure was set between 45 and 55 cm of H2O to
ensure expiratory volumes in the 250–300 mL range.
The respiratory rate was set at 20 breaths·min–1 and
the inspiratory time set to maximize patient comfort
at 0.8 sec. The patient was able to trigger the ventila-
tor with spontaneous breaths when the flow trigger
was set to the 0.5 L·sec–1 cm H20 range, with no auto-
cycling. Gas exchange improved after one hour, with
PaO2 levels stabilizing between 55 and 68 mmHg
with 30% FIO2, and PaCO decreasing to values rang-
ing from 62 to 67 mmHg. 2pH rose from 7.18 to 7.31.
The patient was ventilated in this manner, with daily
adjustments for his PEEP to match his auto-peep
level, for 72 hr. He was able to speak in brief sentences
and was able to swallow well enough to allow for oral
feeding (see audiovisual supplement at www.cja-
jca.org). The attending physician adjusted his therapy,
which included antibiotics, corticosteroids, and
inhaled bronchodilators. The only sedation required
was a small dose of benzodiazepine at night. He was
evaluated daily for clinical evidence of sinusitis, which
Performing a mini-tracheotomy is invasive and
requires specific expertise. We hypothesized that
attempting mechanical ventilation through a small size
naso-tracheal tube used with a deflated cuff (“transla-
ryngeal open ventilation”) in COPD patients could
provide adequate ventilatory support and be of bene-
fit in terms of comfort and preserved glottic function.
We wish to describe our initial experience with this
technique.
Clinical features
Case 1
The first patient, a 68-yr-old male with severe COPD
(FEV1 of 0.4 L) on home oxygen therapy was admit-
ted to hospital with acute hypercapnic respiratory fail-
ure. He complained of symptoms of upper respiratory
infection and worsening dyspnea. On admission his
heart rate was 123 beats·min–1, his blood pressure was
140/80 mmHg with a pulsus paradoxus of 25
mmHg. He had a respiratory rate of 44 breaths·min– 1.
He was afebrile. His physical examination showed

Skrobik et al.: TRANSLARYNGEAL O P E N VENTILATION
1163
did not occur. PaCO2 slowly returned to his baseline
level of 55 mmHg, and he was extubated on the third
day. Over the next 48 hr he required intermittent face
mask ventilation, and was then discharged to the ward
and home after 20 days in the hospital. He requested
that he never be subjected to standard orotracheal
intubation again, having found this mode of ventila-
tion much more comfortable.
costeroids and inhaled bronchodilators. The patient
required only a small dose of haloperidol for sedation.
He was evaluated daily for clinical evidence of sinusitis.
He was extubated successfully after 80 hr. After extuba-
tion 24-hr nose mask ventilation was maintained for
two days. Subsequently, only nocturnal nasal ventilation
was required and he could be weaned from mechanical
ventilation nine days after hospital admission.
Case 2
Discussion
A (70-yr-old) severe COPD patients (FEV1 of 0.45 L)
on home oxygen therapy was admitted to hospital
with acute hypercapnic respiratory failure and symp-
toms of recent viral illness. His vital signs showed a
heart rate of 112 beats·min– 1, arterial blood pressure
of 160/90 mmHg, and a respiratory rate of 38
breaths·min– 1. He was afebrile. His blood gases on
admission on 2 L of oxygen via nasal cannulae
In these case reports translaryngeal open ventila-
tion improved gas exchange in awake COPD patients
with acute respiratory failure. The patients described
were offered an experimental treatment in the context
of lack of improvement with mask ventilation, immi-
nent respiratory failure, and their refusal of conven-
tional intubation. The patients’ level of consciousness,
preserved glottic function, and lack of vomiting or
gastric distension suggested it was safe to initiate
translaryngeal open ventilation.
