Bedside Percutaneous Tracheostomy: Clinical Comparison of Griggs and Fantoni Techniques

Elective tracheostomy is widely considered the preferred airway management of patients on long-term ventilation. In addition to open tracheostomy, a number of percutaneous procedures have been introduced during the last two decades, among them techniques according to Griggs (guidewire dilating forceps, or GWDF) and to Fantoni (translaryngeal tracheostomy, or TLT). The aim of the study was to evaluate these two techniques in terms of perioperative complications, risks, and benefits in critically ill patients. A series of 100 critically ill adult patients on long-term ventilation underwent elective percutaneous tracheostomy, either according to the Griggs (n= 50) or Fantoni (n= 50) technique. Tracheostomy was performed under general anesthesia at the patient's bedside. The mean (±SD) operating times were short, 9.2 ± 3.9 minutes (TLT) and 4.8 ± 3.7 minutes (GWDF) on average. Perioperative complications were noted in 4% of patients during either TLT or GWDF and included massive bleeding, mediastinal emphysema, posterior tracheal wall injury, and pretracheal placement of the tracheostomy tube. With regard to oxygenation, pre- and postoperative arterial oxygen tension divided by the fraction of inspired oxygen (PaO₂/FiO₂) ratios did not vary significantly, and no perioperative hypoxia was noted regardless of the technique used. We conclude that both TLT and GWDF represent attractive, safe alternatives to conventional tracheostomy or other percutaneous procedures if carefully performed by experienced physicians and under bronchoscopic control.     

Perkutane Tracheotomie in der Intensivmedizin Praktikabilität und Frühkomplikationen der translaryngealen Technik nach Fantoni

Tracheostomy is considered the airway management of choice in long-term ventilated ICU patients. In the last few years, percutaneous dilatational tracheostomy (PDT) has been established as an attractive and safe alternative to conventional open tracheostomy. Recently, there is another percutaneous technique according to Fantoni with translaryngeal airway access (TLT) available. Our study seeks to evaluate TLT in terms of complications and practicability. In 47 patients of our surgical ICU, elective TLT was performed. Mean operative time was 9.8 +/- 10.9 (range 6-27) minutes. Severe complications, such as bleeding, aspiration or infection of the tracheostoma have never been noted. A slight deterioration of arterial oxygen tension occurred in 25 patients intraoperatively, demanding to rise the concentration of inspired oxygen temporarily. However, no patient became hypoxic during the procedure. Since during the procedure gas exchange may worsen, TLT should not be employed in patients whose inspired oxygen concentration exceeds 80%. Despite the fact that severe complications associated with TLT have recently not yet been reported, physicians who perform TLT should be well-trained in the technique of conventional open tracheostomy, too. According to our present data, TLT seems to be an attractive and safe alternative to PDT. Nevertheless, for a definitive evaluation of TLT, further investigations in larger groups of patients and in the long term seem to be necessary.     

Tracheostomy in cardiosurgical patients: surgical tracheostomy versus ciaglia and fantoni methods.

BACKGROUND: Patients requiring prolonged mechanical ventilation are not uncommon in a cardiosurgical intensive care unit. Elective tracheostomy is considered the airway treatment of choice in these patients. METHODS: To evaluate different techniques for tracheostomy, we prospectively investigated 120 patients who had conventional open (n = 40), minimally invasive percutaneous dilatational (n = 40), or translaryngeal (n = 40) tracheostomy techniques. The main areas of investigation included oxygenation index (partial pressure of arterial oxygen divided by fraction of inspired oxygen), complications, infection, and cost. RESULTS: The oxygenation index decreased in almost every patient, regardless of the technique used, but the extent of decrease was significantly lower in both minimally invasive techniques compared with the conventional method. Overall complication rate was 12.5% both in open tracheostomy and in percutaneous dilatational tracheostomy, whereas no complications occurred in translaryngeal tracheostomy procedures. Bacterial contamination of the tracheostomy site was found in 35% of the open tracheostomies, whereas no infection was seen in percutaneous dilatational or translaryngeal tracheostomies. In terms of costs, PDT ($506) and TLT ($362) were both much cheaper than open tracheostomy ($699). CONCLUSIONS: Percutaneous dilatational and translaryngeal tracheostomies are safe and cost-effective procedures that can be done easily at the patient's bedside and thus are attractive alternatives to conventional surgical tracheostomy in long-term airway access in a cardiosurgical intensive care unit.     

