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The History ofTracheostomy
Fig. 3 George Washington, on his death bed, diagnosed with a peritonsillar abscess
5
Fig. 4 Performing a
bronchotomy
(tracheostomy). Chirurgie
Scènes de la vie médicale:
Traité des opérations de
chirurgie. Paris:
G.Cavelier, 1731
6
S. Monteiro et al.
The Period ofDramatization (AD 1833–1932)
“The question always arises in the mind of the young surgeon whether the symptoms are
sufciently urgent to render the operation necessary.”McKenzie [11]
This sentence by McKenzie helps us to understand the idea that physicians had of
the procedure back then. Trousseau, in 1833, described 200 cases of tracheostomies
performed in patients with diphtheria (also known as croup). Patients usually
develop a membrane on one or both tonsils, with extension to the tonsillar pillars,
uvula, soft palate, oropharynx, and nasopharynx. Corynebacterium diphtheria multiplies on the surface of the mucous membrane, resulting in formation of the pseudomembrane. He reported that 25% of these interventions were successful.
In 1869, Dr.Erichsen described four complications of tracheostomy: exposing of
the air tube, hemorrhage, opening of the air passage, and misplacement of the tracheostomy tube. He further recommended that the tube be cleaned with a sponge
and a solution of silver nitrate [12].
With time, tracheostomy became an accepted technique to bypass upper airway obstruction. In 1909, Chevalier Jackson dened factors that predisposed to
complications, such as a high incision, use of an improper cannula, poor postoperative care, and splitting of the cricoid cartilage. He designed a metal doublelumen tube of proper length and curvature with just the right tting to avoid
excessive pressure on the anterior or posterior wall of the trachea and to reduce
the risks of ulceration and tracheal erosion (Fig.5). Jackson favored a vertical
Fig. 5 Durham Flexible
Pilot (introducer) Lobster
tail. Tracheostomy tube,
inner cannula, and
introducer
The History ofTracheostomy
7
incision from the thyroid notch to the suprasternal notch for best visibility of the
surgical eld. His teachings signicantly reduced the complication rate and mortality rate of tracheostomy [13].
With the introduction of immunization for diphtheria and the discovery of
sulfonamides to help reduce other upper respiratory infections, the need for
emergency tracheostomy became less common. For a brief period, tracheostomy was the only means of securing airways through general anesthesia, but
the increasing popularity of endotracheal intubation replaced the need for
tracheostomy.
The Period ofEnthusiasm (AD 1932–1965)
“If you think tracheostomy … do it!”Unknown author
Almost in direct opposition to McKenzie’s statement, this sentence became very
popular during this period. The indications for tracheostomy were being actively
pursued by the medical world. In 1932, with the outbreak of bulbar poliomyelitis,
tracheostomy was used to prevent impending pulmonary infection, since the affected
patients were unable to cough and raise secretions. For the rst time, tracheostomy
was considered as an elective procedure [14]. Polio remained an epidemic until the
early 1950s, when the invention of positive pressure respiration, together with tracheostomy, greatly reduced its mortality.
Tracheostomy was openly advocated for tetanus; head, chest, and maxillofacial
injuries; drug overdose; and following major surgery where airway patency was
compromised [7]. During the Spanish Civil War (1936–1939), while soldiers with
maxillofacial trauma were waiting for surgery, they underwent tracheostomy to prevent aspiration and respiratory distress. This practice decreased mortality rates for
soldiers waiting for such surgeries [15]. Tracheostomy became more prevalent as
intensive care and postanesthetic care units were established in the 1950s, with better care for tracheostomy patients [16].
With the control of many infectious diseases, the indications for tracheostomy
were changing. In 1961, Meade, in a series of 212 cases, showed that 41% of tracheostomies were still carried out on patients with upper airway obstruction due to
tumors, infectious disease, and trauma, and 55% were performed to assist in
mechanical ventilation [17].
The Period ofRationalization (AD 1965–Present)
With improvements in the techniques of orotracheal and nasotracheal intubation,
these have become safer and faster alternatives to tracheostomy. Improvements in
tracheostomy tubes, aspiration equipment, and use of biocompatible materials have
improved the safety of the procedure.
Goldenberg etal. showed that 76% of tracheostomies were prophylactically performed in patients requiring prolonged mechanical ventilation, while only 6% of
8
S. Monteiro et al.
patients were tracheostomized due to upper airway obstruction. Only 0.26% of tracheostomies were performed on an emergency basis [18].
Percutaneous dilational tracheostomy (PDT) is an alternative to open tracheostomy because it can be comfortably performed at the bedside (Fig. 6). In 1953,
Seldinger introduced the technique of percutaneous guide wire needle placement
for arterial catheterization. In 1985, the guide wire technique was adapted to percutaneous tracheostomy by Ciaglia et al. In 1969, Toy and Weinstein developed a
tapered straight dilator for performing percutaneous tracheostomy over a guiding
catheter [19], and in 1989 Schachner etal. developed dilating tracheostomy forceps
over a guide wire.
