In Reply:-Thank you for giving us the opportunity to respond to Drs. Fuhrman and Bouvette. We agree with them in principle that simultaneous bronchoscopic monitoring in our reported case would most likely have prevented the problem.
In comparing groups with and without bronchoscopy, Berrouschot et al. found no difference in the rate of perioperative complications; however, there were more severe complications in the group without bronchoscopy. Although invaluable to percutaneous dilational tracheostomy, bronchoscopic guidance is of special value for patients with abnormal or poorly felt surface anatomy. Percutaneous dilational tracheostomy in our intensive care unit is performed as described by Ciaglia and is only performed by experienced consultant anesthesiologists. We do not routinely pass a fiberoptic scope down the endotracheal tube before puncturing the trachea in all our percutaneous dilational tracheostomies. Typically we have a consultant anesthesiologist performing the procedure and a senior resident providing anesthesia and minding the airway. Fiberoptic bronchoscopic proficiency varies among our residents; therefore, to have bronchoscopic monitoring would require the presence of an extra consultant anesthesiologist. We have found that bronchoscopic monitoring makes ventilation more difficult because of the reduced gas flow though the endotracheal tube because of the presence of the fiberoptic scope. Increasing the fractional inspired oxygen tension (FiO(2)) to 1 can compensate for oxygenation but hypercapnia remains a problem. Patient selection is vital, we refer obese patients and those with abnormal anatomy to the head and neck surgeons for an open procedure.
Our complication rate is similar to that quoted in the literature, [1,3,4]and so far we have had only minor complications. Bronchoscopic guidance may prevent complications such as the one we reported; we are currently reviewing our practice to incorporate simultaneous bronchoscopic monitoring.
Thomas Mphanza, F.R.C.A.
Sydney Jacobs, F.R.C.A., F.A.N.Z.C.A.
Director of Adult Intensive Care Unit; Department of Anaesthesia; Riyadh Military Hospital; Riyadh 11159, Kingdom of Saudi Arabia;firstname.lastname@example.org
(Accepted for publication October 12, 1998.)