PercuTwist: a new alternative to Griggs and Ciaglia's techniques

BACKGROUND AND OBJECTIVE: Tracheostomy is one of the most common procedures in intensive care units worldwide. In this study we aimed to compare three different tracheostomy techniques with respect to duration of procedure and complications. METHODS: One hundred and thirty patients requiring endotracheal intubation for more than 10 days due to acute respiratory distress syndrome, infections or cerebrovascular events were consecutively selected to undergo the percutaneous dilatational tracheostomy technique (PDT n = 44), the guide-wire dilating forceps technique group (GWDF n = 41) or the PercuTwist technique (n = 45). The time taken to perform the procedure (skin incision to successful placement of tracheostomy tube) and complications were recorded. RESULTS: The operating times were found to be 9.9 +/- 1.1, 6.2 +/-1.4 and 5.4 +/- 1.2 min in PDT, GWDF and PercuTwist groups, respectively. The duration of the procedure was significantly shorter in the PercuTwist group as compared to the percutaneous dilatational tracheostomy (P < 0.01) and guide-wire dilating forceps (P < 0.05) groups. During postoperative bronchoscopy, eight cases of longitudinal tracheal abrasion (four in the PDT group, two in the GWDF group and two in the PercuTwist group), two cases of posterior tracheal wall injury (one in PDT and one in GWDF) and one case of tracheal ring rupture in the PDT group were seen. CONCLUSIONS: Percutaneous tracheostomy techniques have their own advantages and complications. PercuTwist, a new controlled rotating dilatation method, was associated with minimal complications, appears to be easy to perform and a practical alternative to percutaneous dilatational tracheostomy and guide-wire dilating forceps techniques.     

Tracheostomy in cardiosurgical patients: surgical tracheostomy versus ciaglia and fantoni methods.

BACKGROUND: Patients requiring prolonged mechanical ventilation are not uncommon in a cardiosurgical intensive care unit. Elective tracheostomy is considered the airway treatment of choice in these patients. METHODS: To evaluate different techniques for tracheostomy, we prospectively investigated 120 patients who had conventional open (n = 40), minimally invasive percutaneous dilatational (n = 40), or translaryngeal (n = 40) tracheostomy techniques. The main areas of investigation included oxygenation index (partial pressure of arterial oxygen divided by fraction of inspired oxygen), complications, infection, and cost. RESULTS: The oxygenation index decreased in almost every patient, regardless of the technique used, but the extent of decrease was significantly lower in both minimally invasive techniques compared with the conventional method. Overall complication rate was 12.5% both in open tracheostomy and in percutaneous dilatational tracheostomy, whereas no complications occurred in translaryngeal tracheostomy procedures. Bacterial contamination of the tracheostomy site was found in 35% of the open tracheostomies, whereas no infection was seen in percutaneous dilatational or translaryngeal tracheostomies. In terms of costs, PDT ($506) and TLT ($362) were both much cheaper than open tracheostomy ($699). CONCLUSIONS: Percutaneous dilatational and translaryngeal tracheostomies are safe and cost-effective procedures that can be done easily at the patient's bedside and thus are attractive alternatives to conventional surgical tracheostomy in long-term airway access in a cardiosurgical intensive care unit.     

