The History of Tracheotomy

The history of tracheotomy

Garret Choby, MD, and David Goldenberg, MD, FACS Dr. Choby (AΩA, Pennsylvania State University, 2010) is racheotomy is one of the oldest known surgical a resident in Otolaryngology—Head and Neck Surgery at procedures, dating back to ancient Egypt and India. the University of Pittsburgh Medical Center. Dr. Goldenberg Throughout its history, utilization of the operation (AΩA, Pennsylvania State University, 2009) is associate has wavered between widespread acceptance and extensive professor of Surgery and Oncology at the Pennsylvania rejection both because of controversy over its safety, neces- State University. sity, and technique selection, and because the indications and methods for tracheotomy have changed and expanded over time. Today, advances in intensive care medicine and the widespread use of mechanical ventilation have made tracheotomy From Armamentarium chirurgicum bipartitum, plate 34, oppo. page 71. Courtesy of the National Library of Medicine. T

34 The Pharos/Summer 2011 one of the most commonly performed surgical procedures. Tracheotomy is derived from two Greek words meaning The historical development of tracheotomy can be divided incision or opening of the trachea and carries no implication The history of tracheotomy into five periods:1 of permanence. On the other hand, tracheostomy is the surgi- 1. The Period of Legend (2000 BC to 1546 AD). cal creation of an opening into the trachea through the neck, 2. The Period of Fear (1546 to 1833), during which the op- with the tracheal mucosa being brought into continuity with eration was performed only by a brave few, often at the risk of the skin.2 This procedure is often, but not always, permanent. their reputations. Despite animated discussion about the correct usage of the 3. The Period of Dramatization (1833 to 1932), during which two terms, authors continue to use them interchangeably. For tracheotomy was performed only in emergency situations on the sake of correctness, tracheotomy is used throughout this acutely obstructed airways. manuscript. 4. The Period of Enthusiasm (1932 to 1965), during which the saying, “if you think of tracheotomy—do it!” 1 became The Period of Legend (2000 BC–1546 AD) popular. The Period of Legend stretches from the first mention of 5. The Period of Rationalization (1965 to the present), dur- tracheotomy in the BC era until 1500 AD.1 Although it is dif- ing which the merits of tracheotomy versus intubation remain ficult to tell for sure when the earliest tracheotomy procedure a topic of debate. was performed, two ancient Egyptian hieroglyph slabs from