Die Tracheotomie in der Intensivmedizin

Tracheostomy is one of the oldest surgical procedures and in the past decades has become the method of choice in the management of patients requiring long-term mechanical ventilation. At present, several alternatives exist to conventional surgical tracheostomy, such as the percutaneous dilatational techniques according to Ciaglia (PDT), Griggs (GWDF), and Schachner (Rapitrach). In particular, PDT according to Ciaglia which was introduced in 1985, has been recognized as an equally safe, but less expensive procedure than conventional tracheostomy. Fantoni's translaryngeal percutaneous technique is another new and safe procedure, which was first performed in 1996. Nonetheless, we believe that percutaneous procedures should only be performed by experienced physicians who are well-trained in both endotracheal intubation and mask ventilation. Furthermore, the capacity to perform surgical tracheostomy immediately in case of complications should be given. Only if the contraindications are carefully observed, will these new procedures retain their value and benefit in airway management of long-term ventilated patients.     

Translaryngeal tracheostomy in highly unstable patients

Percutaneous tracheostomy is a widely accepted and commonly performed technique for attaining long-term airway access in critically ill patients. However, severe respiratory failure and coagulopathy are relative contraindications for these procedures. We describe two patients with severe respiratory failure and inhibitor-complicated haemophilia A who underwent elective percutaneous tracheostomy performed translaryngeally, using the new Fantoni technique. Apart from two minor bleeding episodes in the haemophilic patient which were controlled promptly, no other complications occurred. If certain precautions are observed carefully, we believe that translaryngeal tracheostomy is a procedure which is superior to other percutaneous techniques and safe even in patients with severe respiratory failure and coagulopathy.     

Prospective evaluation of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) in a surgical intensive care unit: technique and results of the Fantoni tracheostomy

BACKGROUND: Controversy surrounds the safety and practicality of the retrograde percutaneous translaryngeal tracheostomy (Fantoni procedure) compared with other percutaneous methods. METHODS: We used the Fantoni tracheostomy for 245 patients in our intensive care unit (ICU) over a period of 3 years 6 months and conducted a prospective analysis. RESULTS: We are able to report a low incidence of complications (1.2%) with the Fantoni procedure. Advantages of the method are reduced tissue trauma and optimal adaptation of the stoma to the cannula, leading to less stomal bleeding and fewer infectious complications. We observed no procedure-related mortality. Under mandatory bronchoscopic control, proper puncture location and cannula placement are ensured, which prevents tracheal wall injury and paratracheal placement of the cannula. CONCLUSIONS: Our experience shows that the major advantage of the use of the Fantoni tracheostomy is the retrograde dilatation of the stoma, which prevents serious complications compared with other techniques.     

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

Purpose  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). Methods  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). Results  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. Conclusions  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.     

Comparison of open, percutaneous, and translaryngeal tracheostomies.

INTRODUCTION: With 3 tracheostomy techniques currently available, controversy exists regarding which is safest and most economical. Percutaneous (PDT) and the new translaryngeal (TLT) tracheostomies are cited as more cost-effective than the traditional open surgical procedure because they are bedside techniques. Our objective was to compare the perioperative and postoperative complications of the 3 techniques.Study Design: This was a prospective trial involving 100 consecutive patients who underwent tracheostomy between April and December of 1997 at the London Health Sciences Centre and St Joseph's Health Centre in London, Canada. RESULTS: Fifty open tracheostomies were performed. Indications included prolonged ventilation (n = 42), airway protection (n = 5), pulmonary hygiene (n = 2), and sleep apnea (n = 1). A tension pneumothorax was the one significant intraoperative complication. Fifteen postoperative complications occurred, most notable of which was a 2-L hemorrhage at 24 hours. Thirty-seven TLTs were performed, 20 in patients with coagulopathy. Indications were prolonged intubation (n = 27), airway protection (n = 9), and pulmonary hygiene (n = 1). One intraoperative complication of accidental decannulation occurred. One postoperative complication, a pretracheal abscess, occurred in a decannulated transplant patient 2 weeks after the procedure. Thirteen PDTs were performed. Indications were prolonged intubation (n = 6), airway protection (n = 6), and tracheal toilet (n = 1). No significant complications occurred. CONCLUSIONS: TLT and PDT have fewer complications than the traditional open technique. TLT appears to have the greatest utility in the coagulopathic patient.     