Percutaneous versus surgical tracheostomy: a double-blind randomized trial

OBJECTIVE: To compare surgical (SgT) and percutaneous (PcT) tracheostomies. BACKGROUND: Percutaneous tracheostomy has been said to provide numerous advantages over classical SgT. METHODS: A prospective randomized trial with a double-blind evaluation was used to compare SgT and PcT. SgT and PcT were performed according to established techniques (n = 70). The procedure was performed at the bedside in the intensive care unit in 21 cases (30%). The outcome measures were divided into procedure-related variables, perioperative complications, and postoperative complications. The procedure-related variables (location, duration, and difficulty) were evaluated by the surgeon. The perioperative and postoperative complications were divided into serious, intermediate, and minor. Perioperative and early postoperative (14 days) complications were evaluated daily by an intensive care unit nurse blinded to the technique used. Long-term postoperative complications were evaluated 3 months after decannulation by a surgeon blinded to the surgical technique. RESULTS: There were no major complications in either group. Most variables studied were not statistically different between the PcT and SgT groups. The only variables to reach statistical significance were the size of the incision (smaller with PcT, p < 0.0001), minor perioperative complications (greater with PcT, p = 0.02), and difficult cannula changes (greater with PcT; p < 0.05). Among nonsignificant differences, difficult procedures and false passages were more frequent with PcT, whereas long-term unesthetic scars were more frequent with SgT. CONCLUSIONS: Both techniques are associated with a low rate of serious or intermediate complications when performed by experienced surgeons. There were more minor perioperative complications with PcT and more minor long term complications with SgT.     

Surgical tracheostomy versus percutaneous dilatational tracheostomy. A prospective-randomized study with long-term follow-up.

BACKGROUND: To compare surgical tracheostomy (ST) versus percutaneous dilatational tracheostomy (PDT) in terms of complication rates. In particular we specifically studied the late tracheal complications of both methods by means of endoscopic controls of patients up to 6 months after the procedures. METHODS: Design: prospective-randomized clinical study. Setting: University-affiliated tertiary care referral hospital. Patients: 50 consecutive translaryngeally intubated patients with respiratory failure were randomized to undergo either ST (25 patients) or endoscopic guided PDT (25 patients). RESULTS: ST was performed in 41+/-14 min versus 14+/-6 min for PDT (p<0.0001). There was no procedure-related death. In the ST group there were no intraoperative complications. In the PDT group 2 intraoperative complications (minor hemorrhages) were observed. In the ST group 9 early postoperative complications occurred: one minor bleeding, 7 stomal infections and one accidental decannulation. In the PDT group only one early postoperative complication (minor bleeding) occurred. Early postoperative complication rates were 36% for ST and 4% for PDT. In the ST group there were no late tracheal complications. In the PDT group 2 late tracheal complications (one segmental malacia and one stenosis at the level of the stoma) were observed. CONCLUSIONS: This study confirms that PDT is a simpler and quicker procedure than ST and that it has a lower rate of early postoperative complications. Late tracheal complications were more frequent, although the difference was not statistically-significant, in the PDT group. Further investigations of long-term outcome following PDT are therefore necessary.     

A comparison of percutaneous and operative tracheostomies in intensive care patients

The aim of our study was to compare the complication rate of convenional surgical and percutaneous dilational tracheostomies performed under general anaesthesia in critically ill patients. Fifty-three consecutive patients whose lungs were mechanically ventilated and who required tracheostomy were randomised to undergo either conventional surgical tracheostomy (n = 28) in the operating room or percutaneous dilational tracheostomy (n = 25) in the intensive care unit under general anaesthesia. All of the procedures were successfully completed. No deaths were related to the performance of either tracheostomy technique. Three patients in each group required a dressing change for minor bleeding at the tracheostomy site. There was no major bleeding requiring blood transfusion. One patient in each group developed atelectasis detected on chest x-ray postoperatively. In the surgical tracheostomy group, there were two patients with cuff leaks, one with a stomal infection and one with a pneumothorax. None of these complications occurred after percutaneous, dilational tracheostomy. We conclude that the low incidence of complications in both groups indicates that percutaneous dilational tracheostomy can be performed as safely in the intensive care unit with general anaesthesia as surgical tracheostomy can be performed in the operating room.     

