Principles and Practice of Percutaneous Tracheostomy Sushil P Ambesh
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History of Tracheostomy and Evolution of Percutaneous TracheostomyChapter 1

Sushil P Ambesh
 
INTRODUCTION
Tracheostomy is one of the oldest surgical procedures described in the literature and refers to the formation of an opening or ostium into the anterior wall of trachea or the opening itself, whereas tracheotomy refers to the procedure to create an opening into the trachea (Fig. 1.1).1 The term tracheostomy is used, by convention, for all these procedures and is considered synonymous with tracheotomy and is interchangeable. When done properly, it can save lives; yet the tracheotomy was not readily accepted by the medical community. The tracheotomy began as an emergency procedure, used to create an open airway for someone struggling for air. For most of its history, the tracheotomy was performed only as a last resort and mortality rates were very high.
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Fig. 1.1: Tracheostomy(Courtesy: Anatomy Library of University of Greifswald, Germany)
 
HISTORY OF TRACHEOSTOMY
One famous American whose life could have been saved by a tracheostomy was General George Washington, the first President of United States of America. At the end of the 18th century, however, the procedure was still considered too risky. In December 1799 Washington took his daily ride in heavy, wintry weather. He developed a sore throat and a malarial type of fever during the following days. He lay in his bed at Mount Vernon, Virginia, suffering from a septic sore throat and struggling for air (Fig. 1.2). Amongst the several physicians called to Washington's bedside was personal friend, Dr James Craik. Dr Craik and his colleagues diagnosed Washington with an “inflammatory quinsy”, an inflammation of the throat accompanied by fever, swelling, and painful swallowing.
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Fig. 1.2: George Washington lay in his bed at Mount Vernon, Virginia, suffering from a septic sore throat and struggling for air is attended by his friends and family members(Courtesy: Library of Congress)
Three physicians gathered around him and gave him sage tea with vinegar to gargle, but this increased the difficulty further and almost choked him. Elisha Cullen Dick, youngest amongst three physicians present, proposed a tracheotomy to help relieve the obstruction of the throat, but his suggestion was considered futile and irresponsible. He was vetoed by the other two physicians, who preferred more traditional treatment methods like bleeding by arteriotomy which was undertaken approximately four separate times equaling to a total loss of more than 2500 ml.2 General Washington died that night. History buffs may recognize this story as the death of George Washington.3 Modern day doctors now believe that Washington died from either a streptococcal infection of the throat, or a combination of shock from the loss of blood, asphyxia, and dehydration. One historian has stated that “whatever was the direct cause of General Washington's death, there can be little doubt that excessive bleeding reduced him to a low state and very much aggravated his disease.” Had a tracheostomy been performed he could have been saved.
Only in the past century has the tracheotomy evolved into a safe and routine medical procedure. The tracheotomy is actually one of the oldest surgical procedures and a very ancient one. Tracheostomy has probably existed for more than 4000 years. Rigveda, an ancient sacred Hindu book referenced the tracheostomy dates back between 3000-2000 BC.4 Egyptian wooden tablets depicts the surgical procedure of tracheostomy as early as 3000 BC.5 One of the Egyptian tablets from the beginning of the first dynasty of King Aha was discovered to have engravings showing a seated person directing a pointed instrument towards the throat of another person (Fig. 1.3). Some people believe it human sacrifice but most experts believe that tablet depicts formation of a tracheostomy as human sacrifice was not practiced in ancient Egypt.
The history of surgical access to the airway is largely one of condemnation. This technique of slashing the throat to establish emergency airway access in order to save the life was known as “semi slaughter.” During the Roman era, tracheostomies were performed using a large incision but with a warning to not to divide the whole of trachea as it could be fatal.6
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Fig. 1.3: A tablet depicting tracheotomy during the king Aha Dynasty
However, in largely hopeless cases of diphtheria, the opportunities tracheostomy offered for medical heroism ensured its place in the surgical armamentarium. Fabricius wrote in the 17th century, “This operation redounds to the honor of the physician and places him on a footing with the gods.” Mcclelland had divided various phages of 3the evolution of tracheostomy into five periods: The period of legend: dating from 2000 BC to 1546; the period of fear: from 1546 to 1833 during which operation was performed only by a brave few, often at the risk of their reputation; the period of drama: from 1833 to 1932 during which the procedure was generally performed only in emergency situations as a life saving measure in patients with upper airway obstruction; the period of enthusiasm: from 1932 to 1965 during which the adage, ‘if you think tracheostomy could be useful do it’ became popular; and the period of rationalization; from 1965 to the present during which the relative merits of intubation versus tracheostomy were debated.7 Various important dates in the evolution of tracheostomy are documented as follows:
