Ciaglia Blue Rhino Research Articles

Percutaneous Dilational Tracheostomy in the Emergent Setting

Objective: Since its inception, the use of the percutaneous dilational tracheostomy (PDT) has been contraindicated in the setting of an emergent airway. Emerging in the literature are several cases of successful emergent PDTs. Here we present our experience with the use of PDT in managing emergent airways. Study Design: All patients who underwent emergent PDT, using the Ciaglia Blue Rhino Introducer Set (Cook Critical Care, Bloomington,IN), in an academic county hospital setting between February 2010 and May 2012 were included in the study. Electronic medical records were reviewed for demographic and procedural data. Results: Twelve patients were included in the study with ages ranging from 20 to 87 (mean 57) years-old. The most common reason for emergent airway was trauma (7 patients), followed by obstructing neck mass (2 patients), septic shock (2 patients), and angioedema (1 patient). Seven PDTs were performed in the OR, four at bedside and one in the ER. Three of the 12 patients had emergent cricothyroidotomies in place that malfunctioned, requiring emergent conversion. No patients suffered from short term complications. One patient developed a neck abscess at the site of the PDT one month post operatively, two patients had accidental decanulation post operatively, and both were replaced without complication. Conclusions: PDT can be used in the emergent setting in the hands of trained practitioners with minimal complications. A larger, prospective trial is needed to make conclusions regarding patient care.

Percutaneous dilatational tracheostomy: collaborative team approach for safe airway management

Since Jackson first standardized the technique in 1909 [1], surgical tracheostomy (ST) has been the golden standard surgical procedure by which to manage the airway in critically ill patients. An alternative procedure, cricothyrotomy (cricothyroidotomy) [2], has also been utilized as a surgical option to secure the failed airway in selected emergency situations. To simplify the tracheostomy procedure, Shelden (1950) described the technique of percutaneous dilatational tracheostomy (PDT). However, due to the increased potential to induce extra injury to arteries and the esophagus, the PDT as proposed by Sheldon did not gain popularity among intensive care physicians and airway surgeons. In 1985, Ciaglia et al. [3] introduced a novel PDT method to create a stoma by a series of graduated dilators following needle puncture into the trachea. This method involved the relatively easy Seldinger technique to introduce the serial dilators and a tracheostomy tube. The Griggs guidewire dilating forceps (GWDF) technique introduced in 1990 was aimed at enlargening a small tracheal aperture with a guidewiredilating forceps especially manufactured for this purpose [4]. In 1998, a modification of the Ciaglia technique was introduced (Ciaglia Blue Rhino Percutaneous Tracheostomy Introducer kit; Cook Critical Care, Bloomington, IN). The Ciaglia Blue Rhino (CBR) technique incorporated a single, sharply tapered dilator with a hydrophilic coating, allowing complete dilation of the stoma in one step [5]. Although all of these methods have the potential to be improved and refined, the CBR is—mainly due to its simplified concept—currently the most popular PDT technique worldwide. In Japan, as in other countries, PDT is becoming a wellknown procedure. It is being performed as one of the technical options to secure the airway in multiple situations by physicians of various specialties. However, although this procedure is gaining in popularity in Japan, critical information on its indications, contraindications, and safety issues, including potential risks, have not yet been precisely defined and discussed. Thus, while the handiness of this technique is attractive to anesthesiologists and critical care physicians the best approach to perform PDT for successful airway management still needs to be considered and decided upon. K. Saito (&) Department of Otolaryngology–Head and Neck Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku, Tokyo 160-8582, Japan e-mail: koichiro@ja2.so-net.ne.jp

Punktionstracheotomie in der Intensivmedizin – Update 2012

Percutaneous tracheostomy has become an established procedure in airway management of critically ill patients. It offers advantages over prolonged tracheal intubation. To date, there is no evidence of the optimal timing of the procedure. The Ciaglia Blue Rhino technique is the most common technique and, as any other techniques of percutaneous tracheostomy, is performed under general anaesthesia and with continuous bronchoscopic control. The recently introduced Ciaglia Blue Dolphin technique is based on radial dilatation with a fluid-filled high pressure balloon. Provided that specific contraindications are observed (e.g. difficult tracheal intubation, inability to identify anatomic landmarks, severe coagulopathy etc.), all techniques have low complication rates. The use of ultrasound may further enhance perioperative safety. Finally it must be noted that percutaneous tracheostomy is an elective procedure that requires informed consent from the patient or an attorney of law.

