Innovative use of the fiberoptic bronchoscope
A 50-year old male, a diagnosed case of anaplastic carcinoma of thyroid, presented with a large thyroid swelling causing respiratory distress. A decision for emergency tracheostomy was made by the surgical team and the patient was transferred to the operation theater. Comorbidities included hypertension, for which he was on regular medications. Chest X-ray showed tracheal deviation to the right [] and Hopkins (indirect laryngoscopy) examination showed decreased right vocal cord movement. All other investigations were normal.\nThe procedure was explained to the patient and informed consent was taken. All standard monitors were attached and basal vital parameters were noted. Intravenous access was secured and a difficult intubation trolley was kept ready in the theater with all airway adjuvants.\nAfter preoxygenation, inhalational induction was performed with sevoflurane and direct laryngoscopy was performed. The vocal cords were sprayed with 4% lignocaine and the airway was secured with an endotracheal tube. Anesthesia was maintained with a mixture of oxygen and air with sevoflurane and intravenous drugs including fentanyl and vecuronium, which were given after confirmation of endotracheal tube in the trachea by auscultation and waveform capnography.\nOn neck exploration, there was a plaque of disease infiltrating various tissue planes. The trachea that appeared to be shifted on the right side could not be seen or felt because of disease plaque. The endotracheal tube that was passed also could not be felt. Usual test of tracheal puncture, with aspiration of air through syringe, was also not helpful. Therefore, it was considered unsafe to make an incision blindly on a structure that was assumed to be the trachea.\nTo locate the trachea, a fiberoptic bronchoscope was then introduced through the endotracheal tube, which helped, as it was seen as a trans-illumination, and the tracheal position could be confirmed []. The rest of the tracheostomy was uneventful. Endotracheal tube was then withdrawn over the fiberoptic bronchoscope and a tracheostomy tube was introduced into the trachea. The placement of the tracheostomy tube was confirmed with waveform capnography and then the fiberoptic bronchoscope was removed.\nPostprocedure, the neuromuscular blockade was reversed and the patient was shifted to the intensive care unit for further management.