The percutaneous dilatational tracheostomy, a comparative clinical trial

Introduction

The dilatational tracheostomy becomes more and more a standard procedure in many ICU. Several systems for the procedure are available. Few clinical experiences are published about this procedure, even less about a comparison of the different kind of systems. On the bases of the experience of 96 self-practiced dilatational tracheostomies we critically report our experiences with two different kind of tracheostomy-sets.

Methods

Between December 1998 to September 2001 we initiated a prospective, comparing observational study on 96 patients on a surgical 12-bed ICU who were undergoing a percutaneous dilatational tracheostomy (PDT). In 36 patients the multi-step-dilatation-procedure, following Ciaglia (Cook®) was used, the Criggs-Method (Portex®), a one-step-dilatation with a certain dilatation-forceps was practiced 59 times. We documented operation-time, costs and complications in the daily practice at a university-teaching-ICU. As complications we considered all transfusion or surgical intervention requiring bleedings, infections which needed surgical treatment or antibiotics or intraoperative lowering of the SpO₂-pressure. The operation teams were classified following their surgical experience: Team 1: senior-resident/resident, Team 2: resident/resident, Team 3: resident/house-man.

Results

The operation-time for the Ciaglia-procedure was 25(SD ± 14)min, with the Criggs-procedure 20(SD ± 13)min. Considering the costs was the Criggs-system with 127.- E clearly cheaper than the Ciaglia-system with 165.- E. We found the Criggs-system easy to learn and to handle, which explains the different durations of operation-times in the different qualified teams: Team 1 needed with a mean operation-time of 36.4 min (n = 11/SD 14 min) significantly longer than Team 2 with a mean operation-time of 27.3 min (n = 24/SD 14.7 min) and Team 3 with a operation-time of 29.2 min (n = 36/SD 18.6). A short-time lowering of the SpO₂-pressure down to 70% occurred in five patients, relevant bleedings were not observed. Dependent on the age of the patients we found fractures of the tracheal cartilage in 25% of the patients but just in one patient further interventions following decannulation were necessary.

Conclusion

The PDT - independent of the used system – became a safe, cheap and fast standard-procedure on our ICU. So far we prefer the Criggs-procedure due to the lower risk of damaging the posterior wall of the trachea, the shorter operation-time and the lower costs. Nevertheless we practice both methods because each surgeon achieves best results with the system of it's own convenience. No difference was found in the incidence of complications.