Safety analysis of percutaneous dilational tracheostomies with bronchoscopy in the obese patient

Since originally described in 1985 by Ciaglia, percutaneous dilational tracheostomy (PDT) has grown in popularity, and today is widely used for critically ill patients requiring long-term mechanical ventilation. Since the inception of PDT, obesity has been considered a relative contraindication to its use. The purpose of this study is to evaluate the risks of PDT in obese patients. Retrospective review. A retrospective review was performed of prospectively collected data from 426 patients who underwent PDT at a single teaching institution from July 2003 to October 2009. The groups were separated into those who had a body mass index (BMI) of <30 or ≥30 kg/m(2) . The following variables were collected: blood loss at the time of procedure, difficulty in tracheotomy dilation and/or tracheostomy placement, presence of tracheal ring breaks, any bleeding episodes requiring treatment by surgery or blood transfusion, pre- and postprocedure pneumonia, and stoma infection requiring antibiotics. All tracheostomies were placed using the Ciaglia Blue Rhino Introducer Kit (Cook Medical Inc., Bloomington, IN). Statistical analysis was performed with nonparametric statistics using χ(2) testing with P < .05 as significant. No statistically significant difference was found between the obese and nonobese groups for any of the variables studied. Similar results were found when BMI of 40 was used for grouping. PDT can be performed safely in obese patients. There were no statistically significant differences in measured variables found between the two study groups. This study supports the use of intensive care unit bedside PDT in the obese population.

Low-Frequency Jet Ventilation Through a Bronchial Blocker for Tracheal Repair After a Rare Complication of Percutaneous Dilatational Tracheostomy

p f ( t t a v t m m o r d t c t t n r l p q A67-YEAR-OLD woman was admitted to the hospital with a left hemispheric hemorrhagic insult. Previously, the atient had been treated with low-dose aspirin for a transient schemic attack and had moderate obesity (with an estimated eight of 90 kg and an estimated height of 1.70 m) but was therwise healthy and independent. Because of a lack of neuologic improvement and difficulties weaning from ventilation weeks after the insult, a decision was made to perform a edside percutaneous dilatational tracheostomy using a comercial kit set (CIAGLIA Blue Rhino; Cook Incorporated, loomington) in the intensive care unit. The procedure was erformed under bronchoscopic guidance. After puncture of the rachea and subsequent aspiration of air into a saline-filled yringe, a guidewire was placed, and the position was conrmed by bronchoscopy. The dilatational sequence was neventful, and the tracheostomy tube was placed. After a entilation check, the absence of CO2 return was noted by apnography. Bronchoscopy showed that the tracheostomy ube had passed through both the anterior and the left posteroateral tracheal wall. The tracheostomy tube was withdrawn, nd an endotracheal tube with a 7.0-mm internal diameter was eplaced beyond the lesion under bronchoscopic guidance. Efective ventilation was confirmed by CO2 return waveform with cceptable value. During the entire procedure, no significant decrease in oxyen saturation or major hemodynamic instability was noted; owever, extensive subcutaneous emphysema in the neck and pper chest was found. The chest x-ray revealed a left-sided neumothorax, which was treated by inserting a chest tube. hereafter, the patient was transferred rapidly to the operating oom for repair of the tracheal tear. The planned operative pproach was through an anterior cervical incision with the eck fully extended. It was believed this would provide good xposure to the site of injury and allow for an open tracheosomy to be performed at the end of the case. The surgeons were repared to perform a partial sternal split if necessary. Before he start of the surgery, a 2nd chest tube was inserted because f the posterior malposition of the 1st tube. Bronchoscopy was erformed through the endotracheal tube so that a bronchial lesion ould be excluded. Thereafter, a 7F Arndt bronchial blocker Arndt Endobronchial Blocker Set; Cook Incorporated, Bloomingon, IN) was advanced successfully through the single-lumen .0-internal diameter endotracheal tube into the right main ronchus under bronchoscopic guidance using the guidewire

Who is performing percutaneous tracheotomies? Practice patterns of surgeons in the USA

