The first step to build a standardised approach to percutaneous tracheostomy was to understand the real size and extent of the problem. Therefore, Vargas et al. in 2012, in collaboration with Italian Society of Anaesthesia Analgesia and Intensive Care (SIAARTI), carried a survey that was intended to assess the most common procedures associated with tracheostomy in Italian ICU [1]. The aim of the study was to evaluate the frequency of different techniques, indications, timing as well as procedural features, sedation and ventilation protocols and early and late complications of tracheostomy in intensive care unit [1]. It was a retrospective survey on data collected in 2011. A questionnaire was mailed to all members of the Italian Society of SIAARTI.

The questionnaire was organised in two main sections. The first section included questions about hospital and ICU demographics as well as the number of beds, ICU admissions and number of tracheostomies performed in 2011. The second section aimed to evaluate the type of tracheostomy technique applied, timing, indication, procedural features, sedation and ventilation protocol and early and late complications [1]. In this national survey investigating the most frequent clinical practice to perform the tracheostomy in the Italian ICUs, the authors found that (1) the most commonly used tracheostomy was Ciaglia Blue Rhino and the main indication was prolonged mechanical ventilation. CBR was the most popular technique reported in previous surveys in Germany and the UK. On the contrary, GWDF was the most used in Spain, while ST in Switzerland, the Netherlands and France. TLT technique was the third technique performed in the Italian ICUs, while it was used in only 13 % of the German and 1.2 % of the Spanish ICUs and not evaluated in other published surveys. The popularity of CBR, GWDF and ST is likely due to the fact that they are easier to be performed with a faster learning curve. However, the TLT, a technique developed in Italy, is a more complex tracheostomy with less potential damage for anterior and posterior tracheal wall and requiring a specialised training. In this survey, the most important reported indication for tracheostomy was prolonged mechanical ventilation followed by neurological/surgical/traumatic disorders for which the physician does not expect a resumption of airway protective reflexes and consciousness in a short time, prolonged or difficult weaning and inability to airway protection as also reported by the previous surveys performed in Switzerland and France. (2) The tracheostomy was performed between 7 and 15 days after ICU admission, followed by a similar distribution of the first week (<7 days) and the third week (15–21 days), as reported in the previous European survey. These data do not follow the most common published recommendations on tracheostomy timing [1]. A consensus conference in 1989 recommended endotracheal intubation in the first 10 days of mechanical ventilation and to perform tracheostomy after 3 weeks of endotracheal intubation. In 1992, the French Society of Intensive Care Medicine recommended that the decision to perform a tracheostomy should be taken within the first 5–7 days, if the duration of mechanical ventilation longer than 15 days is expected [5]. In 2000, it has been suggested that the optimal timing should be chosen according to the patient conditions [6]. In a randomised controlled trial, Terragni et al. failed to demonstrate any beneficial effects of early (6–8 days) versus late (13–15 days) tracheostomy [7]. More recently, Freeman et al. suggested that tracheostomy should be performed at least 2 weeks after the onset of acute respiratory failure but neurological patients might benefit from an earlier tracheostomy [8]. Most of the Italian participating ICUs had a dedicated tracheostomy team made up of more than one intensive care physician and a nurse [1]. In other surveys, different specialists were involved in performing surgical or percutaneous tracheostomy in ICU, in Switzerland mainly by the surgeon, followed by the intensive care or ENT physician, in the Netherlands by the surgeon and the intensive care physician and in France, equally by the surgeon, the intensive care or ENT physician [1]. More similar to Italy, in Germany percutaneous tracheostomy was mainly performed by intensive care physicians, while ST by surgeons [1]. A previous survey in the UK reported that doctors were more frequently involved to perform tracheostomy in ICU. (3) In the ICUs participating to this survey, the sedation-analgesia and neuromuscular blocking protocol was more frequently implemented than a ventilation protocol. The finding that the ventilation protocol was less common than a sedation protocol was unexpected because tracheostomy involves the airway management, potentially leading to hypoxia and alveolar derecruitment [1]. Volume-controlled protective mechanical ventilation with an inspiratory oxygen fraction of 100 % was more often used during the procedure; (4) tracheostomy was frequently guided by fibre-optic bronchoscope, as reported in the German and the UK survey, while neck ultrasounds were used as a screening procedure to assess at-risk structure; (6) bleeding controlled by local pressure was the most common early and late complication in line with data reported in both the Swiss and the UK surveys. Previous studies showed higher risk of post-procedural major bleeding in surgical compared to percutaneous tracheostomy techniques [1].