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Dr. Ciaglia is a Clinical Assistant Professor, Department of Surgery, SUNY Health Science Center, Syracuse, NY; Airway Consultant of Trauma Center, Level II and Consultant Medical Director of Respiratory Care, St. Elizabeth Medical Center, Utica, NY; and Coordinator of Clinical Research, Bassett-St. Elizabeth Family Practice Residency Program, Utica, NY.
Correspondence to: Pasquale Ciaglia, MD, FCCP, General Thoracic Surgery, Endoscopy, 2215 Genesee Street, Utica, NY 13501
Following the introduction of "blind" percutaneous dilatational tracheostomy (PDT) by Ciaglia and colleagues1 in 1985, the first simultaneous bronchoscopic monitoring of the procedure was reported by Paul and colleagues.2 This was an important improvement in safety and ease of performance and has justifiably become a part of the procedure as many reports describe it.3 ,4 ,5 ,6 ,7 ,8 ,9 ,10 However, only a few reports describe the use of video-assisted endoscopy in PDT.11 ,12 ,13 This is an even better and safer method of performing the procedure. It is comparable to performing modern laparoscopic surgery in which video-assisted laparoscopy is done and in which the operator looks at the image of what they are working on while someone else merely holds a scope to project the image on the monitor. In fact, as pointed out by Spaner and colleagues,14 "It was not until after 1986, following the development of a video computer chip that allowed the magnification and projection of images onto television screens, that the techniques of laparoscopic surgery truly became integrated into the discipline of general surgery."
Along the same lines, Ballantyne and colleagues15 in the book Laparoscopic Surgery wrote in the preface, "Attachment of a video camera to a traditional laparoscope reached the isolation that separated GI surgery from the rest of society for nearly a century and opened the flood gate of biotechnology transfer from the rest of 20th Century civilization into the practice of general surgery." As is also pointed out by Stellato,16 "acceptance of laparoscopy into general surgery awaited the development in the 1980s of the computer-chip television camera, which allowed videolaparoscopy to be performed. Undoubtedly, the user-friendly instrumentation for therapeutic laparoscopy has revolutionized the management of biliary tract disease and general surgery." Of course, the same applies to video-assisted endoscopy in PDT. The one holding the flexible bronchoscope does not have to be an expert experienced bronchoscopist but a technician or respiratory therapist, just as the one holding and directing the laparoscope in surgery is not necessarily a surgeon but a nurse or one of the surgical technicians.
I have observed a serious complication that arose because the "bronchoscopist" was a good general surgeon who did not do bronchoscopy or PDT, and evidently was of no help in avoiding the serious complication. With video-assisted bronchoscopy, the operator would see the field and be guided in management. A video-assisted endoscopy unit can be set up in an ICU and should be no problem. With the video, the bronchoscope need not be kept in the trachea throughout the procedure, but should be used at the beginning to aid in proper location of the initial tracheal puncture and insertion of the double guide. It could then be removed and reinserted whenever deemed necessary. In this way, PDT could become a minimally invasive procedure with maximally increased visibility.
References
This article has been cited by other articles:
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  J. J. See and D. T. Wong Unilateral subcutaneous emphysema after percutaneous tracheostomy: [Emphyseme sous-cutane unilateral apres une tracheotomie percutanee] Can J Anesth, December 1, 2005; 52(10): 1099 - 1102. [Abstract] [Full Text] [PDF]
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F. Agro, M. Carassiti, C. Magnani, and D. Alfery Airway control via the CobraPLATM during percutaneous dilatational tracheotomy in five patients: [Le controle des voies aeriennes par le CobraPLATM pendant la tracheotomie dilatatrice percutanee chez cinq patients] Can J Anesth, April 1, 2005; 52(4): 418 - 420. [Abstract] [Full Text] [PDF]
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 G. Raghuraman, S. Rajan, J. K. Marzouk, D. Mullhi, and F. G. Smith Is Tracheal Stenosis Caused by Percutaneous Tracheostomy Different From That by Surgical Tracheostomy? Chest, March 1, 2005; 127(3): 879 - 885. [Abstract] [Full Text] [PDF]
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 G. A. Fritz, G. Buerschaper, S. Wolf, B. Madden, and G. McAnulty Novel approach to management of a posterior tracheal tear complicating percutaneous tracheostomy Br. J. Anaesth., October 1, 2004; 93(4): 598 - 598. [Full Text] [PDF]
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 F. Agro, M. Carassiti, and C. Magnani Percutaneous Dilatational Cricothyroidotomy: Airway Control via CobraPLATM Anesth. Analg., August 1, 2004; 99(2): 628 - 628. [Full Text] [PDF]
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