Tracheotomy is one of the most common surgical procedures performed in the ICU setting. Traditionally tracheotomy has been performed by otolaryngologists as well as general surgeons. While percutaneous tracheotomy (PT) has been available for some time, it has only recently gained widespread acceptance with the advent of convenient and safe kits. Over the past decade, there has been increased utilization of this technique. However, there is a relative reluctance of certain surgical specialties to perform and train residents in PT; a previous study identified that only 29% of otolaryngology head and neck surgery (OTO-HNS) departments in the USA perform PT. In this study we aim to investigate the trends of PT usage in general surgery training programs and compare them to those previously described in otolaryngology programs. The study design is multi-institution physician survey and the study method was a survey of 250 general surgery program directors. This survey was identical to a published survey of OTO-HNS and a head-to-head comparison of results was performed. The response rate was 53% (133 programs). 89% of general surgery programs performed open tracheotomy on a regular basis. 75% performed percutaneous tracheotomy on a regular basis. 79% use the Ciaglia Blue Rhino method. Simultaneous video bronchoscopy was used by 67%. 83% of general surgery residency programs train their residents in PT. 61% felt that PT was either safer than or equal to open tracheotomy. PT is performed in a majority of general surgery residency programs and taught to their trainees. This is in contrast to otolaryngology residency programs, which have been shown to prefer open tracheotomies in both practice and teaching. This trend may severely impact the skills of the next generation of otolaryngologists.

Comparison between single-step and balloon dilatational tracheostomy in intensive care unit: a single-centre, randomized controlled study

BackgroundBalloon dilatational tracheostomy using the Ciaglia Blue Dolphin device has recently been introduced as a modification of the Ciaglia technique. The aim of this study was to compare the new Dolphin system with the single-step dilatational tracheostomy (Ciaglia Blue Rhino) in intensive care unit (ICU) patients. MethodsConsecutive patients admitted to the ICU of the Emergency Department (Careggi Teaching Hospital, Florence, Italy) from January 2009 to October 2009, aged >18 years and with an indication for percutaneous dilatational tracheostomy (PDT), were enrolled. Exclusion criteria were infection/injury/malignancy of the neck, thyroid gland hypertrophy, severe head injury with uncontrolled intracranial hypertension, and coagulopathy. Patients were randomly assigned to undergo PDT using either the Ciaglia Blue Rhino (n=35) or the Ciaglia Blue Dolphin technique (n=35). Groups were compared according to tracheal puncture, tracheal tube placement time, procedure-related complications, and bleeding. ResultsBaseline clinical data were comparable between the two groups. Median procedure time was significantly shorter in the Rhino group compared with the Dolphin group (1.5 vs 4 min, P = 0.035). The presence of limited intra-tracheal bleeding at bronchoscopy examination after 6 h from PDT was more frequent in the Dolphin group than in the Rhino group patients (68.6% vs 34.3%, respectively, P = 0.008). No major bleeding occurred in either group. ConclusionsPDT using the Ciaglia Blue Dolphin technique is a feasible and viable option in ICU patients, but the Rhino technique had a shorter execution time and seemed to be associated with fewer tracheal injuries.

Early Tracheostomy in Intensive Care Unit: A Retrospective Study of 506 Cases of Video-Guided Ciaglia Blue Rhino Tracheostomies

Percutaneous dilatational tracheostomy (PDT) is a common procedure in critically ill patients, but the correct timing is still controversial. This study was designed to establish whether an early timing in video-guided Ciaglia Blue Rhino PDT affects the duration of mechanical ventilation (MV) and the length of stay (LOS) in intensive care unit (ICU). Secondary clinical outcomes were the overall hospitalization duration and the mortality rate. A retrospective, single-center study of 2,210 patients admitted to the ICU of the Emergency Department of the Careggi Teaching Hospital (Florence, Italy) between 2002 and 2007. Among the 506 patients who underwent PDT, 256 and 250 patients were retrospectively assigned to the early tracheostomy (ET) or late tracheostomy (LT) group according to whether the procedure was performed before (ET) or after (LT) 3 days of MV (median time of procedure execution). The two groups of patients showed comparable demographic and clinical characteristics. The video-guided PDT procedures were performed without major complications in all cases. The average timing of tracheostomy in the ET group was 1.9 +/- 0.9 days, whereas in LT group resulted 6.8 +/- 3.8 days (mean +/- SD). Total hospital LOS and mortality rate were not different between the two groups. However, the duration of MV days and of ICU LOS group were significantly shorter in the ET group (13.3 +/- 9.6 and 16.9 +/- 13.0 days, respectively; p = 0.0001) than in the LT group (16.7 +/- 8.3 days and 20.8 +/- 9.2 days, respectively; p < 0.0001). Stratified analysis by the three major ICU admission diagnosis confirmed that both traumatized and nontraumatized (medical and postsurgical) ET patients had a shorter MV duration and ICU LOS as compared with LT patients. Video-guided Ciaglia Blue Rhino PDT is safe and easy to perform in ICU. No difference in overall hospital LOS, incidence of pneumonia, and mortality rate between the ET and LT groups was found. However, in both traumatized and nontraumatized patients, shortened duration of ICU LOS and MV in the ET group (<or=3 days) indicates this procedure as a useful approach for patients and healthcare system.