First line application of a modified dilatational tracheostomy in the intensive care

BACKGROUND: Despite the growing clinical use of the percutaneous dilatational tracheostomy data concerning their first line application are still lacking. METHODS: Retrospective analysis of the intra- and postinterventional morbidity of a modified dilatational tracheostomy in a surgical intensive care unit of a German university hospital over a 2-year period. RESULTS: A total of 107 elective dilatational tracheostomies were performed in 105 patients. There were no intraoperative complications. 2 accidental decannulations occurred in the postoperative period. One conventional tracheostomy had to be performed secondary. Stoma side bleeding or clinical relevant infection had not been observed. After definite decannulation wound closure was spontaneous in all patients. CONCLUSIONS: The first line application of the dilatational tracheostomy has a low morbidity.     

Percutaneous tracheostomy

OBJECTIVES: The aim of this study was to evaluate the different techniques of percutaneous tracheostomies, their advantages, drawbacks, complications and to compare them to standard surgical tracheostomies. This study will consider only elective (non emergency) bedside procedures in intensive care units. DATA SOURCES: Extraction from Medline database of english and french articles on percutaneous tracheostomies and searching along with major review articles. STUDY SELECTION: The collected articles were selected according to their qualities regarding to their evidence level. In addition to several important or historic references, the literature of the five past years was studied. DATA EXTRACTION: The articles were reviewed according to their contribution for techniques, perioperative and postoperative complications, recent advances, advantages and drawbacks of all procedures. Publications addressing recent comparisons between surgical and percutaneous tracheostomies were specially studied. DATA SYNTHESIS: Four techniques of bedside percutaneous tracheostomies are available and marketed, in France: Ciaglia's dilation technique (with multiple or unique dilator), Griggs's technique (using a special designed forceps), and Fantoni's technique (Trans Laryngeal Tracheostomy). The most spred but also first described technique is the Ciaglia's (1985). The most recent articles comparing surgical and percutaneous tracheostomies techniques are not able to demonstrate a superiority of one of them in terms of feasibility or safety. In other words, there should be a slight advantage for the percutaneous tracheostomy regarding to the late post-operative complications, as there should be a slight advantage for the surgical techniques regarding to the perioperative complications. The literature analysis point out firstly the learning curve for percutaneous dilational tracheostomy, with a significant decrease of complication incidence with the operator's experience and secondly the continuous endoscopic guidance seems to increase the safety of the percutaneous procedure. CONCLUSION: Since there has been a great deal of percutaneous tracheostomy in the intensive care units, the incidence of tracheostomy have increased in those services. There is a trend to replace the surgical procedure by the percutaneous one. However, according to the potentially jeopardizing complications, percutaneous tracheostomy should be done by an experienced operator with the help of a continuous endoscopic guidance.     

Neurophysiological consequences of three tracheostomy techniques: a randomized study in neurosurgical patients

We describe the effects of different tracheostomy techniques on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral extraction of oxygen. We attempted to identify the main mechanisms affecting intracranial pressure during tracheostomy. To do so we conducted a prospective, block-randomized, clinical study which took place in a neurosurgical intensive care unit in a teaching hospital. The patients studied consisted of thirty comatose patients admitted to the intensive care unit because of head injury, subarachnoid hemorrhage, or brain tumor. Ten patients per group were submitted to standard surgical tracheostomy, percutaneous dilatational tracheostomy or translaryngeal tracheostomy. In every technique a significant increase of ICP (P < .05) was observed at the time of cannula placement. Intracranial hypertension (ICP > 20 mm Hg) was more frequent in the percutaneous dilatational tracheostomy group (P < .05). Cerebral perfusion pressure dropped below 60 mm Hg in eleven cases, more frequently during surgical tracheostomy. Arterial tension of CO2 significantly increased in all three groups during cannula placement. No other major complications were recorded during the procedures. At follow-up no severe anatomic or functional damage was detected. We conclude that the three tracheostomy techniques, performed in selected patients where the risk of intracranial hypertension was reduced to the minimum, were reasonably tolerated but caused an intracranial pressure rise and cerebral perfusion pressure reduction in some cases.     

