Introduction: Tracheal stenosis is the most common severe late complication of percutaneous tracheostomy causing significant decrease in quality of life. Applying modified Griggs technique reduced the number of late tracheal stenoses observed in our clinical study. The aim of this study was to investigate the mechanism of this relationship. Materials and methods: Forty-six cadavers were randomized into two groups according to the mode of intervention during 2006-2008. Traditional versus modified Griggs technique was applied in the two groups consequently. Wider incision, surgical preparation, and bidirectional forceps dilation of tracheal wall were applied in modified technique. Injured cartilages were inspected by sight and touch consequently. Age, gender, level of intervention, and number of injured tracheal cartilages were registered. Results: Significantly less frequent tracheal cartilage injury was observed after modified (9%) than original (91%) Griggs technique (p<0.001). A moderate association between cartilage injury and increasing age was observed, whereas the level of intervention (p=0.445) and to gender (p=0.35) was not related to injury. Risk of cartilage injury decreased significantly (OR: 0.0264, 95%, CI: 0.005-0.153) with modified Griggs technique as determined in adjusted logistic regression model. Discussion: Modified Griggs technique decreased the risk of tracheal cartilage injury significantly in our cadaver study. This observation may explain the decreased number of late tracheal stenosis after application of the modified Griggs method. © 2012 Akadémiai Kiadó, Budapes

Achtzehn U.

Ambesh S.P.

Brook A.D.

Delaney A.

Elo G.

Fikkers B.G.

Griggs W.M.

Hotchkiss K.S.

Kluger Y.

Kusafuka K.

Melloni G.

Norwood S.

Paran H.

Raghuraman G.

Richardson J.D.

Rumbak M.J.

Steele A.P.

Watters M.

Interventional Medicine & Applied Science

Abstract
        
          Introduction
          Tracheal stenosis is the most common severe late complication of percutaneous tracheostomy causing significant decrease in quality of life. Applying modified Griggs technique reduced the number of late tracheal stenoses observed in our clinical study. The aim of this study was to investigate the mechanism of this relationship.
        
        
          Materials and methods
          Forty-six cadavers were randomized into two groups according to the mode of intervention during 2006–2008. Traditional versus modified Griggs technique was applied in the two groups consequently. Wider incision, surgical preparation, and bidirectional forceps dilation of tracheal wall were applied in modified technique. Injured cartilages were inspected by sight and touch consequently. Age, gender, level of intervention, and number of injured tracheal cartilages were registered.
        
        
          Results
          Significantly less frequent tracheal cartilage injury was observed after modified (9%) than original (91%) Griggs technique (p&lt;0.001). A moderate association between cartilage injury and increasing age was observed, whereas the level of intervention (p=0.445) and to gender (p=0.35) was not related to injury. Risk of cartilage injury decreased significantly (OR: 0.0264, 95%, CI: 0.005–0.153) with modified Griggs technique as determined in adjusted logistic regression model.
        
        
          Discussion
          Modified Griggs technique decreased the risk of tracheal cartilage injury significantly in our cadaver study. This observation may explain the decreased number of late tracheal stenosis after application of the modified Griggs method.
        </jats:sec

Gábor Élő

László Zubek

Zoltán Hargitai

Zsolt Iványi

Judit Branovics

János Gál

Crossref

Interventional Medicine and Applied Science

Prevention of tracheal cartilage injury with modified Griggs technique during percutaneous tracheostomy — Randomized controlled cadaver study

