Objective: Presentation of a new technique of dilation tracheostomy projected to offer a minimum risk of complication and tissue trauma.
Design: Prospective study carried out between July 1993 and December 1995, to evaluate the feasibility of the procedure, its possible advantages over other methods, and possible complications.
Setting: General ICU with a Paediatrics Section.
Patients: Uninterrupted series of 84 adults and 12 children with multifactorial respiratory insufficiency.
Intervention: Through a needle inserted in the trachea, a guide wire is retrogradely pushed out of the mouth and attached to a special device formed by a flexible plastic cone with pointed metal tip joined to an armoured tracheal cannula. This device is then pulled back through the oral cavity, larynx, trachea-hence the definition: TransLaryngeal Tracheostomy (TLT)- and outwards across the neck wall by applying traction on the wire with one hand and counterpressure on the neck wall with the fingers of the operator's other hand. When the cone and part of the cannula have emerged, the cone is separated from the cannula. The cannula is further extracted until its inside portion can be turned downwards to its final placement.
Results: A precise localisation of the stoma placement and the needle introduction are facilitated by the rigid tracheoscope and protrusion. Thanks to the very pointed cone, the piercing resistances are lowered. At the same time, every degree of traction power is allowed through the counterpressure practised by the fingers. The channel is very regular with a strong adherence to the cannula that secures a virtual lack of bleeding and local inflammation. We observed this in the fifty cases, in which the final version of our technique was applied. Trachea CT scan and endoscopic control did not show late lesions of the airway.
Conclusions: TLT is characterised by highest inherent safety and lowest tissue traumatism, that it can also be performed in patients who would risk complications from any other tracheostomy techniques.