Affiliations: Dumfries and Galloway Royal Infirmary
Dumfries, United Kingdom,
Hôpital d’Instruction des Armées
Correspondence to: Sarah Hedges, MBBS, Dumfries and Galloway Royal Infirmary, Bankend Rd, Dumfries, United Kingdom DG1 4AP
To the Editor:
We were interested to read the article by Briche et al (April
2001)1concerning complications following percutaneous
tracheostomy. However, in both cases, we are simply told that“
percutaneous tracheostomy was performed.” There was no comment as
to whether or not the procedure was aided by a separate operator
performing simultaneous fiberoptic bronchoscopy of the trachea. The
complication rate of percutaneous dilational tracheostomy may be
reduced using endoscopic guidance,2since experience does
not seem to reduce the incidence of paramedian wire
insertion.3The study of Dexter,4 assessing
blind wire placement, found that only 45% of wires entered the trachea
at the intended level, 30% of wires pierced the thyroid isthmus, and
only 15% of wires punctured the trachea centrally.
The proposed mechanism of stenoses in the two cases (a difficult
perforation of the trachea causing fracture of the tracheal ring, thus
creating an intralumenal tracheal flap) would surely have been noted if
the fiberoptic bronchoscope had been used. We would advocate the use of
bronchoscopy in all cases of percutaneous dilational tracheostomy in
order to minimize immediate and long-term complications resulting from
this valuable bedside technique.
For 4 years, we have performed bedside percutaneous tracheostomy
with two physicians, always with the same procedures. The first
physician, in each case a senior physician, is located at the head of
the patient and performs fiberoptic bronchoscopy (Olympus NFT3
Rhino-Laryngo Fiberscope; Olympus Optical; Hamburg, Germany) to prevent
complications. The second physician performs the procedure.
To prevent abnormal insertion and tracheal injury, the use of a single
progressive conic dilator (Ciaglia Blue Rhino; William Cook Europe;
Bjaeverskov, Denmark) is better than the use of several dilators with
progressive size. In our experience, complications can occur even if we
are satisfied with the immediate fiberoptic bronchoscopy result. I
agree with Dr. Perkins’s opinion that fiberoptic bronchoscopy is
required. Even better, it must be performed for a long time even after
decannulation. Other methods can be performed to reduce tracheal
impaction. A kit by Mallinckrodt (Tracheostomia translazingea Fautoni
methode; Mallinckrodt Medical; Mirandola, Italy) uses a similar
procedure as an endoscopic gastrostomy (internal to external
procedure), but in our experience, this procedure is more complicated
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