In 1982, the experience with tracheostomy at The Children's Hospital of Philadelphia was reported for 1971 through 1980. We have now reviewed 450 cases for the period from 1981 through 1992, and compared the characteristics of these cases with those in the previous review. Long-term follow-up was available on 83% of cases, and the median follow-up was 2.96 years. Patients received a tracheostomy for airway obstruction (38%), chronic ventilation (53%), or multiple indications (9%). The mean duration of tracheotomy (adjusted for death and loss to follow-up) was 2.13 years. The tracheostomy-related mortality was 0.5%, and the nontracheostomy-related mortality was 22%. Nineteen percent of patients had complications in the first postoperative week, and 58% had 1 or more late complications. In comparison with the previous study from our institution, there was a great increase in long-term tracheostomy and a continuing trend away from tracheostomy for short-term airway management. Better monitoring and improvements in parental teaching may have contributed to a decrease in tracheostomy-related mortality.