The Pharos/Summer 2011 35 The history of tracheotomy

about 3100 BC show images strongly suggestive of tracheotomy of tracheotomy to bypass an obstruction of the airway. Early in procedures.3 his career, he wrote “The terrified surgeons of our times have The first written documentation of tracheotomy appears in not dared to exercise this surgery (tracheotomy) and I also the Rig Veda, a sacred book of Hindu medicine written between have never performed it . . . it is called a scandal.” 4 Sometime 2000 and 1000 BC.3,4 It describes “the bountiful one, who can later, however, Fabricius successfully performed tracheotomies cause the windpipe to reunite when the cervical cartilages are to relieve laryngeal foreign body obstruction. His version of cut across, provided that they are not entirely severed.” 1 the tracheotomy used a vertical incision to allow insertion of Homer, writing in the eighth century BC, referred to the a cannula with flanges. Following this series of operations, his operation to relieve choking persons by cutting the trachea.3–5 pupil Casserius introduced the curved cannula with stay tapes The next recorded mention is in the fourth century BC when to hold it in position. This improvement in tube shape was Alexander the Great is said to have saved the life of a soldier quickly forgotten by the rest of the medical world; the straight choking from a bone lodged in his throat by puncturing his tracheotomy tube remained in use for many years.3 trachea with the point of his sword.3–5 By the early to mid 1600s, tracheotomy began to be consid- In 100 BC, Asclepiades of Bithynia is credited as being the ered acceptable for acute upper airway obstruction caused by first man to perform an elective tracheotomy.2–4 Described foreign body ingestion or aspiration.4 This advance was stimu- over 200 years later by the renowned physician Claudius Galen lated in part by Theophilus Bonetus, a renowned surgical pa- in 131 AD, who is also credited with the description of the thologist, who in 1650 recommended the use of a tracheotomy structures of the head and neck, Galen included characteriza- for a seven-year-old child who had aspirated a piece of bone. tion of the laryngeal muscles, cartilages, and trachea. Galen This suggestion was rejected by the internist, in accordance also taught that the voice was produced by the vocal cords and with the times, and the child subsequently died.3 not, as believed at the time, by the heart.4 Another interesting case was that of noted Parisian sur- In 340 AD, Antyllus of Rome described a patient whose geon Nicholas Habicot, who performed a tracheotomy on difficult breathing was relieved by a transverse incision into a youth who, to protect his possessions from robbers, swal- the trachea between the third and fourth cartilaginous rings, lowed a bag of coins. The bag became lodged in his esopha- which was then sutured together after the patient was breath- gus. Habicot performed an emergency tracheotomy to relieve ing more easily.3 the obstruction and manually manipulated the coins into the Although these cases of successful tracheotomy received boy’s stomach. Following this success, Habicot also suggested some attention, not all medical practitioners of the time as- that the operation be used for inflammatory conditions of cribed to the procedure. Aretaeus, in his book entitled The the larynx.3-4 Therapeutics of Acute Diseases, confirmed the idea of elective The widespread fear of tracheotomy extended across the tracheotomy done by Asclepiades of Bithynia, but condemned Atlantic into the New World. When Dr. Elisha Dick sug- it on the grounds that cartilage wounds do not heal.3 Similarly, gested a tracheotomy for his most famous patient, George Coelias Aurelinianis in the fifth century AD condemned both Washington, Drs. James Craig and Gustavus Brown rejected the operation and Asclepiades, writing that it was a “futile and the idea, instead suggesting treatment with bloodletting to irresponsible idea.” 3 release “evil humors.” 7 Washington, under their care for sepsis and hemorrhagic shock, subsequently developed a The Period of Fear (1546–1833) peritonsillar abscess that acutely worsened his breathing. On The Dark Ages eclipsed the world of science and medicine. December 14, 1799, the first President of the United States Little was heard of any type of surgery until the fifteenth cen- died of an acute upper airway obstruction secondary to a tury. This period between 1546 and 1833 marks the so-called peritonsillar abscess.3 Period of Fear. Many of the authors of this period described Another important development during the Period of Fear tracheotomy in great detail, but denied performing the opera- was the modification of the terminology used to describe the tion themselves. Although many references were made to tra- procedure. Up until this time, the operation was known as a cheotomy, the operation was officially considered both useless “laryngotomy.” In 1707, Pierre Dionis wrote that “laryngotomy” and dangerous. During this time, only twenty-eight successful was being used incorrectly and that the procedure should be tracheotomies were recorded in the literature.6 called “bronchotomy.” 3-4 However, in 1718, Lorenz Heister wrote In 1546 Antonio Musa Brasavola is quoted as saying “When in the prestigious Chirurgie that the operation should be called there is no other possibility, in angina, of admitting air to the tracheotomy and that all other names should be discarded.3 By heart, we must incise the larynx below the abscess.” 4 This ac- the nineteenth century, this term became widely accepted. count describes the use of tracheotomy to attain emergency airway in the case of a submental-submandibular space ab- The Period of Dramatization (1833–1932) scess, commonly referred to as Ludwig’s Angina. During this stage, the tracheotomy was considered an Fabricius ab Aquapendente (1537–1619) described the use operation of life or death. A common debate among surgeons

36 The Pharos/Summer 2011 was whether or not the symptoms of the patient were severe enough to justify tracheotomy.3 Armand Trousseau reported experiencing great satisfaction that, of more than two hundred tracheotomies, one-fourth were successful.8 These outcomes were considered satisfactory compared to the averages of the day. It was also during this period that tracheotomy’s high patient morbidity rates began to be addressed. In 1909, Chevalier Jackson analyzed the operative technique3,9 and defined the factors leading to complications such as a high incision, use of an improper cannula, poor postoperative care, and splitting the cricoid. Through Jackson’s groundbreaking analysis and teachings, the complication and mortality rate of tracheotomy fell significantly. Thus tracheotomy came to be used with in- creasing frequency to bypass upper airway obstruction caused by foreign bodies and infections. When, early in the twentieth century, diphtheria began to be controlled by immunization and the discovery of sulfonamides helped curb other bacterial upper respiratory infections, the need for emergency tracheotomy for infections waned. The Period of Dramatization began to come to an end.