Single-step vs balloon dilatation tracheostomy: a pilot study on 20 tracheostomies

The Ciaglia Blue Rhino percutaneous dilatational tracheostomy (PDT) technique, introduced in 1998 as a modification of the original procedure described in 1985, has been indicated as procedure of choice (level 2C) because of its technical simplicity and short procedure time. Recently, a modified balloon dilatation technique (Ciaglia Blue Dolphin) has been introduced with the intention to increase feasibility and safety. Here we report our initial experience in Ciaglia Blue Dolphin tracheostomy in comparison with a prospective control group of Ciaglia Blue Rhino procedures, which are actually the goal-standard in our ICU.

Résultats préliminaires des trachéotomies percutanées

Objectives Percutaneous tracheotomy (PT) is an alternative to surgical tracheotomy (ST). We describe our procedure and discuss the current status of PT through a retrospective study of our first 30 cases. Material and methods Thirty patients had a PT between October 2006 and March 2008 in the intensive care units of Caen University Hospital (France). Twenty-eight were done with the Ciaglia Blue Rhino (CBR) and two with the Percutwist. Each PT was endoscopically guided. We retrospectively collected preoperative data and most of the intraoperative as well as early postoperative complications. Results No death was reported with the PT application. Twenty-two (73.3%) PTs had neither preoperative nor early postoperative complications. Eight complications were observed, half preoperative and half early postoperative. The most frequent complication was minor bleeding in three cases (10%), the most important one was the intraoperative appearance of a tracheoesophageal fistula with the CBR. Discussion The principal advantages of PT are safety attributable to simultaneous endoscopic guidance as well as shorter operative time and lower cost in comparison with the ST technique. Conclusion PT is a safe and valid alternative procedure to ST. Initially performed by intensivists, it should be part of the ENT/head and neck surgeon's repertory as the upper airway specialist.

Fantoni translaryngeal tracheostomy versus ciaglia blue rhino percutaneous tracheostomy: A retrospective comparison

To compare the operative technique and complications of the Fantoni tracheostomy (TLT) with those of the Ciaglia Blue Rhino tracheostomy (CBR). We also compared the costs of mini-invasive tracheostomy with those of surgical tracheostomy (ST). Between January 1998 and January 2006, 530 patients needed emergency intubation and protracted assisted ventilation in our department. We performed 470 mini-invasive tracheostomies: as TLT in 350 and as CBR in 120. The time between intubation and tracheostomy was 4 +/- 1 days. Interventions were carried out in our intensive care unit (ICU). One hundred and nine patients died within 20 +/- 5 days of intervention, but 361 are still alive after 100 +/- 3 months. TLT and CBR complications were independent of the operative technique (P = 0.74, r = 0.285 vs P = 0.61, r = 0.271) or procedure time (P = 0.95, r = 0.297 vs P = 0.92, r = 0.295). Ciaglia Blue Rhino tracheostomy was noted to have a cost-benefit advantage over TLT and ST (P = 0.0002, P = 0.009, P = 0.22, respectively). The average time until decannulation was 20 +/- 1 days. Mini-invasive tracheostomies are easy, safe, and fast. Ciaglia Blue Rhino tracheostomy took less time to perform and had fewer complications than TLT, because the technique was simpler.

