Communications to the Editor |

Percutaneous Tracheostomy Is Really Better—If Done Correctly FREE TO VIEW

Pasquale Ciaglia, MD, FCCP
Author and Funding Information

Utica, NY

Correspondence to: Pasquale Ciaglia, MD, FCCP, General Thoracic Surgery, 2215 Genes c St, Utica, NY 13501; e-mail: pdt@borg.com

Chest. 1999;116(4):1138-1139. doi:10.1378/chest.116.4.1138-a
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Published online

To the Editor:

I am writing in regard to the article, “Percutaneous Tracheostomy, Is It Really Better?,” which appeared recently in CHEST (December 1998).1

The authors start out by praising percutaneous tracheostomy and cite their first five references supporting the procedure. But then they state, “The evidence supporting this procedure, however, is lacking.” Their main complaint was that there were not enough randomized studies, and they then reported two cases of complications from tertiary care centers with regional trauma programs. Their first patient had a percutaneous tracheostomy performed by “a surgeon experienced with the procedure.” But, “the procedure was moderately difficult” on this 18-year-old woman. The authors do not state whether the procedure was performed with endoscopic monitoring or what the difficulties were. The operation was performed “by a surgeon experienced with the procedure.”

In the second patient, the procedure was performed “by a trauma team leader.” I have met trauma team leaders who have never even seen a percutaneous tracheostomy performed.

The authors do not state exactly which percutaneous tracheostomy procedure they used, but they mentioned the Seldinger wire, so they must have used either the Cook Set (Cook Critical Care; Bloomington, IN) or the Portex Set (Sims Medical Systems; Keene, NH). Damage to the posterior membranous wall of the trachea is possible with either set if the operator does not constantly bear in mind that one is going around a curve on entering the tracheal lumen. For this reason, the Cook Set dilators have a curve to them in an effort to avoid injury to the posterior tracheal wall. The Portex dilators are straight.

Improvements have been made in the technique of percutaneous dilatational tracheostomy (PDT), and in the learning phase endoscopic monitoring helps; video-assisted tracheoscopy is even better. If this monitoring had been done, the complications probably could have been avoided.

PDT is a new, minimally invasive technique that, like any new operation, has a so-called “learning phase segment.” The only valid comparison with an old, recognized operation that has been performed for years should be made by operators who have passed out of their learning phase, not by individuals who are in that phase. As more operators emerge from their learning phase, the results should continue to improve.


Malthaner RA, Telang H, Miller JD, et al. Percutaneous tracheostomy: is it really better? 1998; 114:1771–1772.




Malthaner RA, Telang H, Miller JD, et al. Percutaneous tracheostomy: is it really better? 1998; 114:1771–1772.
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