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EanchdeoossctoopmicyS Jamadarkhana, A Mallick, A Bodenham
Department of Anaesthesia & Intensive Care, Leeds General Infirmary, Leeds, UKI!

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Endoscopic guidance during percutaneous dilatational tracheostomy (PDT) is increasingly used on the intensive care unit (ICU)1.
Reusable flexible fibre-optic bronchoscopes are commonly used
for this purpose and there is always a risk of needle damage tothe scope during PDT. Bonfil’s semi-rigid scopes have been used
to avoid this problem. However, manoeuvring of Bonfil’s scopethrough the endotracheal (ET) tube is sometimes difficult becauseof its distal bend. Both these scopes need sterilisation before use.
National guidelines and recommendations should also be strictly
followed for the sterilisation process, which is time consuming
and expensive2-4. There have been reports of bronchoscopyrelated infections caused by faulty reprocessing procedures.
With increasing risk of resistantbacterial strains, there are increasing
indications for the use of disposablebronchoscopes. The Ambu® aScope™
2 (Ambu Ltd, Ballerup, Denmark) is asingle-use flexible scope, which has
recently become available for difficult
airway intubations (Fig 1). It’s external
diameter is 5.4mm with a working lengthof 630mm. We were interested to assess
Fig 1
the feasibility of this scope during PDT.
M()"#*Ten patients who underwent PDT on the Adult General and
Neurosurgical ICUs were enrolled in this study. Ethics committee
approval was questioned but not required and informed assent was
obtained from next of kin. All patients were anaesthetised with Propofol
and Alfentanil infusions, paralysed with atracurium and ventilatedwith 100% oxygen (using pressure/volume control modes) prior to
the procedure. After appropriate positioning, an ultrasound scan of
the front of the neck was performed to delinate the anatomy. Theexisting ET tube was withdrawn until the cuff was just seen at the vocalcords. The site of the procedure was infiltrated with 20 mls of xylocaine
2% with 1:200,000 adrenaline. PDT was performed using Portex
Ultraperc™ (Smith Medical, Hythe, Kent, UK) single stage dilator
percutaneous tracheostomy set following full aseptic precautions.
The following data was collected during the procedure: a) easeof use of the scope; b) quality of images (brightness, focus,resolution) on a scale of 1-10 (1= poor view, 10= best view); c)
arterial blood gases, ventilatory (tidal volume, peak airway pressure,PEEP, arterial Ph, PaCO2, PaO2, FiO2, SpO2) and cardiovascularparameters (heart rate, mean arterial pressure) prior to, during andafter the procedure. The correct position of tracheostomy wasconfirmed using the ambuscope and end-tidal CO2 monitor. Theglottis was also viewed as the endotracheal tube was withdrawn.

R(*$,*The average age of the patients was 62 years (range55-80). In 90% of the patients PDT was performed
between 3 and 6 days after tracheal intubation.
The average time to set up the scope and monitor
was less than 5 minutes. The procedure time fromneedle puncture of the trachea to tracheostomy
tube placement ranged from 5-10 minutes. In one
patient, the procedure time was 45 minutes due
to a tracheal ring fracture and cuff damage of thetracheostomy tube.
All the anaesthetists looking after the airway
reported easy handling and manoeuvrability
because of its light-weight design. The operators
performing the procedure scored the clarity andquality of endoscopic view (of needle, guidewire,stomal dilatation and tracheostomy tube placement)
to be between 8-10. Cardiovascular and ventilatory
parameters were not significantly changed during
procedure in all the patients. No complications
were reported during the use of the Ambuscope.

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We conclude that in our experience Ambu® aScope™
2 is an alternative to reusable bronchoscopes for
PDT on ICU.
The light-weight design makes it very easy tohandle and allows the operator to have a clear
endoscopic view of the needle, guidewire and thetracheostomy tube.
It’s single use design eliminates the risk of crosscontamination and delays with sterilisation.

References
1. Kost KM. Endoscopic percutaneous dilatational tracheotomy: aprospective evaluation of 500 consecutive cases. Laryngoscope.
2005; 115: 1-30.
2. Norris A, Wakeling P, Wiles M et al. Costs associated with fibrescope
inventory: what role for a disposable scope? DAS 2010 (Poster).
3. Weber DJ, Rutala WA. Lessons from Outbreaks associated withBronchoscopy. Infection Control and Hospital Epidemiology. 2001; 22:403-408.
4. Schraag J. Scope-related Infections, The same challenges haveremained for decades, but have the processes improved? 2007.
www.infectioncontroltoday.com. (Date accessed 22/8/2011).

Acknowledgements
We thank Ambu Ltd (Cambridgeshire, UK) for their technical support andall ICU staff for their cooperation during this study

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