Tracheal gas insufflation for refractory hypercapnia

A 65 year male patient got admitted to ICU after alleged intake of ~ 250 ml of Chlorpyrifos (Organophosphate insecticides which cause cholinergic toxidrome) and cypermethrin (Synthetic pyrethroid) and presented with cholinergic toxidrome with severe hypercapnia (supercarbia). All conventional and advanced modes of ventilation failed to ventilate the patient because of severe bronchospasm and a prolonged expiratory time constant with high airway pressures and high auto-peep. As a last resort, we resorted to unconventional modes, as the patient could not afford ECMO. Tracheal gas insufflation was done using a coaxial flow of humidified oxygen at 8 lpm with a suction catheter and ventilator parameter were adjusted to match the added gas flows. Tracheal gas insufflation can be delivered by a thin catheter placed through the endotracheal tube (terminating within 1 to 2 cm of the main carina) or via a modified endotracheal tube with channels embedded in the walls of the tube. Tracheal gas insufflation flow can be forward (toward the alveoli) or reversed in direction toward the proximal end of the endotracheal tube. Keywords: TGI, Hypercapnia, organophosphate toxicity