Percutaneous versus Conventional Tracheostomy in Burned Patients with Inhalation Injury

The aim of the study was to compare conventional tracheostomy with percutaneous dilatational tracheostomy in patients with inhalation burn injury. A total of 37 patients with severe burn injuries and associated inhalation injury, underwent percutaneous tracheostomy in our burn unit and were retrospectively compared with 22 patients who underwent conventional surgical tracheostomy. In the first group, 25 of 37 patients and in the second group 17 of 22 patients presented with partial or full-thickness burn injuries (or both) in the neck region. The cost of the procedure, operating time, complications, and incidence of pulmonary infection were recorded. There were no significant perioperative complications in the percutaneous tracheostomy group, and no patient required surgical revision or conversion to surgical tracheostomy. In the conventional tracheostomy group, 2 patients developed tracheal stenosis, 1 had a tracheoesophageal fistula, and 10 had stomal infections. The average procedure time in the first group was 9 minutes, and in the second group it was 22 minutes. The cost of the bedside percutaneous tracheostomy was one-fifth the cost of a conventional tracheostomy. The incidence of pulmonary sepsis was 45% after percutaneous tracheostomy compared to 68% after conventional tracheostomy. With the percutaneous technique, spontaneous closure of the stoma occurred within 1 to 3 days after removal of the tracheostomy tube, whereas with the conventional technique it was within 5 to 7 days. Percutaneous tracheostomy is associated with a lower complication rate and can be safely performed at the bedside. Moreover, it is faster and can be done at a lower cost than conventional open tracheostomy.     

Comparison of safety and cost of percutaneous versus surgical tracheostomy

Tracheostomy continues to be a standard procedure for the management of long-term ventilator-dependent patients. Traditionally the procedure has been performed by surgeons in the operating theater using an open technique. This routine practice has recently been challenged by the introduction of bedside percutaneous dilatational tracheostomy (PDT), which has been reported to be a cost-effective alternative. The purpose of this study is to evaluate and compare the safety, procedure time, cost, and utilization of percutaneous and surgical tracheostomies at a university hospital. A retrospective medical chart review was performed on all ventilator-dependent intensive care unit patients at the University of Virginia Medical Center undergoing tracheostomy during a 23-month period beginning December 26, 1996. Of the 213 patients identified for review, 74 and 139 patients received percutaneous and surgical tracheostomies, respectively. Of 74 percutaneous tracheostomies, 73 reviewed were performed by general surgeons, pulmonary physicians, or anesthesiologists in the intensive care unit; all open tracheostomies were performed by surgeons in the operating room, and one percutaneous procedure was performed in the operating room. Perioperative complications occurred in five of 74 patients (6.76%) during PDT; of these, three patients (4.1%) experienced major complications requiring emergent operative exploration of the neck. Three patients (2.2%) experienced perioperative complications during surgical tracheostomy. The mean procedure time was significantly shorter for the percutaneous procedure. Average charges per patient in an uncomplicated case including professional fees, inventory, bronchoscopy (if performed), and operating room charges were $1753.01 and $2604.00 for percutaneous and standard tracheostomies, respectively. These charges do not include the charges associated with surgical intervention after PDT complications. In contrast to previously published reports showing complications clustered during a physician's first 30 percutaneous cases, our study demonstrated no relationship between complication occurrence and physician experience. That is, no learning curve associated with performing PDT was evident. In addition there was no association seen between physician specialty and complication rate. PDT in the intensive care unit costs less than surgical tracheostomy performed in the operating room and can be performed in less time. Several other studies have recommended that bronchoscopy during PDT provides additional safety; however, in our series all three major complications took place during bronchoscopy-assisted percutaneous procedures. Our series suggests that PDT carries an appreciable risk of major complications. Careful patient selection and additional experience with the procedure may decrease complication rates to an acceptable level.     

