Percutaneous versus surgical tracheostomy in mechanically ventilated ICU patients: a bibliometric review and visual analysis (1990–2024)

Introduction

Tracheostomy is a widely performed procedure, especially for critically ill patients who require prolonged mechanical ventilation due to conditions such as acute respiratory failure, severe airway obstruction, or neurological impairments that impair respiratory drive and airway protection. It is often indicated when patients are expected to need long-term ventilatory support, typically beyond 7–10 days, as it provides an alternative to endotracheal intubation (1-4). The procedure involves creating an opening in the trachea, which facilitates easier access to the airway for mechanical ventilation and other respiratory interventions (5).

One of the primary goals of tracheostomy is to improve patient comfort. By bypassing the upper airway and reducing the discomfort associated with prolonged endotracheal intubation, patients can experience improved oral hygiene, better communication, and a lower need for sedative drugs (6). Additionally, the procedure can reduce airway resistance, which in turn makes it easier to manage mechanical ventilation and reduces the overall work of breathing (7). The reduced need for prolonged sedation contributes to a more favorable clinical trajectory, potentially reducing the incidence of ventilator-associated pneumonia (VAP)—a common and serious complication in critically ill patients (8).

Furthermore, the evidence suggests that early tracheostomy can result in significant clinical benefits, such as shortening the duration of mechanical ventilation, reducing the length of intensive care unit (ICU) stay, and even lowering the risk of mortality in certain patient populations (8). Despite these advantages, the decision of when and how to perform tracheostomy is often nuanced, influenced by patient-specific factors and institutional protocols. While surgical tracheostomy has long been considered the gold standard, percutaneous tracheostomy has become increasingly popular due to its perceived advantages in terms of safety, cost-effectiveness, and reduced procedural time (9-11). Nevertheless, ongoing debate persists regarding the optimal technique for tracheostomy, with some studies suggesting that percutaneous approaches may be associated with fewer complications in experienced hands, while others caution about potential risks, especially in patients with anatomical challenges or those requiring rapid intervention.

Bibliometrics, a quantitative and statistical analysis of published research, provides a valuable tool for assessing trends in scientific literature, identifying key research themes, and evaluating the impact of different studies. This approach allows for the objective examination of large volumes of articles, facilitating a deeper understanding of the development and current state of research in a given field (12-14). To date, however, no bibliometric analysis has specifically compared the body of literature on percutaneous versus surgical tracheostomy. This study aims to fill this gap by applying bibliometric methods to the literature comparing the two techniques, thus providing a comprehensive and data-driven analysis of the global research landscape. We present this article in accordance with the BIBLIO reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-306/rc).

Methods

We conducted a comprehensive search of all published studies comparing percutaneous tracheostomy with surgical tracheostomy. Utilizing the Scopus database, searches were performed January 1, 1990, until February 9, 2024. To mitigate bias stemming from database updates, both literature retrieval and data download were completed on a single day, February 10, 2024. No restrictions were imposed regarding language or data category. The search terms employed to identify the most relevant publications were “Tracheostomy” AND “Percutaneous tracheostomy” AND “Surgical tracheostomy”. Two pairs of reviewers (R.M., S.T. and C.I., F.C.) independently extracted data, including title, authors, journal, year of publication, affiliation, language, keywords, document type, abstract, and citation count. Discrepancies were resolved through consensus or referral to a third pair of reviewers (M.V. and A.R.). The data were exported in CSV format.

Data analysis

VOSviewer (version 1.6.20) served as the tool for analyzing co-authorship, co-occurrence, citation, bibliographic coupling, and co-citation. For this study, VOSviewer parameters included a fractional counting method, and documents with numerous authors (up to a maximum of 25 authors per document) were disregarded. Two standard weight attributes were utilized: the Links attribute, representing the number of links of an article to other articles, and the Total link Strength attribute, indicating the total link strength of an article to other articles.

Results

A total of 186 records comparing percutaneous versus surgical tracheostomy were derived from the Scopus database. After independent screening by two pairs of reviewers, 51 papers were finally included. The selection process is outlined in Figure 1. These records included 39 (76.5%) original research articles, 3 (5.9%) review articles, 6 (11.7%) letter articles, and 3 (5.9%) other forms of publication including 2 editorials and 1 book chapter.

Figure 1 Selection process for bibliometric analysis.

