To the Editor:
Since the rejuvenation of interest in the percutaneous dilational tracheostomy in 1985, a number of percutaneous dilational tracheostomy kits have been made available. The commonly used percutaneous dilational tracheostomy kits are Ciaglia’s serial dilators, Griggs guidewire dilating forceps, Ciaglia Blue Rhino, and Frova’s PercTwist (1–4). Each kit has several advantages and disadvantages. Further efforts are underway to develop a percutaneous tracheostomy kit that is easy to operate and has minimal potential complications. Recently, Ambesh’s T-Dagger, a new percutaneous dilational tracheostomy device (patent pending), has been introduced. It is here described in brief.
Ambesh’s T-Dagger is a T-shaped, semi-rigid device made up of polyvinyl chloride (Fig. 1). The shaft of Ambesh’s T-Dagger is smoothly curved at approximately a 30° angle, is elliptical in cross-section; it has a number of oval holes. These holes are meant to provide to-and-fro airflow during ventilation when the shaft lies inside the tracheal lumen during stoma formation. The elliptical shape of the T-Dagger should provide sufficient room for ventilation without air trapping and the passage of fiberoptic bronchoscope into the trachea. The tapered sides of the Ambesh’s T-Dagger shaft should reduce the difficulty in its insertion during tracheal stoma formation. The distal end of the T-Dagger is incorporated with a 5-cm long Teflon guide catheter and the proximal end has two shoulders for a better grip. A J-tip guidewire can be passed through a tunnel of the shaft and the guide catheter to facilitate tracheal stoma formation over it. The inherent design of the device should form adequate size of tracheal stoma for respective sizes of tracheostomy tube and overdilation of tracheal stoma is not possible. Ambesh’s T-Dagger is available in two sizes for 7-mm and 7.5-mm and 8-mm and 8.5-mm tracheostomy tube sizes. Economically, it is much cheaper than the Ciaglia’s Blue Rhino.
The steps of forming the percutaneous dilational tracheostomy with Ambesh’s T-Dagger are essentially the same as with the Ciaglia’s Blue Rhino except that the introduction of a separate guide catheter is not required. After a 1-cm transverse skin incision at the intended tracheostomy site, the trachea is punctured with the cannula on the needle and the J-tip guidewire is inserted. A small tracheal stoma is formed with a 14-gauge initial dilator. Ambesh’s T-Dagger is now loaded over the guidewire and advanced, preferably with both the hands holding its shoulder, until its proximal mark lies inside the tracheal lumen. The Ambesh’s T-Dagger is then removed, leaving the guidewire in situ. An appropriately sized tracheostomy tube with its obturator can be introduced over the guidewire. The obturator and guidewire is removed, the tracheal cuff is inflated, and air entry into lungs is confirmed on ventilation. As with other percutaneous dilational tracheostomy techniques, fiberoptic bronchoscopic assistance is advisable.
Sushil P. Ambesh, MD
Chandra K. Pandey, MD
Department of Anesthesiology
Sanjay Gandhi Post Graduate Institute of Medical Sciences
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