Tracheotomy
Encyclopedia
Among the oldest described surgical
procedures, tracheotomy (also referred to as pharyngotomy, laryngotomy, and tracheostomy) consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea
. The resulting stoma
can serve independently as an airway
or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe
without the use of his or her nose or mouth. Both surgical and percutaneous
techniques are widely used in current surgical practice.
of the word tracheotomy comes from two Greek
words: the root
tom- meaning "to cut", and the word trachea. The word tracheostomy, including the root stom- meaning "mouth," refers to the making of a semi-permanent or permanent opening, and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma
at the time it is created.
, head and neck cancer
s, large congenital tumor
s of the head and neck (e.g., branchial cleft cyst
), and acute angioedema
and inflammation
of the head and neck. In the context of failed orotracheal or nasotracheal intubation, either tracheotomy or cricothyrotomy
may be performed. In the chronic setting, indications for tracheotomy include the need for long-term mechanical ventilation and tracheal toilet (e.g. coma
tose patients, or extensive surgery involving the head and neck). In extreme cases, the procedure may be indicated as a treatment for severe Obstructive Sleep Apnea seen in patients intolerant of Continuous Positive Airway Pressure (CPAP) therapy.
As with most other surgical procedures, some cases are more difficult than others. Surgery on children is more difficult because of their smaller size. Difficulties such as a short neck and bigger thyroid glands make the trachea hard to open. There are other difficulties withpatients with irregular necks, the obese, and those with a large goitre
. The many possible complications include hemorrhage, loss of airway, subcutaneous emphysema
, wound infections, stomal cellulites, fracture of tracheal rings, poor placement of the tracheotomy tube, and bronchospasm".
By the late 19th century, some surgeons had become proficient in performing the tracheotomy. The main instruments used were:
The best position for a tracheotomy was and still is one that forces the neck into the biggest prominence. Usually, the patient was laid on his back on a table with a cushion placed under his shoulders to prop him up. The arms were restrained to ensure they would not get in the way later. The tools and techniques used today in tracheotomies have come a long way. The tracheotomy tube placed into the incision through the windpipe comes in various sizes, thus allowing a more comfortable fit and the ability to remove the tube in and out of the throat without disrupting support from a breathing machine. In today’s world general anesthesia is used when performing these surgeries, which makes it much more tolerable for the patient. Special tracheostomy tube valves (such as the Passy-Muir valve ) have been created to assist people in their speech. The patient can inhale through the unidirectional tube. Upon expiration, pressure causes the valve to close, redirecting air around the tube, past the vocal folds, producing sound.
The tracheotomy underwent centuries of denial and rejection as well as much failure. Finally, in recent decades, it has become a commonly accepted, crucial, and successful surgery that has saved the lives of hundreds of thousands of patients.
, an Australian intensive care specialist. This technique involves the use of a specially modified pair of forceps with a central hole enabling them to pass over a guidewire enabling the performance of the main dilation in a single step. Since then a number of other techniques have been described. A variant of the original Ciaglia technique using a single tapered dilator known as a "blue rhino" is the most commonly used of these newer techniques and has largely taken over from the early multiple dilator technique. The Griggs and Ciaglia Blue Rhino techniques are the two main techniques in current use. A number of comparison studies have been undertaken between these two techniques with no clear differences emerging
s (the nerves that control the vocal folds
), tracheotomy is performed as high in the trachea as possible. If only one of these nerves is damaged, the patient will experience dysphonia
; if both of the nerves are damaged, the patient will experience complete aphonia
.
A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10–15% and a procedural mortality of 0%, which is comparable to those of other series reported in the literature from the Netherlands and the United States.
A 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases. The comparative study above also identified ring fractures in 9 of 30 live patients while another small series identified ring fractures in 5 of their 20 patients. The long term significance of tracheal ring fractures is unknown.
is a form of non-invasive mechanical ventilation that can in many cases allow patients an alternative mode of respiratory support, allowing patients to avoid an invasive tracheostomy and its many complications. While this method has not been proven to help in every case, it has been shown to be an effective alternative for many.
ian artifacts in 3600 BCE. It was described in the Rigveda
, a Sanskrit
text, circa 2000 BCE. Homerus of Byzantium
is said to have written of Alexander the Great saving a soldier from suffocation
by making an incision with the tip of his sword in the man's trachea. Hippocrates
condemned the practice of tracheotomy as incurring an unacceptable risk of damage to the carotid artery. Warning against the possibility of death from inadvertent laceration of the carotid artery during tracheotomy, he instead advocated the practice of tracheal intubation
. Because surgical instruments were not sterilized
at that time, infections following surgery also produced numerous complications, including dyspnea
, often leading to death.
Despite the concerns of Hippocrates, it is believed that an early tracheotomy was performed by Asclepiades of Bithynia
, who lived in Rome around 100 BCE. Galen
and Aretaeus, both of whom lived in Rome in the 2nd century AD, credit Asclepiades as being the first physician to perform a non-emergency tracheotomy. Antyllus
, another Roman physician of the 2nd century AD, supported tracheotomy when treating oral diseases. He refined the technique to be more similar to that used in modern times, recommending that a transverse
incision be made between the third and fourth tracheal rings for the treatment of life-threatening airway obstruction. Antyllus (whose original writings were lost but not before they were preserved by the Greek historian Oribasius
) wrote that tracheotomy was not effective however in cases of severe laryngotracheobronchitis
because the pathology was distal to the operative site. In AD 131, Galen clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice.
