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LETTERS TO EDITOR
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 34-35
 

Warranted use of fiberscope in elective percutaneous dilatational tracheostomy


Department of Anaesthesia, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi, India

Date of Web Publication22-May-2018

Correspondence Address:
Dr. Bhavna Gupta
Department of Anaesthesia and Critical Care, Maulana Azad Medical College, Lok Nayak Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_46_17

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How to cite this article:
Gupta B, Kerai S. Warranted use of fiberscope in elective percutaneous dilatational tracheostomy. Indian Anaesth Forum 2018;19:34-5

How to cite this URL:
Gupta B, Kerai S. Warranted use of fiberscope in elective percutaneous dilatational tracheostomy. Indian Anaesth Forum [serial online] 2018 [cited 2019 Sep 16];19:34-5. Available from: http://www.theiaforum.org/text.asp?2018/19/1/34/232911




Sir,

A 72-year-old female weighing 40 kg was admitted to our Intensive Care Unit (ICU) with diagnosis of sepsis and Type II respiratory failure because of long-standing chronic obstructive pulmonary disease and bronchiectasis. She was on support of mechanical ventilation for 21 days and planned for percutaneous dilatational tracheostomy (PCDT) to aid in weaning and to improve orodental hygiene and pulmonary toileting. After appropriate preparation of PCDT, the patient was sedated, paralyzed, and was placed with the neck in extended position. Surgical area was painted and drapped, and a horizontal small incision was made on the skin located half way between cricoid cartilage and sternal notch after infiltration with 2 ml of 2% lignocaine with adrenaline, blunt dissection of subcutaneous tissue was done till pretracheal fascia. Using modified Ciaglia technique of PCDT, the trachea was punctured in single attempt and air was aspirated. Guidewire was inserted, followed by dilatation and introduction of the tracheostomy tube. Bain circuit was attached to the tracheostomy tube, but there was difficulty in ventilating the patient, and there was minimal chest rise. Endotracheal tube (ETT) was restored, and the patient was ventilated through the same, tracheostomy tube was slightly pulled back but not entirely taken out of stoma. Fiberscope was inserted through tracheostomy tube to look into the tracheal lumen, to our surprise, there was a mass in the tracheal lumen, just above the carina, with very little lumen left for ventilation [Figure 1]. Since the mass was not completely occluding the tracheal lumen, it was allowing ventilation through ETT; however, when the tracheostomy tube was inserted, its tip was impinging on the carinal mass leading to inadequate ventilation. Peak pressures were very high and with minimal tidal volume while ventilating through tracheostomy tube. After failing to negotiate tracheostomy tube, ENT surgeon was called for help, they confirmed the presence of mass and advised to abandon the procedure. We could not negotiate our fiberscope beyond the mass to look into the details of bronchus. Carinal growth was missed when fiberscope was inserted through ETT, as during the PCDT procedure, we keep the fiberscope above the level of vocal cords, so as to avoid needle trauma to the fiberscope. The presence of carinal mass was made only during PCDT procedure under fiberscope. The site of incision of tracheostomy was sutured, and the patient was ventilated through ETT. She was referred to cardiothoracic vascular surgeon and was planned to undergo contrast-enhanced computed tomography or high-resolution computed tomography of tracheobronchial tree, but the same could not be done owing to her renal dysfunction, and she succumbed to death after a week owing to her sepsis and multiorgan failure.
Figure 1: Note can be made of huge mass (2) and obstruction of lumen (1)

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PCDT is a common procedure done in patients requiring prolonged mechanical ventilation in ICU. Ciaglia et al. originally described progressive dilatation method, using Seldinger guidewire inserted into a Teflon cannula without the use of fiberscope.[1] Bronchoscope visualization of insertion needle, Seldinger wire, and tracheostomy tube has been used by some authors to reduce the incidence of insertion failure.[2] However, other authors have suggested that bronchoscopy visualization is not necessary, and there is no increase in overall complications without its use.[3] Some authors have also commented that bronchoscopy is associated with more complications, more chances of desaturation during procedure and increase the overall time of PCDT.[4]

Our patient had a mass just above the carina, the presence of the same could be made by means of fiberscope. In the presence of a tracheal mass, positive pressure ventilation through ETT depends on the degree of obstruction and type of growth. In our case, carinal mass was occluding almost 60%–70% of tracheal lumen, thus allowing ventilation through ETT; however, the tip of tracheostomy tube was directly impinging upon the mass, hence leading to difficulty in ventilation. Real-time use of fiberscope not only confirms all the steps of PCDT but also helpful in identifying abnormal tracheal or bronchial condition and is also helpful in aspirating secretions or blood. It was missed by fiberscope through ETT because we did not go beyond the level of vocal cord to look into the details of trachea and bronchi. On the basis of our case, we conclude that clinician should ascertain the anatomical difficulties in the tracheal and bronchial lumen (tracheal or bronchial mass or tracheomalacia, etc.) before proceeding for PCDT, and all the steps of PCDT should be done under fiberscope visualization till confirmation of tracheostomy tube placement and ventilation is made.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) relatives has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients relatives understand that their patient's name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ciaglia P, Firsching R, Syniec C. Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report. Chest 1985;87:715-9.  Back to cited text no. 1
[PUBMED]    
2.
Marelli D, Paul A, Manolidis S, Walsh G, Odim JN, Burdon TA, et al. Endoscopic guided percutaneous tracheostomy: Early results of a consecutive trial. J Trauma 1990;30:433-5.  Back to cited text no. 2
[PUBMED]    
3.
Lima EJ. Percutaneous tracheostomy without bronchoscopy a safe procedure. J Intensive Crit Care 2016;2:2.  Back to cited text no. 3
    
4.
Gadkaree SK, Schwartz D, Gerold K, Kim Y. Use of bronchoscopy in percutaneous dilational tracheostomy. JAMA Otolaryngol Head Neck Surg 2016;142:143-9.  Back to cited text no. 4
[PUBMED]    


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