Élő Gábor

Zubek László

Hargitai Zoltán

Iványi Zsolt

Branovics Judit

Gál János

Semmelweis Repository

Interventional Medicine & Applied Science, Vol. 4 (2), pp. 206–xx (2012) DOI: 10.1556/IMAS.4.2012.1.1 ISSN 2061-1617 © 2012 Akadémiai Kiadó, Budapest  206IntroductionLong-term mechanical ventilation with prolonged intu-bation is one of the most important task of intensive care resulting in possible severe early and late complications. Ventilator-associated pneumonia (VAP), septic compli-cations, decreased patient’s comfort, increased nursing days, and late tracheal stenosis could be anticipated per-forming early tracheostomy [1–3]. Percutaneous dila-tional tracheostomy (PDT) could be superior to surgical method during prolonged mechanical ventilation [4, 5].Progress in intensive therapy resulted in development of new percutaneous techniques. However, percutane-ous techniques can also result in severe early and late complications especially acute bleeding and late tracheal stenosis [6–8]. The applied technique and the available time for mechanical hemostasis allowing careful tissue preparation between tracheal cartilages could be impor-tant factors preventing these complications. Modified Griggs technique was used to be developed in our clinical practice in order to decrease early and late complications. Our retrospective clinical study showed that both early and late complications were reduced with these technical amendments [9]. Applying the modified Griggs technique could prevent tracheal cartilage injury during insertion of the tracheostomy tube. The aim of this randomized cadaver study was to obtain further ob-servational data for safety of the modified bidirectional forceps dilation with special regard to tracheal cartilage destruction. Materials and Methodsforty-six cadavers were assessed for eligibility dur-ing 2006–2008. Gender, age, level of intervention, and number of injured cartilages were recorded. four groups of age, two groups of gender, two groups of the level of intervention in relation to cricoid cartilage, and three groups of the number of injured cartilages were established. inclusion criteria were as follows: a) autopsy performed in 72 hours after death, b) patient has not 4 209 (2012) 4 5  Prevention of tracheal cartilage injury with modified Griggs technique during percutaneous tracheostomy – Randomized controlled cadaver studyGÁBOR ÉLÔ1*, LÁSZLÓ ZUBEK1, ZOLTÁN HARGITAI1, ZSOLT IVÁNYI1, JUDIT BRANOVICS1,2, JÁNOS GÁL11Department of Anaesthesia and Intensive Therapy, Semmelweis University, Kútvölgyi út 4, H-1125 Budapest, Hungary2Department of Otolaryngology, Head and Neck Surgery, Semmelweis University, Szigony utca 36, H-1083 Budapest, Hungary*Corresponding author: Dr Gábor élô; Phone/fax: +36-1-355-6565; E-mail: gelo@kut.sote.hu(Received: May 16, 2012; Accepted after revision: August 28, 2012)Abstract: Introduction: Tracheal stenosis is the most common severe late complication of percutaneous tracheostomy causing significant decrease in quality of life. Applying modified Griggs technique reduced the number of late tracheal stenoses observed in our clinical study. The aim of this study was to investigate the mechanism of this relationship. Materials and methods: forty-six cadavers were randomized into two groups according to the mode of intervention during 2006–2008. Traditional versus modified Griggs technique was applied in the two groups consequently. Wider incision, surgical preparation, and bidirectional forceps dilation of tracheal wall were applied in modified technique. injured cartilages were inspected by sight and touch consequently. Age, gender, level of intervention, and number of injured tracheal cartilages were registered. Results: Significantly less frequent tracheal cartilage injury was observed after modified (9%) than original (91%) Griggs technique (p<0.001). A moderate association between cartilage injury and increasing age was observed, whereas the level of intervention (p=0.445) and to gender (p=0.35) was not related to injury. Risk of cartilage injury decreased significantly (OR: 0.0264, 95%, Ci: 0.005–0.153) with modified Griggs technique as determined in adjusted logistic regression model. Discussion: Modified Griggs technique decreased the risk of tracheal cartilage injury significantly in our cadaver study. This observation may explain the decreased number of late tracheal stenosis after application of the modified Griggs method.Keywords: percutaneous tracheostomy, tracheal stenosis, tracheal cartilage injury, cadaver, Griggs techniqueor i g ina l  pap er3T Mr imaging of isolated pig heartsInterventional Medicine & Applied Science ISSN 2061-1617 © 2012 Akadémiai Kiadó, Budapest 207prevention of tracheal car ilage during pCT ISSN 2061-1617 © 2012 Akadémiai Kiadó, Budapest  Interventional Medicine & Applied Sciencesuffered from laryngeal illness or from tracheal injury, c) patient was not tracheostomized before, and d) patient was older than 40 years of age. Cadavers were randomly assigned into two groups according to the method of in-tervention (standard versus modified Griggs technique) after inclusion.incisions were performed on the midpoint of crico-thyroid ligament and jugulum resulting in intercartilagi-nous puncture in the level of 2nd or 3rd tracheal car-tilages during autopsy in both groups. Standard Griggs technique: 20 mms skin incision, no surgical preparation, direct tracheal punction, and unidirectional (transverse) tracheal dilation were performed followed by the