Tracheostomy is a common procedure for intensive care patients requiring prolonged mechanical ventilation. In this case report, we describe a 78-year-old female patient admitted for an aneurysm of the cerebral anterior communicating artery. Following immediate endovascular coiling, she remained ventilated and was transferred to the neurological intensive care unit. On postoperative day ten, a percutaneous tracheostomy (PCT) was requested; however, a large ulcer or possible tracheoesophageal fistula was identified on the posterior tracheal wall following bronchoscopic assessment of the trachea. Therefore, the requested PCT procedure was aborted. An open tracheostomy in the operating room was completed; however, due to the position and depth of the ulcer, a reinforced endotracheal tube (ETT) was placed via the tracheostomy. Four days later, the reinforced ETT was replaced with a Shiley distal extended tracheostomy tube to bypass the ulceration. Careful inspection and evaluation of the tracheostomy site before PCT prevented a potentially life-threatening issue in our patient. 1. Introduction Tracheostomy is a routine procedure for critically ill patients. The percutaneous tracheostomy (PCT) approach has been shown to be safer and is the preferred method compared to the open technique [1, 2]. However, there are still some instances in which open tracheostomies are the necessary method. The technique and equipment of PCT have significantly evolved since the first description of the percutaneous dilatational report described by Ciaglia et al. . Bronchoscopic guidance with a fiberoptic endoscope during PCT allows direct visualization for tracheal tube positioning placement and control of the entire PCT [4–6]. Lower complication and infection rates with PCT procedures performed under bronchoscopic guidance versus “blind” PCT have been demonstrated [5, 7, 8]. Bronchoscopic guidance may also prevent iatrogenic damage to the posterior tracheal wall. Despite this, recent reports have concluded that routine bronchoscopy is not recommended prior to PCT [9, 10]. This case presents a sequence of altered clinical decisions after bronchoscopic visualization of the trachea revealed a large unexpected posterior wall ulcer before PCT. We aim to emphasize the importance of routine bronchoscopy before a tracheostomy, to assess the tracheal wall and to verify correct placement. 2. Case Report A 78-year-old female with past medical history of hypertension, chronic obstructive pulmonary disease, gastroesophageal reflux disease, dyslipidemia, and panic disorder was admitted to
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