Differences in percutaneous dilational tracheostomy kits.

I read with puzzlement the “Communication to the Editor” by Dean P. Sandifer, MD, FCCP,1 in regard to the article by Trottier et al,2 pertaining to percutaneous dilatational tracheostomy (PDT) using the PDT kit manufactured by Smith Industries (Keene, NH). Dr. Sandifer justifiably criticized the high rate of complications that occurred in the 24 PDT cases studied. But then Dr. Sandifer stated, “We have completed scores of PDTs using this kit without a single tension pneumothorax, mainstem tracheostomy tube placement, or tracheostomy tube obstruction, and certainly without any patients requiring postPDT thoracotomy.” He went on to say “the tapered Portex PDT tube (Smith Industries) offers a distinct advantage over the kit manufactured by Cook Inc. (Bloomington, IN) regarding the final step of tracheostomy tube insertion over a dilator.”1 This opinion may have some validity, but the Portex tube was in the kit used in the 24 PDTs performed by Trottier et al,2 as they pointed out on page 1384, under “Materials and Methods,” that they used “a custom Portex tracheostomy tube (Sims Portex Inc; Keene, NH), with a tapered, flush opening.” Trottier et al2 then showed, clinically and in animal and laboratory work, a very clear explanation of their complications. What puzzles me (and we believe him) is that Dr. Sandifer, using the same kit, got such good results. Evidently, in his technique, he observed certain points such as the obliquity of the dilators and avoidance of excessive force, and he probably has a lot more experience. Such an operator may not need a stabilizing ridge, but because many operators are not as skilled as Dr. Sandifer, Smith Industries has now placed a ridge on the tube, as shown in Figure 3 of the article by Trottier et al,2 to prevent the dilator from sliding onto the wire guide. However, with the new, flexible, long-cone, one-pass dilator, recently put on the market by Cook Inc, the problems associated with rigid dilators will be avoided.