trache-ostomy cannula insertion in the first group as was de-scribed by Griggs et al. [10]. Modified Griggs technique: 50-mm wide skin incision, surgical pretracheal tissue preparation, and careful visualized bidirectional (trans-verse and longitudinal) intercartilagenous forceps dila-tion of tracheal wall were performed in the second group. The 50-mm wide horizontal skin incision provided enough place for secure pretracheal preparation until tracheal wall could be visualized and palpated as well as in our modified technique. Preparations were performed using blunt technique, and Griggs forceps were usually used in order to ascertain tissue resistance followed by the tracheal puncture according to Watters recommen-dations [11]. Visualized tracheal wall puncture next to the palpating finger and continuous aspiration of air se-cured correct intratracheal needle position as mentioned by Paran et al. [12]. insertion of the guidewire followed by the introducer was the next step. Griggs forceps was introduced using the guidewire according to the stan-dard method as deep as about 15 mm from the axis of rotation, and horizontal dilation was performed using both hands. Then, the forceps was rotated 90 degrees in longitudinal direction and another double-handed for-ceps dilation was made in the vertical direction. After removing the forceps, tracheostomy tube was inserted into the trachea using the guidewire. Leaving the tracheostomy tube in place, the larynx, pharynx and trachea were dissected, carefully avoiding further tracheal injury in both groups. The posterior la-ryngeal wall was opened up, and tracheal cartilage inju-ries were verified by visualization and palpation as well.Gender, age, level of intervention, number of injured tracheal cartilages, and the method of Griggs technique (standard vs. modified) were recorded by the same in-vestigator in all cases. Pearson chi-square tests were ap-plied for data evaluation, then logistic regression was performed, adjusting to the potential confounders in the study. Licence number of the investigation issued by re-sponsible Research Ethical Committee is TUKEB 117/2006.ResultsPercutaneous tracheostomy was carried out in 46 cadav-ers (24 men/22 women) altogether. Nine subjects were 41–60 years old, 12 were 61–70 years old, 14 were 71–80 years old, and 11 were older than 80 years of age at the time of death. Tracheal puncture was performed in the level of second tracheal cartilage in 25 cases and in the level of third tracheal cartilage in 21 cases. Standard Griggs technique was applied in 23 cases, and modified Griggs technique also in 23 cases according to random-ization. There was no cartilage injury observed in 20 cases, one or two injured cartilages were noticed in 13 of the 13 cases consequently. The method of intervention was significantly associated with cartilage injury: 9% of subjects in the modified technique group, whereas 91% in the standard Griggs method group suffered any car-tilage injury (p<0.0001). No relationship was observed between the method of intervention and interventional level (p=0.767), age (p=0.642), and gender (p=0.555), respectively (Table I).furthermore, the number of injured tracheal carti-lages was associated with increased age (p=0.030), while there was no association between the number of injured cartilages and the level of intervention (p=0.445) and gender (p=0.35) (Table II).Logistic regression analysis was performed to rule out the effect of potential confounders in our study. Table I  Association between the method of intervention during percutaneous tracheostomy (standard versus modified Griggs technique) and baseline clinical data and number of cartilage injuriesStandard Griggs tech-niqueModified Griggs tech-niqueP-value, Chi-square testLevel of intervention:  Above the 2nd / 3rd tracheal cartilage12 / 11 13 / 10 0.767Age (year): 41–60 / 61–70 / 71–80 / >804 / 5 / 9 / 5 5 / 7 / 5 / 6 0.642Gender: Male / female10 / 13 12 / 11 0.555Number of injured cartilages: 0 / 1 / 22 / 11 /10 18 / 2 / 3 < 0.0001Élô et al. ISSN 2061-1617 © 2012 Akadémiai Kiadó, Budapest  Interventional Medicine & Applied Science208The presence of tracheal cartilage injury was signifi-cantly related to method of intervention in our model adjusted for age, gender, and the level of intervention. Application of the modified Griggs technique (bidirec-tional forceps dilation) resulted in a ~37-fold decrease in risk of cartilage injury (adjusted OR: 0.0264, 95%, Ci: 0.005–0.153). furthermore, increased age was also an independent predictor of injury (p=0.019). DiscussionSignificant number of late tracheal stenoses were ob-served after (in vivo) percutaneous tracheostomies in our clinical practice using standard Griggs technique con-gruently with literary data [7, 8, 13, 14]. Tracheal carti-lage injuries varies 2–30% in clinical studies and may be associated with the development of tracheal stenoses [7, 15, 16]. Only a few PDT cadaver studies were found in literature reporting more common cartilage injury [17] and emphasizing the importance of mode and force of forceps dilation [11]. Stenoses frequently have subglottic type which could be reconstructed with difficulty at a later stage [13]. Age and interventional techniques could be highlighted as common independent factors of carti-lage injury during percutaneous tracheostomy. Cartilage flexibility usually decreases in the elderly [18]. impor-tance of technical aspects could be evaluated by compar-ing surgical and percutaneous techniques [4, 