by Harwood Academic Publishers Printed in Singapore The Use of Fiberoptic Bronchoscopy During Percutaneous

The aim of our research is to evaluate the advantage by the combined use of fiberoptic bronchoscopy and laryngeal mask during the performance of percutaneous dilatational tracheostomy in an intensive care unit. Patients: 16 adult patients who were candidates to middle-long term mechanical ventilation. Environment: Intensive Care Unit of a Community General Hospital. Results: We experienced 3 minor complications (2 minor bleedings and 1 neck emphysema). Difficulties were found in 3 patients with particular anatomical conformation (obese patients with short neck and limited mobility of the cervical spine). Conclusion: The combined use of fiberoptic tracheo-bronchoscopy with the laryngeal mask permits a better endoscopic visualisation of the operatory field, providing a more secure and precise procedure.


INTRODUCTION
Methods of percutaneous dilatational tracheostomy, originally described by Ciaglia in 1985 [1], and similar techniques, are having a wide employment in intensive care in comparison with the classic surgical tracheostomy. The global incidence of complications in the scientific literature for the classic technique is about 22% [2][3][4][5][6][7][8].
However, employing the percutaneous technique, these same complications only reach a 12% global incidence, with a greatly reduced rate of stomal infections. Additionally, the percutaneous tracheotomy has some significant advantages such as: (a) feasibility of the operation at the patient's bedside in the Intensive Care Unit; (b) low learning curve due to ease of procedure; years old. The SAPS II average value was 49.9, (c) operatory room cost savings; ranging between 21 and 75.
(d) short length of procedure.
The global mortality rate during the hospital stay was 56%, out of which 37.5% (6 patients) The introduction of endoscopic guides, first in the Intensive Care Unit. However, no death suggested by Marelli and associated in 1990 was related to complications due to percutaneous [9,10] and followed by other Authors [11], repredilatational tracheostomy. sented an improvement of the original technique The following pathologies were observed: 10 and caused a further reduction of complications patients were affected by reacute chronic obstrucrelated to tracheostomy, tive bronchopneumonopathy, with pneumonia in In fact, endoscopic vision permits a precise 5 of these patients; 2 patients were affected by visualisation of the dilators and tracheostomy intraparenchymatous brain haemorrhage; 3 patube, and allows an immediate correction of tients were affected by a septic state caused by improper accesses or procedures such as parasurgical pathologies (perforated gastric ulcer; liver median needle insertion, carcinoma; perforated empyema of the gallblad-In our experience with the fiberoptic bronchoder). The last patient had an acute respiratory scope we also employed the laryngeal mask, as failure due to a cardiogenic shock following an previously described by Dexter [12] and Tarpey infarction. In average, we performed percutaneous [13], in order to reduce several disadvantages dilatational tracheostomy on the 10th day of adassociated with the classic procedure, which mittance, ranging between one and twenty days. included difficulty in maintaining the endotra-The average time of the operation was about cheal tube in the correct position, and problems 17 min, ranging from a minimum of 10 min for related to the relative pressure of the endotrapatients with favourable anatomical conditions cheal tube cuff, positioned immediately proximal to a maximum of about 25 min for obese to the vocal cords, on the larynx and on the patients with short and less mobile necks. same vocal cords, sometimes damaging these The percutaneous dilatational tracheostomy structures. The laryngeal mask permits, indeed, a was performed at the bedside of the patient by more clear endoscopic vision of the operatory two doctors of the Intensive Care Unit: one field in comparison to introducing the scope doctor performed the operation and the other through the endotracheal tube. managed the anaesthesia and particularly drugs, ventilation, and the correct positioning of the laryngeal mask. The procedure was also followed by two graduate nurses. The use of fiberoptic PATIENTS AND METHODS bronchoscope allowed everybody to follow the entire operation on the monitor, permitting a From March 1995 to March 1996 in the Intenwide participation.
sive Care Unit of the Community General Hos-The operation was performed in intravenous pital of Menaggio (Como) 16 percutaneous general anaesthesia. Primary anaesthesia was dilatational tracheostomy were performed in obtained with propofol 2mg/kg and fentanyl patients candidate to middle-long term mechani-0.05-0.1 mg; maintenance with propofol 1-3 mg/ cal ventilation. Data regarding our series are kg/h, pancuronium 0.8mg/kg. Patients were shown in Table I. ventilated via a Siemens 900 C until the laryngeal Of the 16 patients included in our series, 9 mask was positioned.
were females (56%) and 7 were males (44%), the The ventilation was led in the following way: average age was 77, ranging between 65 and 93 CPPV, TV of 7 ml/kg, FiO2: 1.0. We monitored blood's saturation by a pulse tional tracheostomy was performed following the oximetry (DATEX SATLITE trans), non-schema described by Ciaglia [7]. The  Under the direct vision of the laryngoscopy, subcutis is performed, avoiding damage to blood we initially suctioned the pharynx. The patient vessels by transillumination of the bronchoscope. was then estubated and the laryngeal mask was A needle connected to a syringe filled with positioned. In this phase, the patient was ventisaline solution is inserted between the first and lated with 100% oxygen via a manual breathing the second tracheal ring with a 35 cranio-caudal unit. We introduced the fiberscope in order to angle. The aspiration of air demonstrates the obtain the transillumination of the interspace penetration of the needle in the trachea. A guidebetween the first and the second tracheal cartiwire of 0.052 inch diameter with a "J" tip is lages, which had been previously identified by inserted through the needle. Then a dilator and palpation. Subsequently, percutaneous dilataan 8-French Teflon guide are inserted on the  guidewire in order to make the system rigid ( Fig. 1). The guide has a small ring on the distal end in order to avoid damages by the dilators, especially to the posterior wall of the trachea.
Next, dilators from 12 to 36 French are inserted on the guide. When the required dilatation is obtained, a 7, 8, or 9mm diameter tracheostomy tube is inserted, using a smaller dilator as a guide. Subsequently, the double guide is removed and the tube can be cuffed.

