Tracheostomy is frequently performed on critically ill patients in many intensive care units (ICUs) (1). In England and Wales, the most common procedure is based on a technique introduced by Ciaglia et al. in 1985 (2) that involves the use of serial dilators of increasing diameter to create a tracheostomy.
In 2001, a new percutaneous tracheostomy set, the PercuTwist™ Tracheostomy Dilator Set (Rüsch, Kernen, Germany ,Fig. 1), was introduced. This technique features controlled rotating dilation using a single-step dilator with a self-tapping screw. The PercuTwist™ dilator is covered in a hydrophilic coating that, when wet, reduces friction during dilation of the tracheal stoma. The dilator’s screw-tap design allows access to the trachea without the need for excessive pressure towards the posterior tracheal wall, theoretically reducing the risk of posterior tracheal wall injury (3–5).
In the 3-yr period before 2002, more than 125 percutaneous tracheotomies were performed in our unit by 4 consultants using a serial dilation (Ciaglia) technique. In November 2001, we were introduced to the Percutwist™ technique, and after favorable experience with 10 procedures, we adopted its routine use in February 2002.
With local institutional ethical approval and informed consent from patients’ next of kin, all patients requiring percutaneous tracheostomy in the ICU were assessed. The manufacturers’ absolute contraindications included emergency tracheostomy, enlarged thyroid gland, pediatric patients, difficulty in intubation, impalpable cricoid cartilage/trachea, active infections or malignant process in the tracheostomy area, stenosis of the upper airways, unstable cervical spine fracture, extreme circulatory insufficiency, and fresh tracheal suture. Relative contraindications included definitive tracheostoma, spontaneously breathing patient, and tracheomalacia.
All patients were sedated, paralyzed, and ventilated with 100% oxygen by a physician who was also responsible for continuous fiberoptic monitoring of the procedure. Continuous electrocardiogram, invasive arterial blood pressure, and pulse oximetry were measured throughout the procedure. To facilitate access to the trachea, patients were positioned either with the neck in a neutral position or with the head slightly extended by means of a pillow under the shoulders.
A second operator performed the procedure using an aseptic modified Seldinger technique as previously described (4). Operators ranged from consultants to trainees operating under close bedside supervision. The first or second intratracheal ring spaces were identified as the insertion site and the area was disinfected, draped, and anesthetized locally with 20 mL 1% lidocaine. No vasoconstrictor was used. The cuff of the tracheal tube was deflated and the tube withdrawn so that the region below the cricoid cartilage was freely accessible. Using the cannula provided in the PercuTwist™ set, the trachea was punctured along its midline at the proposed level. The tracheal placement of the cannula was confirmed by bronchoscopy and air aspiration. A J-guidewire was introduced into the trachea in a caudal direction. The cannula was then removed while the guidewire was held firmly in position. The skin incision traversed the skin and was extended to 1–2 cm at the insertion site to facilitate the introduction of the PercuTwist™ screw dilator (Fig. 1). After activation of its hydrophilic coating with sterile water, the dilator was fed over the guidewire via its central lumen to direct it along the correct track into the trachea.
Using the Seldinger technique and bronchoscopic guidance, the screw dilator was advanced by clockwise rotation and gentle intermittent upward vertical traction to avoid tracheal distortion and direct contact with the posterior tracheal wall (Fig. 2). Dilation continued until the dilator’s maximum diameter was visualized in the trachea. The dilator was then removed from the trachea by careful anticlockwise rotation, leaving a circular tracheostoma, with the guidewire remaining in situ.
The PercuQuick™ tracheostomy tube was first checked for cuff leak before its cuff was deflated completely. It was then loaded onto its introducer (Fig. 1) and lubricated with water-based lubricant before both the introducer and the tube were fed into the trachea via the guidewire under bronchoscopic control. Once the tracheostomy tube position was 3–5 cm above the carina on bronchoscopy, the guidewire and the introducer were removed and the tracheostomy cuff was inflated. After suctioning of any residual blood or secretions within the trachea, the tracheostomy was secured and connected to the ventilator. The tracheal wall was also inspected from above via the endotracheal tube for tracheal ring fractures, posterior tracheal wall lacerations, and other mucosal damage.
Patient demographics, original condition leading to ICU admission, prior endotracheal intubation duration, seniority of doctors performing the tracheostomy, and procedure times were recorded. Using the classification by Frova and Quintel (4) the difficulty of the procedures was graded as I (no difficulties), II (some difficulties encountered, but possible), and III (procedure abandoned). Bleeding during the process was classified (4) as 1) absent or minimal (no bleeding, or bleeding requiring no intervention), 2) medium (need for special wound dressing and/or vasoconstrictive drugs), or 3) serious (requiring surgical intervention). All complications encountered were recorded.
