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Correspondence  |   September 1995
Rigid Bronchoscope: A Possible New Option for Percutaneous Dilational Tracheostomy
Author Notes
  • J. Brimacombe, F.R.C.A., Clinical Associate Professor.
  • G. Clarke, F.R.C.A., Clinical Senior Lecturer, FNQ Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns 4870, Australia.
Article Information
Correspondence
Correspondence   |   September 1995
Rigid Bronchoscope: A Possible New Option for Percutaneous Dilational Tracheostomy
Anesthesiology 9 1995, Vol.83, 646-647.. doi:
Anesthesiology 9 1995, Vol.83, 646-647.. doi:
To the Editor:--The performance of percutaneous dilational tracheostomy has increased in recent years with the advent of guidewire-based techniques and better materials. [1] Claimed advantages over conventional tracheostomy are that dilational techniques are safer, easier and quicker to perform at the bedside, with a low incidence of late complications. [2] Technical problems associated with the procedure include (1) incorrect placement of the needle, (2) over/under-withdrawal of the endotracheal tube (ETT), (3) transfixion of the ETT by the needle or cuff puncture, and (4) ventilation difficulties during passage of the dilators. The first three problems may be avoided by passing a fiberoptic scope down to the tip of the ETT, allowing better control over needle placement and ETT position. However, this may make ventilation more difficult because gas flow through the ETT is limited by the presence of the fiberoptic scope. [3] A possible improvement in selected patients is to exchange the ETT for a laryngeal mask airway (LMA), [4] but this technique has limited application. Another option is to use the rigid bronchoscope.
A 25-yr-old, 68-kg man whose lungs had been ventilated for 2 weeks after a cardiac arrest underwent fiberoptic-guided percutaneous tracheostomy, a routine procedure at our institute. Two senior anesthesiologists were present, one to provide airway care and anesthesia, the other to perform the procedure. A superficial horizontal incision was made over the subcricoid area and a 14-G needle passed into the trachea between the second and third tracheal rings. A guidewire was inserted and the position confirmed by fiberoptic inspection via the ETT, which had been withdrawn into the larynx. A tract was created by blunt dissection and the passage of progressively larger dilators until an 8-mm tracheostomy tube could be placed. The procedure was uneventful, but an hour afterward, the lungs became difficult to ventilate. A large blood clot was found to be obstructing the left main bronchus, an uncommon but well documented complication of the technique. Several attempts at removing the clot with fiberoptic-guided suction and grasping forceps failed. Eventually, the tracheostomy tube was removed, and a rigid venturi bronchoscope (RVB) was used to extract a semisolid 20-ml clot, resulting in considerable improvement in lung function. There was no active bleeding from the tracheostomy site. Because the patient was stable, the percutaneous tracheostomy was repeated with the RVB functioning as a guide and for airway control. The approach to the trachea was made via the same incision, but the guidewire was inserted between the first and second tracheal rings to minimize the risk of further bleeding. The procedure was uneventful.
We subsequently used the RVB to perform percutaneous tracheotomy on six patients without difficulty and have been impressed with the advantages it offers over other techniques. It provides a clear, undistorted view of the surgical site and supports the tracheal architecture while the dilators are being passed. Also, there are none of the difficulties in ventilation that commonly accompany percutaneous tracheostomy. We found that the position of the bronchoscope was controlled easily and that tracheal suction could be performed readily. Potential limitations of the technique include difficulties in placing the RVB and damage to teeth. Aspiration is possible, but if this occurred, it would be identified immediately and cricoid pressure could be applied while the airway was made more secure and suction was performed. Aspiration may still occur with the standard technique if the ETT is withdrawn too far or the cuff is damaged. In addition, the risk/benefit ratio of exchanging the ETT for the rigid bronchoscope must be considered. Perhaps the main limitation of the technique, however, is the inexperience of most anesthesiologists and intensivists with placement of the rigid bronchoscope. This traditionally has been the domain of surgeons, with anesthesiologists and intensivists providing anesthesia and control of the upper airway, as was the case with tracheostomy before the advent of the percutaneous technique. [2] .
In summary, we believe the rigid bronchoscope offers some advantages over standard techniques for percutaneous tracheostomy and is worth investigating further. It may be particularly useful if ventilation difficulties are experienced or bleeding has occurred.
J. Brimacombe, F.R.C.A., Clinical Associate Professor.
G. Clarke, F.R.C.A., Clinical Senior Lecturer, FNQ Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns 4870, Australia.
(Accepted for publication June 8, 1995.)
REFERENCES
Toye FJ, Weinstein JD: Clinical experience with percutaneous tracheostomy and cricothyrotomy in 100 patients. J Trauma 26:1034-1040, 1986.
Bodenham AR: Percutaneous dilational tracheostomy: Completing the anaesthetist's range of airway techniques. Anaesthesia 48:101-102, 1993.
Marelli D, Paul A, Manolidis S, Walsh G, Odim JN, Burdon TA, Shennib H, Vestweber KH, Fleiszer DM, Mulder DS: Endoscopic guided percutaneous tracheostomy: Early results of a consecutive trial. J Trauma 30:433-435, 1990.
Dexter TJ: The laryngeal mask airway: A method to improve visualisation of the trachea and larynx during fibreoptic assisted percutaneous tracheostomy. Anaesth Intens Care 22:35-39, 1994.