Eur J Cardiothorac Surg 2007;31:114-119. doi:10.1016/j.ejcts.2006.10.006
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
A simple modification of Ciaglia Blue Rhino technique for tracheostomy: using a guidewire dilating forceps for initial dilation
Chau-Chyun Sheu*,
Jong-Rung Tsai,
Jen-Yu Hung,
Meng-Hsuan Cheng,
Inn-Wen Chong,
Jhi-Jhu Hwang,
Ming-Shyan Huang
Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung 807, Taiwan
Received 19 August 2006;
received in revised form 1 October 2006;
accepted 9 October 2006.
* Corresponding author. Address: Division of Pulmonary and Critical Care Medicine, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Road, Kaohsiung 807, Taiwan. Tel.: +886 7 3208159; fax: +886 7 3161210. (Email: sheu{at}kmu.edu.tw).
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Abstract
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Objective: The potential difficulty in doing initial dilation in the percutaneous dilational tracheostomy (PDT) with the Ciaglia Blue Rhino (CBR) technique has been reported by others and encountered in our clinical practice. To resolve this problem, we developed a modified CBR technique by using a guidewire dilating forceps (GWDF) to facilitate initial dilation. The present before-and-after comparison study aimed to evaluate the clinical benefits of this modified CBR technique. Methods: Consecutive 120 patients undergoing CBR technique in the pre-conversion year and 114 patients undergoing GWDF-CBR technique in the post-conversion year were enrolled for analysis. The procedure time and procedure-related complications were compared between these two groups. Results: The mean procedure time with GWDF-CBR technique was 4.5 ± 1.6 min, significantly shorter than 5.7 ± 3.0 min with CBR technique (p
< 0.001). Only two patients in the GWDF-CBR group required prolonged procedure time (>8 min), compared with 14 patients in the CBR group. Thirty three (27.5%) of 120 patients undergoing CBR technique and 15 (13.1%) of 114 patients undergoing GWDF-CBR technique had PDT-related complications (p
= 0.006). Most of the complications were minor and transient. Only 13 patients in the CBR group and 3 patients in the GWDF-CBR group encountered major complications (10.8% vs 2.6%, p
= 0.012). Regarding the high-risk patients, 21 (36.2%) of 58 patients in the CBR group and 9 (15.8%) of 57 patients in the GWDF-CBR group had PDT-related complications (p
= 0.011). Conclusions: Pre-dilation with a GWDF in the CBR technique helped to prevent prolonged procedure time and procedure-related complications. We suggest that the bronchoscopy-guided GWDF-CBR serves an easy-to-operate and relatively safe PDT technique for critically ill patients.
Key Words: Percutaneous dilational tracheostomy • Ciaglia Blue Rhino • Guidewire dilating forceps • Complications • Bronchoscopy
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1. Introduction
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Since the introduction of the original Ciaglia technique in 1985 [1], percutaneous dilational tracheostomy (PDT) has been largely used worldwide. Studies have shown that PDT is a cost-effective and safe alternative to conventional surgical tracheostomy in critically ill patients [2–4]. Furthermore, PDT can be performed at the patient's bedside under simple intravenous anesthesia and as a result, needs no operating room scheduling. Thus, it has become the choice of surgical procedure to establish a long-term airway in many intensive care units (ICU).
A number of PDT techniques have been developed and are now available for clinical use: the Griggs’ technique using a guidewire dilating forceps (GWDF) (manufactured by Sims Portex) [5]; the Fantoni's translaryngeal tracheostomy (TLT) using a specially designed canula (manufactured by Mallinckrodt) to dilate the trachea in a retrograde manner [6]; the Ciaglia Blue Rhino (CBR) technique using a single Blue Rhino dilator (manufactured by Cook) instead of multiple dilators in the original Ciaglia technique [7]; and the PercucTwist technique using a screw-type dilator (manufactured by Ruesch) [8]. Among them, the CBR technique is currently the most popular PDT procedure worldwide. According to our experiences in performing the CBR technique, we have sometimes encountered difficulties in doing initial dilation of the soft tissue and tracheal wall with the Blue Rhino dilator, a device equipped with a soft and flexible tip to minimize the risk of posterior tracheal wall injury. This finding is consistent with the report by Fikkers et al. [9] that there are more occasions of difficult dilation with the CBR technique compared with the Guidewire Dilating Forceps technique. We also found that the difficulty in initial dilation with the Blue Rhino dilator occurred more commonly among young or obese patients and usually resulted in a longer procedure time and more procedure-related complications.