From February 2002 to October 2003, 90 procedures were performed. The patients’ ages ranged from 23 to 89 yr, with a mean of 64.6 yr. The underlying conditions leading to ICU admission are summarized in Table 1. More than 80% of patients had had a recent midline sternotomy. The mean duration of tracheal intubation before performance of tracheostomy was 11 days (range, 3–35 days). The PercuTwist™ tracheostomy dilator set was used in all patients during the study period, except for nine patients with gross cervical obesity who were considered unsuitable and had surgical tracheotomies.
In this series, 68 of 90 (75.6%) procedures were performed by intensive care trainees under supervision and 22 of 90 (24.4%) were performed by experienced consultants (Table 2). The mean time from guidewire insertion to bronchoscopically confirmed tracheostomy tube insertion was 13 min 7 s. Some difficulty was encountered in one patient during the procedure because the initial skin incision was too small. Once the skin incision was extended to 2 cm, the tracheostomy was inserted without further difficulty. The remaining 89 procedures were graded as uneventful (Grade I).
All procedures performed were graded as having absent or minimal bleeding. This included 6 patients who had abnormal clotting profiles at the time of their procedures as a result of anticoagulation therapy (Table 3). Bleeding present after the initial skin incision stopped immediately after the first twists had been performed. Two patients were noted to have a tracheal ring fracture. None of the following complications occurred: posterior tracheal wall injury, mucosal laceration, or desaturation (SaO2 < 90%).
Percutaneous tracheostomy is the procedure of choice in many ICUs around the world (1,6). Many studies have demonstrated a comparable rate of perioperative complications and a less frequent rate of postoperative complications for percutaneous techniques when compared with the surgical technique (6,7). Airway loss, serious bleeding, pneumothorax, surgical emphysema, and injury to the posterior tracheal wall (5,8–11) are complications associated with previous techniques of percutaneous tracheostomy using serial dilators (2) and single dilators (12). The PercuTwist™ technique attempts to reduce the risks associated with percutaneous tracheostomy by the introduction of a screw dilator with sharp threads to create the stomal opening.
The mean time from guidewire insertion to bronchoscopic confirmation of successful tracheostomy tube position using controlled rotating dilation was 13 minutes 7 seconds. This compared favorably with the mean time reported with the Ciaglia method (14 min) but not with the Portex dilating forceps (6 min 30 s) or the Blue Rhino™ technique (2 min 7 s) (12,13). However, the mean times in those studies reflected procedures performed by experienced operators. Two operators experienced in the PercuTwist™ technique have reported a procedure time of no more than 5 minutes (4). In our study, intensive care trainees, under bedside supervision, in a routine setting, performed 75% of the procedures, highlighting the safety and simplicity of this technique, especially considering the fact that minimal complications were encountered (Table 2). The absence of multiple dilator changes meant that adverse effects on oxygenation attributable to the loss of the positive end-expiratory pressure level, exposure of the lower airway to bleeding, and repeated airway obstruction by the dilators is avoided. A recent report using the Percutwist™ in 6 patients classified 5 of these procedures as having difficulty in dilation of the trachea (Grade II), with associated twisting of the skin, a problem that was not resolved by lubrication (14). In our series, no problem with initial dilation was identified. Mild force was required in dilating the trachea; this is common to all percutaneous tracheostomy techniques. During the dilation procedure, intermittent upward traction was performed, which may be one reason for the small rate of complications in this series. The opening created by the screw also showed no tendency towards closure after the removal of the dilator, which contrasts with previous dilation techniques in which the stomal opening might close very quickly after the removal of the final or only dilator (4).
In this series, there were no episodes of moderate or severe bleeding despite the lack of use of vasoconstrictor skin infiltration. Six patients with abnormal clotting profiles had minimal bleeding (Table 3). Any bleeding from the initial incision stopped when the dilator was rotated into the pretracheal tissues and did not reappear after removal of the device or insertion of the tracheostomy tube. Bronchoscopic examination of the trachea postprocedure did not identify any endotracheal bleeding. One patient who had a double lung transplant for congenital arteriovenous malformations had had obvious bleeding on the posterior wall of the trachea before the procedure commenced. Percutaneous tracheostomy of this patient avoided the posterior wall by vertical traction of the dilating screw during rotation, and no procedural-related bleeding was encountered.
Our results are consistent with those of Frova and Quintel (4). However, they are in contrast to those from a recent study by Byhahn et al. (11). The latter group initially published a successful series of 10 Per-cuTwist™ insertions (18) with minimal complications. Subsequently they conducted a randomized controlled trial comparing the Ciaglia Blue Rhino™ and PercuTwist™ tracheostomy (11) with 35 patients in each group. Twelve complications were encountered in the Percutwist™ group compared with 7 in the Blue Rhino™ group. A major complication rate of 33% is in stark contrast to our experience. Specifically, adequately supervised junior physicians did most procedures in our series; i.e., there was confidence among all the senior members of the team that the technique could be safely taught.
