Defining Percutaneous Dilational Tracheostomy

Defining Percutaneous Dilational Tracheostomy To the Editor: The article, "Bedside Percutaneous Tracheostomy in Critically Ill Patients," by Yaakov Friedman and Amy D. Mayer, which appeared in the August 1993 issue of Chest 1 calls for some comment on the importance of the difference between a "percutaneous tracheostomy" and a " percutaneous dilational tracheostomy." Friedman and Mayer 1 state, "Percutaneous tracheostomy using the guidewire approach of Seldinger for percutaneous arterial catheterization was first described in 1969 by Toye and Weinstein. " 2 Correct-but this was not a percutaneous dilational tracheostomy, because a sharp, cutting blade was incorporated in their instrument. Even before Toye and Weinstein, Sheldon 3 in 1957 reported percutaneous tracheostomy with an instrument using multiple cutting blades. For years, both methods did not become very popular, no doubt, due to the cutting blades incorporated in the instruments. It was in 1985 that Ciaglia et al 4 first reported the technique of percutaneous dilational tracheostomy in which the only cutting done was the very small skin incision. In our follow-up article entitled, "Percutaneous Dilational Tracheostomy: Results and Long-Term Follow-Up," which appeared in the February 1992 issue of Chest, 5 in the first sentence, the word dilational is italicized to emphasize the difference in the techniques of Sheldon, et aP and Toye and Weinstein 2 who used cutting blades. This is not a hair-splitting semantic argument since it may, at times, be the difference between a successful procedure and a life-threatening complication 6 Friedman and Mayer 1 state, "Since 1985 several centers have reported their experience with modifications of the original procedure" and cite as his references 15 to 33. His reference 15 is the earliest and was in 1991 by Hazard et aJ.7 The original percutaneous dilational tracheostomy was first reported, as we mentioned above, by Ciaglia in 1985 and the title purposely included the word dilational. We believe that the main reason the procedure is being accepted is that it is a dilation with only a small skin incision. We may do a percutaneous tracheostomy using a very small skin incision, but then use a blade to dilate the opening further. This is not a percutaneous dilational tracheostomy but is the type that Sheldon, Toye, and Weinstein used, and which probably explains their lack of acceptance. Even all percutaneous dilational tracheostomies are not done the same way. Schachner et al 8 in 1990 reported a dilational technique with only a skin incision and used a pointed, narrow , sharp clamp to grasp a wire guide and to follow it into the tracheal lumen. Once there, the clamp was opened to dilate the tissues. But this exposed two points of the clamp; a dangerous situation which could and did lead to a life-threatening complication. The article by Friedman and Mayer 1 continues, "Customized kits designed for bedside insertion of a full-sized cuffed tracheostomy tube have been developed." But Ciaglia et al 4 since 1985, and Ciaglia and Graniero5 have used only the Cook kit with its instruction booklet in 170 procedures. We have been worried about some of the changes in "customized kits" and "simple improvements." Another example, Wang et al9 in 1992 described their experience with percutaneous tracheostomy. They had serious technical problems including difficulty with dilatation, false passage of the tube, pneumothorax, and death. When one reads the Wang et al technique and looks at their

diagrams, the results are understandable. They stated, "percutaneous tracheostomy tube systems were provided by Shiley Inc (Irvine, Calif)." In their technique, a 16-gauge introducer needle was placed into the tracheal lumen and then a ]-tipped guidewire was inserted through the needle into the tracheal lumen. They did not use a double guide. A cannula needle was not used for tracheal penetration, a safer approach, since after proper penetration, the needle is removed leaving the safe, blunt plastic cannula within the trachea. This is then checked again with a syringe to certify proper position in the air column. All surgeons and physicians have their own minor and major modifications of operations and the use of drugs. But even in minor operations some minor details, if changed, may result in devastating complications.

Pasquale Ciaglia, M.D., F.C.C.P., Utica, New York REFERENCES

1 Friedman Y, Mayer AD. Bedside Percutaneous Tracheostomy in Critically Ill Patients. Chest 1993; 104:532-35 2 Toye FJ, Weinstein JD. A percutaneous tracheostomy device. Surgery 1969; 65:384-89 3 Sheldon CH, Pudenz RH, Tichy FY. Percutaneous tracheotomy. JAMA 1957; 165/ 16:2068-70 4 Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilational tracheostomy: a new simple bedside procedure; preliminary report. Chest 1985; 87:715-19 5 Ciaglia P, Graniero K. Percutaneous dilational tracheostomy: results and long-term follow-up. Chest 1992; 101:464-67 6 Hutchinson RC, Mitchell RD. Life-threatening complications from percutaneous dilational tracheostomy. Crit Care Med 1991; 19:118-20 7 Hazard P, Jones C, Benitone J. Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy. Crit Care Med 1991; 65:384-89 8 Schachner A, Ovil J, Sis J, Avram A, Levy MJ. Rapid percutaneous tracheostomy. Chest 1990; 98:1266-70 9 Wang MB, Berke GS, Ward PH, Calcatera TC, Watts D. Early experience with percutaneous tracheotomy. Laryngoscope 1992; 102:157-62

To the Editor: We appreciate Dr. Ciaglia's clarification of the conclusion of our article, that percutaneous dilational tracheostomy is the preferred procedure for critically ill patients who require tracheostomy. Toye and Weinstein's article was mentioned as the first Seldinger's technique percutaneous tracheostomy to provide historical perspective. From this Ciaglia developed the dilational percutaneous tracheostomy. We mentioned the three different kits used in three different techniques of percutaneous tracheostomy in the introduction and discussion to compare their complication rates. As noted, the single lead dilator technique of Toye and Weinstein and Schachner's dilator forceps technique have higher rates of more serious complications compared with the dilational technique initially described by Ciaglia. Thus, while we have made some modifications in the type and number of dilators, performing percutaneous tracheostomy with multiple dilations over a double guide makes this a safe procedure that we have now used in over 180 patients with continued low complication rates.

Yaakov Friedman, M.D., and Amy D. Mayer, M.D., Provident Hospital of Cook County, Chicago CHEST /106/3/ SEPTEMBER, 1994

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