Aerosol treatment in the emergency department.

Dr. Vianello and colleagues understand very well that it is usually because of an inability to cough out airway secretions during chest colds, rather than because of chronic hypoventi¬ lation, that patients with neuromuscular disease develop acute respiratory failure (ARF). They deserve commendation for directing their attention to these patients' primary impedi¬ ment to extended survival. They propose using indwelling minitracheostomy tubes to facilitate secretion aspiration in times of need and note that hospitalization rates can also be decreased in this manner. It is not surprising that their approach can decrease the risk of respiratory failure and decrease hospitalization days, at least early on. However, although not mentioned in their letter, complications of minitracheostomy can be similar to those of full-sized indwell¬ ing tracheostomy tubes. They include tracheal damage, chronic bacterial colonization, granulation tissue formation, bleeding, diminished autonomous cough flows (because of air leak around the outer walls of the tube), and increased secretion generation. Furthermore, Vianello and colleagues note that "subjects. .who require hospitalization because of