Catheterization of the Trachea and Bronchi by a Modified Seldinger Technic: A New Approach to Bronchography

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Abstract
On occasion, a technic developed in one field finds unexpected application in another and thereby satisfies a need which for many years has remained unmet. It is believed that the Seldinger technic of catheterization, until now applied exclusively to angiography (1), may ultimately find an important application in bronchography. Specifically, a modified Seldinger technic has been employed to introduce a radiopaque catheter through the cricothyroid membrane and then to maneuver it into various primary and secondary bronchi under fluoroscopic control. The technic is safe, relatively easy to perform, comfortable for the patient, and capable of producing selective bronchograms of superior quality. Method The pharynx is first lightly anesthetized to prevent coughing, which may result if radiographic contrast material flows back through the glottis during filling of the upper lobes. The patient is then placed in the supine position with the head well extended (Fig. 1). The notch between the lower border of the thyroid cartilage and the cricoid cartilage is easily palpated in this position. After careful aseptic preparation, the skin overlying the cricothyroid membrane is infiltrated in the midline with 1 to 2 cc of 2 per cent Xylocaine. A small amount of Xylocaine is then injected through the membrane with the No. 25 infiltrating needle to anesthetize the trachea locally. Free flow of air into the syringe is, of course, obtained immediately upon entering the trachea. A tiny nick is made in the overlying skin with a Bard-Parker blade, and a Seldinger 160 needle is carefully introduced through the cricothyroid membrane, in the midline. The needle is introduced only a few millimeters into the trachea to avoid injury to the posterior wall. This step is accomplished with ease if the patient's head is well extended. Furthermore, if all needles are introduced in the midline where the cricothyroid membrane is close to the skin surface, there is no danger to more lateral vascular structures of the neck. The needle obturator is removed, the end of the needle pointed toward the carina, and a soft-tipped wire guide is introduced several centimeters into the trachea. Next, the needle is removed, and a radiopaque thin-walled Teflon catheter with a gently curved tip is threaded in over the wire guide (outside diameter of catheter, 1.96 mm; inside diameter, 1.35 mm). A slight oscillating, rotary motion helps introduce the catheter smoothly through the skin and cricothyroid membrane. The wire guide is withdrawn, the patient's head is returned to a neutral position, and the transcricoid catheter is easily manipulated under fluoroscopic control into (or adjacent to) the desired bronchial orifice, prior to introduction of the contrast material. During placement of the catheter, excellent anesthesia of the trachea and bronchi can be obtained by injecting small amounts of 2 per cent Xylocaine through the catheter.

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