Safety and complications of percutaneous tracheostomy in a cohort of 800 mixed ICU patients

Percutaneous tracheostomy is used primarily to assist weaning from mechanical ventilation in the intensive care unit. We report our experiences of 800 such procedures performed in the intensive care unit by a collaborative team (critical care and ENT specialists). Most procedures (85.6%) were performed by residents supervised by the intensive care unit staff. Complications occurred in 32 patients (4%). Intraprocedural complications occurred in 17 patients (2.1%), early postprocedural complications in six (0.75%), and late postprocedural complications in nine (1.1%). No deaths were directly related to percutaneous tracheostomy. The incidence of complications was greater in percutaneous tracheostomy performed by the residents during their initial five attempts compared to their later attempts (9.2% vs 2.6%, p < 0.05). The low incidence of complications indicates that bedside percutaneous tracheostomy can be performed safely as a routine procedure in daily care of intensive care unit patients.     

Near total transection of the trachea following percutaneous dilatational tracheostomy

The bedside procedure of percutaneous dilatational tracheostomy (PDT) in the intensive care unit continues to gain popularity. Percutaneous dilatational tracheostomy is recommended as simple, safe and cost-effective. The procedure can be associated with serious life-threatening complications. We report a case of near total transection of the trachea following PDT.     

Percutaneous tracheostomy: a clinical comparison of dilatational (Ciaglia) and translaryngeal (Fantoni) techniques.

A number of percutaneous procedures for tracheostomy have been established within the last few years, among them a new technique by Fantoni using a translaryngeal approach for cannula placement. To compare the new translaryngeal tracheostomy (TLT) to the common percutaneous dilatational technique (PDT), we prospectively studied 90 patients who required elective tracheostomy. Tracheostomy was performed according to either the Ciaglia or the Fantoni technique in 45 patients at bedside. The overall complication rate was 11.1% (n = 5) in PDT, including aspiration of blood (n = 4) and severe bleeding requiring surgical intervention (n = 1). During TLT, there were technical difficulties involving guidewire placement in 31.1% (n = 14), and one patient required conversion to PDT. No other complications were noted in TLT. Regardless of the technique used, the postoperative PaO2/FIO2 ratio was slightly lower than preoperatively (P was not significant). When PDT and TLT were compared, the postoperative PaO2/FIO2 ratio was significantly lower in PDT than in TLT (P < 0.05), whereas the preoperative levels did not vary significantly between PDT and TLT. During TLT, the PaCO2 increased significantly, whereas it remained stable throughout PDT. No infection of the tracheostoma was noted in either the PDT or the TLT. We therefore consider both the PDT and the TLT equally safe and attractive techniques for establishing long-term airway access in critically ill patients. IMPLICATIONS: Elective tracheostomy is a widely accepted procedure for gaining long-term airway access. Two techniques for percutaneous tracheostomy-the established Ciaglia method and the new translaryngeal Fantoni technique-were prospectively studied for perioperative complications and practicability in 90 critically ill-patients.     

Weaning from ventilator after cardiac operation using the Ciaglia percutaneous tracheostomy.

OBJECTIVE: To determine the predictors of weaning from mechanical ventilation after cardiac operation with the Ciaglia percutaneous dilatational tracheostomy (PDT) in our preliminary experience in the use of this technique. METHODS: We prospectively analysed 33 consecutive patients (mean age 70.9+/-12.7 years) who underwent PDT in our intensive care unit after cardiac operation. The investigation involved preoperative and postoperative clinical status, operative procedure, indication and timing for PDT. RESULTS: PDT was performed after a mean time of 7.7+/-5.0 consecutive days of translaryngeal intubation. Twenty-four (73%) patients were weaned from ventilator after a mean time of mechanical ventilation of 15.8+/-9.1 days. Time point of PDT was the only predictor of ventilator weaning (P=0.0029): there was significant association between PDT performed before the seventh consecutive day of translaryngeal intubation (early PDT) and successful weaning from ventilator (P=0.01; odds ratio=11.2, 95% confidence interval=1.2-104.3). Among the patients weaned from ventilator, those who underwent early PDT had significantly shorter times of mechanical ventilation, and intensive care unit and hospital stays than patients with later PDT (P=0.035, 0.011 and 0.0073, respectively). Nine (27%) patients died of their underlying disease while still being mechanically ventilated; another six (18%) spontaneously breathing but still incannulated patients died afterward. No major PDT-related complications were observed. Two minor peristomal bleedings and one self-resolving subcutaneous emphysema were recorded. CONCLUSIONS: Early PDT was a safe and effective method to wean from mechanical ventilation the cardiosurgical patients of this series.     

