| JOURNAL HOME | CME HOME | THIS MONTH | PAST ISSUES | ETOC | COLLECTIONS |
| AUTHORS | REVIEWERS | EDITORIAL BOARD | FEEDBACK | RSS | HELP |
| ||||||||||||||
| ||||||||||||||
|
|
|
|
||||||||||||
|
||||||||||||||
Consultant in Anaesthesia and Intensive Care Medicine, Great Western Hospital, Swindon, England
To the Editor:
I have read the comparison single dilation technique percutaneous tracheostomy methods reported in your journal (1) and would like to make a couple of points concerning the Griggs guide wire dilation forceps (GWDF) method. The authors state that "overenthusiastic attempts at dilation using this method may result in overdilation or occult subtototal transection of the trachea," but do not reference this statement. In fact, we have undertaken just such an investigation (2) and believe the GWDF method to be safer than the authors suggest.
In a necessarily cadaveric study, we compared therapeutic dilation of the trachea with destructive dilation using the GWDF and found that the force to destroy the trachea was more than twice that required for a therapeutic dilation, giving a reasonable margin of safety. Moreover, we also measured the force required for dilation of the pretracheal tissues and found this to be more than that required for the therapeutic tracheal dilation. This therefore acts as a useful marker, in that dilation of the pretracheal tissue is performed first and the operator should then use less force for the subsequent therapeutic tracheal dilation.
Given that the instructions for use of the GWDF tell the operator to open the forceps 1.5 to 2 cm once in the trachea, we believe that the technique does provide a reasonable level of safety and that inadvertent destruction of the trachea is unlikely to happen if the correct technique is followed.
References
Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
In Response:
We would like to thank Dr. Watters for his interest in our study (1) and for making couple of points concerning our questioned safety of Griggs guidewire dilating forceps (GWDF). Contrary to our findings, Dr. Watters, quoting his cadaver model study (2), has commented that use of GWDF is safer and is unlikely to cause inadvertent destruction of trachea.
We do not agree with his opinion. In our study, we performed percutaneous tracheostomy in 60 patients, 30 each with GWDF and Ciaglia Blue Rhino (CBR). Postprocedure endoscopy by a blinded operator revealed overdilation of tracheal stoma in seven patients in the GWDF group while no overdilation was seen in the CBR group. There was more overdilation with the more experienced operators and that was probably due to the overconfident or overenthusiastic attempt on stoma dilation. We have not cited any reference to support the overdilation of tracheal stoma with the GWDF, as it is the finding of our study (1). Although we agree with Dr. Watters that dilation of pretracheal tissues requires comparatively less force than the force required to dilate the tracheal tissues, it is difficult to gauge the force required during clinical tracheal dilation, as it is a subjective phenomenon. Furthermore, it is difficult to know the exact extent of forceps opening (1.5 – 2 cm.) in situ, as it is not always possible to visualize stoma during its formation, especially in the patients with thick short neck who have abundance of pretracheal tissues and fat with deeply seated trachea. In conclusion, we would like to reiterate our remark that GWDF is associated with uncontrolled formation (under- or overdilation) of tracheal stoma, and one does not require a bad intention to cause overdilation of tracheal stoma with the GWDF.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
