PercuTwist: A New Single-Dilator Technique for Percutaneous Tracheostomy

With the introduction of modern percutaneous tracheostomy by Pasquale Ciaglia in 1985 and the guidewire dilating forceps technique, introduced by Griggs in 1990, a new era was begun in airway maintenance in intensive care medicine (1,2). Percutaneous tracheostomy is an established procedure for airway management in critically ill patients who require long-term respiratory support, and within the last few years, the number of percutaneous tracheostomies and the use of this technique by intensivists without specialized surgical training are steadily increasing (3). Despite its reportedly small rate of complications, severe adverse events have been reported during percutaneous tracheostomy including bleeding, posterior tracheal wall injury, pneumomediastinum, and even death (4–7). A reduction of these potentially life-threatening complications was observed with the introduction of single-step dilator techniques (7–11). These include translaryngeal tracheostomy (TLT), introduced by Fantoni and Ripamonti in 1997 (8), and the Blue Rhino technique (CBR) (9), an extensive modification of the basic technique of percutaneous dilational tracheostomy that was developed by Ciaglia in 1999. Recently, a third technique with one-step dilation has become available, the PercuTwist tracheostomy set. PercuTwist mainly consists of a screwlike dilating device that lifts the anterior tracheal wall during dilation thus keeping the tracheal lumen open and enabling an unrestricted bronchoscopic view of the dilation site at any given time. Theoretically, the risk of posterior tracheal wall perforation could be further minimized with this new technique. We report the use of the new PercuTwist technique in 10 patients to preliminarily evaluate and discuss practicability, safety, and eventual complications. Methods Ten consecutive adult patients on long-term ventilation underwent elective PercuTwist tracheostomy with the approval of our IRB and after informed, written consent was obtained from a designated power of attorney. Contraindications were infection of the tracheostomy site, known or expected difficult endotracheal intubation, distorted anatomy with unidentifiable anatomic landmarks, an unstable cervical spine, and age <18 yr. All tracheostomies were performed at the bedside on the intensive care unit under general IV anesthesia using propofol, fentanyl, and pancuronium. Ten minutes before the tracheostomy procedure, the positive end-expiratory pressure was reduced stepwise to 5 mm Hg if required, and all patients received positive-pressure ventilation with 100% oxygen throughout the tracheostomy. After insertion of the tracheostomy tube, the fraction of inspired oxygen (Fio2) and the positive end-expiratory pressure were set to the preoperative levels. If under this regimen hemoglobin saturation (Spo2) measured by pulse oximetry decreased to less than the preoperative level, the Fio2 was increased stepwise until the baseline Spo2 was reestablished. Besides pulse oximetry, intraoperative monitoring consisted of invasive blood pressure monitoring and electrocardiogram. To assess the influence of tracheostomy on the patient’s oxygenation, arterial blood gas samples were obtained 15 min before tracheostomy and again after completion of the procedure and reestablishment of the preoperative Spo2. The blood samples were immediately analyzed for arterial partial pressure of oxygen (Pao2) (ABL3, Acid Base Laboratory/Hemoxymeter, Radiometer, Copenhagen, Denmark). For percutaneous tracheostomy, the PercuTwist Set with a 9.0-mm internal diameter (ID) PercuQuick tracheostomy cannula (Rüsch GmbH, Kernen, Germany;Fig. 1) was used.Figure 1: PercuTwist set with 9.0 internal diameter (ID) PercuQuick tracheostomy cannula (Rüsch GmbH, Kernen, Germany; left) and the PercuTwist dilator with rotating movements under gentle elevation of the cervical tissues and the anterior tracheal wall (right).The patient’s neck was slightly reclined, and the surgical area was cleansed and prepared with surgical drapes in the typical manner. A flexible fiberoptic bronchoscope was used in every instance. To facilitate access to the trachea, the tracheal tube in place was withdrawn under direct laryngoscopy to the level of the glottic opening. After identification of the anatomical landmarks, the puncture cannula was advanced through the anterior wall of the trachea, generally between the second and third tracheal ring, and positioned centrally in the midline of the trachea. Once the cannula tip was intratracheally positioned, the syringe and the internal metal guide were removed. The guidewire with the flexible J tip was sufficiently advanced caudally into the trachea through the plastic indwelling cannula, and an incision of approximately 3–4 mm long into the skin on both sides of the guidewire was made to facilitate penetration with the dilator. The hydrophilic coating of the PercuTwist dilator was then activated by wetting and advanced over the guidewire to widen the initial access to the trachea by carefully rotating the dilator clockwise into the soft tissue. Once the end of the thread of the dilator cut through the anterior tracheal wall and was endoscopically seen in the trachea, the dilation process was continued by gentle elevation of the anterior tracheal wall with the dilator while screwing it further intratracheally under endoscopic vision of the puncture site (Fig. 1). Then the dilator was removed by carefully rotating it in a counter-clockwise direction out of the trachea, with the guidewire remaining in the trachea. The tracheostomy cannula with an insertion dilator was then placed over the in situ guidewire using Seldinger’s technique. Once the tracheostomy cannula had been positioned, the insertion stylet was removed along with the guidewire. The tracheostomy cannula was fixed and adjusted with the retention plate and the locking mechanism. All data are presented as mean ± sd and range when appropriate. Calculation and data analysis were performed using a statistical package (GraphPad InStat 3.0, GraphPad Software, San Diego, CA). Statistical significance was determined with the