5]. Our previous retrospective clinical study suggested that tracheal cartilage injury could be prevented with the undermentioned technical amendments [9]. Wide skin incision, surgical pretracheal tissue preparation, careful visualized bidirectional (transverse and longitudinal), and intercartilagenous forceps dilation of tracheal wall may potentially prevent cartilage injury during insertion of the tracheostomy tube. Total length of this technique is longer but critical intervention (i.e. tracheal punction with partially lost airway) is shorter than the original ones as was described in our retrospective clinical study [9].Number of injured tracheal cartilages decreased significantly with applying the modified Griggs tech-nique as observed in this cadaver study. Aging but not gender was also an independent risk factor of injuries. Decreased numbers of injured tracheal cartilages may result in a decreased number of late tracheal stenoses in vivo suggesting widespread application of the modified Griggs technique during percutaneous tracheostomy.Limits of the study: 1. Procedures were not double-blinded, i.e. the same investigator performed and evalu-ated identical procedures. All of the procedures were performed by three investigators. 2. Non-original tra-cheostomy sets were used resulting in incidentally fur-ther injuries. 3. Cartilage flexibility could depend on the mortem period as well. Shortening this period could re-sult in more accurate data. further prospective randomized clinical studies are required to support the relevance of our cadaver study. AcknowledgementsAuthors are grateful to the Pathological Department of Kútvölgyi Clinical Hospital for supplying cadavers and special help during dissections. The critical reading of the manuscript by istván Pénzes and the help in biosta-tistical analysis by Zoltán Prohászka (Semmelweis Uni-versity) are acknowledged with many thanks.References  1. Brook AD et al.: Early versus late tracheostomy in patients who require prolonged mechanical ventilation. Am J Crit Care 9, 352–359 (2000)  2. Kluger Y, Paul DB: Early tracheostomy in trauma patients. Eur J Emerg Med 2, 95–101 (1996)  3. Rumbak MJ et al.: A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged transla-ryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 32, 1689–1694 (2004)  4. Delaney A et al.: Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care 10, R55 (2006)  5. Melloni G et al.: Surgical tracheostomy versus percutaneous dila-tional tracheostomy. A prospective-randomized study with long-term follow-up. J Cardiovasc Surg 43, 113–121 (2002)  6. fikkers BG et al.: Percutaneous tracheostomy with the guide wire dilating forceps technique: presentation of 171 consecutive pa-tients. Head Neck 24, 625–631 (2002)Table II  Relationship between cartilage injury and study variables injured cartilages No.P-value, Chi-square test0 1 2Level of intervention:  Above the 2nd / 3rd tracheal cartilage13 / 7 6 / 7 6 / 7 0.445Age (year): 41–60 / 61–70 / 71–80 / >807 / 7 / 3 / 3 2 / 2 / 7 / 2 0 / 3 / 4 / 6 0.030Gender: Male / female12 /8 5 / 8 5 / 8 0.350Griggs technique: Standard / Modified2 /18 11 / 2 10 / 3 < 0.0001prevention of tracheal cartilage during pCTInterventional Medicine & Applied Science ISSN 2061-1617 © 2012 Akadémiai Kiadó, Budapest 209  7. Norwood S et al.: incidence of tracheal stenosis and other late complications after percutaneous tracheostomy. Ann Surg 32, 233–241 (2000)  8. Steele AP et al.: Long-term follow-up of Griggs percutaneous tra-cheostomy with spiral CT and questionnaire. Chest 117, 1430–1433 (2000)  9. élô G: Perkután és sebészi tracheosztómia határán: módosítások a kevesebb szövôdmény érdekében. (Border of percutaneous and surgical tracheostomy: modified technique for less complications.) Aneszteziológiai és intenzív Terápia, 36, 19–23 (2006) 10. Griggs WM et al.: A simple percutaneous tracheostomy technique. Surg Gynecol Obstet 170, 543–545 (1990) 11. Watters M et al.: Tracheal trauma from percutaneous tracheos-tomy using the Griggs method. Anaesthesia 57, 249–252 (2002) 12. Paran H et al.: Evaluation of a modified percutaneous tracheos-tomy technique without bronchoscopic guidance. Chest 126, 868–871 (2004) 13. Raghuraman G et al.: is tracheal stenosis caused by percutaneous tracheostomy different from that by surgical tracheostomy? Chest 127, 879–885 (2005) 14. Richardson JD: Outcome of tracheobronchial injuries: a long-term perspective. J Trauma  56, 30–36 (2004) 15. Ambesh SP et al.: Percutaneous tracheostomy with single dilata-tion technique: a prospective, randomized comparison of Ciaglia Blue Rhino versus Griggs’ guidewire dilating forceps. Anesth Analg 95, 1739–1745 (2002) 16. Achtzehn U et al.: Bronchoscopically controlled percutaneous puncture tracheotomy. Pneumologie 52, 629–634 (1998) 17. Hotchkiss KS, McCaffrey JC: Laryngotracheal injury after percu-taneous dilational tracheostomy in cadaver specimens. Laryngo-scope 113, 16–20 (2003) 18. Kusafuka K et al.: Ossification of tracheal cartilage in aged hu-mans: a histological and immunohistochemical analysis. J Bone & Mineral Metab 19, 168–174 (2001)

Prevention of tracheal cartilage injury with modified Griggs technique during percutaneous tracheostomy - Randomized controlled cadaver study

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Prevention of tracheal cartilage injury with modified Griggs technique during percutaneous tracheostomy - Randomized controlled cadaver study

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