Percutaneous tracheotomy in otolaryngology–head and neck surgery residency training programs

Percutaneous tracheotomy (PT) has been garnering attention in otolaryngology-head and neck surgery (OTO-HNS) community for many years. This procedure is used routinely by a variety of surgical disciplines; yet its use remains controversial especially in OTO-HNS. The purpose of this study is to understand the current practices pertaining to PT in OTO-HNS training programs. Multi-institution physician survey. A survey of 102 American OTO-HNS residency program directors. The response rate was 80%. 29% of programs perform PT on a regular basis. Ciaglia Blue Rhino method was used by all respondents who could identify the method used. Simultaneous video bronchoscopy was always used by 91% of those who performed PT. Among respondents in programs where PT was not done regularly, 18% felt that it was the method of choice for selected patients; among those in programs where PT was done regularly, 72% felt that it was the method of choice. 64% of respondents indicated that other hospital services regularly performed PT in their institution, and this was evenly split between trauma, general surgery, pulmonology and intensive care unit (ICU). There was no significant difference in this regard between respondents from hospitals that did or did not do PT. 71% of OTO-HNS graduates are not trained in PT. Only 29% of otolaryngology residency programs in the U.S. perform PT regularly. This study objectively shows that this is a highly polarized subject amongst OTO-HNS but apparently not in medicine in general. Further study is needed to understand the reason for this controversy.

Fiberoptic bronchoscopy–assisted percutaneous tracheostomy is safe in obese critically ill patients: A prospective and comparative study

Background Obesity has reached epidemic proportions worldwide. In Latin America, 10% to 35% of the population is obese. Obese critically ill patients are at greater risk for requiring intubation and prolonged mechanical ventilation; and in some cases, it is necessary to perform a tracheostomy. Objective The objective of the study was to compare the incidence of perioperative complications associated with percutaneous tracheostomy (PT) using the fiberoptic bronchoscopy–assisted Ciaglia Blue Rhino technique (Cook Critical Care, Bloomington, IN) in obese vs nonobese critically ill patients. Patients and Method A prospective evaluation was made of 120 patients who underwent PT because of prolonged mechanical ventilation. An analysis of the incidence of operative and early postoperative complications was performed comparing an obese patient group (n = 25) with a nonobese patient group (n = 80). Obesity was defined by a body mass index of at least 30 kg/m 2. Results The 2 groups had no significant differences in their demographic characteristics. The average body mass index for the obese patient group was 38 ± 9 kg/m 2 vs 22 ± 3 kg/m 2 for the nonobese patient group ( P < .001). The obese patients required 18 ± 7 days of mechanical ventilation, on average, before PT vs 16 ± 7 days for the nonobese patients ( P = .15). The incidence of operative complications for the obese patients vs nonobese patients was 8% and 7.5%, respectively ( P = 1). The incidence of early postoperative complications was 8% for the obese patients vs 2.5% for the nonobese patients ( P = .2). Conclusion Percutaneous tracheostomy using the fiberoptic bronchoscopy–assisted Ciaglia Blue Rhino technique is safe for obese critically ill patients when performed by an experienced intensivist.

P.147 Percutaneous tracheostomy with the Ciaglia Blue Rhino Dilator

To sum up our experience in percutaneous dilatational tracheostomy (PDT) in ICU patient with severe brain injury.Between November 2011 and April 2014, PDTs were performed on 32 severe brain injury patients in ICU by a team of physicians and intensivists. The success rate, efficacy, safety, and complications including stomal infection and bleeding, paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, as well as clinically significant tracheal stenosis were carefully monitored and recorded respectively.The operations took 4-15 minutes (mean 9.1 minutes±4.2 minutes). Totally 4 cases suffered from complications in the operations: 3 cases of stomal bleeding, and 1 case of intratracheal bloody secretion, but none required intervention. Paratracheal insertion, pneumothorax, pneumomediastinum, tracheal laceration, or clinically significant tracheal stenosis were not found in PDT patients. There was no procedure-related death occurring during or after PDT.Our study demonstrats that PDT is a safe, highly effective, and minimally invasive procedure. The appropriate sedation and airway management perioperatively help to reduce complication rates. PDT should be performed or supervised by a team of physicians with extensive experience in this procedure, and also an intensivist with experience in difficult airway management.