Safety of percutaneous tracheostomy in obese critically ill patients: a prospective cohort study

Obesity has been described as a relative contraindication for percutaneous tracheostomy. The objective of our study was to examine the safety and complications of percutaneous tracheostomy in obese patients. We conducted a prospective cohort study of all consecutive patients who underwent percutaneous tracheostomy at a tertiary medical-surgical intensive care unit between May 2004 and October 2005. We compared percutaneous tracheostomy in obese patients (body mass index > or = 30 kg/m2) to non-obese patients. We documented the occurrence of the following complications: aborting the procedure, accidental extubation, conversion to surgical tracheostomy, paratracheal placement, the development of pneumothorax, major bleeding (requiring blood product transfusion or surgical intervention) or death. We also documented hypoxia, minor bleeding (requiring pressure dressing or suturing), subcutaneous emphysema and transient hypotension. During the study period, 227 percutaneous tracheostomies were performed. There were 50 percutaneous tracheostomies in the obese group and 177 in the non-obese group. In 45 obese patients, percutaneous tracheostomy was performed without bronchoscopic guidance. Major complications were significantly higher in obese patients (12% vs. 2%, P = 0.04), while the rate of minor complications was not significantly different between the two groups. There were no instances of death or pneumothorax, subcutaneous emphysema or need for surgical intervention during or in the postoperative period in either group. Our study suggests that percutaneous tracheostomy can be performed safely in the majority of obese patients.     

Comparison of percutaneous dilatational tracheostomy with surgical tracheostomy

RATIONALE: Tracheostomy is done mostly in critically ill patients, many of whom may not survive. We still do not know the long term complications oftracheostomy itself; tracheal and subglottic stenosis, and tracheomalacia. OBJECTIVES: To compare the complications of surgical tracheostomy (ST) versus percutaneous dilatational tracheostomy (PDT) by means of MRI control up to 1 month after closed tracheostomy. RESULTS: There was no death related to tracheostomy. In both groups there were two preoperative complications: one minor hemorrhage and one subcutaneous empysema in the ST group, and one minor bleeding and one puncture ofendotracheal tube cuff in the PDT group. When the early and the late postoperative complications of the two groups were compared, it was observed that in the ST group, five early (one minor bleeding, three stomal infections and one accidental decannulation), and two late (one peristomal granuloma and one persistent stoma) postoperative complications had occurred. In the PDT group, four early (minor bleeding) and two late postoperative complications (two minor bleeding) were observed. MRI of two patients in the PDT group demonstrated tracheal stenosis. CONCLUSIONS: PDT is as safe and as effective as ST. Although the early and late postoperative complication rates were not significant in the PDT group, we believe that further investigations with larger groups are necessary to find long-term outcome following PDT. MRI scanning provides an excellent non-invasive method of assessing the tracheal lumen.     

微创气管切开术在危重病人的应用

目的 探讨经皮穿刺扩张气管切开术在危重病患的应用。方法回顾本院1996-2000年间实施的28例危重病患经皮穿刺扩张气管切开术的手术时间、围手术期手术并发症及随访结果。结果 28例均顺利完成手术，手术期间无严重并发症发生，术中出血极少。随访最长18个月，美容效果好。结论 经皮穿刺扩张气管切开术是一种非常好的微创手术，只要经过严格训练并掌握适应证，可以满足绝大部分的临床需要，对危重病患尤为需要。     

Percutaneous dilatational tracheostomy: still a surgical procedure.

