Percutaneous tracheostomy

We read with interest the survey report ‘Use and safety of percutaneous tracheostomy in intensive care’ (Anaesthesia 1998; 53: 1209–27). We would like to comment on some aspects of practice in percutaneous tracheostomy, as borne out in the survey. We agree with the author that percutaneous tracheostomy is a well-established technique in intensive care. The reasons for this are its simple bedside application, ease of scheduling, avoidance of transporting critically ill patients requiring invasive monitoring, and its cost-effectiveness. Of the four known methods of percutaneous tracheostomy (PCT), only two are currently used widely [1]: the percutaneous dilatation technique described by Ciaglia (PDT) and the guidewire dilatation forceps technique (GWDF). The ‘Toye’ method and the ‘Rapitrac’ method have mostly fallen into disuse because of high complication rates [2–5]. Dr Cooper's survey also shows that the Ciaglia method is in much greater use in the UK ICUs than is the GWDF method (72% vs. 43% of the survey respondents). Although there are no data available directly comparing the two methods, the literature indicates that the GWDF method is a much safer, quicker and more cost-effective method. Pooled data from over 1600 patients who underwent percutaneous tracheostomy shows that the overall peri-operative complication rate for the GWDF method is 1.2% compared with 7.6% for the Ciaglia method. The long-term postoperative complication rate reported is 2% for the GWDF method, and 5.5% for the Ciaglia method [1]. Serious complications, although uncommon, have been reported with the Ciaglia method (PDT) — false passage, pneumothorax, difficulty with dilatation, bronchospasm and death [6, 7]. There is no mortality reported with the GWDF method [8–10]. In our ICU, we performed 17 percutaneous tracheostomies in 1998. All of them were done using the GWDF (Portex kit) technique. A minor complication was encountered in only one patient — skin edge bleeding. Our very low complication rate may in part be due to proper patient selection, and previous experience with the standard open surgical tracheostomy technique. By sterilising and reusing the guidewire dilating forceps, the cost of the method is decreased. The dilators in the Ciaglia method are for single use only. The mean (SD) operative time reported for performing PCT by the Ciaglia method is 15 (8) min [11]. The operative time reported for the GWDF method is 1–10 min [9]. The duration for percutaneous tracheostomy by GWDF method in our own ICU is 4–7 min. We consider that endoscopic guidance via the pre-operatively established airway is not necessary when using the GWDF technique because of: 1 visualisation of the trachea with the guidewire dilating forceps as a separate step, before introduction of the tracheostomy cannula, 2 ease of the procedure and 3 extremely low complication rate. On the other hand, endoscopic guidance seems to be desirable with the Ciaglia technique [12]. Based on current literature and our own experience, the GWDF method of performing percutaneous tracheostomy seems to be safer, quicker and more cost-effective than the Ciaglia method. The rationale for development of alternative methods of tracheostomy has been the number and frequency of complications associated with the standard open method [1]. The complications associated with Ciaglia's method are similar to those associated with the standard open technique [1], defeating one of the main reasons for developing alternative techniques. Further studies are needed to compare directly the Ciaglia method and the GWDF method for percutaneous tracheostomy. We are surprised that 2% of the survey respondents still use the Rapitrac method, considering that a 22.9% complication rate has been reported with this technique [1].