Among them, 1 (1.96%) paper was published in 2023, 3 (5.88%) in 2022, 5 (9.81%) in 2021, 3 (5.88%) in 2020, 1 (1.96%) in 2019, 4 (7.85%) in 2018, 1 (1.96%) in 2017, 2 (3.92%) in 2016, 4 (7.85%) in 2015, 2 (3.92%) in 2014, 1 (1.96%) in 2013, 1 (1.96%) in 2011, 2 (3.92%) in 2010, 1 (1.96%) in 2008, 2 (3.92%) in 2007, 2 (3.92%) in 2006, 3 (5.88%) in 2005, 1 (1.96%) in 2003, 2 (3.92%) in 2002, 2 (3.92%) in 2001, 2 (3.92%) in 2000, 4 (7.85%) in 1999, 1 (1.96%) in 1998 and 1 (1.96%) in 1991.

Almost all the publications (45, 88.2%) were written in English; the remaining publications (6, 11.8%) were written in Turkish [2], Italian [1], Korean [1], Persian [1] and Spanish [1]. Only 28 (54.9%) papers were open access.

Bibliometric analysis of the co-authorship

A total of 258 authors contributed to the publication of articles comparing percutaneous versus surgical tracheotomy. The top twenty most active authors are listed in Table 1. Maria Vargas from the University of Naples Federico II (Italy) emerged as the most prolific author, having contributed to 3 published articles. The attribute of links for Maria Vargas was 9, indicating connections to other articles, while the total link strength attribute was 3.

Our analysis further revealed that 23 countries have published related papers. The United States demonstrated the highest level of activity with 9 published articles, with a links attribute of 1 and a total link strength attribute of 1. Italy and Turkey followed closely behind, with both countries contributing 6 articles each.

Bibliometric analysis of the co-occurrence

In the final analysis, keywords provided by the article authors were included if they appeared more than 5 times in the Scopus database. Among the 437 keywords examined, 57 met this threshold (Figure 2). The most frequently occurring keyword was “tracheostomy”, which appeared 45 times, with a links attribute of 56 and a total link strength attribute of 45. Following closely were “human” and “article”, occurring 42 and 31 times, respectively. “Human” had a links attribute of 56 and a total link strength attribute of 42, while “article” had a links attribute of 55 and a total link strength attribute of 31.

Figure 2 Bibliometric analysis of the co-occurrence of all keywords. The size of nodes indicates the frequency of occurrence; the curves between the nodes represent their co-occurrence in the same publication; the shorter the distance between two nodes, the larger the number of co-occurrence of two keywords.

Bibliometric analysis of the citations

The top ten most cited articles comparing percutaneous tracheostomy with surgical tracheostomy are listed in Table 2 (9,10,15-22). The average number of citations of the top ten most cited articles was 146.7 (range, 84–299).

“Percutaneous versus surgical tracheostomy: a meta-analysis” by Dulguerov et al. (Critical Care Medicine, 1999) was the most cited article (299 times).

Thirty-six journals published articles comparing percutaneous versus surgical tracheostomy. A total of 25 articles were published in the top ten active journals, representing 49% of the publications in the Scopus database. The most active and most cited journal was Critical Care Medicine.

The top ten most cited journals from the Scopus database are listed in Table 3.

The bibliometric analysis of authors’ citations is shown in Figure 3. Jean-Claude Chevrolet, Pavel Dulguerov, Thomas V. Perneger of the University of Geneva and Claudine Gysin of the University of Zurich were the most cited authors (434 times); the link attribute and total link strength attribute were 102 and 144, respectively. The top fifty most cited authors are listed in Table 4. Switzerland, Australia and the United States were the most cited countries, 434, 347 and 315 times, respectively. Switzerland had a linkage attribute of 13 and a total linkage strength attribute of 32.

Figure 3 Bibliometric analysis of the citations of authors. Different colors indicate different clusters and the size of circles indicates the counts of citations.

Bibliometric analysis of the bibliographic coupling

Bibliographic coupling maps of papers, sources and authors are shown in Figure 4. Five clusters were derived from the bibliographic coupling analysis of papers. Cluster 4 (shown in yellow), the most represented, includes 6 items including the most cited article: Dulguerov et al. Percutaneous or surgical tracheostomy: a meta-analysis, Critical Care Medicine, 1999 (links attribute 34; total link strength attribute 51).

Figure 4 Bibliometric analysis of the bibliographic coupling. (A) Bibliographic coupling of documents. (B) Bibliographic coupling of sources. (C) Bibliographic coupling of authors.

Four clusters were obtained from the bibliographic coupling analysis of the sources. Cluster 1 (shown in blue), the most represented, includes 10 items including Critical Care Medicine, journal with the highest number of published and cited articles (links attribute 29; total link strength attribute 97.53).