In order to resolve this problem, we modified the CBR technique by using a specially designed GWDF (Portex) to facilitate initial dilation of the trachea and pretracheal soft tissue. Our preliminary experiences with this guidewire dilating forceps-assisted Ciaglia Blue Rhino (GWDF-CBR) technique in 30 cases showed the PDT procedures could be easily completed within 5 min in almost all patients. Moreover, we observed that the procedure-related complications occurred rarely, including minor bleeding in two patients only. Therefore, we replaced the GWDF-CBR technique for the standard CBR technique as the choice of PDT procedure in our institution since January 2005. To evaluate the clinical benefits of the GWDF-assisted CBR technique, we conducted this before-and-after study comparing the procedure time and perioperative complications between patients undergoing the CBR technique and the GWDF-CBR technique.
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2. Materials and methods
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2.1 Patients and study design
Consecutive patients undergoing PDT in a 26-bed medical ICU and a 12-bed coronary ICU of Kaohsiung Medical University Hospital between January 2004 and December 2005 were retrospectively analyzed. The subjects undergoing the CBR technique in the pre-conversion year (January–December 2004) were designated as the CBR group, and those undergoing the GWDF-CBR technique in the post-conversion year (January–December 2005) were as the GWDF-CBR group. This study has been approved by the Institution Review Board (IRB) of Kaohsiung Medical University Hospital and the written informed consents were waived by the IRB.
The indications for tracheostomy included the followings: prolonged mechanical ventilation, inadequate airway protection, and upper airway obstruction. Patients with uremia, liver cirrhosis, laboratory coagulopathy (INR 
1.5, aPTT 45 s, or platelet 
50,000/µl), obesity (body mass index [BMI] 30 kg/m2), poor oxygenation (PaO2/FiO2
200 or positive end-expiratory pressure [PEEP] 10 cm H2O), previous tracheostomy, or previous barotrauma (pneumothorax, pneumomediastinum, or subcutaneous emphysema occurring during current mechanical ventilation period) were considered as high-risk patients for PDT. Patients with laboratory coagulopathy received fresh frozen plasma and/or platelet transfusion before the tracheostomy procedures to correct their coagulopathy. In addition, according to our protocol, PDT was usually postponed in patients with very poor oxygenation until they could tolerate fraction of inspired oxygen (FiO2) of 0.6 or less.
2.2 Percutaneous dilational tracheostomy techniques
All PDT procedures were performed at the bedside by one of the three attending physicians of the medical ICU. All of them were qualified specialists in both pulmonology and critical care medicine, and had experiences of performing PDT in more than 50 patients before January 2004. During PDT, patients were positioned supinely with pillows placed under their shoulders to achieve neck hyperextension and were ventilated on pressure control mode, FiO2 of 1.0, and PEEP unchanged. Fentanyl, midazolam, and atracrium were used for intravenous anesthesia. Vital signs were continuously monitored. In the pre-conversion year, PDT was performed by using the standard CBR technique with some modifications. Briefly, under local anesthesia with lidocaine infiltration, a 10 mm incision was made vertically on the skin over the midline trachea at the level about one to two finger breadths below the cricoid cartilage, and the subcutaneous tissue was dissected with a curved hemostat to the level of trachea. Then, a flexible bronchoscope was inserted and aligned with the tip of the endotracheal tube. The bronchoscope and endotracheal tube were slowly withdrawn to a proper position. After that, the trachea was punctured with a 14-gauge Teflon catheter introducer needle, followed by insertion of a J-tip guidewire. After initial dilation of trachea with an introducer dilator, a guiding catheter was introduced; a Blue Rhino dilator (Cook Critical Care, Bloomington, IN, USA) was used to dilate the opening to a sufficient size; and a preloaded tracheostomy tube was then inserted. The endotracheal tube was not removed until bronchoscopic visualization of the carina through the tracheostomy tube was confirmed. Finally, the tracheostomy tube was sutured to the skin for securement.
