Percutaneous dilatational tracheotomy (PDT) has gained popularity since its introduction to our Critical Care Medicine Department in 1999, as more than 2000 cases have been successfully operated, nearly replacing the surgical technique on an elective basis (Beshey 2002). Several studies compared different percutaneous techniques with various assisting tools, like ultrasonography and bronchoscopy (Hassanin et al. 2013; Hamdy 2017; Beshey et al. 2014a; Beshey et al. 2014b). The largest (Beshey et al. 2014a) was a comparative study between cricothyrotomy and PDT using Griggs’ forceps technique on an emergency basis in 169 failed airway patients. It was concluded that although the success rate and time to complete both procedures were comparable, performing PDT as a definitive airway was superior to the temporary cricothyrotomy with its ventilatory obstacles.

To date, all studies on percutaneous tracheotomy stressed the importance of endotracheal tube withdrawal, avoiding its puncture while performing tracheotomy to ensure smooth operation. Despite the importance of this step, it leaves the trachea exposed to false passage, para-tracheal insertion, and posterior tracheal wall injury (Romem and Gilboa 2022). Several assisting tools like bronchoscopy and ultrasonography have been evaluated in previous studies to decrease the incidence of such complications (Mallick et al. 2003; Kollig et al. 2000; Hassanin et al. 2013; Hamdy 2017). Another issue is that some tracheas are weak to the degree that they become narrowed upon ETT withdrawal. At the same time, the patient’s neck is extended, increasing the incidence of peri-operative complications even with bronchoscopic guidance.

Accordingly, the idea was created as leaving ETT in place, working as a protective tracheal stent during needle insertion as an initial necessary step to access the airway. Adopting such an idea has a lot of advantages. First, it enables safe blind airway access through the semi-rigid ETT inside the trachea. Second, it avoids sudden release of the needle into the trachea and, consequently, posterior tracheal wall injury. Finally, and in the same sequence, false passage and para-tracheal insertion are remote complications.

The trigger beyond this idea was patient zero, who was a female tracheostomized after prolonged mechanical ventilation using a bronchoscope-assisted dilating forceps technique. Unexplained progressive rise in her peak pressures and bradycardia without cardiac arrest were noticed upon smooth completion of the procedure due to bilateral tension pneumothorax. Immediate needle decompression followed by bilateral intercostal tube insertion was done. Such events were not explained even by post-procedure revision using bronchoscopy. Computed chest tomography with virtual reconstruction bronchoscopy was done after stabilization and revealed resolving bilateral pneumothorax and pneumomediastinum with small rent in the posterior tracheal wall. Feeding gastrostomy was done, and the patient died 1 month later due to her original disease (spontaneous subarachnoid hemorrhage).

After initial airway access by needle insertion and to accomplish tracheotomy, there should be some modifications of the conventional technique in order not to hinder subsequent steps. The challenge was safely releasing the ETT off the trachea while the needle transfixed both together. This was thoroughly described in the current work.

The current study was carried out to evaluate such modification of percutaneous tracheotomy on success rate, duration of procedure, and rate of complications. Over 4 years, 386 patients were tracheostomized using this technique and included in this retrospective case series study.

The described technique in this work was a merge of guidewire dilating forceps (Griggs’) technique (Griggs et al. 1990) as the original technique, blunt pre-tracheal dissection as described by Paran et al. (Paran et al. 2004), and our modification in airway access as detailed in our methodology. Griggs’ technique for percutaneous tracheotomy has been applied in our institution since 2002 (20, 23), with less duration and lower complication rates. Şahiner İT and Şahiner Y (Şahiner and Şahiner 2017), in their study, concluded that their acquaintance with Griggs’ technique led to fewer complications. However, they recommended using assisting tools to decrease the rate of complications. Paran et al. (Paran et al. 2004), in their study evaluating a modified PDT without bronchoscopic guidance, concluded that modified blind PDT with limited surgical pre-tracheal dissection was simple and safe when performed by physicians with surgical training.