Weaning from ventilator after cardiac operation using the Ciaglia percutaneous tracheostomy.

OBJECTIVE: To determine the predictors of weaning from mechanical ventilation after cardiac operation with the Ciaglia percutaneous dilatational tracheostomy (PDT) in our preliminary experience in the use of this technique. METHODS: We prospectively analysed 33 consecutive patients (mean age 70.9+/-12.7 years) who underwent PDT in our intensive care unit after cardiac operation. The investigation involved preoperative and postoperative clinical status, operative procedure, indication and timing for PDT. RESULTS: PDT was performed after a mean time of 7.7+/-5.0 consecutive days of translaryngeal intubation. Twenty-four (73%) patients were weaned from ventilator after a mean time of mechanical ventilation of 15.8+/-9.1 days. Time point of PDT was the only predictor of ventilator weaning (P=0.0029): there was significant association between PDT performed before the seventh consecutive day of translaryngeal intubation (early PDT) and successful weaning from ventilator (P=0.01; odds ratio=11.2, 95% confidence interval=1.2-104.3). Among the patients weaned from ventilator, those who underwent early PDT had significantly shorter times of mechanical ventilation, and intensive care unit and hospital stays than patients with later PDT (P=0.035, 0.011 and 0.0073, respectively). Nine (27%) patients died of their underlying disease while still being mechanically ventilated; another six (18%) spontaneously breathing but still incannulated patients died afterward. No major PDT-related complications were observed. Two minor peristomal bleedings and one self-resolving subcutaneous emphysema were recorded. CONCLUSIONS: Early PDT was a safe and effective method to wean from mechanical ventilation the cardiosurgical patients of this series.     

Percutaneous tracheostomy: ciaglia blue rhino versus the basic ciaglia technique of percutaneous dilational tracheostomy

Percutaneous dilational tracheostomy (PDT), according to Ciaglia's technique described in 1985, has become the most popular technique for percutaneous tracheostomy and is demonstrably as safe as surgical tracheostomy. In 1999, an extensively modified technique of PDT was introduced, the Ciaglia Blue Rhino (CBR; Cook Critical Care, Bloomington, IL), that consists of one-step dilation by means of a curved dilator with hydrophilic coating. To compare CBR with the basic technique of PDT, we performed a prospective, randomized trial in 50 critically ill adults. Twenty-five of these patients had PDT, and 25 had CBR. Average operating times were <3 min for CBR (range: 50-360 s) and <7 min for PDT (range: 4-20 min; P<0.0001). Tracheostomy was successfully completed in all patients. When CBR was performed, 11 minor, nonlife-threatening complications were noted: nine fractures of tracheal cartilage and two short periods of intraoperative oxygen desaturation. During PDT, seven complications occurred, of which three were potentially life-threatening: two injuries to the posterior tracheal wall, one pneumothorax, two tracheal cartilage fractures (P< 0.05 vs CBR), one case of bleeding, and one short episode of intraoperative oxygen desaturation. Regardless of whether PDT or CBR was performed, oxygenation was not significantly affected, and there was no infection of the tracheostoma. Based on our data, we conclude that new CBR is more practicable than PDT. No life-threatening complications occurred during CBR. Implications: To assess practicability and safety of the Ciaglia Blue Rhino (Cook Critical Care, Bloomington, IL)-an extensively modified technique of percutaneous dilatational tracheostomy-50 critically ill adults on long-term ventilation underwent either new Ciaglia Blue Rhino or percutaneous dilatational tracheostomy in a prospective, randomized clinical trial.     