By AD 700, the tracheotomy was well described in India
n and Arabian
literature, although it was rarely practiced on humans. In 1000, Abu al-Qasim al-Zahrawi (936-1013), an Arab who lived in Arabic Spain
, published the 30-volume Kitab al-Tasrif
, the first illustrated work on surgery. He never performed a tracheotomy, but he did treat a slave girl who had cut her own throat in a suicide attempt. Al-Zahrawi (known to Europeans as Albucasis) sewed up the wound and the girl recovered, thereby proving that an incision in the larynx could heal. Circa AD 1020, Avicenna
(980-1037) described tracheal intubation in The Canon of Medicine
in order to facilitate breathing
. The first correct description of the tracheotomy operation for treatment of asphyxiation was described by Ibn Zuhr
(1091–1161) in the 12th century. Ibn Zuhr (also known as Avenzoar) successfully practiced the tracheotomy procedure on a goat, justifying Galen's approval of the operation.
brought with it significant advances in all scientific fields, particularly surgery. Increased knowledge of anatomy was a major factor in these developments. Surgeons became increasingly open to experimental surgery on the trachea. During this period, many surgeons attempted to perform tracheotomies, for various reasons and with various methods. Many suggestions were put forward, but little actual progress was made toward making the procedure more successful. The tracheotomy remained a dangerous operation with a very low success rate, and many surgeons still considered the tracheotomy to be a useless and dangerous procedure. The high mortality rate for this operation, which had not improved, supports their position.
From the period 1500 to 1832 there are only 28 known reports of tracheotomy. In 1543, Andreas Vesalius (1514–1564) wrote that tracheal intubation and subsequent artificial respiration
could be life-saving. Antonio Musa Brassavola
(1490–1554) of Ferrara
treated a patient suffering from peritonsillar abscess
by tracheotomy after the patient had been refused by barber surgeon
s. The patient apparently made a complete recovery, and Brassavola published his account in 1546. This operation has been identified as the first recorded successful tracheostomy, despite many ancient references to the trachea and possibly to its opening. Ambroise Paré
(1510–1590) described suture of tracheal lacerations in the mid-16th century. One patient survived despite a concomitant injury to the internal jugular vein. Another sustained wounds to the trachea and esophagus and died.
Towards the end of the 16th century, anatomist and surgeon Hieronymus Fabricius
(1533–1619) described a useful technique for tracheotomy in his writings, although he had never actually performed a the operation himself. He advised using a vertical incision and was the first to introduce the idea of a tracheostomy tube. This was a straight, short cannula
that incorporated wings to prevent the tube from advancing too far into the trachea. He recommended the operation only as a last resort, to be used in cases of airway
obstruction by foreign bodies
or secretion
s. He counseled that the operation should be performed only as a last option. Fabricius' description of the tracheotomy procedure is similar to that used today. Julius Casserius (1561–1616) succeeded Fabricius as professor of anatomy at the University of Padua and published his own writings regarding technique and equipment for tracheotomy. Casserius recommended using a curved silver tube with several holes in it. Marco Aurelio Severino
(1580–1656), a skillful surgeon and anatomist, performed multiple successful tracheotomies during a diphtheria
epidemic
in Naples
in 1610, using the vertical incision technique recommended by Fabricius. He also developed his own version of a trocar.
In 1620 the French surgeon Nicholas Habicot (1550–1624), surgeon of the Duke of Nemours
and anatomist, published a report of four successful "bronchotomies" which he had performed. One of these is the first recorded case of a tracheotomy for the removal of a foreign body, in this instance a blood clot in the larynx of a stabbing victim. He also described the first tracheotomy to be performed on a pediatric
patient. A 14 year old boy swallowed a bag containing 9 gold coins in an attempt to prevent its theft by a highwayman
. The object became lodged in his esophagus
, obstructing his trachea. Habicot performed a tracheotomy, which allowed him to manipulate the bag so that it passed through the boy's alimentary tract, apparently with no further sequela
e. Habicot suggested that the operation might also be effective for patients suffering from inflammation of the larynx. He developed equipment for this surgical procedure which displayed similarities to modern designs (except for his use of a single-tube cannula).
Sanctorius
(1561–1636) is believed to be the first to use a trocar in the operation, and he recommended leaving the cannula in place for a few days following the operation. Early tracheostomy devices are illustrated in Habicot’s Question Chirurgicale and Julius Casserius' posthumous Tabulae anatomicae in 1627. Thomas Fienus (1567–1631), Professor of Medicine at the University of Louvain
, was the first to use the word "tracheotomy" in 1649, but this term was not commonly used until a century later. Georg Detharding (1671–1747), professor of anatomy at the University of Rostock
, treated a drowning victim with tracheostomy in 1714.
employed it as a last resort to treat a case of diphtheria
. In 1852, Bretonneau's student Armand Trousseau
reported a series of 169 tracheotomies (158 of which were for croup
, and 11 for "chronic maladies of the larynx") In 1858, John Snow was the first to report tracheotomy and cannulation of the trachea for the administration of chloroform anesthesia in an animal model. In 1871, the German surgeon Friedrich Trendelenburg
(1844–1924) published a paper describing the first successful elective
human tracheotomy to be performed for the purpose of administration of general anesthesia. In 1880, the Scottish surgeon William Macewen
(1848–1924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with chloroform
. At last, in 1880 Morrell Mackenzie's book discussed the symptoms indicating a tracheotomy and when the operation is absolutely necessary.
who required mechanical ventilation
. However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were described and employed, along with many different surgical instruments and tracheal tubes. Surgeons could not seem to reach a consensus on where or how the tracheal incision should be made, arguing whether the "high tracheotomy" or the "low tracheotomy" was more beneficial. The currently used surgical tracheotomy technique was described in 1909 by Chevalier Jackson
of Pittsburgh, Pennsylvania
. Jackson emphasised the importance of postoperative care, which dramatically reduced the death rate. By 1965, the surgical anatomy was thoroughly and widely understood, antibiotic
s were widely available and useful for treating postoperative infections, and other major complications had also become more manageable.