The Period of Enthusiasm (1932–1965) MedicalRF.com/Corbis. During the fourth stage in the history of tracheotomy, indications were actively sought and the medical world largely became proponents of tracheotomy. In 1932, J. L. Wilson made the landmark suggestion that fifty-five percent were performed to assist in mechanical venti- tracheotomy be used to prevent impending pulmonary infec- lation and four percent were performed as an adjunct to head tion in poliomyelitis,10 the first time that tracheotomy was and neck procedures.13 With the invention of the fiberoptic considered appropriate for averting pulmonary distress before endoscope in the mid-1960s, it began to be clear that oral or it actually happened. Suddenly, tracheotomy began to be advo- nasal intubation was both quicker and safer than tracheotomy. cated for tetanus; head, chest, and maxillofacial injuries; drug Thus the Period of Enthusiasm began to give way to the Period overdoses; and following many major surgeries.3 of Rationalization. Shortly thereafter, tracheotomy began to be promoted widely for use in several medical fields. In 1943, Thomas C. The Period of Rationalization (1965–present) Galloway introduced tracheotomy to the neurology world Beginning in 1965, the indications for tracheotomy dras- when he recommended the use of tracheotomy for removal tically changed. Vaccines and antibiotics had dramatically of bronchial secretions in cases of myasthenia gravis and teta- decreased the number of upper airway obstructions from nus.11 In 1951, B. N. Carte and J. Giuseffi realized the physio- infections. The flexible fiberoptic endoscope began to allow logical benefits of tracheotomy, including the reduction of dead oral or nasal intubation in acute situations. Endoscopy was space volume. In light of this realization, the procedure began also applicable to other situations that previously necessitated to be used in the treatment of chronic obstructive pulmonary tracheotomy, such as cervical spine injuries. Acute obstruction disease and severe pneumonia.12 During the polio epidemics of with impending asphyxia began to fade as an indication for the early 1950s, the invention of positive pressure respiration in tracheotomy as alternative procedures, such as endotracheal combination with tracheotomy greatly reduced mortality. But, intubation and cricothyrotomy, became more widely available. as in the case of diphtheria before it, the Salk vaccine greatly These modern trends are illustrated in an analysis reduced the need for tracheotomy. published in 2000 of a series of 1130 tracheotomies per- In a 1961 New England Journal of Medicine article, J. W. formed over a decade. In this large series, 76 percent of Meade eloquently described the state of tracheotomy of that tracheotomies were prophylactically performed on patients time, including the accepted indications for the procedure. In requiring prolonged mechanical ventilation, while only a series of 212 cases, he showed that forty-one percent of tra- 6 percent of patients were tracheotomized due to upper cheotomies were still performed on patients with upper airway airway obstruction and only 0.26 percent were performed obstruction due to tumor, infectious disease, and trauma, while on an emergency basis.2 This illustrates a significant shift

