Percutaneous Tracheostomy: The Ciaglia Techniques

Fig. 5.1

Ciaglia Blue Rhino technique

The Blue Dolphin technique is novel, using a combined dilator-tube introducer assembly, which uses a high-pressure balloon to dilate the stoma. The unique feature of this technique is the balloon-tipped catheter with tube-loading dilator assembly (Fig. 5.2). The balloon measures 70 mm total with a 54 mm central section and 16 mm (48 Fr) in diameter when fully inflated. The loading dilator size varies between 24 and 30 F. The final component of the set is a manual inflation device with a pressure gauge. The balloon device and inflator are modified from standard and well-established radiology equipment used for angioplasty and other interventions. The balloon is factory tested and is not test inflated before use.

Fig. 5.2

Ciaglia Blue Dolphin dilating assembly

After withdrawal of the 14 F punch dilator, the compressed balloon in the distal portion of the balloon-tube assembly is advanced over the guidewire until the distal 1–2 cm of the balloon is seen in the tracheal lumen.

A manual inflation device with aneroid pressure gauge, containing 20 ml of saline solution, is connected to a side port of the balloon-tube assembly, and the balloon is inflated with saline solution to 11 atm/bar (Fig. 5.3). Care needs to be taken to position the functional part of the balloon so it extended from the skin into the trachea, with a portion of balloon seen outside the skin and the distal portion seen inside the trachea.

Fig. 5.3

Fully inflated balloon

The balloon needs to be kept inflated for 5–15 s. Thereafter, all fluid is evacuated from the balloon, and the balloon-tube assembly carrying the tracheostomy tube is further advanced into the trachea under endoscopic control, until the tracheostomy tube is within the trachea. The balloon-catheter assembly and guidewire are then withdrawn together, leaving the tracheostomy tube in place.

5.3 Which Ciaglia Technique Should I Use?

Simply said, all Ciaglia techniques are equally safe. The basic technique has been widely replaced by the Blue Rhino technique, mainly because the latter is more simple to perform and fewer steps are necessary to dilate the stoma, thereby reducing the risk of bleeding and airway loss. Although being introduced ten years ago, very little data is available regarding the Blue Dolphin technique [5–7]. In theory, because radial dilation is performed with a high-pressure balloon, no pressure at all needs to be applied from the anterior. The tracheal lumen is not compressed during dilation, and the risk of posterior tracheal wall injury is virtually eliminated. Furthermore, dilating the tissues with 11 bar results in temporary ischemia, during which the tissue loses its ability to accommodate. The dilated stoma stays open for approximately 15 s after dilation, allowing for gentle cannula insertion. Once the wound edges are reperfused, circumferential tissue contraction results in an extremely tight fit around the tube.

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