In the post-conversion year, PDT was performed by using the GWDF-CBR technique. Briefly, local anesthetic infiltration, skin incision, minimal pre-dissection of the subcutaneous tissue with a curved hemostat, proper positioning of the bronchoscope and endotracheal tube, trachea puncturing, and J-tip guidewire insertion were sequentially performed. After initial dilation with an introducer dilator, both the subcutaneous tissue and anterior tracheal wall were dilated at once with a guidewire dilating forceps (SIMS Portex Ltd., Hythe, Kent, UK) to approximately 8 mm in diameter. A Blue Rhino dilator, preloaded with the guiding catheter, was then inserted for the second dilation, followed by steps described above.
2.3 Data collections
The demographic and clinical information of all the patients undergoing PDT were retrospectively analyzed by reviewing their medical records. Patient characteristics including age, sex, APACHE II, and causes for acute respiratory failure were recorded upon ICU admission. Indications for tracheostomy as well as BMI, coagulation profiles, baseline ventilator settings, PaO2/FiO2 before the procedure, ventilator days prior to PDT, and comorbidities were preoperatively recorded on the day of PDT. The procedure time and perioperative complications were recorded prospectively on a predesigned form. The procedure time was defined as the time spent from skin incision to successful placement of the tracheostomy tube. Minor and major procedure-related complications (Table 1
) were recorded during the perioperative period (within 24 h from the start of anesthesia).
2.4 Statistical analysis
All data were analyzed by the Statistical Package for the Social Sciences version 11.5 software (SPSS Inc., Chicago, IL, USA). Continuous data are presented as mean ± SD and/or median (range). Proportions are presented as number (%). Comparisons between groups were analyzed by using unpaired two-tailed t-test, Mann–Whitney U-tests, Chi-square test, or Fisher's exact test as appropriate. Statistical significance was defined as p
< 0.05.
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3. Results
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3.1 Patients included
During the 24-month study period, a total of 237 patients underwent tracheostomy procedure. Surgical tracheostomy was selected as the tracheostomy procedure of choice in three patients for the presence of midline neck masses. As a result, 120 consecutive patients undergoing the CBR procedure and 114 consecutive patients undergoing the GWDF-CBR procedure were enrolled. The patients’ demographic data and clinical features are shown in Table 2
. There were no significant differences in age and sex distributions, APACHE II scores, and causes for acute respiratory failure between the CBR group and the GWDF-CBR group. Indications for tracheostomy, BMI, ventilator days prior to PDT, PaO2/FiO2 before the procedure, and coagulation profiles were consistent between the two groups. Fifty-eight (48.3%) of 120 patients in the CBR group and 57 (50%) of 114 patients in the GWDF-CBR group were considered at higher risk for PDT (p
= 0.896).
3.2 Procedure time
The mean procedure time was 5.7 ± 3.0 min with the CBR technique and 4.5 ± 1.6 min with the GWDF-CBR technique (p
< 0.001). Of the 114 patients in the GWDF-CBR group, 85 (74.6%) patients underwent PDT procedures taking less than 5 min, 27 (23.7%) required 5–8 min, and 2 (1.7%) required longer than 8 min, compared with 67 (55.8%), 39 (32.5%) and 14 (11.7%) of 120 patients in the CBR group, respectively (p
= 0.001) (Table 3
).
3.3 Procedure-related complications
The procedure-related complications encountered in these two groups are summarized in Table 3. Hypotension and minor bleeding were the two most common complications of PDT in both groups. In the CBR group, 6 patients had hypotension and 12 had minor bleeding, compared with 4 and 7 in the GWDF-CBR group, respectively. Other minor complications such as loss of airway for more than 20 s, desaturation, and procedure failure occurred rarely in both groups, and were less commonly observed in the GWDF-CBR group. Serious complications such as false route, esophageal perforation, subcutaneous emphysema, pneumomediastinum, pneumothorax, and major bleeding were also less commonly observed in the GWDF-CBR group than in the CBR group. None of the patients in both groups experienced cardiopulmonary resuscitation within 24 h of PDT. One patient in the CBR group died of refractory septic shock 22 h after PDT. In summary, 33 (27.5%) of 120 patients undergoing the CBR procedures and 15 (13.1%) of 114 patients undergoing the GWDF-CBR procedures encountered PDT-related complications (p
= 0.006). Most of the complications were minor and transient. Regarding the major complications, there were only 15 complications occurring in 13 (10.8%) of 120 patients undergoing the CBR procedure. With the assistance of a GWDF, the occurrence of major complications was further decreased to 3 (2.6%) of 114 patients (p
= 0.012)
3.4 PDT in high-risk patients
Among the patients at higher risk for PDT, 21 (36.2%) of 58 patients in the CBR group and 9 (15.8%) of 57 patients in the GWDF-CBR group had procedure-related complications (p
= 0.011) (Table 4
). Among the low-risk patients, the complication rates were also lower in the GWDF-CBR group than in the CBR group. However, the difference between the two groups was not statistically significant (19.4% vs 10.5%, p
= 0.208).