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...
procedures, tracheotomy (also referred to as pharyngotomy, laryngotomy, and tracheostomy) consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea
Vertebrate trachea
In tetrapod anatomy the trachea, or windpipe, is a tube that connects the pharynx or larynx to the lungs, allowing the passage of air. It is lined with pseudostratified ciliated columnar epithelium cells with goblet cells that produce mucus...
. The resulting stoma
Stoma (medicine)
A stoma is an opening , either natural or surgically created, which connects a portion of the body cavity to the outside environment...
can serve independently as an airway
Airway
The pulmonary airway comprises those parts of the respiratory system through which air flows, conceptually beginning at the nose and mouth, and terminating in the alveoli...
or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe
Breathing
Breathing is the process that moves air in and out of the lungs. Aerobic organisms require oxygen to release energy via respiration, in the form of the metabolism of energy-rich molecules such as glucose. Breathing is only one process that delivers oxygen to where it is needed in the body and...
without the use of his or her nose or mouth. Both surgical and percutaneous
Percutaneous
In surgery, percutaneous pertains to any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an "open" approach where inner organs or tissue are exposed .The percutaneous approach is commonly used in vascular procedures...
techniques are widely used in current surgical practice.
Etymology and terminology
The etymologyEtymology
Etymology is the study of the history of words, their origins, and how their form and meaning have changed over time.For languages with a long written history, etymologists make use of texts in these languages and texts about the languages to gather knowledge about how words were used during...
of the word tracheotomy comes from two Greek
Greek language
Greek is an independent branch of the Indo-European family of languages. Native to the southern Balkans, it has the longest documented history of any Indo-European language, spanning 34 centuries of written records. Its writing system has been the Greek alphabet for the majority of its history;...
words: the root
Root (linguistics)
The root word is the primary lexical unit of a word, and of a word family , which carries the most significant aspects of semantic content and cannot be reduced into smaller constituents....
tom- meaning "to cut", and the word trachea. The word tracheostomy, including the root stom- meaning "mouth," refers to the making of a semi-permanent or permanent opening, and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma
Stoma (medicine)
A stoma is an opening , either natural or surgically created, which connects a portion of the body cavity to the outside environment...
at the time it is created.
Indications
In the acute setting, indications for tracheotomy include such conditions as severe facial traumaFacial trauma
Facial trauma, also called maxillofacial trauma, is any physical trauma to the face. Facial trauma can involve soft tissue injuries such as burns, lacerations and bruises, or fractures of the facial bones such as nasal fractures and fractures of the jaw, as well as trauma such as eye injuries...
, head and neck cancer
Head and neck cancer
Head and neck cancer refers to a group of biologically similar cancers that start in the upper aerodigestive tract, including the lip, oral cavity , nasal cavity , paranasal sinuses, pharynx, and larynx. 90% of head and neck cancers are squamous cell carcinomas , originating from the mucosal lining...
s, large congenital tumor
Tumor
A tumor or tumour is commonly used as a synonym for a neoplasm that appears enlarged in size. Tumor is not synonymous with cancer...
s of the head and neck (e.g., branchial cleft cyst
Branchial cleft cyst
A branchial cleft cyst is an oval, moderately movable cystic mass that develops under the skin in the neck between the sternocleidomastoid muscle and the pharynx.-Pathology:...
), and acute angioedema
Angioedema
Angioedema or Quincke's edema is the rapid swelling of the dermis, subcutaneous tissue, mucosa and submucosal tissues. It is very similar to urticaria, but urticaria, commonly known as hives, occurs in the upper dermis...
and inflammation
Inflammation
Inflammation is part of the complex biological response of vascular tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. Inflammation is a protective attempt by the organism to remove the injurious stimuli and to initiate the healing process...
of the head and neck. In the context of failed orotracheal or nasotracheal intubation, either tracheotomy or cricothyrotomy
Cricothyrotomy
A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive...
may be performed. In the chronic setting, indications for tracheotomy include the need for long-term mechanical ventilation and tracheal toilet (e.g. coma
Coma
In medicine, a coma is a state of unconsciousness, lasting more than 6 hours in which a person cannot be awakened, fails to respond normally to painful stimuli, light or sound, lacks a normal sleep-wake cycle and does not initiate voluntary actions. A person in a state of coma is described as...
tose patients, or extensive surgery involving the head and neck). In extreme cases, the procedure may be indicated as a treatment for severe Obstructive Sleep Apnea seen in patients intolerant of Continuous Positive Airway Pressure (CPAP) therapy.
Surgical instruments
Goitre
A goitre or goiter , is a swelling in the thyroid gland, which can lead to a swelling of the neck or larynx...