In the current study, the mean novel technique time (NT time) was less than a minute, while the mean total procedure duration (TT time) was 2–2.5 min. The entire period in our study was comparable, even shorter than that recorded in the literature (Beshey 2002; Hassanin et al. 2013; Hamdy 2017; Beshey et al. 2014a; Beshey et al. 2014b; Şahiner and Şahiner 2017; Pattnaik et al. 2014). Both times showed a moderately positive correlation with neck circumference. This can be explained simply by the longer time spent during blunt pre-tracheal dissection before airway access in those with bigger neck circumferences.

No procedure-related deaths or major intra-operative complications were encountered in the studied patients. Mild and moderate bleeding (84.75 and 9.84%, respectively) were self-limited by local compression.

Desaturation in the present study occurred in 33 patients; 30 improved immediately after the procedure. The rest (3 patients; 0.78%) developed pneumothorax and subcutaneous emphysema and were managed by intercostal tube insertion. Isolated subcutaneous emphysema was evident in 3 patients and was relieved by widening the tight skin incision around the tracheotomy to abolish its ball valve effect.

Pattnaik et al. (Pattnaik et al. 2014), in their study, concluded that the Griggs technique (without bronchoscopic assistance), modified with the technique developed by Paran et al. (Paran et al. 2004), was safe with less time and a lower complication rate. (Hassanin et al. 2013) conducted a study on fibreoptic bronchoscopic guidance in PDT and concluded that blind PDT, when done by experienced personnel, was a safe and effective procedure. It showed a shorter procedure time and avoided hypercapnia. Bronchoscopic guidance decreased the number of needle insertion trials and overall complications rate.

Rezende-Neto et al. (Rezende-Neto et al. 2011), in their prospective case series study on 100 patients, reported a safe and simple technical modification for PDT, merging both Griggs’ and Percu-Twist techniques in a reusable kit. They concluded that such modification was safe and simple to execute, with the need for long-term follow-up of complications.

Six patients in the current study were COVID-19 positive and were successfully and safely managed. The procedure did not disrupt the closed ventilation circuit, ensuring protection for healthcare workers. Angel et al. (Angel et al. 2020) studied novel PDT for critically ill COVID-19 patients. They developed a novel PDT technique that placed the bronchoscope alongside ETT, not inside, to improve visualization during the procedure. This technique lessened the risk of virus aerosolization during the procedure. They concluded that this technique appears to be safe and effective for COVID-19 patients and safe for healthcare workers.

Kumar et al. (Kumar et al. 2021) concluded in their study that mini-surgical PDT was faster than bronchoscope-guided PDT with comparable incidence of complications and could be used safely in ICUs where fibreoptic bronchoscope is not available. Lin et al. (Lin et al. 2021) in their systematic review and meta-analysis comparing the effectiveness of ultrasound-guided-tracheotomy (UGT) and conventional blind anatomic landmark-tracheotomy (LT) found that despite increased first trial success rate and fewer complications with UGT, the procedure duration and major bleeding rate were comparable.

Sangwan and Chasse (Sangwan and Chasse 2016) reviewed retrospectively 60 PDTs done using a modified technique (with intermittent bronchoscopy and ultrasound by a single operator). This was done to prevent hypoventilation associated with the use of continuous bronchoscopy. They found no procedure-related deaths or major intra-operative complications with a possibility of reducing accidental intra-operative airway loss and bleeding while possibly improving gas exchange.

The success rate in the present study was 100% without the need to convert to alternative techniques to accomplish tracheotomy. Dennis et al. (Dennis et al. 2013) evaluated more than 3000 PDT procedures regarding bedside PDT safety in the critically ill. They found that the safety of this technique, even in the obese population, was demonstrated by its low complication rate. Routine bronchoscopic guidance was not necessary. They concluded that specially trained procedure nurses and process improvement programs contribute to the safety and efficacy of this procedure.

Piercing the ETT is potentially dangerous if the airway is lost. Moreover, if the ETT is not positioned correctly, this would result in a rupture of the cuff or the pilot balloon. However, we did not encounter such threats in the present study; all preparations for immediate tracheal tube replacement should be available and ready.

The present study has several limitations. It was a retrospective study with all its inherited biases. Moreover, the study was a single-center study, and the technique was performed by a single investigator with a long experience in the studied technique.