RESULTS AND CONCLUSIONS
Data reported in literature, as previously described, demonstrates that most common complications following percutaneous tracheotomy include: subcutaneous emphysema, bleedings, stomal infections, difficulties in tracheostomy tube insertion and paramedian insertions. Global incidence of complications is about 12%. Our experience does not significantly differ from these results, and particularly, the complications which occurred in our patients are described in Table II. We globally had 3 minor complications, and particularly two cases of minor bleeding stopped only by the compression obtained with the tracheostomy tube, and one case of subcutaneous emphysema of the neck which spontaneously healed in a few days.
By employing the fiberoptic bronchoscopy and the laryngeal mask we avoided incorrect introduction of the dilators, as we were able to correct any improper placement of the guidewire.
The difficulties we encountered always occurred in patients with unfavourable anatomical conditions (obese patients with short neck and limited mobility of the cervical spine), which do not appear ideally suited for this procedure.
In two of these patients, it was necessary to perform the tracheostomy between the cricoid cartilage and the first tracheal ring. In these two as well as one other patient, we found several difficulties in maintaining the laryngeal mask in the correct position, but were always able to complete the procedure.
Notwithstanding several other reports [12], in our series all patients had a nasogastric tube but we didn't have any noticeable leakage around the laryngeal mask attributable to it; in three cases the mask leakage has been ascribed to unfavourable anatomical conditions (obesity and short neck).
Other Authors [14] evidenced that laryngeal mask could be dangerous due to the possibility of aspiration pneumonia: in our experience-this evidence is not justified since we perform percutaneous dilatational tracheostomy only in elective patients and never in emergency, which is a different approach compared to other published literature [1 5]. We can conclude that the use of fiberoptic bronchoscopy with the laryngeal mask facilitates the performance of the Ciaglia's percutaneous dilatational tracheostomy. Particularly, endoscopic vision of the operatory field offered by laryngeal mask is greatly improved compared to insertion the instrument through the endotracheal tube.
Furthermore, the connection of the scope to a monitor allows the operator and his team to follow every step of the operation and perform the procedure with a greater safe and coordination.