. The many possible complications include hemorrhage, loss of airway, subcutaneous emphysema
Subcutaneous emphysema
Subcutaneous emphysema, sometimes abbreviated SCE or SE and also called tissue emphysema, or Sub Q air, occurs when gas or air is present in the subcutaneous layer of the skin. Subcutaneous refers to the tissue beneath the cutis of the skin, and emphysema refers to trapped air...
, wound infections, stomal cellulites, fracture of tracheal rings, poor placement of the tracheotomy tube, and bronchospasm".
By the late 19th century, some surgeons had become proficient in performing the tracheotomy. The main instruments used were:
“Two small scalpels, one short grooved director, a tenaculum, two aneurysmAneurysmAn aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel. Aneurysms can commonly occur in arteries at the base of the brain and an aortic aneurysm occurs in the main artery carrying blood from the left ventricle of the heart...
needles which may be used as retractors, one pair of artery forceps, haemostatic forceps, two pairs of dissecting forceps, a pair of scissors, a sharp-pointed tenotome, a pair of tracheal forceps, a tracheal dilator, tracheotomy tubes, ligatures, sponges, a flexible catheter, and feathers”.
Haemostatic forceps were used to control bleeding from separated vessels that were not ligatured because of the urgency of the operation. Generally, they were used to expose the trachea by clamping the isthmus thyroid gland on both sides. To open the trachea physically, a sharp-pointed tentome allowed the surgeon easily to place the ends into the opening of the trachea. The thin points permitted the doctor a better view of his incision. Tracheal dilators, such as the “Golding BirdGolding BirdGolding Bird was a British medical doctor and Fellow of the Royal College of Physicians of London. Bird became a great authority on kidney diseases and published a comprehensive paper on urinary deposits...
”, were placed through the opening and then expanded by “turning the screw to which they are attached.” Tracheal forceps, as displayed on the right , were commonly used to extract foreign bodies from the larynx. The optimum tracheal tube at the time caused very little damage to the trachea and “mucus membrane”.
The best position for a tracheotomy was and still is one that forces the neck into the biggest prominence. Usually, the patient was laid on his back on a table with a cushion placed under his shoulders to prop him up. The arms were restrained to ensure they would not get in the way later. The tools and techniques used today in tracheotomies have come a long way. The tracheotomy tube placed into the incision through the windpipe comes in various sizes, thus allowing a more comfortable fit and the ability to remove the tube in and out of the throat without disrupting support from a breathing machine. In today’s world general anesthesia is used when performing these surgeries, which makes it much more tolerable for the patient. Special tracheostomy tube valves (such as the Passy-Muir valve ) have been created to assist people in their speech. The patient can inhale through the unidirectional tube. Upon expiration, pressure causes the valve to close, redirecting air around the tube, past the vocal folds, producing sound.
The tracheotomy underwent centuries of denial and rejection as well as much failure. Finally, in recent decades, it has become a commonly accepted, crucial, and successful surgery that has saved the lives of hundreds of thousands of patients.
Percutaneous tracheotomy
While there were some earlier false starts, the first widely accepted Percutaneous Tracheotomy technique was described by Pat Ciaglia, a New York surgeon, in 1985. This technique involves a series of sequential dilatations using a set of seven dilators of progressively larger size. The next widely used technique was developed in 1989 by Bill GriggsBill Griggs
Dr William "Bill" Middleton Griggs AM ASM, began his medical career in 1976 as a volunteer paramedic while studying as a medical student. As a paramedic he attended his 100th fatal road crash prior to graduating as a doctor in 1981...
, an Australian intensive care specialist. This technique involves the use of a specially modified pair of forceps with a central hole enabling them to pass over a guidewire enabling the performance of the main dilation in a single step. Since then a number of other techniques have been described. A variant of the original Ciaglia technique using a single tapered dilator known as a "blue rhino" is the most commonly used of these newer techniques and has largely taken over from the early multiple dilator technique. The Griggs and Ciaglia Blue Rhino techniques are the two main techniques in current use. A number of comparison studies have been undertaken between these two techniques with no clear differences emerging
Complications
In order to limit the risk of damage to the recurrent laryngeal nerveRecurrent laryngeal nerve
The recurrent laryngeal nerve is a branch of the vagus nerve that supplies motor function and sensation to the larynx . It travels within the endoneurium...
s (the nerves that control the vocal folds
Vocal folds
The vocal folds, also known commonly as vocal cords, are composed of twin infoldings of mucous membrane stretched horizontally across the larynx...
), tracheotomy is performed as high in the trachea as possible. If only one of these nerves is damaged, the patient will experience dysphonia
Dysphonia
Dysphonia is the medical term for disorders of the voice: an impairment in the ability to produce voice sounds using the vocal organs . Thus, dysphonia is a phonation disorder...
; if both of the nerves are damaged, the patient will experience complete aphonia
Aphonia
Aphonia is the inability to speak. It is considered more severe than dysphonia. A primary cause of aphonia is bilateral disruption of the recurrent laryngeal nerve, which supplies nearly all the muscles in the larynx...
.
A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10–15% and a procedural mortality of 0%, which is comparable to those of other series reported in the literature from the Netherlands and the United States.
A 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases. The comparative study above also identified ring fractures in 9 of 30 live patients while another small series identified ring fractures in 5 of their 20 patients. The long term significance of tracheal ring fractures is unknown.
