Tracheotomy

Tracheotomy - What is a Tracheotomy?

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.

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 Griggs, 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.

Biphasic Cuirass Ventilation 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.

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Tracheotomy History

Prior to 16th century

Tracheotomy was first depicted on Egyptian artifacts in 3600 BCE. It was described in the Rigveda, a Sanskrit text, circa 2000 BCE. 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. 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.

16th-18th centuries

The European Renaissance 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 surgeons. 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.

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 sequelae. Early tracheostomy devices are illustrated in Habicot’s ''Question Chirurgicale'' 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.

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 Bretonneau 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 1869, the German surgeon Friedrich Trendelenburg reported the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia. In 1878, the Scottish surgeon William Macewen reported the first orotracheal intubation. At last, in 1880 Morrell Mackenzie's book discussed the symptoms indicating a tracheotomy and when the operation is absolutely necessary. There are other difficulties with patients 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".

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.

This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article on "Tracheotomy" All material adapted used from Wikipedia is available under the terms of the GNU Free Documentation License. Wikipedia® itself is a registered trademark of the Wikimedia Foundation, Inc.

Tracheotomy Complications

In order to limit the risk of damage to the recurrent laryngeal nerves (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 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 The long term significance of tracheal ring fractures is unknown.

This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article on "Tracheotomy" All material adapted used from Wikipedia is available under the terms of the GNU Free Documentation License. Wikipedia® itself is a registered trademark of the Wikimedia Foundation, Inc.