Although the complication rate reported by Byhahn et al. (11) is impressively high—including posterior wall tears, a tracheoesophageal fistula, a false cannula passage, and 4 failures to insert the cannula—it is difficult for us to ascertain why these complications were not prevented with careful and full bronchoscopic control. With a fully visualized trachea, proximity to the posterior wall can be ascertained and the required anterior traction or control of the introducing needle and cannula can be maintained. It is possible that unfamiliarity with a newer technique and the availability of a more familiar alternative technique led to a loss of confidence in the PercuTwist™ percutaneous tracheostomy set.
Tracheal ring fracture is another well recognized complication of percutaneous tracheostomy that does not correlate with future tracheal stenosis (15). It is normally recognized at the time of the procedure by continuous fiberoptic bronchoscopy, where the two split halves of the tracheal cartilage herniate into the tracheal lumen. Its incidence using other techniques ranges from 2% to 8.9% (12,16). Bewsher et al. (12) suggest that tracheal ring fractures occur most commonly during the insertion of the tracheostomy with its introducer. Roberts et al. (17) reported a case of tracheal ring fracture after PercuTwist™ tracheostomy during the screw dilation process. Although its significance is uncertain, our experience (2%) is similar to other reports.
Our series is a prospective observational study, and one of the largest to illustrate that PercuTwist™ tracheostomy can be performed by doctors of various experience, under appropriate supervision, in a routine clinical setting, even in patients with recent sternotomies. We offer an alternative experience to that of Byhahn et al. (11) and consider the PercuTwist™ Tracheostomy Dilator set to be an improvement over other tracheostomy sets in our hands. This novel technique of rotational dilation is simple to use, is easy to teach, and was associated with minimal early complications.
The authors would like to thank the doctors and nurses of the intensive care unit at Harefield Hospital for their help in performing the procedures described above.
1. Cooper RM. Use and safety of percutaneous tracheostomy in intensive care: report of a postal survey of ICU practice. Anaesthesia 1998;53:1209–12.
2. Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report. Chest 1985;87:715–9.
3. PercuTwist™: dilator set for controlled percutaneous dilative tracheostomy: instructions for use [package insert]. Rüsch, Germany, 2001.
4. Frova G, Quintel M. A new simple method for percutaneous tracheostomy: controlled rotating dilation. Intensive Care Med 2002;28:299–303.
5. Trottier SJ, Hazard PB, Sakabu SA, et al. Posterior tracheal wall perforation during percutaneous dilational tracheostomy: an investigation into its mechanism and prevention. Chest 1999;115:1383–9.
6. Freeman BD, Isabella K, Lin N, Buchman TG. A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 2000;118:1412–8.
7. Quintel M, Roth H. Tracheostomy in the critically ill: impact of new technologies. Curr Opin Crit Care 2000;6:46–51.
8. Beiderlinden M, Karl WM, Sander A, et al. Complications of bronchoscopically guided percutaneous dilational tracheostomy: beyond the learning curve. Intensive Care Med 2002;28:59–62.
9. Hinerman R, Alvarez F, Keller CA. Outcome of bedside percutaneous tracheostomy with bronchoscopic guidance. Intensive Care Med 2000;26:1850–6.
10. Thant M, Samuel T. Posterior tracheal wall tear with Per-cuTwist. Anaesthesia 2002;57:507–8.
11. Byhahn C, Westphal K, Meininger D, et al. Single-dilator percutaneous tracheostomy: a comparison of PercuTwist and Ciaglia Blue Rhino techniques. Intensive Care Med 2002;28:1262–6.
12. Bewsher MS, Adams AM, Clarke CW, et al. Evaluation of a new percutaneous dilatational tracheostomy set apparatus. Anaesthesia 2001;56:859–64.
13. Ambesh SP, Kaushik S. Percutaneous dilational tracheostomy: the Ciaglia method versus the Portex method. Anesth Analg 1998;87:556–61.
14. Fikkers BG, Venwiel JM, Tillmans RJ. Percutaneous tracheostomy with the PercuTwist technique not so easy. Anaesthesia 2002;57:935–6.
15. Walz MK, Schmidt U. Tracheal lesion caused by percutaneous dilatational tracheostomy: a clinicopathological study. Intensive Care Med 1999;25:102–5.
16. Edwards SM, Williams JC. Tracheal cartilage fracture with the Blue Rhino Ciaglia percutaneous tracheostomy system. Eur J Anaesthesiol 2001;18:487.
17. Roberts RG, Morgan P, Findlay GP. Percutaneous dilatational tracheostomy and tracheal ring rupture. Anaesthesia 2002;57:933–4.
18. Westphal K, Maeser D, Scheifler G, et al. PercuTwist: a new single-dilator technique for percutaneous tracheostomy. Anesth Analg 2003;96:229–32.