Alternatives
Biphasic Cuirass VentilationBiphasic Cuirass Ventilation
Biphasic cuirass ventilation is a method of ventilation which requires the patient to wear an upper body shell or cuirass, so named after the body armor worn by medieval soldiers. The ventilation is biphasic because the cuirass is attached to a pump which actively controls both the inspiratory and...
is a form of non-invasive mechanical ventilation that can in many cases allow patients an alternative mode of respiratory support, allowing patients to avoid an invasive tracheostomy and its many complications. While this method has not been proven to help in every case, it has been shown to be an effective alternative for many.
History
Prior to 16th century
Tracheotomy was first depicted on EgyptEgypt
Egypt , officially the Arab Republic of Egypt, Arabic: , is a country mainly in North Africa, with the Sinai Peninsula forming a land bridge in Southwest Asia. Egypt is thus a transcontinental country, and a major power in Africa, the Mediterranean Basin, the Middle East and the Muslim world...
ian artifacts in 3600 BCE. It was described in the Rigveda
Rigveda
The Rigveda is an ancient Indian sacred collection of Vedic Sanskrit hymns...
, a Sanskrit
Sanskrit
Sanskrit , is a historical Indo-Aryan language and the primary liturgical language of Hinduism, Jainism and Buddhism.Buddhism: besides Pali, see Buddhist Hybrid Sanskrit Today, it is listed as one of the 22 scheduled languages of India and is an official language of the state of Uttarakhand...
text, circa 2000 BCE. Homerus of Byzantium
Homerus of Byzantium
Homerus from Byzantium was an ancient Greek grammarian and tragic poet. He was also called ho Neoteros , to distinguish him from the older Homerus ....
is said to have written of Alexander the Great saving a soldier from suffocation
Asphyxia
Asphyxia or asphyxiation is a condition of severely deficient supply of oxygen to the body that arises from being unable to breathe normally. An example of asphyxia is choking. Asphyxia causes generalized hypoxia, which primarily affects the tissues and organs...
by making an incision with the tip of his sword in the man's trachea. Hippocrates
Hippocrates
Hippocrates of Cos or Hippokrates of Kos was an ancient Greek physician of the Age of Pericles , and is considered one of the most outstanding figures in the history of medicine...
condemned the practice of tracheotomy as incurring an unacceptable risk of damage to the carotid artery. Warning against the possibility of death from inadvertent laceration of the carotid artery during tracheotomy, he instead advocated the practice of tracheal intubation
Tracheal intubation
Tracheal intubation, usually simply referred to as intubation, is the placement of a flexible plastic or rubber tube into the trachea to maintain an open airway or to serve as a conduit through which to administer certain drugs...
. Because surgical instruments were not sterilized
Sterilization (microbiology)
Sterilization is a term referring to any process that eliminates or kills all forms of microbial life, including transmissible agents present on a surface, contained in a fluid, in medication, or in a compound such as biological culture media...
at that time, infections following surgery also produced numerous complications, including dyspnea
Dyspnea
Dyspnea , shortness of breath , or air hunger, is the subjective symptom of breathlessness.It is a normal symptom of heavy exertion but becomes pathological if it occurs in unexpected situations...
, often leading to death.
Despite the concerns of Hippocrates, it is believed that an early tracheotomy was performed by Asclepiades of Bithynia
Asclepiades of Bithynia
Asclepiades was a Greek physician born at Prusa in Bithynia in Asia Minor and flourished at Rome, where he established Greek medicine near the end of the 2nd century BCE. He attempted to build a new theory of disease, based on the flow of atoms through pores in the body...
, who lived in Rome around 100 BCE. Galen
Galen
Aelius Galenus or Claudius Galenus , better known as Galen of Pergamon , was a prominent Roman physician, surgeon and philosopher...
and Aretaeus, both of whom lived in Rome in the 2nd century AD, credit Asclepiades as being the first physician to perform a non-emergency tracheotomy. Antyllus
Antyllus
For the son of Mark Antony, see Marcus Antonius AntyllusAntyllus was a Greek surgeon, who lived in the 2nd century AD in Rome. He is most notable for his method of treatment of aneurysms...
, another Roman physician of the 2nd century AD, supported tracheotomy when treating oral diseases. He refined the technique to be more similar to that used in modern times, recommending that a transverse
Transverse plane
The transverse plane is an imaginary plane that divides the body into superior and inferior parts. It is perpendicular to the coronal and sagittal planes....
incision be made between the third and fourth tracheal rings for the treatment of life-threatening airway obstruction. Antyllus (whose original writings were lost but not before they were preserved by the Greek historian Oribasius
Oribasius
Oribasius or Oreibasius was a Greek medical writer and the personal physician of the Roman emperor Julian the Apostate. He studied at Alexandria under physician Zeno of Cyprus before joining Julian's retinue. He was involved in Julian's coronation in 361, and remained with the emperor until...
) wrote that tracheotomy was not effective however in cases of severe laryngotracheobronchitis
Croup
Croup is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness...
because the pathology was distal to the operative site. In AD 131, Galen clarified the anatomy of the trachea and was the first to demonstrate that the larynx generates the voice.
