The SCOOP Program is composed of four clinically defined phases of care:

A specific goal in phase I is to define specific benefits that may be of value to the potential candidate. The potential benefits have been discussed. An additional important goal is to exclude individuals for whom TTO is contraindicated. The third task is to appropriately prepare the patient for the procedure while minimizing risk of complications.

The major goals of phase II are to create a quality tracheocutaneous tract and maintain stabilization of the patient. Phase III is focused on a smooth transition to a fully healed, mature tracheocutaneous fistula. The goal in phase IV is to ensure proficiency in catheter and tract self-care with ongoing collaborative care with the physician. The individual phases are the subject of greater discussion in this chapter.

A care team including the interventional pulmonologist as the team leader as well as trained respiratory therapists and nurses administers the TTO program. The surgeon is a key member of the team when the surgical method of tract creation is selected.

Both the MST and surgical technique developed by otolaryngologist Alan Lipkin, MD (Lipkin procedure) utilize the four phases of the SCOOP Program. Publications for further information regarding both insertion procedures and companion program modifications can be found in the “Suggested Reading” section. Phases I and IV are nearly identical for the two methods, but phases II and III differ based upon the requirements of the methods of creation of the tracheocutaneous fistula.

Though the short-term procedure-specific stents utilized in phase II differ in design, the long-term transtracheal oxygen catheter used in both phases III and IV is identical for both insertion techniques. Complications encountered with the two procedures will be presented. For the variety of reasons identified in this chapter, the author concludes that the Lipkin surgical approach is the method of choice.

The Kampelmacher study is representative of the complications encountered with MST. Results of this large series are illustrated in Table 68.2. An initial experience with 10 patients was compared to subsequent care with the next 65 subjects. Complications were minor. There was a substantial overall reduction in percent complications as the investigators gained experience. Subcutaneous emphysema (3%) was the only complication during the procedure and stent week (phase II). In general, during the immature and mature tract periods (phases III and IV), complications were reduced in frequency of occurrence with experience. However, assuming no patient had more than one event, the prevalence of complications was 34%. The most prevalent complications were keloids (11%), chondritis (3%), inadvertent ­dislodgement of the catheter with successful reinsertion by clinical staff (9%), and lost tracts that were not recovered (2%). In the 64 patients, they accounted for a complication incidence of 25% and comprised 74% of the total complications. In another two series, catheter dislodgement occurred more frequently at 38% and 44%, respectively. These issues were likely precipitated by inflammation of exposed cartilage during the MST procedure.

A minor complication not identified in the Kampelmacher study was the formation of symptomatic mucus balls, which are accumulations of inspissated mucus on the outer aspect of the catheter tip. They generally occur during the 6–8 weeks when the tract is immature (phase III) during which time the patient cannot routinely remove the catheter for cleaning. Mucus balls cause cough and dyspnea, which resolve when the mucus is removed by the clinician. Reported incidence in three series was 14%, 25%, and 38%. As with any technology, outcomes can vary substantially among caregivers. A variety of factors such as team experience, modifications in the program of care, and the characteristics of the patients selected can all play a role.

Fatalities with the MST have been reported over the past 24 years. There have been rare case reports of one death and five life-threatening events due to airway obstruction from mucus balls. In addition, there has been one case report of death due to tracheal perforation and one report of death due to catheter misplacement.

The surgical technique was initially designed for tract revision in the occasional patient with chronic problems encountered with the MST such as lost tracts, keloids, chondritis, and mucus balls. Kampelmacher utilized the Lipkin procedure to manage another set of 12 individuals from a patient base of an unspecified size with chronic tract problems related to the MST. These included major keloids (6), unrecovered tract closure (3), excessively prolonged tract maturation (1), tracheal chrondritis (1), and mispositioned supracricoidal tract (1). In addition, Kampelmacher selected the Lipkin surgical approach as the initial procedure in two patients with difficult anatomy due to obese neck and one individual with an ossified trachea. Of the 15, one patient had postoperative bleeding. Three had minor keloids excised, and all were doing well at 9 months follow-up.

Lipkin reported complications encountered in 33 consecutive patients who underwent the surgical technique as the initial procedure as compared to 64 consecutive individuals managed using the MST that were followed for a similar period. Chondritis occurred in 12% relative to 25% in MST cohort, and the incidence of symptomatic mucus balls was 15% compared to 44%, respectively. Of note, keloids, temporarily dislodged catheters, and lost tracts were not encountered, compared to 2%, 41%, and 14% in the MST group. No operative complications were experienced. No life-threatening complications or deaths have been reported in the literature since the procedure’s introduction in 1996.