title: Tracheal ring fracture secondary to percutaneous tracheostomy: is tracheal flaccidity a risk factor?
abstract: OBJECTIVE
  To evaluate the risk factors of tracheal ring fracture and whether previous tracheal ring flaccidity predisposes to it in consecutive, mechanically ventilated, intensive care unit patients undergoing different percutaneous dilatational tracheostomy procedures (Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin).
  
  
  METHODS
  Single-center retrospective study performed between November 2006 and July 2013.
  
  
  METHODS
  Single-center university hospital.
  
  
  METHODS
  Two hundred nineteen consecutive intensive care unit patients.
  
  
  METHODS
  Video bronchoscopic percutaneous dilatational tracheostomies using different techniques, including Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin, were performed consecutively. During the procedure, the tracheal wall response to the routine external palpation was evaluated endoscopically to find the interanular space. An abnormal change in the tracheal ring shape (fingerprint) with anterior airway wall collapse was diagnosed as tracheal flaccidity.
  
  
  RESULTS
  Tracheal ring fracture occurred in 21 patients (9.6%). The proportion of tracheal ruptures was 16 (76.2%) after PercuTwist, 3 (14.3%) after Ciaglia Blue Dolphin, and 2 (9.5%) after the Blue Rhino technique. Significant risk factors for tracheal rupture were PercuTwist procedure (p = 0.02), tracheal flaccidity (p = 0.0001), and a period of intubation before a percutaneous dilatational tracheostomy procedure>14 days (p = 0.01).
  
  
  CONCLUSIONS
  In addition to the PercuTwist technique and intubation>14 days before tracheostomy, tracheal flaccidity was a significant risk factor for tracheal ring fracture. In the presence of this finding, a less traumatic tracheostomy procedure should be applied.
authors: Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, Naples, Italy.
authors: Fausto
authors: F
authors: Ferraro
authors: Department of Geriatrics and Metabolic Diseases, Second University of Naples, Naples, Italy.
authors: Raffaele
authors: R
authors: Marfella
authors: Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, Naples, Italy.
authors: Marianna
authors: M
authors: Esposito
authors: Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, Naples, Italy.
authors: Jole
authors: J
authors: Petruzzi
authors: Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, Naples, Italy.
authors: Annarita
authors: A
authors: Torino
authors: Department of Anesthesiological, Surgical and Emergency Sciences, Second University of Naples, Naples, Italy.
authors: Anna
authors: A
authors: d'Elia
authors: Thoracic Surgery Unit, Second University of Naples, Naples, Italy.
authors: Mario
authors: M
authors: Santini
authors: Thoracic Surgery Unit, Second University of Naples, Naples, Italy. Electronic address: alfonso.fiorelli@unina2.it.
authors: Alfonso
authors: A
authors: Fiorelli
mesh_terms: D018806:APACHE; D000368:Aged; D000369:Aged, 80 and over; D001999:Bronchoscopy; D003422:Critical Care; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012121:Respiration, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D014132:Trachea / Q000293:injuries* / Q000503:physiopathology*; D055090:Tracheomalacia / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology*; D014139:Tracheostomy / Q000009:adverse effects*
keywords: bronchoscopic surgical procedures; intensive care; mechanical ventilation; percutaneous; tracheal rupture; tracheomalacia; tracheostomy