By AD 700, the tracheotomy was well described in India
India
India , officially the Republic of India , is a country in South Asia. It is the seventh-largest country by geographical area, the second-most populous country with over 1.2 billion people, and the most populous democracy in the world...
n and Arabian
Arab world
The Arab world refers to Arabic-speaking states, territories and populations in North Africa, Western Asia and elsewhere.The standard definition of the Arab world comprises the 22 states and territories of the Arab League stretching from the Atlantic Ocean in the west to the Arabian Sea in the...
literature, although it was rarely practiced on humans. In 1000, Abu al-Qasim al-Zahrawi (936-1013), an Arab who lived in Arabic Spain
Al-Andalus
Al-Andalus was the Arabic name given to a nation and territorial region also commonly referred to as Moorish Iberia. The name describes parts of the Iberian Peninsula and Septimania governed by Muslims , at various times in the period between 711 and 1492, although the territorial boundaries...
, published the 30-volume Kitab al-Tasrif
Al-Tasrif
The Kitab al-Tasrif was an Arabic encyclopedia on medicine and surgery, written near the year 1000 by Abu al-Qasim al-Zahrawi...
, the first illustrated work on surgery. He never performed a tracheotomy, but he did treat a slave girl who had cut her own throat in a suicide attempt. Al-Zahrawi (known to Europeans as Albucasis) sewed up the wound and the girl recovered, thereby proving that an incision in the larynx could heal. Circa AD 1020, Avicenna
Avicenna
Abū ʿAlī al-Ḥusayn ibn ʿAbd Allāh ibn Sīnā , commonly known as Ibn Sīnā or by his Latinized name Avicenna, was a Persian polymath, who wrote almost 450 treatises on a wide range of subjects, of which around 240 have survived...
(980-1037) described tracheal intubation in The Canon of Medicine
The Canon of Medicine
The Canon of Medicine is an encyclopedia of Galenic medicine in five books compiled by Ibn Sīnā and completed in 1025. It presents a clear and organized summary of all the medical knowledge of the time...
in order to facilitate breathing
Breathing
Breathing is the process that moves air in and out of the lungs. Aerobic organisms require oxygen to release energy via respiration, in the form of the metabolism of energy-rich molecules such as glucose. Breathing is only one process that delivers oxygen to where it is needed in the body and...
. The first correct description of the tracheotomy operation for treatment of asphyxiation was described by Ibn Zuhr
Ibn Zuhr
Abū Merwān ’Abdal-Malik ibn Zuhr was a Muslim physician, surgeon and teacher in Al-Andalus.He was born at Seville...
(1091–1161) in the 12th century. Ibn Zuhr (also known as Avenzoar) successfully practiced the tracheotomy procedure on a goat, justifying Galen's approval of the operation.
16th-18th centuries
The European RenaissanceRenaissance
The Renaissance was a cultural movement that spanned roughly the 14th to the 17th century, beginning in Italy in the Late Middle Ages and later spreading to the rest of Europe. The term is also used more loosely to refer to the historical era, but since the changes of the Renaissance were not...
brought with it significant advances in all scientific fields, particularly surgery. Increased knowledge of anatomy was a major factor in these developments. Surgeons became increasingly open to experimental surgery on the trachea. During this period, many surgeons attempted to perform tracheotomies, for various reasons and with various methods. Many suggestions were put forward, but little actual progress was made toward making the procedure more successful. The tracheotomy remained a dangerous operation with a very low success rate, and many surgeons still considered the tracheotomy to be a useless and dangerous procedure. The high mortality rate for this operation, which had not improved, supports their position.
From the period 1500 to 1832 there are only 28 known reports of tracheotomy. In 1543, Andreas Vesalius (1514–1564) wrote that tracheal intubation and subsequent artificial respiration
Artificial respiration
Artificial respiration is the act of assisting or stimulating respiration, a metabolic process referring to the overall exchange of gases in the body by pulmonary ventilation, external respiration, and internal respiration...
could be life-saving. Antonio Musa Brassavola
Antonio Musa Brassavola
Antonio Musa Brassavola was an Italian physician and one of the most famous of his time. He studied under Niccolò Leoniceno and Manardi. He was the friend and physician of Ercolo II, the prince of Este...
(1490–1554) of Ferrara
Ferrara
Ferrara is a city and comune in Emilia-Romagna, northern Italy, capital city of the Province of Ferrara. It is situated 50 km north-northeast of Bologna, on the Po di Volano, a branch channel of the main stream of the Po River, located 5 km north...
treated a patient suffering from peritonsillar abscess
Peritonsillar abscess
Peritonsillar abscess , also called a quinsy or abbreviated as PTA is a recognised complication of tonsillitis and consists of a collection of pus beside the tonsil .-Symptoms and signs:...
by tracheotomy after the patient had been refused by barber surgeon
Barber surgeon
The barber surgeon was one of the most common medical practitioners of medieval Europe - generally charged with looking after soldiers during or after a battle...
s. The patient apparently made a complete recovery, and Brassavola published his account in 1546. This operation has been identified as the first recorded successful tracheostomy, despite many ancient references to the trachea and possibly to its opening. Ambroise Paré
Ambroise Paré
Ambroise Paré was a French surgeon. He was the great official royal surgeon for kings Henry II, Francis II, Charles IX and Henry III and is considered as one of the fathers of surgery and modern forensic pathology. He was a leader in surgical techniques and battlefield medicine, especially the...
(1510–1590) described suture of tracheal lacerations in the mid-16th century. One patient survived despite a concomitant injury to the internal jugular vein. Another sustained wounds to the trachea and esophagus and died.