Ciaglia Blue Rhino: Ein weiterentwickeltes Verfahren der perkutanen Dilatationstracheotomie

OBJECTIVE: Elective tracheostomy has become an established treatment modality in modern intensive care medicine, and the number of percutaneously performed tracheostomies is steadily increasing. The Ciaglia Blue Rhino (CBR) represents another percutaneous technique in which the tracheostoma is formed by one-step dilation. Our study presents the technique itself and the early clinical experiences. METHODS: In 20 adult patients on long-term ventilation, CBR was done. After puncture of the trachea in typical manner, dilation of the tracheostoma was achieved in one single step by means of a curved dilator with a special hydrophilic coating. Then, the tracheostomy tube was inserted over a curved loading dilator. Practicability and safety were determined as well as gas exchange during the procedure by means of arterial blood gas samples. RESULTS: As a result of the dilator's hydrophilic coating, dilation of the tracheostoma was rapidly achieved within 152 +/- 22 s, virtually free from resistance of the trachea or the cervical tissues. Complications such as bleeding, aspiration or postoperative infection of the stoma were not noted in any of our patients. Fractures of isolated tracheal cartilage rings were seen in 5 patients, however, no therapeutic intervention was necessary. In terms of perioperative gas exchange, pre- and postoperative levels of FiO2, PaO2, PaCO2 and the oxygenation index (PaO2/FiO2) did not change significantly. CONCLUSIONS: Based on our early clinical experience, Ciaglia Blue Rhino represents a new method that may combine the typical advantages of each of the other techniques for percutaneous tracheostomy (i.e. Ciaglia, Griggs, Fantoni) in one single technique. This method is distinguished by a high level of safety and practicability. However, further comparative trials need to be done before a definitive judgement can be made.     

Peri-operative complications during percutaneous tracheostomy in obese patients

The safety of percutaneous tracheostomy in 73 obese patients (body mass index > or = 27.5 kg.m(-2)) in a cohort of 474 adults was studied. Four percutaneous techniques were employed (percutaneous dilational tracheostomy, n = 48; Ciaglia Blue Rhino, n = 157; guide wire dilating forceps, n = 62, translaryngeal tracheostomy, n = 207). The overall complication rate was 43.8% (n = 32) in the obese group compared to 18.2% (n = 73) in the control group (p < 0.001). Seven (9.6%) obese patients suffered life-threatening complications compared to three non-obese patients (0.7%, p < 0.001). Obese patients had a 2.7-fold increased risk for peri-operative complications, and a 4.9-fold increased risk for serious complications. The data suggest that percutaneous tracheostomy in obese patients is associated with a considerably increased risk for peri-operative complications, especially for serious adverse events.     

The Fantoni translaryngeal tracheostomy: perioperative complications In a series of 220 consecutive patients

BACKGROUND: To evaluate problems arisen du-ring Fantoni translaryngeal tracheostomy (TLT). METHODS: Setting: intensive care unit. Patients: 220 patients (aged from 18 to 87). Exclusion criteria: coagulopathy, difficult intubation, local infections, previous neck surgery, suspected cervical spine lesion, severe hypoxemia, hemodynamic instability, patients close to be discharged from ICU. Operation: TLT was performed in general anesthesia, using the technique described by Fantoni in 206 cases; in the other 14 cases changes were made. RESULTS: Perioperative clinical complications were separated from instrumental problems. Clinical complications were 28 (12.7% of TLT): 20 (9.1% of total TLT, 71.4% of total complications) were considered minor and ascribed to medical staff training; among these the complete drawing of the cannula and the difficulty in pushing it in trachea. Eight complications (3.6% of TLT, 28.6% of total complications) were considered major; they were: the impossibility to place the cannula in trachea, the displacement of the prothesis in the peritracheal tissue, the rupture of tracheal ring, the bleeding and the infection of tracheostomy, the dental uprooting. Among instrumental problems, the faulty closure of the ring nut, the overdimension of rigid tracheoscope, and the difficult change of the cannula were observed. CONCLUSIONS: With expert medical staff, this technique is effective and safe, with a low rate of complications. Major complications were rare, and occurred in spite of patients selection, often needing changing of TLT in surgical tracheostomy.     