The development of PDT using serial dilators over a guide wire made the procedure safer in elective situations and can be performed by various medical personnel
at the beside [20]. We now have two possible techniques for performing tracheostomy in intensive care units for patients requiring prolonged mechanical
ventilation.
Carried out in the operating room, intensive care, and intermediate care units—
and even inlocations with minimal medical support—tracheostomy remains one of
the most important and commonly performed surgical procedures to this day. It may
be dreaded, scorned, and carried out with extreme hesitancy, or in other instances, a
noble and dramatic life-saving procedure.
Fig. 6 Ciaglia dilators, guide wire, rigid dilator, guide catheter, and Blue Rhino dilator
The History ofTracheostomy
9
References
1. Cooper JD.Surgery of the airway: historic notes. J Thorac Dis. 2016;8(Suppl 2):S113–20.
2. Gordon BL, FA Davis. The romance of medicine. 1947;461.
3. Wright JA.History of laryngology and rhinology. Philadelphia: Lea & Feiber; 1914. p.65.
4. CG Kuhn. Galen. Introductio Seu Medicus. (Trans) Leipzig; 1856. P. 406. Adam F.Areataeus:
the therapeutics of acute diseases. (Trans) London: Syndenham Society; 1856. P. 406.
5. Goodall EW.The story of tracheostomy. Br J Child Dis. 1934;31:167–76, 253–72. 618–24.
6. Stock CR.What is past is prologue: a short history of the development of tracheostomy. Ear
Nose Throat J. 1987;66(4):166–9.
7. Frost EA.Tracing the tracheostomy. Ann Otol Rhinol Laryngol. 1976;85(5 Pt.1):618–24.
8. Borman J, Davidson JT.A history of tracheostomy. Si Spiritum Ducit Vivit Br J Anesthesiol.
1963;35:388–90.
9. Dionis P.Cours d’operatione de chirurgiris, ed. Paris: L dHoury; 1751.
10. Heister L.General system of surgery, vol. 2. 8th ed. London: Printed for W Innys, J Richardson,
C Davis, and J Clark; 1768. p.52.
11. McKenzie M.Diseases of the pharynx, larynx and trachea. NewYork: Wood and Co.; 1880.
p.397.
12. Erichsen JE.The science and art of surgery. Philadelphia: Henry C Lea; 1869. p.919.
13. Jackson C.Tracheostomy. Laryngoscope. 1909;19:285.
14. Wilson JL.Acute anterior poliomyelitis treatment of bulbar and high spinal types. N Engl J
Med. 1932;206:887.
15. Booth JB. Tracheostomy and tracheal intubation in military history. J R Soc Med.
2000;93:380–3.
16. Collins CG. Rationale and value of tracheostomy in severe preeclampsia and eclampsia.
Postgrad Med. 1955;17:259–66.
17. Meade JW. Tracheostomy—its complications and their management. N Engl J Med.
1961;265:519–23.
18. Goldenberg D, Ari EG, Golz A, Danino J, Netzer A, Joachims HZ. Tracheostomy complica-
tions: a retrospective study of 1130 cases. Otolaryngol Head Neck Surg. 2000;123:495–500.
19. Toy FJ, Weinstein JD.A percutaneous tracheostomy device. Surgery. 1969;65(2):384–9.
20. Schachner A, Ovil Y, Sidi J, Rogev M, Heilbronn Y, Levy MJ.Percutaneous tracheostomy, a
new method. Crit Care Med. 1989;17(10):1052–6.
Anatomy oftheTrachea
JulianaFernandesde Oliveira, TerencePiresde Farias,
JulianaMariade AlmeidaVital, MariaEduardaGurgelda
TrindadeMeiraHenriques, MariaAliceGurgelda
TrindadeMeiraHenriques, andMariaEduardaLimade Moura
For practice of any surgery, it is essential to know the anatomy of each structure
involved in the technique, as well as the elements that surround it. The trachea is
not just a tube that connects the larynx to the bronchi, as well as other organs of
the respiratory tree; it has the function of cleaning and heating the air that transits
in its lumen. Anatomical variations, whether congenital or acquired, are challenging and should never be overlooked. In this chapter, we will provide an explanation illustrated with a photographic and schematic collection, with emphasis on
surgical details.
J.F. de Oliveira, M.D. (*)
Head and Neck Surgery at Brazilian National Cancer Institute – INCA, Rio de Janeiro, RJ, Brazil
e-mail: ju.foliveira@yahoo.com.br
T.P. de Farias, M.D., Ph.D., M.Sc., Researcher.
Department of Head and Neck Surgery, Brazilian National Cancer Institute—INCA,
Rio de Janeiro, RJ, Brazil
Department of Head and Neck Surgery, Pontical Catholic University,
Rio de Janeiro, RJ, Brazil
J.M. de AlmeidaVital, M.D.
Head and Neck Department, Irmandade Santa Casa de de São Paulo,
São Paulo, SP, Brazil
Head and Neck Surgeon, Private Practice, São Paulo, SP, Brazil
e-mail: jujuliana.a@gmail.com
M.E.G. da TrindadeMeiraHenriques, M.S., (Medical Student).