Comparison between the Percutwist® and the Ciaglia® percutaneous tracheotomy techniques

A prospective study was designed to compare two single-dilator percutaneous tracheotomy techniques, the Ciaglia BlueRhino and the Percutwist technique. One hundred and ninety adult patients were included, 166 with the BlueRhino, a conical shaped, flexible rubber dilator, and 24 with the Percutwist, a screw like dilating device. The procedure was performed under fiberscopy in the intensive care unit (ICU). Age, body mass index (BMI), indication for tracheotomy, surgical landmarks, duration of the procedure and surgical complications were recorded. Median age and indications were similar for the two groups. Dilation was successful in all patients. The mean time for surgery was shorter with the Ciaglia technique: 8 +/- 3 versus 12 +/- 5 min with the Percutwist technique (P = 0.004). There was no significant difference related to weight, BMI, duration of tracheotomy and complications between both groups. One posterior tracheal wall puncture was observed with the Ciaglia technique and four with the Percutwist technique. No serious complications were noted with either technique. The Percutwist technique represents an alternative to the more established Ciaglia BlueRhino technique. The Ciaglia technique is a safe and more rapid procedure for bedside tracheotomy.

Percutaneous Dilational Tracheostomy in a Community Intensive Care Unit.

Percutaneous dilational tracheostomy (PDT) is increasingly being used to replace traditional surgical tracheostomy (ST) in the management of critically ill patients. There is considerable controversy regarding the safety of this procedure in the hands of non-surgeons, and most data so far have come from large tertiary care centres. We report our experience and safety data in the implementation of a PDT program for critically ill patients in a teaching community hospital in an attempt to demonstrate that this procedure can be performed safely outside of an academic ICU. Prospective observational study in a large community teaching hospital. All patients without contraindications were considered for enrollment. Contraindications to PDT included evidence of infection at the surgical site, the presence of a coagulopathy not correctable to an international normalized ratio of less than 1.5, or unstable cervical spine injuries. A total of 42 patients were included in the study and all received PDT using the Ciaglia Blue Rhino single dilator introducer set (Cook Critical Care, Bloomington, IN, USA). Data collected included patient age, sex, reason for intubation, and complications. Of 42 patients, 25 were males, and 17 were females. The average age was 47.6 years (range 16-87 years). The commonest admitting diagnosis was traumatic brain injury, followed by sepsis and cardiac arrest. Our total recorded complication rate was 7.1%, with no deaths. There were two episodes of transient hypotension (4.8%). Percutaneous dilational tracheostomy appears to be at least as safe as traditional ST, and may have advantages with respect to timeliness and minimization of patient transport. The complication rate seen in our program is similar to that seen in other PDT series.

Tracheotomy: clinical review and guidelines

Tracheotomy is a commonly performed procedure. The Belgian Society of Pneumology (BVP-SBP) and the Belgian Association for Cardiothoracic Surgery (BACTS) developed guidelines on tracheotomy for mechanical ventilation in adults. The levels of evidence as developed by the American College of Chest Physicians (ACCP) were used. The members of the guideline committee reviewed peer-reviewed publications on this subject. After discussion, a proposal of guidelines was placed on the website for remarks and suggestions of the members. Remarks and suggestions were discussed and used to adapt the guidelines when judged necessary. The different techniques of tracheotomy are described. The potential advantages and disadvantages of surgical and percutaneous tracheotomy versus endotracheal intubation are discussed. An overview of early and late complications is given. Low-pressure, high-volume cuffs should be used. The cuff pressure should be monitored with calibrated devices and recorded at least once every nursing shift and after manipulation of the tracheotomy tubes. Inspired gas should be humidified and heated. Regarding the timing of tracheotomy there are not enough well-designed studies to establish clear guidelines. Therefore, the timing of tracheotomy should be individualised. In critically ill adult patients requiring prolonged mechanical ventilation, tracheotomy performed at an early stage (within the first week) may shorten the duration of artificial ventilation and length of stay in intensive care. Percutaneous dilatational tracheotomy (PDT) appears to be at least as safe as surgical tracheotomy (ST) as measured in terms of peri-procedural complications. With PDT, less wound infection is observed. When PDT is compared to ST performed in the operating room, PDT is less expensive, reduces the time between the decision and the performance of tracheotomy and has a lower mortality rate. Different techniques of PDT are discussed. We recommend performing PDT under bronchoscopic guidance. Because of its technical simplicity and short procedure time, the modified Ciaglia Blue Rhino technique is advocated as technique of choice. PDT should be considered the procedure of choice in elective non-urgent tracheotomy. There are some relative contraindications for PDT, but with growing experience, they become less frequent.