Nineteen clusters were derived from the analysis of authors’ bibliographic coupling. Cluster 8 (shown in brown), the most represented, includes 12 items including the most cited authors Jean-Claude Chevrolet, Pavel Dulguerov, Thomas V. Perneger and Claudine Gysin (links attribute 173; total link strength attribute 149.61).

Bibliometric analysis of the co-citation

Bibliometric analysis of the co-citation revealed 1.070 cited references; only 78 of these were cited more than 1 time. The article “Comparative clinical trial of standard operative tracheostomy with percutaneous tracheostomy” of Patrick B. Hazard and coworkers published on Critical Care Medicine in 1991, was the most cited reference (12 times). Links attribute was 46 and the total link strength attribute was 12.

Bibliometric analysis of the co-citation of cited sources showed that 326 sources were cited and 41 of them were cited at least 5 times (Figure 5A). Critical Care Medicine in blue cluster was the most cited source (111 times). Links attribute was 37 and the total link strength attribute was 90.97.

Figure 5 Bibliometric analysis of the co-citation. (A) Co-citations of cited sources. (B) Co-citations of cited authors.

Bibliometric analysis of co-citation showed 2,163 authors cited; among them only 135 were cited at least 5 times (Figure 5B). Karen Isabella from Washington University in the green cluster was the most cited author (31 times). Links attribute was 130 and the total link strength attribute was 30.50.

Discussion

This study represents the first bibliometric analysis of publications comparing percutaneous versus surgical tracheostomy. Given the ongoing debate over the advantages and disadvantages of these two techniques, our analysis provides an objective, comprehensive, and visually insightful examination of the most relevant publications in this field. This approach allows for a deeper understanding of research trends, influential studies, leading contributors, and the collaborative networks shaping this area of study.

The analysis reveals a steady increase in publications over the past two decades, reflecting the growing interest in tracheostomy techniques. Early research primarily focused on the safety and feasibility of percutaneous and surgical tracheostomy. In contrast, more recent studies have expanded to compare long-term outcomes, patient quality of life, and healthcare resource utilization. This trend indicates a shift from foundational research to more nuanced investigations addressing clinical efficacy and patient-centered outcomes. Furthermore, emerging themes include the management of tracheostomy in coronavirus disease 2019 (COVID-19) patients, technological innovations in tracheostomy techniques, and the application of enhanced recovery protocols.

Several landmark studies have significantly influenced the field, often serving as foundational references for subsequent research. Notably, the most cited article, “Percutaneous versus surgical tracheostomy: a meta-analysis” by Dulguerov et al. [1999], has been pivotal in shaping clinical practice and research directions. Influential authors, including Maria Vargas from the University of Naples Federico II and researchers from institutions like the University of Geneva (Jean-Claude Chevrolet, Pavel Dulguerov, Thomas V. Perneger) and the University of Zurich (Claudine Gysin) have contributed extensively, highlighting the importance of prolific and high-impact authors in advancing the field.

The analysis identifies key journals such as “Critical Care Medicine” as primary platforms for disseminating research on tracheostomy. These journals not only publish a significant volume of relevant articles but also achieve high citation counts, underscoring their role in shaping clinical guidelines and practice. Leading institutions, particularly those with robust surgical and critical care departments, emerge as major contributors to the literature, demonstrating the importance of specialized centers in driving research advancements.

Our analysis highlights strong international and interdisciplinary collaboration networks. These collaborations are crucial to conduct large-scale studies and integrate different expertise, improving their quality and overall impact. The presence of international consortia and multicenter studies reflects the collective effort to address complex clinical questions and improve patient outcomes, trying as much as possible to create evidence that can help in the daily clinical practice of each health center.

This bibliometric analysis provides valuable insights for future research. By highlighting the direction of research on this topic in a given time frame, it helps those engaged in research in this field to identify gaps and perhaps study them. Therefore, future research should continue exploring under-investigated areas such as the long-term impact of tracheostomy on quality of life and the cost-effectiveness of different techniques. There is also a need for standardized guidelines and protocols to harmonize clinical practice across institutions. The integration of advanced technologies, such as image-guided tracheostomy and telemedicine, represents promising avenues for innovation and improved patient care.

Despite the comprehensive nature of this analysis, certain limitations are inevitable. The primary constraint is the reliance on the Scopus database, which may not encompass all relevant studies. Future analyses incorporating multiple databases could provide a more exhaustive overview. Additionally, the inclusion criteria and methodological differences between studies can introduce variability that may affect the generalizability of the findings.