Faculdade Pernambucana de Saúde - FPS, Recife, PE, Brazil
M.A.G. da TrindadeMeiraHenriques, M.S., (Medical Student).
Centro Universitário Maurício de Nassau (UNINASSAU), Recife, PE, Brazil
M.E.L. de Moura, M.S., (Medical Student).
Faculdade de Medicina Nova Esperança - (FAMENE), João Pessoa, PB, Brazil
© Springer International Publishing AG 2018
T.P. de Farias (ed.), Tracheostomy, https://doi.org/10.1007/978-3-319-67867-2_2
11
12
Thyroid Cartilage
Sternotireoid muscle
Sternocleidomastoid muscle
J.F. de Oliveira et al.
Macrostructure
The trachea is a tube located in the midline, connecting the cricoid cartilage in the
neck to the main bronchi in the thorax. In its cervical portion, it begins at the
height of the sixth or seventh vertebra, and is deep to the cervical fascia and infrahyoid muscles (Figs.1 and 2). It is bordered by the thyroid gland on the anterior
face, with lateral recurrent laryngeal nerves. As it progresses caudally, it remains
anterior to the esophagus, between the common carotid arteries, internal jugular
veins, and vagus nerve (Figs.3, 4, 5, and 6). The brachiocephalic or innominate
artery is the rst blood vessel found in pretracheal dissection during airway
Subplatismal flat
Thyrohyoid muscle
Esternal Head
Clavicular Head
Sternohyoid muscle
Pectoralis major muscle
Sternal furcula
Fig. 1 Cervical region with the subplatysmal myocutaneous ap highlighted. Infrahyoid muscles
arise medially and the sternocleidomastoid laterally
ab
Trapezius
Fig. 2 Individualized neck muscles . (a) Anterior view. (b) Anterior view.The sternohyoid has
been cut (right)
Sternocleido-
mastoid
Clavicular head Stemal head
Mylohyoid
Mylohyoid raphe
Hyoid bone
Thyrohyoid
Thyroid cartilage
Sternothyroid
Anterior
belly
Posterior
belly
Stylohyoid
Sternohyoid
Omohyoid,
superior and
inferior belly
Digastric
Cricothyroid muscle
of Sternocleidomastoid muscle
Anatomy oftheTrachea
13
Subplatismal flap
Hyoid bone
Esternal head
Calvicular head
Pectoralis major muscle
Fig. 3 Dissection through the pretracheal visceral fascia exposing the midline organs
Thyroid membrane
Thyroid cartilage
Strap muscles
Thyroid gland
Trachea
mobilization, justifying the reason for trachea–innominate stula occurrence. The
brachiocephalic vein crosses the front of the innominate artery in a plane even
more anterior to the trachea. The carina is in the lower border of the trachea,
where the two primary bronchi originate, at the height of the fourth or fth thoracic vertebra (Figs.7 and 8) [1].
The trachea surfaces with cervical extension allowing half of it to be accessible
by this route, facilitating most surgical procedures. Maximal exion leads to cricoid
cartilage at the level of the sternum, minimizing the tension of anastomoses after
resection of the tracheal segment. With current anatomical knowledge and blood
supply, good mobilization promotes greater safety for resection and reconstruction
of half the length of the trachea [2].
The trachea has an incomplete cartilaginous ring structure, the posterior face
lled by smooth muscle with longitudinal (external) and transverse bers (internal tracheal muscle). The annular ligament is found between the tracheal rings
and it is composed of two layers of brous membrane: an external layer, covering
the surface of each ring; and another internal layer. In the intervals of the cartilage, these membranes meet, conferring both exibility and xation to the respiratory tract.
The external diameter of the trachea measures approximately 2.3cm in the coronal cut, and 1.8cm in the sagittal cut in men, forming a U-like structure. In females
these dimensions are 2.0cm and 1.4cm, respectively, forming an elliptical framework in the axial section. The length in the adult phase is, on average, 11.8cm and
14
t
Right and left
innominate v
Right
subclavian
artery
Right vagus
nerve (CNX)
Right
recurrent
laryngeal
nerve
J.F. de Oliveira et al.
Left common
carotid artery
Left vagus
nerve (CNX)
Left subclavian
artery
Trachea
eins
Innominate
artery
Superior
vena cava
Aorta
Left recurren
laryngeal
nerve
Pulmonary
trunk
Fig. 4 Relationships of trachea to surrounding structures. Anterior view. Note the tight packing of
major mediastinal vessels adjacent to the trachea
Inte
Ster
muscle
Common carotid ar
ngeal
Anatomy oftheTrachea
rnal jugular vein
nocleidomastoid
tery
Fig. 5 Vessels and nerves lateral to the tracheal compartment
Parotid gland
15
Trachea
Recurrent lary
nerve
Mandible
Investing
Muscular portion,
pretracheal layer
layer
Sternohyoid
Visceral portion,
pretracheal layer
Sternocleidomastoid
Carotid sheath
Omohyoid
Prevertebral
layer
Trapezius
Clavicle
Fig. 6 Cervical fascia and neck muscles illustrating the planes until identication of the trachea