Noninvasive ventilation is usually carried out in pres-
sure pre-set modes. Assisted pressure control ventilation
was chosen rather than pressure support ventilation10 to
avoid patient-ventilator dys-synchrony, because of the
patient’s inability to reach the flow threshold value due
to air leaks.1 1Proximal airway pressure was high during
inspiration. Previous studies have shown that distal air-
way pressure does not rise, because of high endotra-
cheal tube resistance.12–16 During expiration high tube
resistance may be of concern; here expiration occurred
partly through the native airway, decreasing the resis-
tance caused by the tube, ventilator expiratory valve and
circuit.1 7 With translaryngeal open ventilation PEEP
could be applied to decrease the work of breathing or
improve triggering.1 8
The patients tolerated the technique well. The
uncuffed 6-mm ID tube interfered little with speech.
Glottic function also seemed preserved clinically.
Patients could ingest food and liquid. We did not
observe any evidence of aspiration. The patients were
able to cough and clear secretions. Endoscopic or
radiologic investigations were not performed to vali-
date objectively our clinical observations. “Silent”
aspiration, although unlikely given the patients’ clini-
cal behaviour and course, could not be excluded.
The objective of the present report was to present
the feasibility of improving gas exchange with transla-
ryngeal open ventilation in conscious patients with
acute decompensation of chronic respiratory disease.
The technique, described in only two COPD patients,
might not be applicable to patients with other clinical
presentations, such as acute lung injury. Our clinical
observations with regard to the preservation of glottic
revealed a pH of 7.32 PaCO of 60 mmHg, HCO of
3
31 and paO2 48 mmHg. Fa2ce mask ventilation (PSV
20 cm H20, PEEP 4 cm H20) was initiated. Blood
gases did not improve after one hour due to mask
intolerance (pH 7.33 PaC02 59 mmHg Pa02 50
mmHg), with O at 4 L delivered via nasal prongs.
2
Nose mask ventilation also failed. His blood gases
deteriorated further (pH 7.22, PaC02 69 mmHg Pa02
55 mmHg) with O delivered at 40% via a face mask
for two hours. The 2patient was still able to communi-
cate and refused to be intubated. He accepted a trial
with a small endotracheal tube with the understanding
the treatment was experimental .
A 6-mm ID (Rusch, Germany), 380 mm long tube
was inserted, after topical anesthesia, into the patient’s
right nostril and advanced blindly into the trachea.
The cuff was left deflated. The extrinsic PEEP was set
at 4 cm H2O without self-triggering. The pressure
trigger sensitivity was set at 0.5 cm H20. The patient
was ventilated with a Siemens 300 ventilator (Siemens
Elema, Uppsala, Sweden) in the assisted pressure con-
trol mode at a rate of 15 breaths·min–1. The inspirato-
ry pressure was set at 55 cm H O with an inspiratory
2
time of one second to ensure expiratory volumes mea-
sured by the ventilator in the 250–300 mL range.
Blood gases showed a marked improvement (pH
7.39, PaC02 51 mmHg P02 60 mmHg on FI02 0.4)
after one hour. Respiratory rate decreased from 32 to
25 breaths·min– 1.
Within 24 hr PaC02 dropped to 45 mmHg with a
pH of 7.44; Pa02 rose to 70 with the same FI02. Glottic
function was not impaired (clinically) allowing the
patient to speak and swallow well enough to allow for
oral feeding as in the patient described above.
Therapeutic interventions included antibiotics, corti-

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CANADIANJOURNAL OF ANESTHESIA
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function, patient comfort and ability to communicate
suggest there may be advantages to this technique.
The benefits may parallel those observed in mask ven-
tilated patients.
Conclusion
In summary, we describe two cases of translaryngeal
open ventilation with pressure control mode for the
treatment of respiratory failure in patients with
COPD. While very preliminary, our observations sug-
gest that this approach is well tolerated by patients and
may preserve glottic function. Further evaluation of
this approach is required.
16 van Lunteren E, Van de Graaff WB, Parker DM, et al.
Nasal and laryngeal reflex responses to negative upper
airway pressure. J Appl Physiol 1994; 56: 746–75.
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on inspiratory work of breathing. Chest 1988; 93:
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18 Petrof BJ, Legare M, Goldberg P, Milic-Emili J,
Gottfried SB. Continuous positive airway pressure
reduces work of breathing and dyspnea during weaning
from mechanical ventilation in severe chronic obstruc-
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