Transtracheal puncture: a forgotten procedure

Abstract

Transtracheal puncture has long been known as a safe, low-cost procedure. However, with the advent of bronchoscopy, it has largely been forgotten. Two researchers have suggested the use of α-amylase activity to diagnose salivary aspiration, but the normal values of this enzyme in tracheobronchial secretions are unknown. We aimed to define the normal values of α-amylase activity in tracheobronchial secretions and verify the rate of major complications of transtracheal puncture. From October 2009 to June 2011, we prospectively evaluated 118 patients without clinical or radiological signs of salivary aspiration who underwent transtracheal puncture before bronchoscopy. The patients were sedated with a solution of lidocaine and diazepam until they reached a Ramsay sedation score of 2 or 3. We then cleaned the cervical region and anesthetized the superficial planes with lidocaine. Next, we injected 10 mL of 2% lidocaine into the tracheobronchial tree. Finally, we injected 10 mL of normal saline into the tracheobronchial tree and immediately aspirated the saline with maximum vacuum pressure to collect samples for measurement of the α-amylase level. The α-amylase level mean ± SE, median, and range were 1914 ± 240, 1056, and 24-10,000 IU/L, respectively. No major complications (peripheral desaturation, subcutaneous emphysema, cardiac arrhythmia, or hemoptysis) occurred among 118 patients who underwent this procedure. Transtracheal aspiration is a safe, low-cost procedure. We herein define for the first time the normal α-amylase levels in the tracheobronchial secretions of humans.

Activity of Alpha Amylase in Tracheobronchial Secretions of Patients without Morbid Salivary Aspiration

“…His group considered these values as the normal levels of this enzyme in normal human beings. We disagree with that conclusion because it has long being demonstrated that normal people microaspirate saliva [7][8][9][10][11][12][13]. This is the main reason of our work, to define the normal levels of this enzyme in tracheobronchial secretions of people with very low possibility of morbid aspiration, based on known risk factors.…”

“…Therefore, evaluating patients without the signs of morbid aspiration to obtain normal values of α-amylase in the lungs needs to be performed. This is important because α-amylase could be a useful tool in the diagnosis of morbid aspiration [7][8][9][10][11][12][13]. The gold standard for diagnosis aspirations are videofluoroscopy and videoendoscopy [10].…”

“…Videofluoroscopy is only useful in patients with some degree of cognition to obey the order made by the speech therapy specialist for treating oropharyngeal dysphagia. Videoendoscopy has advantages and disadvantages in comparison with videofluoroscopy [10]; for example, videoendoscopy does not evaluate the oral phase of dysphagia, and, akin to videofluoroscopy, is not worldwide economically viable.Transtracheal aspiration or puncture (TTA, TTP) has been used widely because of the original publication, although it is not an ideal procedure because transfixing the anterior wall of the trachea, as in the original method carries major risk of haemorragic complications [7][8][9][10][11][12][13]. The recommended name for this technique would be, "transcricothyroid membranes puncture" owing the fact it is an avascularity structure and with less chance of thyroid gland penetration, therefore with less chance of bleeding [11][12][13].…”

“…This technique of anesthesia eliminates the cough reflex and leaves no free lidocaine in the major airways. The transtracheal puncture was then performed using an intravenous catheter passing into a 14G needle (BioCat R -são Paulo-Brazil) [7][8][9][10][11][12][13]. After the puncture, the needle was positioned about 45°in the cranial-caudal direction.…”

A Resuscitation Option for Upper Airway Occlusion Based on Bolus Transtracheal Lung Inflation

“…Transtracheal insufflation and jet ventilation are related options for introducing oxygen to stabilize an oxygen supply in a variety of settings, including emergencies, intensive care, and surgeries where airway management is or becomes problematic (see also other variants reviewed elsewhere.…”