Locally Developed Guidelines Reduce Immediate Complications from Percutaneous Dilatational Tracheostomy Using the Ciaglia Blue Rhino Technique: A Report on 200 Procedures

Ciaglia Blue Rhino percutaneous dilatational tracheostomy is used as an aid to ventilatory weaning. It carries an immediate complication rate previously reported in 100 consecutive patients by Fikkers et al at 6% for "major" complications and 30% for "minor" complications. Mortality has been associated with the procedure. Our institution has performed dilatational percutaneous tracheostomy since 1998 and used the Blue Rhino technique since 2002. Consensus guidelines were developed following initial experiences. They focus on preoperative risk assessment including levels of ventilatory support and anatomical considerations, seniority of staff use of bronchoscopy and capnography and correction of coagulopathies. Following introduction of the guidelines we conducted an audit of the first 200 Ciaglia Blue Rhino tracheostomies performed. There was an immediate major complication rate of 3% and minor complication rate of 18%. No deaths occurred within 24 hours of the procedure. We conclude that applying our consensus guidelines produced an immediate complication rate for Ciaglia Blue Rhino percutaneous dilatational tracheostomy below published audits.

Safety of Performing Percutaneous Dilational Tracheostomy in Patients with Preexisting Barotrauma

Since its introduction in 1985 by Ciaglia et al, percutaneous dilational tracheostomy (PDT) has gradually become the procedure of choice in establishing a long-term airway in many intensive care units (ICU). However, the safety of performing PDT in patients with barotrauma is still unknown and has never been reported. We present the case of a 35-year-old man with AIDS, who was admitted to our medical ICU for pneumonia and acute respiratory distress syndrome. He developed subcutaneous emphysema and pneumomediastinum as complications of mechanical ventilation. After stabilization of the barotrauma, he underwent PDT with the standard Ciaglia Blue Rhino technique. However, rapid and extensive progression of preexisting barotraumas occurred shortly after PDT. This severe complication was nearly fatal. The prolonged procedure during which the susceptible lung was exposed to longer duration of high airway pressure was thought to be the mechanism of rapid deterioration of the preexisting barotrauma. With aggressive supportive care, the patient survived. To prevent further deterioration of preexisting barotraumas during and after PDT in future cases, we propose some principles that should be strictly followed. Under administration of these principles, we safely performed PDT in another case with preexisting barotrauma 1 month later.

A simple modification of Ciaglia Blue Rhino technique for tracheostomy: using a guidewire dilating forceps for initial dilation

The potential difficulty in doing initial dilation in the percutaneous dilational tracheostomy (PDT) with the Ciaglia Blue Rhino (CBR) technique has been reported by others and encountered in our clinical practice. To resolve this problem, we developed a modified CBR technique by using a guidewire dilating forceps (GWDF) to facilitate initial dilation. The present before-and-after comparison study aimed to evaluate the clinical benefits of this modified CBR technique. Consecutive 120 patients undergoing CBR technique in the pre-conversion year and 114 patients undergoing GWDF-CBR technique in the post-conversion year were enrolled for analysis. The procedure time and procedure-related complications were compared between these two groups. The mean procedure time with GWDF-CBR technique was 4.5+/-1.6min, significantly shorter than 5.7+/-3.0min with CBR technique (p<0.001). Only two patients in the GWDF-CBR group required prolonged procedure time (>8min), compared with 14 patients in the CBR group. Thirty three (27.5%) of 120 patients undergoing CBR technique and 15 (13.1%) of 114 patients undergoing GWDF-CBR technique had PDT-related complications (p=0.006). Most of the complications were minor and transient. Only 13 patients in the CBR group and 3 patients in the GWDF-CBR group encountered major complications (10.8% vs 2.6%, p=0.012). Regarding the high-risk patients, 21 (36.2%) of 58 patients in the CBR group and 9 (15.8%) of 57 patients in the GWDF-CBR group had PDT-related complications (p=0.011). Pre-dilation with a GWDF in the CBR technique helped to prevent prolonged procedure time and procedure-related complications. We suggest that the bronchoscopy-guided GWDF-CBR serves an easy-to-operate and relatively safe PDT technique for critically ill patients.