A reply

Abstract

We are grateful for the opportunity to reply to the letter from Dr Guha, who has raised several points. Although percutaneous dilational tracheostomy (PDT) is faster and easier than surgical tracheostomy (ST), both techniques seem complementary; moreover, some PDT will end in ST [1]. So the choice between ST and PDT will probably depend on the clinical situation. We are, of course, aware of the interest of bronchoscopic guidance (BG) for PDT. We agree with Guha's comments for the Ciaglia and Fantoni techniques. The advantages of this approach are that the position of tracheal puncture can be ascertained and posterior tracheal wall puncture avoided. Unfortunately, direct vision under BG is not always so easy to perform. Thus for the Griggs PDT there is little doubt that BG is necessary. Data from prospective studies are necessary to assess this point of view with the Griggs technique. Your correspondent quotes one paper [2] to justify that hypoventilation and hypercarbia are by no means inevitable. In our ICU we think that assessment of ventilation by capnography is not as accurate as blood gas analysis. The loss of exhaled gases through the tracheostomy may invalidate this technique [3]. We now increase tidal volume to compensate for this air leak and we are very cautious when ventilation needs a high level of Fio2 or Peep. In conclusion, we think that the Griggs technique without bronchoscopy is safe.