A laboratory comparison of two techniques of emergency percutaneous tracheostomy

This laboratory study was designed to compare the speed of placement of a percutaneous tracheostomy using two common methods and to evaluate any damage caused to the trachea. The same operator who was experienced with both techniques placed 10 percutaneous tracheostomies into a pig tracheal model, five using the Griggs tracheostomy forceps technique and five using the Ciaglia sequential dilatation technique. Placement of the tracheostomy was significantly faster using the Griggs technique (mean 89 s, range 69–105 s) than using the Ciaglia sequential dilator technique (mean 217 s, range 180–267 s). Damage to the posterior wall was noted in four of the tracheas. We concluded that the Griggs technique is rapid and in trained hands may be suitable for emergency airway access. In addition, the pig trachea model is easy to set up and provides a very useful training tool.     

Percutaneous dilatational tracheostomy

Methods: Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study.
Results: The median time for insertion of the tracheostomy tube was 13.9 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period, complications were one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion.
Conclusions: Our preliminary results indicate the technique as performed with the Ciaglia Introducer Set to be effective and safe with only minor complications. Furthermore, we now use it as a bedside procedure in the ICU, thus avoiding the transportation of critically. ill patients to the operating theatre. The conclusion of the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies, including more patients.     

Difficult reintubation during a Fantoni's tracheostomy resolved using a laryngeal mask

We report the failure of a reintubation under direct laryngoscopy, during a percutaneous tracheostomy by Fantoni method. After the accidental per-procedural extubation and in front of an unpredicted difficult conventional endotracheal intubation, a laryngeal mask was used as an airway intubator conduit for the blind passage of the set's ventilation tube. This ventilation tube is a 40 cm long, 4 mm internal diameter special catheter with low pressure cuff, included into the TLT kit. The end of the procedure was uneventful.     

Endoscopic guided percutaneous tracheostomy: early results of a consecutive trial

Percutaneous tracheostomy is increasingly being used for patients needing prolonged ventilatory support. The purpose of this study was to assess the feasibility of widespread application of endoscopic guided percutaneous tracheostomy. Sixty-one consecutive ICU patients requiring prolonged mechanical ventilation underwent bedside endoscopic guided percutaneous tracheostomy. Using a modified Ciaglia technique, a #6-10 tracheostomy tube was introduced between the second and third tracheal rings. Bronchoscopic transillumination facilitated identification of the appropriate tracheostomy site, and verified satisfactory placement of dilators and tracheostomy tube. There was one procedure-related death due to arrhythmia. Procedure-related complications included (n = 7): bleeding (controlled with local pressure), two infections, two cuff tears, and two obstructions of the tracheal tube. The tracheostomy was eventually removed in 13 patients. Bronchoscopic evaluation of three patients at 4 months post-tracheostomy removal was normal and there has been no clinical evidence suggestive of tracheal stenosis in the remaining ten extubated patients. There was a 50% reduction in cost when compared to operative tracheostomy. Percutaneous tracheostomy is a simple, safe, cost-effective bedside procedure for critically ill ventilator-dependent patients. Endoscopic guidance appears to increase the safety of this procedure and may prevent complications of pneumothorax, subcutaneous emphysema, and paratracheal false passage previously reported with blinded percutaneous methods.     

