A comparative study of complications and long-term outcomes of surgical tracheostomy and two techniques of percutaneous tracheostomy: Comments.

Sir,

I read with interest the recently published article by Kiran et al.[1] I congratulate the authors for their commendable research on long-term complications of surgical tracheostomy (ST) and percutaneous tracheostomy (PCT). However, I would like to comment on few points which are as follows:

According to this paper, about 50% of the patients expired. It is unclear how many patients expired before attempting decannulation. Patients expired before attempting decannulation should be excluded from study

Six patients were lost to follow-up. Should these patients have not been excluded from final analysis?

Long-term complications are also influenced by level of expertise (trainee/consultant) and experience of operators (both intensivist and ear, nose, throat [ENT] surgeon in this case).[2] Trainee may also take longer time to perform procedure and has to be assisted by consultant which, in turn, can increase the number of operators involved per procedure.[3] It would have been appropriate if authors could incorporate both of these characteristics of operators performing the procedures

In two patients, PCT was converted to ST. Henceforth, in analysis these two patients must have been included in ST group rather than in PCT groups

Severity scoring should have been also calculated and compared among groups as it is unclear whether patients with higher complication rates had more severity of illness

All patients were cannulated with same size of tracheostomy tube (TT). What was the reason of selecting size of 7.0 mmID? Size selection of TT should be based upon patient's demographic characteristics. Smaller tube might pose problems such as cuff leakage, aspirations and increased resistance to airflow leading to increased work of breathing and prolonged time to decannulation. This could seriously affect the outcome of the study

What was the mean time (delay) between making decision and start of procedure? In practice, execution of PCT is faster than ST as ENT surgeons are not always available on the day of planning of procedure, which eventually delays the procedure. Future study can be performed on this aspect which is important to influence the long-term complication such as nosocomial pneumonia.