The recent article by Oreadi and Carlson assessed the complication rate of tracheotomy in a large case series, and we fully agree with their conclusions about the safety and efficacy of open tracheotomy in trained and experienced hands. However, it is worthwhile noting that ‘tracheotomy can be the simplest or the most difficult operation that the surgeon is confronted with’, and the risk of perioperative complications may be greatly increased in case of emergency procedures. Furthermore late complications may occur in up to 65% of patients, as tracheotomy impairs the delicate physiology of the respiratory system often promoting respiratory infections. It may also expose the patient to the risk of tracheomalacia, and it may have significant psychological effects with a following negative impact on the patient’s quality of life.

Our clinical experience was in line with the authors’ observations, so for the past few years, in order to decrease the rate of unnecessary precautionary tracheotomies or risky emergency tracheotomies, we have been performing pre-tracheotomy (pre-trach) in selected patients undergoing surgery for head and neck cancer or deep space infections where precautionary tracheotomy is commonly recommended. Pre-trach aims to pre-expose the anterior tracheal wall directly under the cervical skin and get rid of any interposed bleeding structure (thyroid isthmus, anterior jugular vein, thyroid ima artery) in order to allow, if later required, its fast and bloodless opening. Using this approach we have successfully treated a case-series of patients in the last 12 years, sparing unnecessary precautionary tracheotomy in most of them, and avoiding risky emergency tracheotomy in about 20% of patients.

Pre-trach offers the advantage of ensuring quick and secure access to the trachea if required and reducing the risk of tracheotomy-related complications and sequelae.

In our opinion, pre-trach may represent a useful and effective therapeutic option alternative to elective prophylactic tracheotomy in selected patients at high risk of upper airway obstruction, especially if a predictable failure or unavailability of non-invasive remedies for acute airway obstruction co-exist. The procedure is also indicated when the natural history of the disease and/or the patients’ comorbidities are judged to be negative prognostic factors for an emergency tracheotomy.