Towards the end of the 16th century, anatomist and surgeon Hieronymus Fabricius
Hieronymus Fabricius
Hieronymus Fabricius or Girolamo Fabrizio or by his Latin name Fabricus ab Aquapendende also Girolamo Fabrizi d'Acquapendente was a pioneering anatomist and surgeon known in medical science as "The Father of Embryology."...
(1533–1619) described a useful technique for tracheotomy in his writings, although he had never actually performed a the operation himself. He advised using a vertical incision and was the first to introduce the idea of a tracheostomy tube. This was a straight, short cannula
Cannula
A cannula or canula is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of data...
that incorporated wings to prevent the tube from advancing too far into the trachea. He recommended the operation only as a last resort, to be used in cases of airway
Airway
The pulmonary airway comprises those parts of the respiratory system through which air flows, conceptually beginning at the nose and mouth, and terminating in the alveoli...
obstruction by foreign bodies
Foreign body
A foreign body is any object originating outside the body. In machinery, it can mean any unwanted intruding object.Most references to foreign bodies involve propulsion through natural orifices into hollow organs....
or secretion
Secretion
Secretion is the process of elaborating, releasing, and oozing chemicals, or a secreted chemical substance from a cell or gland. In contrast to excretion, the substance may have a certain function, rather than being a waste product...
s. He counseled that the operation should be performed only as a last option. Fabricius' description of the tracheotomy procedure is similar to that used today. Julius Casserius (1561–1616) succeeded Fabricius as professor of anatomy at the University of Padua and published his own writings regarding technique and equipment for tracheotomy. Casserius recommended using a curved silver tube with several holes in it. Marco Aurelio Severino
Marco Aurelio Severino
Marco Aurelio Severino was an Italian surgeon and anatomist.-Biography:Severino was born in Tarsia , of Giovanni Jacopo Severino, a lawyer. He died of plague in 1656....
(1580–1656), a skillful surgeon and anatomist, performed multiple successful tracheotomies during a diphtheria
Diphtheria
Diphtheria is an upper respiratory tract illness caused by Corynebacterium diphtheriae, a facultative anaerobic, Gram-positive bacterium. It is characterized by sore throat, low fever, and an adherent membrane on the tonsils, pharynx, and/or nasal cavity...
epidemic
Epidemic
In epidemiology, an epidemic , occurs when new cases of a certain disease, in a given human population, and during a given period, substantially exceed what is expected based on recent experience...
in Naples
Naples
Naples is a city in Southern Italy, situated on the country's west coast by the Gulf of Naples. Lying between two notable volcanic regions, Mount Vesuvius and the Phlegraean Fields, it is the capital of the region of Campania and of the province of Naples...
in 1610, using the vertical incision technique recommended by Fabricius. He also developed his own version of a trocar.
In 1620 the French surgeon Nicholas Habicot (1550–1624), surgeon of the Duke of Nemours
Duke of Nemours
In the 12th and 13th centuries the Lordship of Nemours, in the Gatinais, France, was in possession of the house of Villebeon, a member of which, Gautier, was marshal of France in the middle of the 13th century...
and anatomist, published a report of four successful "bronchotomies" which he had performed. One of these is the first recorded case of a tracheotomy for the removal of a foreign body, in this instance a blood clot in the larynx of a stabbing victim. He also described the first tracheotomy to be performed on a pediatric
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
patient. A 14 year old boy swallowed a bag containing 9 gold coins in an attempt to prevent its theft by a highwayman
Highwayman
A highwayman was a thief and brigand who preyed on travellers. This type of outlaw, usually, travelled and robbed by horse, as compared to a footpad who traveled and robbed on foot. Mounted robbers were widely considered to be socially superior to footpads...
. The object became lodged in his esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...
, obstructing his trachea. Habicot performed a tracheotomy, which allowed him to manipulate the bag so that it passed through the boy's alimentary tract, apparently with no further sequela
Sequela
A sequela) is a pathological condition resulting from a disease, injury, or other trauma.Chronic kidney disease, for example, is sometimes a sequela of diabetes, and neck pain is a common sequela of whiplash or other trauma to the cervical vertebrae. Post-traumatic stress disorder may be a...
e. Habicot suggested that the operation might also be effective for patients suffering from inflammation of the larynx. He developed equipment for this surgical procedure which displayed similarities to modern designs (except for his use of a single-tube cannula).
Sanctorius
Sanctorius
Santorio Santorio , also called Santorio Santorii, Sanctorius of Padua, and various combinations of these names, was an Italian physiologist, physician, and professor. From 1611 to 1624 he was a professor at Padua where he performed experiments in temperature, respiration and weight...
(1561–1636) is believed to be the first to use a trocar in the operation, and he recommended leaving the cannula in place for a few days following the operation. Early tracheostomy devices are illustrated in Habicot’s Question Chirurgicale and Julius Casserius' posthumous Tabulae anatomicae in 1627. Thomas Fienus (1567–1631), Professor of Medicine at the University of Louvain
Old University of Leuven
The Old University of Leuven is the name historians give to the university, or studium generale, founded in Leuven, Brabant , in 1425, and closed in 1797, a week after the cession to the French Republic of the Austrian Netherlands and the principality of Liège by the Treaty of Campo Formio.When...
