Question 9

College Answer

Commonly used techniques include: Ciaglia, Griggs (portex}, a combination of  these, and the Translaryngeal approaches.

Ciaglia:

Advantages: initial technique, widely used, well known, well documented complication rate (low),
gradual dilatation, able to insert any type of tracheostomy tube

Disadvantages: need experienced operator and airway operator, endotracheal tube positioning may damage vocal cords or lose PEEP/minute ventilation/protection of airway, takes minutes to dilate
and spray of blood stained respiratory gases with each inspiration unless hole completely covered each time, damage to posterior wall of trachea with initial perforation and subsequent dilatations (? minimised by use of bronchoscope)

Griggs (Portex):

Advantages: less steps in technique, faster dilatation (may be used in emergency), able to insert any
type of tracheostomy tube

Disadvantages: need experienced operator and airway operator, needs sterilization of forceps if previously used, endotracheal tube positioning may damage vocal cords or  lose PEEP/minute ventilation/protection of airway, more abrupt dilatation (may cause more tracheal damage), spray of blood stained respiratory gases with each inspiration unless hole completely covered, damage to posterior wall of trachea with initial perforation and subsequent dilatations (? minimised by use of bronchoscope), may want to insert different tracheostomy tube (wasting tube in pack)

Translaryngeal:

Advantages: well documented complication rate (very low, especially bleeding), has been safely used with marked coagulopathy, initial tracheal puncture under vision from inside trachea, avoids damage to posterior wall of trachea, allows ventilation (separate tube) throughout procedure, can be done as one person technique

Disadvantages: less widely known technique out of Europe, more fiddly technique, need experienced operator, requires Light sowce and scope (rigid or flexible), ventilation may be difficult
with small endotracheal tube, pulling through the tracheostomy  tube may damage vocal cords, only able to insert one type of tracheostomy tube (not tube with inner cannula), need to use different technique to change type of tube

Discussion

This answer, as a table:

	Advantages	Disadvantages
Classical Ciaglia (multiple dilators)	Well known Well studied Well practice Complication rate is notoriously low Multiple sequential dilators ensure that little force and little pressure is required Thus, less risk of posterior wall puncture Less tracheal trauma	Supraglottic ETT position may result in loss of PEEP or loss of the airway altogether Potential of posterior tracheal wall puncture Exposes operators to blood spray Increases exposure to aerosolised airway secretions Prolonged procedure Multiple steps: difficult to learn Long straight dilators lend themselves to posterior tracheal wall laceration Multiple manipulations of the guidewire can result in dislodgement of the wire out of the trachea.
Ciaglia Blue Rhino	Faster than the classic technique Fewer steps Curved dilator: less risk of posterior wall puncture	Single large dilator: risk of tracheal trauma All the same problems with ETT being above the cords (see above)
Griggs forceps technique	Faster technique – less dilatations (potentially, the fastest) Less blood spray exposure (potentially)	Potential for more tracheal damage Requires sterile forceps Less researched More potential for infectious complications Greater potential for guidewire loss
Cianchi balloon dilation technique	No risk of injuring the posterior wall No sequential dilators: one balloon only No forceful pushing required	Takes longer More steps are required Tracheostomy tube is more difficult to pass into the dilated opening
Frova and Quintel (PercuTwist) technique	Less risk of injuring the posterior wall No sequential dilators: one balloon only No forceful pushing required Single dilator technique	No specific protection againt posterior wall lacerations or cartilage fractures Not widely available No speed advantage over Griggs or other single-dilator techniques
Translaryngeal (Fantoni)	Very low complication rate Can be a one-person technique No pressure is directed towards the posterior wall	Largely unknown technique Relies on small endotracheal tube to ventilate Requires additional equipment Chance of vocal cord damage At one point, you are expected to have no airway whatsoever.

Essentially, in the Ciaglia technique one dilates the trachea sequentially using a series of dilators, whereas in the Griggs technique one ends up dilating most of the trachea using forceps.

The Fantoni technique is different. in this one you use a Seldinger technique to pass a guidewire though the trachea and up through the mouth. Then, through the mouth the tracheostomy tube is advanced on an armoured trochar which is pushed to pierce though the wall of the trachea, and to emerge hideously out of the neck like the Alien. Weirdly, it seems to be the safest approach. The main benefit is that one is able to ventilate the patient thoughout this process by using the thin-walled ETT which comes with the set.

Byhahn, C., V. Lischke, and K. Westphal. "Translaryngeal tracheostomy in highly unstable patients." Anaesthesia 55.7 (2000): 678-683.

 

Ambesh, Sushil P., et al. "Percutaneous tracheostomy with single dilatation technique: a prospective, randomized comparison of Ciaglia Blue Rhino versus Griggs’ guidewire dilating forceps." Anesthesia & Analgesia 95.6 (2002): 1739-1745.

 

Antonelli, Massimo, et al. "Percutaneous translaryngeal versus surgical tracheostomy: A randomized trial with 1-yr double-blind follow-up*." Critical care medicine 33.5 (2005): 1015-1020.