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4. Discussion
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Although a number of PDT techniques have been developed and are now available for clinical use, intensivists are still making efforts to search for a timesaving, easy-to-operate, and safer PDT technique. To eliminate the potential difficulty in carrying out initial dilation with the Blue Rhino dilator and in hopes of further improving the safety of PDT procedure, we developed a modified CBR technique into which a GWDF was incorporated to facilitate initial dilation. Our results demonstrated that the GWDF-assisted CBR technique could not only prevent the prolonged procedure time, but also reduce the major and overall perioperative complication rates.
The CBR technique and the Griggs’ (GWDF) technique are currently two most popular PDT procedures in many ICUs. In a prospective, randomized study comparing these two techniques, Ambesh et al. [10] reported that these two techniques were equally effective. However, the Griggs’ technique was associated with under-dilation and over-dilation of the tracheal stoma, each of which occurred in almost one-third of patients. On the other hand, the CBR procedure was associated with a significant increase in peak airway pressure and a higher incidence of tracheal ring fracture. In another prospective, randomized trial, Anon et al. [11] found the main difference between the two techniques was that with GWDF the tracheostomy cannula is more difficult to be inserted through the tracheostomy. This problem was also encountered by van Heurn et al. [12] and they pointed out that it might be due to the relatively soft and short obturator provided with the GWDF set. Another comparison study on a larger population conducted by Fikkers et al. [9] also concluded that although both techniques seemed equally reliable, difficult dilation and minor bleeding were more common in the CBR group than in the GWDF group. Regarding the duration of procedure, Ambesh et al. reported the mean procedure time was 7.5 min with CBR and 6.5 min with GWDF, while Anon et al. reported the median duration was 9 min and 7 min, respectively. Although it was not statistically significant, the GWDF technique apparently required less procedure time than did CBR technique in both studies.
Our modified PDT technique took the advantages of both the Griggs’ technique and the CBR technique. The process of dilation was composed of two steps, the first dilation with a GWDF and the second dilation with a Blue Rhino dilator (Fig. 1
). In the first dilation, the GWDF was used to provide initial dilation with less effort. Compared with the clamp employed to dissect through the pretracheal soft tissue to the tracheal level in the Ciaglia's technique, the Griggs’ GWDF provides a more powerful, more convenient, and more effective pre-dilation for the Blue Rhino dilator. Taking the advantage of pre-dilated stoma, the second dilation with a Blue Rhino dilator could be easily accomplished in a few seconds. This could reduce the duration of high airway pressure caused by the Blue Rhino dilator. Furthermore, the use of Blue Rhino dilator in the second dilation could also prevent under or overdilatation of the tracheal stoma produced by the GWDF. This modified technique is easy to learn and its cost is not higher than that of the standard CBR technique because the forceps is reusable after adequate sterilization.
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Fig. 1. The modified Ciaglia Blue Rhino technique was a combination of the Griggs’ technique and the Ciaglia Blue Rhino technique. The process of dilation was composed of two steps: the first dilation with a guidewire dilating forceps (left) and the second dilation with a Blue Rhino dilator (right).