The Pharos/Summer 2011 37 The history of tracheotomy

from the indications described by Meade in 1961. tions: A retrospective study of 1130 cases. Otolaryngol Head Neck The discussion of the Period of Rationalization would not Surg 2000; 123: 495–500. be complete without including the newest, albeit controversial, 3. Frost EAM. Tracing the tracheostomy. Ann Otol Rhinol addition to tracheotomy techniques: the percutaneous dilation Laryngol 1976; 85 (5 Pt. 1): 618–24. tracheotomy (PDT). 4. Stock CR. What is past is prologue: A short history of the Elective tracheotomy for long-term ventilation is considered development of tracheostomy. Ear Nose Throat J 1987; 66: 166–69. one of the most common operations performed in modern 5. Gordon BL. Ancient Surgery. In: Gordon BL. The Romance ICUs. PDT is a popular substitute to standard surgical trache- of Medicine: The Story of the Evoluation of Medicine from Occult otomy because it can be completed at the bedside, eliminating Practices and Primitive Times. Philadelphia: F. A. Davis; 1944: 461. the need for difficult transfers of critically ill patients from the 6. Goodall EW. The story of tracheotomy. Br J Child Dis 1934; ICU to the operating room.14 In a prospective evaluation of 31: 167–76, 253–72. 500 consecutive cases by Karen Kost in 2005, PDT was shown 7. Jafek BW, Stark AK. Minutiae in Otolaryngology. In: Jafek to have a low complication rate and to be as safe as traditional BW, Stark AK, editors. ENT Secrets. Philadelphia: Hanley & Belfus, open surgical tracheotomy in the ICU setting.14 1996: 425–30. The movement towards PDT had its roots in 1953, when 8. Trosseau A. Lectures on Clinical Medicine, Delivered at the Sven Ivar Seldinger introduced the technique of percutaneous Hôtel-Dieu, Paris. Volume Second. Cormack JR, translator. Philadel- guidewire needle placement in arterial catheterization.15 The phia: Lindsay and Blakiston; 1869: 598. Seldinger technique was adapted to various procedures includ- 9. Jackson C. Tracheotomy. Laryngoscope 1909; 19: 285–90. ing percutaneous tracheotomy. The first modern PDT was 10. Wilson JL. Acute anterior poliomyelitis: Treatment of bulbar reported by C. Hunter Shelden and colleagues in 1955, but the and high spinal types. N Engl J Med 1932; 206: 887–93. complication rate was very high due to lacerations of adjacent 11. Galloway TC. Tracheotomy in bulbar poliomyelitis. JAMA structures by the trocar.16 In 1969, Frederic J. Toy and James D. 1943; 123: 1096–97. Weinstein developed a tapered straight dilator with a recessed 12. Carte BN, Giuseffi J. The use of tracheotomy in the treat- cutting blade for performing percutaneous tracheotomy over a ment of crushing injuries of the chest. Surg Gynecol Obstet 1953; guiding catheter.17 In 1985, the technique of PDT using serial 96: 55–64. dilators over a guidewire was first described by P. Ciaglia and 13. Meade JW. Tracheotomy—its complications and their man- coworkers.18 In 1989, Arie Schachner and Jack Sidi developed a agement: A study of 212 cases. N Engl J Med 1961; 265: 519–23. dilating tracheotomy forceps over a guidewire.19 Following this 14. Kost KM. Endoscopic percutaneous dilatational trache- advancement, W. M. Griggs and colleagues developed another otomy: A prospective evaluation of 500 consecutive cases. Laryn- guidewire dilating forceps for percutaneous tracheotomy in goscope 2005; 115 (10 Pt. 2): 1–30. 1990.20 Soon afterwards, convenient kits to create a full sized 15. Seldinger SI. Catheter replacement of the needle in percuta- percutaneous tracheotomy with a single dilator became readily neous arteriography: A new technique. Acta Radiol 1953; 39: 368–76. available. Today, the majority of tracheotomies are performed 16. Shelden CH, Pudenz RH, Freshwater DB, Crue BL. A new in the ICU setting using the percutaneous technique. method for tracheotomy. J Neurosurg 1955; 12: 428–31. 17. Toy FJ, Weinstein JD. A percutaneous tracheotomy device. Conclusion Surgery 1969; 65: 384–89. The history of tracheotomy has played out over the past 18. Ciaglia P, Firshing R, Syniec C. Elective percutaneous dilata- 4000 years and continues to progress forward in a state of flux tional tracheostomy: A new simple bedside procedure; Preliminary and rapid evolution. Tracheotomy is a reliable tool to manage a report. Chest 1985; 87: 71–719. variety of insults to the upper and lower tracts of the respiratory 19. Schachner A, Ovil Y, Sidi J, et al. Percutaneous tracheos- system and remains a crucial technique to those with severely tomy—A new method. Crit Care Med 1989; 17: 1052–56. impaired respiration. Its progression has developed from the 20. Griggs WM, Worthley LIG, Gilligan JE, et al. A simple thrust of a sword to relieve a choking soldier on the battlefield percutaneous tracheostomy technique. Surg Gynecol Obstet 1990; to the meticulous use of PDT in the aseptic confines of the 170: 543–45. ICU setting. This procedure—at times dreaded and scorned, at others embraced as life-saving—remains one of the most Address correspondence to: commonly performed surgical procedures on the critically ill David Goldenberg, MD, FACS patient. Division of Otolaryngology—Head and Neck Surgery The Pennsylvania State University References The Milton S. Hershey Medical Center 1. McClelland RMA. Tracheostomy: Its management and alter- 500 University Drive, PO Box 850 H091 natives. Proc Roy Soc Med 1972: 65: 401–404. Hershey, Pennsylvania 17033 2. Goldenberg D, Ari EG, Golz A, et al. Tracheotomy complica- Email: [email protected]

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