Conclusions

This bibliometric analysis offers a broad overview of the literature comparing percutaneous and surgical tracheostomy, serving as a valuable supplementary tool to systematic reviews and meta-analyses. In fact, by providing both quantitative and qualitative insights, it enhances our understanding of the research landscape, guiding future investigations and informing clinical practice. The findings underscore the importance of ongoing research and collaboration in optimizing tracheostomy care and improving patient outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the BIBLIO reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-306/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-306/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-306/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Merola R, Vargas M, Sanfilippo F, et al. Tracheostomy Practice in the Italian Intensive Care Units: A Point-Prevalence Survey. Medicina (Kaunas) 2025;61:87. [Crossref] [PubMed]
2. Vargas M, Sutherasan Y, Antonelli M, et al. Tracheostomy procedures in the intensive care unit: an international survey. Crit Care 2015;19:291. [Crossref] [PubMed]
3. Merola R, Vargas M. Economic Indicators, Quantity and Quality of Health Care Resources Affecting Post-surgical Mortality. J Epidemiol Glob Health 2024;14:613-20. [Crossref] [PubMed]
4. Merola R, Iacovazzo C, Troise S, et al. Timing of Tracheostomy in ICU Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Life (Basel) 2024;14:1165. [Crossref] [PubMed]
5. Merola R, Troise S, Palumbo D, et al. Airway management in patients undergoing maxillofacial surgery: State of art review. J Stomatol Oral Maxillofac Surg 2025;126:102044. [Crossref] [PubMed]
6. Nieszkowska A, Combes A, Luyt CE, et al. Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Crit Care Med 2005;33:2527-33. [Crossref] [PubMed]
7. Diehl JL, El Atrous S, Touchard D, et al. Changes in the work of breathing induced by tracheotomy in ventilator-dependent patients. Am J Respir Crit Care Med 1999;159:383-8. [Crossref] [PubMed]
8. Cheung NH, Napolitano LM. Tracheostomy: epidemiology, indications, timing, technique, and outcomes. Respir Care 2014;59:895-915; discussion 916-9. [Crossref] [PubMed]
9. Dulguerov P, Gysin C, Perneger TV, et al. Percutaneous or surgical tracheostomy: a meta-analysis. Crit Care Med 1999;27:1617-25. [Crossref] [PubMed]
10. Putensen C, Theuerkauf N, Guenther U, et al. Percutaneous and surgical tracheostomy in critically ill adult patients: a meta-analysis. Crit Care 2014;18:544. [Crossref] [PubMed]
11. Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care 2006;10:R55. [Crossref] [PubMed]
12. Montazeri A, Mohammadi S, M, Hesari P, et al. Preliminary guideline for reporting bibliometric reviews of the biomedical literature (BIBLIO): a minimum requirements. Syst Rev 2023;12:239. [Crossref] [PubMed]
13. Merola R, Mancino D, Vargas M. Videolaryngoscopy versus direct laryngoscopy: a bibliometric analysis. Br J Anaesth 2024;132:166-8. [Crossref] [PubMed]
14. Merola R, Troise S, Romano A, et al. Tracheostomy in COVID-19 critically ill patients: a bibliometric and visual analysis. J Thorac Dis 2025;17:3106-17. [Crossref] [PubMed]
15. Griggs WM, Myburgh JA, Worthley LI. A prospective comparison of a percutaneous tracheostomy technique with standard surgical tracheostomy. Intensive Care Med 1991;17:261-3. [Crossref] [PubMed]
16. Silvester W, Goldsmith D, Uchino S, et al. Percutaneous versus surgical tracheostomy: A randomized controlled study with long-term follow-up. Crit Care Med 2006;34:2145-52. [Crossref] [PubMed]
17. Massick DD, Yao S, Powell DM, et al. Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy. Laryngoscope 2001;111:494-500. [Crossref] [PubMed]
18. Gysin C, Dulguerov P, Guyot JP, et al. Percutaneous versus surgical tracheostomy: a double-blind randomized trial. Ann Surg 1999;230:708-14. [Crossref] [PubMed]
19. Heikkinen M, Aarnio P, Hannukainen J. Percutaneous dilational tracheostomy or conventional surgical tracheostomy? Crit Care Med 2000;28:1399-402. [Crossref] [PubMed]
20. Brass P, Hellmich M, Ladra A, et al. Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev 2016;7:CD008045. [Crossref] [PubMed]
21. Johnson-Obaseki S, Veljkovic A, Javidnia H. Complication rates of open surgical versus percutaneous tracheostomy in critically ill patients. Laryngoscope 2016;126:2459-67. [Crossref] [PubMed]
22. Bowen CP, Whitney LR, Truwit JD, et al. Comparison of safety and cost of percutaneous versus surgical tracheostomy. Am Surg 2001;67:54-60.