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Our results showed that the GWDF-CBR technique required significantly less procedure time and resulted in less procedure-related complications than the CBR technique. Although the average saving of procedure time with a GWDF was only 1.2 min and the differences in individual complications between the two groups were not statistically significant due to the rarity of complications, we found that the major benefits of this modified technique might be mostly attributed to the numbers of patients requiring prolonged procedures. In the GWDF-CBR group, only two patients underwent PDT for longer than 8 min. One patient had difficulty with tracheal puncture due to obesity and the other's airway was lost during PDT. On the contrary, 12 patients in the CBR group required prolonged procedure for longer than 8 min. Such difference in numbers of patients requiring prolonged procedure time might indirectly indicate the ease and precise of these two dilational techniques. Furthermore, the prevention of prolonged procedure time might provide additional benefits. First, it can decrease the period of time during which the airway is poorly secured. In the GWDF-CBR group, there was only one patient who had loss of airway, compared with three in the CBR group. All these patients required prolonged procedures for longer than 8 min. Second, it can shorten the duration of exposure to potentially inadequate oxygenation and ventilation, particularly evident in patients with very poor lung function or oxygenation preoperatively. In the present study, none of the patients undergoing the GWDF-CBR technique experienced oxygen desaturation during PDT, while three patients undergoing the CBR technique with prolonged procedure time did.
The complication rates with the CBR technique in the present study were comparable with other previous reports [9,10,13]. Although the overall complication rate was apparently high (27.5%), most of the complications were minor and transient. Regarding the major complications, i.e., false route, esophageal perforation, subcutaneous emphysema, pneumomediastinum, pneumothorax, major bleeding, CPR, and death, there were only 15 complications occurring in 13 (10.8%) of 120 patients undergoing the CBR procedure. It's noteworthy that these subjects were critically ill patients, and that quite a few of them had multiple organ failure and coagulopathy. With the assistance of GWDF, the occurrence of major complications associated with the CBR technique was further decreased to 3 (2.6%) during the post-conversion year.
With the evolutions in technique and accumulation of experiences, most of the perceived contraindications of PDT are no longer viewed as prohibitions, but as suggestions related to the skill levels and training of the operators. In our study, only 3 of the 237 patients undergoing tracheostomy were regarded as contraindicated for PDT, and therefore, underwent surgical tracheostomy directly. All these patients had midline neck masses. Two of the masses were goiters and one finally proved to be a metastatic carcinoma. Additional four patients underwent surgical tracheostomy after the failure of PDT attempts. All the surgical tracheostomy procedures were successfully performed with a notably higher rate of minor bleeding that occurred in three of the seven patients.
The use of bronchoscopy in the procedure of PDT is controversial [14–17]. The insertion of bronchoscope into the airway may result in high airway pressure and hypoventilation [18,19]. This short-term hypercapnia is considered to be permissive. The complications resulting from the use of bronchoscopy can be reduced by lessening the procedure time. In contrast, the use of a bronchoscope prevents the airway from being lost and helps re-intubation once the airway is lost. There is increasing evidence that bronchoscopy, which allows direct step-by-step visualization of the procedure, can significantly reduce the incidence of serious complications such as false route and injury of the posterior tracheal wall [20,21]. After PDT is completed, the bronchoscopy helps to confirm the position of tracheostomy tube and, furthermore, perform bronchial toilet to remove the secretions aspirated and accumulated during PDT. Therefore, we performed PDT under bronchoscopic guidance routinely in our ICU.
Although the present study is not a randomized trial, it is still powerful because the design of this large before-and-after comparison study has controlled nearly all the possible confounding factors from patients. The better outcome of GWDF-CBR group in the post-conversion year might at least partly result from the accumulation of experiences in performing PDT was always possible. However, this effect was expected to be minimal because all the operators had experiences of performing PDT in over 50 cases before the start of the study, far beyond the learning curve reported in previous studies [22,23]. Another limitation of this study is that we did not directly record and compare the difficulty of procedure as well as the number of dilation attempts between the two techniques. However, the differences in procedure time and complication rates might indirectly indicate how easy and precise the dilations were with each of the two techniques.
In conclusion, the minor modification of the CBR technique with incorporation of a GWDF made the initial dilation easier and prevented a prolonged procedure time. In addition, the GWDF-CBR technique caused fewer cases of procedure-related complications than the conventional CBR technique. These benefits were more prominent in the high-risk patients. On the basis of our results, we suggest that the bronchoscopy-guided GWDF-CBR PDT serves as an easy-to-operate and relatively safe PDT technique for critically ill patients. However, future large randomized controlled trial is needed to provide more powerful evidence.
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Abstract
1. Introduction
