Percutaneous dilatational tracheostomy – a comparison of three methods: Ciaglia Blue Rhino, PercuTwist and Griggs' Guidewire Dilation Forceps (GWDF)

Introduction

In contrast to conventional surgical tracheostomy, percutaneous dilational tracheostomy (PDT) in different variants is spreading rapidly in intensive care units today. On two intensive care units – cardiological and surgical–anaesthesiological – we performed a comparative investigation of three PDT methods in a prospective randomized study with an emphasis on clinical utility and safety.

Methods

Thirty-one patients (age 64 ± 13 [mean ± SD]) were enrolled, PDT were performed in three groups, 10 Ciaglia Blue Rhino (Cook), 10 PercuTwist (Rüsch) – a device employing a screw with a hydrophilic coating and 11 GWDF – using Griggs' specially designed dilational forceps (Portex). Duration of intervention, oxygenation parameters, blood loss and further complications peri-interventionally and postinterventionally were recorded and compared.

Results

We found significant differences in the duration of procedures: Blue Rhino 5.9 ± 3.7 min, PercuTwist 11.7 ± 9.35 min, GWDF 3.3 ± 1.65 min (P < 0.02). Two PercuTwist procedures proved technically difficult – insufficient penetration depth of the Percu Twist device and formation of a pre-tracheal via falsa, successful tracheostoma placement was achieved only after a procedural switch to Blue Rhino. One of these cases led to significant blood loss. Pre-interventional and postinterventional values for Hb were 10 ± 1.8 g/dl and 9.9 ± 1.2 g/dl in the Blue Rhino group, 10.4 ± 1.8 g/dl and 10.3 ± 1.9 g/dl in the PercuTwist, and 9.8 ± 0.8 g/dl and 9.57 ± 1.4 g/dl in the GWDF group (n.s.). Oxygenation remained unchanged early after intervention with a tendency towards a better PaO₂/FiO₂ in the GWDF group. Three cases of cartilage fracture were recorded. We saw no severe lasting desaturation episodes. We found no stomal infections and no other life-threatening events. Surgical intervention was never required. Mortality in all groups was 42% with no procedure-related deaths. Thirteen patients have been permanently decanulated.

Conclusion

The three methods investigated in this study show comparable feasibility, clinical utility, lack of severe complications and margin of patient safety under the conditions of a secondary academic teaching hospital. However, the PercuTwist method revealed technical limitations in particular in the presence of a wide tracheocutaneous distance. Shortest intervention durations were achieved using the GWDF. To provide evidence of relevant differences – especially regarding long-term outcome – further comparative studies are indispensable.