Percutaneous tracheostomy: what technique is it?

Percutaneous translaryngeal versus surgical tracheostomy: A randomized trial with 1-yr double-blind follow-up

OBJECTIVE

To compare the outcomes and the short- and long-term complications of percutaneous translaryngeal tracheostomy (TLT) and surgical tracheostomy (ST).

DESIGN

Prospective, randomized clinical trial with 1-yr double-blind follow-up.

SETTING

A general intensive care unit of a university hospital.

PATIENTS

A total of 139 consecutive critically ill patients who required a tracheostomy between February 2001 and June 2002 were randomly assigned to receive either ST or TLT.

RESULTS

TLTs were performed more rapidly than STs (17 +/- 10 mins vs. 22 +/- 6 mins, p = .003). Early complications were rare in both groups. Major postoperative bleeding was less frequent with TLT (0 [0%] vs. 6 [8%], p = .03). Only one case of bleeding (in the ST group) required blood transfusion. Immediately after tracheostomy, six TLT patients (9%) and six patients (8%) in the ST group (p = .56) developed culture-confirmed bacteremia with microbes previously isolated from the pharynx or trachea. Group rates for stomal infections and pneumonia after tracheostomy were similar. At 1-yr follow-up, the overall survival rate was 27%, and 14 patients (45% of survivors) still had open tracheostomies. Both groups rated their quality of life as moderately to severely compromised, and the deterioration was strictly related to the presence of tracheostomy. One TLT and two ST survivors (p = .53) had clinical signs of tracheal stenosis, and bronchoscopy revealed narrowing of >50%.

CONCLUSIONS

Compared with ST, the main advantages of TLT are that it is more rapid and associated with less postoperative bleeding. Infectious complications, particularly postoperative bacteremia, and long-term effects (physical and emotional) are similar with the two procedures.

Percutaneous tracheostomy with single dilatation technique: a prospective, randomized comparison of Ciaglia blue rhino versus Griggs' guidewire dilating forceps

Percutaneous tracheostomy with single-step dilation technique using Griggs' guidewire dilating forceps (GWDF) is a well-recognized procedure. Recently, Ciaglia has introduced a one-step dilation technique using a curved, gradually tapered dilator, the Ciaglia Blue Rhino (CBR). In a prospective, randomized study, we performed percutaneous tracheostomy in 60 consecutive patients, using either the CBR or the GWDF technique. Postoperatively, all patients had bronchoscopy by a blinded consultant, and stoma characteristics and injuries to the trachea were studied. Mean tracheostomy time (skin incision to insertion of tracheostomy tube) in the two procedures (CBR 7.5 min versus GWDF 6.5 min) was not different (P > 0.05). The GWDF technique was associated with under-dilation and over-dilation of the tracheal stoma, each in almost one-third of patients. In the CBR group, the procedure was associated with a significant increase in peak airway pressure (P < 0.05) in all patients. There were nine cases of tracheal cartilage rupture, three cases of longitudinal tracheal abrasion, and one pneumothorax. Three patients had tracheal in-drawing at the scar site with huskiness of voice at 8 wk after decannulation; however, none had any breathing difficulty. We conclude that the techniques are equally effective in the formation of percutaneous tracheostomy. However, tracheal stoma over-dilation with GWDF and increase in peak airway pressure and rupture of tracheal rings with CBR remain major concerns.

IMPLICATIONS

The tracheas of 60 patients were cannulated through an artificial opening by using a single-step dilation technique with Ciaglia Blue Rhino or Griggs' dilation forceps. The techniques were equally effective for cannulation of the trachea. However, Ciaglia Blue Rhino was associated with rupture of tracheal rings in one-third of patients and increased airway pressure in all, whereas the Griggs' technique was associated with under- or over-formation of the tracheal opening, each in one-third of patients.