A case of fiberoptic bronchoscopy used as innovative aid for life saving in difficult surgical tracheostomy patient.

Surgical tracheostomy (ST) is a routinely performed lifesaving procedure with a variably reported complication rate [1]. The most commonly reported complications are loss of airway and hemorrhage. Distorted neck anatomy is the most common risk factor for these complications. To perform percutaneous tracheostomy, various adjuncts such as a lightwand, fibreoptic bronchoscopy (FOB), and ultrasound have been reported to help visualize the needle puncture and tracheal tube. However, in ST, the trachea is usually identified using anatomical landmarks, without the help of adjuncts. Here we discuss a case of ST in which FOB was used to visualize the tracheal ring in the presence of distorted neck anatomy.

Informed consent has been taken from the patient prior to publication for usage of data and pictures. A 58-year-old man, diagnosed with papillary carcinoma of the thyroid, with history of multiple surgeries and radiotherapy, presented with collapse of the 5th cervical vertebra due to vertebral metastasis and respiratory distress. The patient was easily intubated using a rapid sequence intubation technique in the emergency department. Subsequently, he was placed on manual traction with a peek cage over his head and neck followed by elective ST before the cervical spine decompression surgery. Intraoperatively, surface anatomical landmarks were not visible clearly because of distortion of the soft tissues of the neck because of prior multiple neck surgeries and radiotherapy. The skin incision was roughly made tracing the back of the sternum and in between the clavicles. After opening the skin and muscle layer, none of the structures were clearly visible, and the trachea was not identifiable. FOB was performed using the endotracheal tube, which made the identification of the tracheal cartilages easier by transillumination. The tracheal cuff was identified, which usually abuts against the 2nd and 4th tracheal cartilages, and the tracheal puncture was made at that level. The rest of the procedure was completed without any complications (Figs. 1A and 1B).

Fig. 1.

(A) Light of fibreoptic bronchoscope seen during surgical tracheostomy, (B) Postoperative tracheostomy in situ with peek cage traction over the head and neck.

Good positioning and neck exposure ensures a successful tracheostomy without creating any false passage. Both the prerequisites were missing in our patient, so we planned an ST. We employed the principle of transillumination to pinpoint the tracheal puncture site with the use of FOB, which was found to be convenient during a difficult ST. With the help of soft tissue transillumination using FOB, we prevented this potentially life-threatening complication. Therefore, in such cases where ST can be strenuous, the anesthesiologist should employ this simple and novel technique, as a life-saving maneuver. Illumination of the soft tissues using a lightwand has also been used to locate the trachea in difficult tracheotomies [2]. To our knowledge, this is the first use of FOB in an open ST. We recommend using FOB routinely to locate the trachea in a difficult ST, such as in neck malignancies and fibrosis.