Prospective randomized comparison of progressive dilational vs forceps dilational percutaneous tracheostomy

This trial prospectively compares two methods of percutaneous tracheostomy, both routinely used in ICU: the Ciaglia progressive dilational tracheostomy and the Griggs forceps dilational tracheostomy. One hundred patients were randomized using a single-blinded envelope method to receive progressive or forceps percutaneous tracheostomy performed at the bedside. Operative time, the occurrence of hypoxaemia or hypercapnia and complications were recorded. The progressive technique took longer than the forceps technique (median 7 (range 2-26) vs. 4 (1-16) minutes, P = 0.0005). Hypercapnia occurred in both groups but was more marked with the progressive technique (56 (16) vs. 49 (13) mmHg, P = 0.0082). Minor complications (minor bleeding, transient hypoxaemia, damage to posterior tracheal wall without emphysema) were also more frequent with the progressive technique (31 vs. 9 complications, P < 0.0001). Six major complications occurred with the progressive technique, none with the forceps technique (P = 0.0085): tension pneumothorax, posterior tracheal wall injury with subcutaneous emphysema, loss of airway with hypoxaemia, loss of stoma with impossible re-catheterization, and two conversions to another technique. In conclusion, progressive dilational tracheostomy took longer, caused more hypercapnia and more minor and major difficulties than forceps dilational tracheostomy.     

A Simplified Technique for Translaryngeal Tracheostomy (TLT). A Preliminary Report

OBJECTIVE: In this prospective observational study we present preliminary results of a modification of the translaryngeal tracheostomy technique that was introduced by Fantoni in 1997. The study was conducted in a five-bed surgical intensive care unit of a university teaching hospital. PATIENTS AND METHODS: The study included 14 consecutive surgical patients (8 men, 6 women) who underwent a modified translaryngeal tracheostomy in a 6-month period. In our modification of the technique, we keep the basic principle of the inside-to-outside approach of the Fantoni technique, and combine it with a blind needle insertion, as reported in the classic subcricoid retrograde intubation technique. The technique that we use involves two medical doctors and a nurse. RESULTS: Mean patient age was 68.9 years (range: 31-85 years) and mean APACHE II score was 15.8 (range: 6-31). Mean operative time for the procedure was 15.2 min (range: 11.5-22 min). Eight of the patients died during the postoperative course in the ICU from causes relevant to their surgical pathology. One patient survived to be discharged from the ICU but died of an acute myocardial infraction later in the same hospital stay. Five patients survived to be discharged from the hospital. CONCLUSIONS: The modified translaryngeal tracheostomy seems to be as reliable and safe as the original technique. In addition, the modified technique is faster and can be performed without the use of an endoscope.     

PercuTwist: a new alternative to Griggs and Ciaglia's techniques

BACKGROUND AND OBJECTIVE: Tracheostomy is one of the most common procedures in intensive care units worldwide. In this study we aimed to compare three different tracheostomy techniques with respect to duration of procedure and complications. METHODS: One hundred and thirty patients requiring endotracheal intubation for more than 10 days due to acute respiratory distress syndrome, infections or cerebrovascular events were consecutively selected to undergo the percutaneous dilatational tracheostomy technique (PDT n = 44), the guide-wire dilating forceps technique group (GWDF n = 41) or the PercuTwist technique (n = 45). The time taken to perform the procedure (skin incision to successful placement of tracheostomy tube) and complications were recorded. RESULTS: The operating times were found to be 9.9 +/- 1.1, 6.2 +/-1.4 and 5.4 +/- 1.2 min in PDT, GWDF and PercuTwist groups, respectively. The duration of the procedure was significantly shorter in the PercuTwist group as compared to the percutaneous dilatational tracheostomy (P < 0.01) and guide-wire dilating forceps (P < 0.05) groups. During postoperative bronchoscopy, eight cases of longitudinal tracheal abrasion (four in the PDT group, two in the GWDF group and two in the PercuTwist group), two cases of posterior tracheal wall injury (one in PDT and one in GWDF) and one case of tracheal ring rupture in the PDT group were seen. CONCLUSIONS: Percutaneous tracheostomy techniques have their own advantages and complications. PercuTwist, a new controlled rotating dilatation method, was associated with minimal complications, appears to be easy to perform and a practical alternative to percutaneous dilatational tracheostomy and guide-wire dilating forceps techniques.