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  • Letter
  • Open Access

Preventing deaths related to percutaneous tracheostomy: safety is never too much!

  • 1Email author,
  • 1,
  • 1,
  • 1,
  • 1 and
  • 1
Critical Care201418:406

  • Published:


  • Pneumothorax
  • Percutaneous Dilational Tracheostomy
  • Percutaneous Tracheostomy
  • Ultrasound Neck
  • Huge Effort

We read with great interest the study by Simon and colleagues about intra- and post-procedural mortality related to percutaneous dilational tracheostomy (PDT) [1]. We appreciated the huge efforts made by the authors to collect valuable data on this rare event: their findings can significantly improve daily practice in PDT performance and management in the ICU. We present three additional comments.

First of all, the authors affirmed that a standard use of ultrasound neck evaluation and continuous bronchoscopy could reduce the incidence of bleeding and airway complications, respectively. However, it must be underlined that the most common intra-procedural cause of death reported in this study was pneumothorax. Thus, the complete or almost complete tracheal occlusion by dilators or the bronchoscope should be minimized to avoid air trapping. Moreover, the safest ventilatory setting while PDT is performed is unknown, and research on this topic is urgently needed. Air trapping within the lungs (a potential cause of overinflation and pneumothorax), caused by a valve effect while performing PDT, should be carefully avoided through the adoption of lower positive end-expiratory pressure, lower respiratory rate, and smaller tidal volumes [2].

Secondly, the dislocation of the tracheal cannula is a common cause of late mortality: the development of a dedicated ‘crisis’ flowchart, the immediate availability of the required equipment, and periodic personnel retraining drills [3] should be considered similarly to other protocols already validated for emergent conditions like intubation in critically ill patients [4].

Finally, the available PDT techniques are not equally safe. Some evidence exists that the single-dilator technique is safer than the others at least intra-procedurally and could be considered the first choice [5].



percutaneous tracheostomy.


Authors’ Affiliations

Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Via Olgettina 60, Milan, 20132, Italy


  1. Simon M, Metschke M, Braune SA, Püschel K, Kluge S: Death after percutaneous dilatational tracheostomy: a systematic review and analysis of risk factors. Crit Care 2013, 17: R258. 10.1186/cc13085PubMed CentralView ArticlePubMedGoogle Scholar
  2. Sheu CC, Tsai JR, Cheng MH, Chong IW, Huang MS, Hwang JJ: Safety of performing percutaneous dilational tracheostomy in patients with preexisting barotrauma. Kaohsiung J Med Sci 2006, 22: 570-574. 10.1016/S1607-551X(09)70354-7View ArticlePubMedGoogle Scholar
  3. Thomas AN, McGrath BA: Patient safety incidents associated with airway devices in critical care: reports to the UK National Patient Safety Agency. Anaesthesia 2009, 64: 358-365. 10.1111/j.1365-2044.2008.05784.xView ArticlePubMedGoogle Scholar
  4. Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, Verzilli D, Jonquet O, Eledjam JJ, Lefrant JY: An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med 2010, 36: 248-255. 10.1007/s00134-009-1717-8View ArticlePubMedGoogle Scholar
  5. Cabrini L, Monti G, Landoni G, Biondi-Zoccai G, Boroli F, Mamo D, Plumari VP, Colombo S, Zangrillo A: Percutaneous tracheostomy, a systematic review. Acta Anaesthesiol Scand 2012, 56: 270-281. 10.1111/j.1399-6576.2011.02592.xView ArticlePubMedGoogle Scholar


© BioMed Central Ltd. 2014