Wilcoxon matched pairs test. Differences were considered to be statistically significant if P < 0.05. Results The PercuTwist procedure was successfully performed in all cases. Before tracheostomy, all patients had their tracheas intubated with oral tubes for a mean of 7.1 ± 2.4 days (range, 4–10 days). The operating time was defined as the interval from puncture of the trachea until connection of the tracheostomy tube to the respirator and was 5.4 ± 1.3 min (range, 4–8 min). No statistically significant deterioration of the Pao2/Fio2 ratio was noted when preoperative values were compared with the postoperative ones (P = 0.1602). During the study, two minor complications (bleeding of approximately 20 mL) were noted. In both patients, the bleeding ceased once the tracheostomy cannula was in place. No fractures of isolated tracheal cartilages were seen via bronchoscopy during the tracheostomy. The patients stayed cannulated for an average of 19 ± 12 days (range, 8–45 days). During a total of 194 days of cannulation, no other complications such as premature decannulation, stoma infections, and so on were seen. Eight patients were successfully decannulated during their hospital stay. Two patients died cannulated as a result of their underlying disease or its complications (Table 1).Table 1: Diagnosis and Perioperative Complications in Patients who Underwent Elective PercuTwist TracheostomyDiscussion Elective tracheostomy is the most common operative intervention in intensive care medicine. Some 31,000 tracheostomies are performed in Germany annually, and more than 50% of them are with percutaneous techniques (12). All percutaneous methods have one thing in common: the initial puncture of the trachea with subsequent dilation up to the degree required for positioning of the tracheal cannula. The difference is the dilation itself with multiple- or single-dilator techniques, the latter technique being supposed to cause fewer and less severe complications than the multiple-dilator technique (7,9–11). TLT represents the only retrograde one-step minimally invasive procedure. Dilation of the stoma is achieved from inside the trachea with the tracheal cannula itself. Because no pressure is applied to the anterior tracheal wall, the risk of posterior tracheal wall injury has been virtually eliminated. There is only one report of posterior tracheal wall injury during TLT that was associated with intratracheal cannula rotation (7). Since the introduction of the first antegrade single-step technique CBR in 1999, not only have very short operating times been reported, but also a remarkable incidence of tracheal ring fractures (9) and even posterior tracheal wall injury in two patients (13,14). A recent analysis of prospective studies on percutaneous tracheostomy reported a serious complication rate less than 3% for the single-step techniques of TLT and CBR (10). There have been no experiences and studies for the new PercuTwist technique until now. With the exception of two minor bleeding episodes during dilation that spontaneously ceased after placement of the tracheal cannula, no complications were observed in our patients. Despite these first encouraging results in a small cohort, we believe that complications such as bleeding and damage to the posterior tracheal wall still may occur for a number of reasons. Before initiating the dilation with the bolt, a sufficient incision into the skin is essential, otherwise there is the possibility of screwing fragments of the skin into the pretracheal soft tissue. While advancing the Percu-Twist dilator, traction and propelling forces may cause bleeding, as observed. The most important advantage of TLT—protection of the posterior tracheal wall—ought to be imitated by the antegrade screwing of the PercuTwist dilator by simultaneous elevation of the anterior tracheal wall. We agree, but with an important reservation: until the firm conical dilator catches hold between two tracheal rings, pressure inevitably has to be exerted upon the trachea. In 6 of our 10 patients, the anterior wall was pressed closely against the posterior wall, so even with the endoscopic viewing, damage of the posterior wall had been possible. As soon as the thread catches hold, gentle elevation is applied, and the dilator is screwed in until the desired degree of dilation is achieved, with the dilator then being approximately 24 mm intratracheally and therefore almost in contact with the posterior wall, even with traction force. Posterior tracheal wall perforation has also been observed with the antegrade single-step dilation CBR technique during placement of the tracheal cannula. Force applied to the anterior tracheal wall and subsequent collapse of the tracheal lumen seems to be the mechanism of this potentially devastating complication (13,14). The danger of posterior tracheal wall injury remains a disadvantage of any percutaneous tracheostomy technique with antegrade dilation but seems to be less with the PercuTwist technique because of two most important differences. First, the dilation degree of the PercuTwist technique is larger than that of the CBR: 13.5 mm for PercuTwist versus 12 mm for CBR. Second, the loading dilator of the PercuTwist technique fits more closely to the tracheal cannula than the dilator used with the CBR technique: the Rüsch 9.0-mm ID PercuQuick tracheal cannula used in our study has a 7-mm conical tip, whereas there is only a 3-mm conical tip with the Mallinckrodt 9.3-mm ID Percsoft cannula (Mallinckrodt Inc, St Louis, MO) that we used with CBR in previous studies (9). For that reason, a lot less strength is required to insert the tracheal cannula with the PercuTwist technique, thereby reducing the risk of posterior tracheal wall injury. In summary, no clinically important complications occurred in our first few patients who underwent tracheostomy with the new PercuTwist technique. Nevertheless, the potential risk of bleeding or posterior tracheal wall injury cannot be definitely excluded. The evaluation and usefulness of the PercuTwist technique compared with the established CBR and TLT techniques, which have very few complications, should be evaluated in randomized, controlled clinical trials.