Although percutaneous dilatational tracheostomy (PDT) has been shown to be a cost-effective bedside alternative to open tracheostomy (OT), prior reports of the complications of the procedure are contradictory. Reported complications range from minor events to fatal ones, in varying percentages. This prospective study was designed to identify the type and severity of complications accompanying the introduction of PDT to a tertiary medical center. Surgical and medical intensive care unit (ICU) patients requiring elective tracheostomy were identified as appropriate for PDT using approved institutional criteria. All procedures were performed at an ICU bedside in the presence of a surgeon privileged to perform OT. Demographic data, procedural information, and patient outcome (including minor and major complications, length of stay, and survival) were collected. PDT was performed in 96 ICU patients, with complete data available for 95 patients. PDT was performed in an average of 13.1+/-1.0 minutes. Twenty-three major and minor complications occurred, including two perioperative deaths, in 15 patients (15.8%). A total of 37 PDT patients (38.9%) died in the hospital, indicative of the severity of illness of patients requiring tracheostomy. Based on the experience to date, Cedars-Sinai Medical Center (Los Angeles, CA) continues to require a surgeon privileged to perform OT to participate in all PDT procedures.     

Suprastomal tracheal stenosis after dilational and surgical tracheostomy in critically ill patients

We have previously reported cases of severe suprastomal stenosis after tracheostomy. In this observational study we investigated the occurrence of suprastomal stenosis as a late complication. Patients with persistent tracheostomy after intensive care underwent an endoscopic examination of tracheostoma, larynx and trachea. A percutaneous dilational tracheostomy was employed in 105 (71.9%) and surgical tracheostomy in 41 (28.1%) of the cases (n = 146). The incidence of severe suprastomal stenosis (grade II > 50% of the lumen) was 23.8% (25 of 105) after dilational tracheostomy and 7.3% (3 of 41) after surgical tracheostomy (p = 0.033). Age, gender, underlying disease, ventilation time, and swallowing ability were not significantly associated with the tracheal pathology. This study suggests that dilational tracheostomy is associated with an increased risk of severe suprastomal tracheal stenosis compared to the surgical technique.     

Open versus percutaneous dilatational tracheostomy: efficacy and cost analysis

The economic advantages of percutaneous dilatational tracheostomies versus open tracheostomies in the operating room have been thoroughly evaluated. We are now reporting our comparison of the costs and charges of percutaneous dilatational tracheostomies with those of open bedside tracheostomies at our institution. The current literature comparing the two open techniques and the percutaneous method of placing tracheostomies was reviewed and the charges and costs for these procedures at our institution were compared. Patients were placed into one of three groups for analysis: open tracheostomies in the operating room (Group I), open tracheostomies in the intensive care unit (Group II), and percutaneous dilatational tracheostomies in the intensive care unit (Group III). Based on our own experience and a literature review it is evident that all three approaches to tracheostomies are safe. Economic analysis showed a savings of $180 in cost per procedure and a $658 savings in charges per procedure for the open method at the bedside when compared with the percutaneous method at the bedside. The professional fee for bronchoscopy was not included in this calculation; including this would lead to greater savings with the open method over the percutaneous method. Open tracheostomy in the operating room increased costs over the bedside procedure by $2194 and increased charges by $2871. For the 150 to 180 tracheostomies done each year at our institution utilization of the open technique at the bedside results in a cost savings of approximately $31,500 and a charge savings of $109,000 compared with the percutaneous dilatational tracheostomy. Both the open bedside and percutaneous dilatational methods are reasonable and safe options. However, the open bedside tracheostomy is a better utilization of resources and is more cost effective, and it is the procedure of choice at our institution.