, was the first to use the word "tracheotomy" in 1649, but this term was not commonly used until a century later. Georg Detharding (1671–1747), professor of anatomy at the University of Rostock
University of Rostock
The University of Rostock is the university of the city Rostock, in the German state of Mecklenburg-Vorpommern.Founded in 1419, it is the oldest and largest university in continental northern Europe and the Baltic Sea area...
, treated a drowning victim with tracheostomy in 1714.
19th century
In the 1820s, the tracheotomy began to be recognized as a legitimate means of treating severe airway obstruction. In 1832, French physician Pierre BretonneauPierre Bretonneau
- Biography :Born at Saint-Georges-sur-Cher, in the Loir-et-Cher département. His father was a surgeon. He studied with his uncle, the vicar at Chenonceaux department along with the children of the Chenonceau château...
employed it as a last resort to treat a case of diphtheria
Diphtheria
Diphtheria is an upper respiratory tract illness caused by Corynebacterium diphtheriae, a facultative anaerobic, Gram-positive bacterium. It is characterized by sore throat, low fever, and an adherent membrane on the tonsils, pharynx, and/or nasal cavity...
. In 1852, Bretonneau's student Armand Trousseau
Armand Trousseau
Armand Trousseau was a French internist. His contributions to medicine include Trousseau sign of malignancy, Trousseau sign of latent tetany, Trousseau-Lallemand bodies , and the truism, "use new drugs quickly, while they still work."-Biography:A native of Tours, Indre-et-Loire, Armand Trousseau...
reported a series of 169 tracheotomies (158 of which were for croup
Croup
Croup is a respiratory condition that is usually triggered by an acute viral infection of the upper airway. The infection leads to swelling inside the throat, which interferes with normal breathing and produces the classical symptoms of a "barking" cough, stridor, and hoarseness...
, and 11 for "chronic maladies of the larynx") In 1858, John Snow was the first to report tracheotomy and cannulation of the trachea for the administration of chloroform anesthesia in an animal model. In 1871, the German surgeon Friedrich Trendelenburg
Friedrich Trendelenburg
Friedrich Trendelenburg was a German surgeon. He was son of the philosopher Friedrich Adolf Trendelenburg, father of the pharmacologist Paul Trendelenburg and grandfather of the pharmacologist Ullrich Georg Trendelenburg.Trendelenburg was born in Berlin and studied medicine at the University of...
(1844–1924) published a paper describing the first successful elective
Choice
Choice consists of the mental process of judging the merits of multiple options and selecting one of them. While a choice can be made between imagined options , often a choice is made between real options, and followed by the corresponding action...
human tracheotomy to be performed for the purpose of administration of general anesthesia. In 1880, the Scottish surgeon William Macewen
William Macewen
Sir William Macewen, CB, FRS, was a Scottish surgeon. He was a pioneer in modern brain surgery and contributed to the development of bone graft surgery, the surgical treatment of hernia and of pneumonectomy .-Career:Macewen was born near Port Bannatyne, Isle of Bute, Scotland in 1848 and studied...
(1848–1924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with chloroform
Chloroform
Chloroform is an organic compound with formula CHCl3. It is one of the four chloromethanes. The colorless, sweet-smelling, dense liquid is a trihalomethane, and is considered somewhat hazardous...
. At last, in 1880 Morrell Mackenzie's book discussed the symptoms indicating a tracheotomy and when the operation is absolutely necessary.
20th century
In the early 20th century, physicians began to use the tracheotomy in the treatment of patients afflicted with paralytic poliomyelitisPoliomyelitis
Poliomyelitis, often called polio or infantile paralysis, is an acute viral infectious disease spread from person to person, primarily via the fecal-oral route...
who required mechanical ventilation
Mechanical ventilation
In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing. This may involve a machine called a ventilator or the breathing may be assisted by a physician, respiratory therapist or other suitable person compressing a bag or set of bellows...
. However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were described and employed, along with many different surgical instruments and tracheal tubes. Surgeons could not seem to reach a consensus on where or how the tracheal incision should be made, arguing whether the "high tracheotomy" or the "low tracheotomy" was more beneficial. The currently used surgical tracheotomy technique was described in 1909 by Chevalier Jackson
Chevalier Jackson
Chevalier Jackson was a laryngologist.Jackson was born in Pittsburgh, Pennsylvania. He went to school at the Western University of Pennsylvania from 1879 to 1883, and received his MD from Jefferson Medical College. He also studied laryngology in England.His work reduced the risks involved in a...
of Pittsburgh, Pennsylvania
Pennsylvania
The Commonwealth of Pennsylvania is a U.S. state that is located in the Northeastern and Mid-Atlantic regions of the United States. The state borders Delaware and Maryland to the south, West Virginia to the southwest, Ohio to the west, New York and Ontario, Canada, to the north, and New Jersey to...
. Jackson emphasised the importance of postoperative care, which dramatically reduced the death rate. By 1965, the surgical anatomy was thoroughly and widely understood, antibiotic
Antibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
s were widely available and useful for treating postoperative infections, and other major complications had also become more manageable.
External links
- Tracheotomy Info (A Community For Tracheotomy-wearers and the people who love them) at tracheotomy.info
- Aaron's tracheostomy page (Caring for a tracheostomy) at tracheostomy.com
- How to perform an emergency tracheotomy (This page actually depicts cricothyroidotomy, not tracheostomy)
- RT Corner (Educational Site for RT's and Nurses) at rtcorner.net
- (Pictures with video clipping) at drtbalu.com
- Smiths Medical Tracheostomy Training Videos