© The Board of Management and Trustees of the British Journal of Anaesthesia 2004
CORRESPONDENCE |
Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy
Editor—We congratulate Dr Madden and colleagues1 on the successful management of a patient who experienced a posterior wall perforation during percutaneous dilatational tracheostomy (PDT). This clearly written and well-presented paper reminds intensivists and anaesthetists performing percutaneous tracheostomy of the potential complication of tracheal wall perforation, which carries a high risk of morbidity and mortality.We are, however, concerned about the statement of the authors—in order to explain that in this case fibreoptic bronchoscopy was not used during tracheostomy—that bronchoscopic guidance during percutaneous tracheostomy to confirm the correct position of the guidewire within the tracheal lumen would be likely to reduce the risk of posterior wall damage and perforation but may not eliminate it. This suggests that bronchoscopy for PDT can be omitted as it does not completely eliminate the risk of complications. This statement is referenced with the paper from Hinerman and colleagues2 who, in contrast, strongly advocate the use of fibreoptic bronchoscopy during PDT.
Ciaglia,3 who introduced this minimally invasive procedure that can be performed at the bedside initially did not consider fibreoptic control to be necessary for PDT. In the following years, numerous case reports about complications such as tracheal wall damage and perforation, and malposition of the tracheostomy tube with pneumomediastinum and hypoxia, were published. Now, Ciaglia recommends the use of fibreoptic bronchoscopy during PDT to ensure correct positioning of the guidewire, dilators and tracheostomy tubes.4
Based on our own experience of 8 yr of single and serial dilatational tracheostomies in more than 400 mainly neurosurgical patients, we believe that fibreoptic bronchoscopy is of paramount importance to increase the safety of PDT; it is the only option to minimize the risk of malposition of guidewires, dilators and tracheostomy tubes. Regularly using fibreoptic bronchoscopy during PDT, we frequently observe that the tip of the dilator touches the posterior tracheal wall if it is not directed strictly caudad. In two cases, we saw the guidewire disappear under the tracheal mucosa and re-enter the tracheal lumen shortly above the carina. Without fibreoptic control, these events would remain undetected, thus potentially leading to serious complications. All the cases of tracheal wall damage and tracheal wall perforation secondary to PDT, which were transferred from other institutions to our hospital for surgical repair, were cases where PDT was performed without fibreoptic control.
There is also increasing evidence that an exact midline puncture of the trachea and midline insertion of the tracheostomy tube might decrease the risk of post-tracheostomy tracheal stenosis. This can only be achieved under fibreoptic control.
Connecting the bronchoscope to a camera and displaying the bronchoscopic image on a monitor provides a highly valuable teaching tool to educate junior staff in correctly performing PDT. It provides a clear view to the operator of the inside of the otherwise invisible surgical field, thus considerably improving the safety of the procedure.4
Therefore, in agreement with most intensivists and anaesthetists who perform PDT, we consider fiberoptic bronchoscopy as mandatory in order to increase the safety of the procedure and to significantly reduce the risk of potentially fatal complications.
Berlin, Germany
Editor—Thank you for giving us the opportunity to respond to Drs Fritz, Buerschaper and Wolf's letter, advocating the use of confirmatory fibreoptic bronchoscopy during percutaneous dilatational tracheostomy (PDT) insertion. We would certainly agree with their argument that it is likely to improve the safety of the procedure. Moreover, we do not suggest in our paper that bronchoscopy can be omitted on the basis that it does not guarantee 100% safety.1
We are not aware of data to support the statement that ‘exact midline puncture of the trachea and midline insertion of the tracheostomy tube might decrease the risk of post-tracheostomy tracheal stenosis’. If this is the case, then we welcome the authors highlighting another reason for encouraging the routine use of the fibreoptic bronchoscope during PDT insertion.
London, UK
References
1 Madden BP, Sheth A, Ho TBL, McAnulty G. Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy. Br J Anaesth 2004; 92: 437–9
2 Hinerman R, Alvarez F, Keller CA. Outcome of bedside percutaneous tracheostomy with bronchoscopic guidance. Intensive Care Med 2000; 26: 1850–6[CrossRef][Medline]
3 Ciaglia P, Firsching K, Suniec C. Elective percutaneous dilational tracheostomy: a new simple bedside procedure; preliminary report. Chest 1985; 87: 715–19
4 Ciaglia P. Video-assisted endoscopy, not just endoscopy, for percutaneous dilatational tracheostomy. Chest 1999; 115: 915–16
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