  • Approximately 400 BC: Hippocrates condemned tracheostomy, citing threat to carotid arteries.
  • 100 BC: Asclepiades of Persia is credited as the first person to perform a tracheotomy in 100 BC. He described a tracheotomy incision for the treatment of upper airway obstruction due to pharyngeal inflammation. There is evidence that surgical incision into the trachea in an attempt to establish an artificial airway was performed by a Roman physician 124 years before the birth of Christ.
  • Approximately 50 AD: Two physicians, Aretaeus and Galen, gave inflammation of the tonsils and larynx as indications for surgical tracheotomy. Aretaeus of Cappadocia warned against performing tracheotomy for infectious obstruction because of the risk of secondary wound infections.
  • Approximately 100 AD: Antyllus described the first familiar tracheostomy: a horizontal incision between 2 tracheal rings to bypass upper airway obstruction. He also pointed out that tracheostomy would not ameliorate distal airway disease (e.g. bronchitis).
  • 131 AD: Galen elucidated laryngeal and tracheal anatomy. He was the first to localize voice production to the larynx and to define laryngeal innervation. Additionally, he described the supralaryngeal contribution to respiration (e.g. warming, humidifying and filtering of inspired air).
  • 400 AD: The Talmud advocated longitudinal incision in order to decrease bleeding. Caelius Aurelianus derided tracheostomy as a “senseless, frivolous, and even criminal invention of Asclepiades.”
  • 600 AD: The Sushruta Samhita contained routine acknowledgment of tracheostomy as accepted therapy in India.
  • Approximately 600 AD: Dante pronounced it “a suitable punishment for a sinner in the depths of the Inferno.”
  • During the 11th century, Albucasis of Cordova successfully sutured the trachea of a servant who had attempted suicide by cutting her throat.
  • 1546: The first record of a tracheostomy being performed in Europe was in the 16th century when Antonius Musa Brasavola (Fig. 1.4), an Italian physician performed a first documented tracheotomy and saved a patient who was suffering from laryngeal abscess and was in severe respiratory distress. The patient recovered from the procedure. Later, he published an account of tracheostomy for tonsillar obstruction. He was the first person known to actually perform the operation.
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    Fig. 1.4: Antonius Musa Brasavola (1490–1554)
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  • 1561–1636: As popularity of the operation increased, it was found that although asphyxia was immediately relieved, better long-term results were achieved if the stoma was kept patent for several days. Sanctorius was the first to use a trocar and cannula. He left the cannula in place for 3 days.
  • 1550–1624: Habicot performed a series of 4 tracheostomies for obstructing foreign bodies.
  • 1702–1743: George Martine developed the inner cannula.
  • 1718: Lorenz Heister coined the term tracheotomy, which was previously known as laryngotomy or bronchotomy.
  • 1739: Heister was the first to use the term tracheotomy and three decades later, Francis Home described an upper airway inflammation as Croup, and recommended tracheostomy to relieve obstructed airway.
  • 1800–1900: Before 1800 only 50 life-saving tracheotomies had been described in the literature (Fig. 1.5). In 1805 Viq d'Azur described cricothyrotomy. A major interest in tracheostomy developed after Napoleon Bonaparte's nephew died of diphtheria in 1807. Research into the technique got a boost with resurrection of some of the old instruments. During the diphtheria epidemic in France in 1825, tracheostomies gained further recognition. Improvements followed: 1833: Trousseau reported 200 patients with diphtheria treated with tracheostomy. In 1852, Bourdillat developed a primitive pilot tube; in 1869 Durham introduced the famous lobster-tail tube; and in 1880 the first pediatric tracheostomy tube was introduced by Parker. Later, introduction of endotracheal intubation in the early 20th century and high mortality rate associated with tracheostomy led to sharp decline in the formation of tracheostomy procedure. During and before this period some very interesting surgical tools were developed to form rapid tracheal stoma and some of these are shown in Figs 1.6 and 1.7.
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    Fig. 1.5: First five photographs (1666) showing the steps of tracheostomy(Courtesy: Health Sciences Libraries, University of Washington)
  • 1909: Chevalier Jackson (Fig. 1.8) standardized the technique of surgical tracheostomy and published the operative details of this procedure.8 He codified the indications and techniques for modern tracheostomy and warned of complications of high tracheostomy and cricothyroidotomy. Since then it became an important part of the surgeon's armamentarium.
  • 1932: Wilson advocated prophylactic tracheostomy in patients with poliomyelitis to facilitate the removal of secretions and to prevent pulmonary infections.
 
EVOLUTION OF CUFFED TRACHEOSTOMY TUBE
From Mid 1800s to 1970 metallic tracheostomy tubes were in clinical practice (Fig. 1.9). These tubes were associated with high rate of tracheal complications and aspiration pneumonia. Tredenlenburg, in 1969, first proposed the incorporation of cuff in a tracheostomy tube. However, it was not until the development of positive pressure ventilation (IPPV) that required cuffed tracheostomy tube.
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Fig. 1.6: Tracheostomy tools used during 1700s-1900s(Courtesy: Archives of Anatomy Library, University of Greifswald, Germany)
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Fig. 1.7: Some more surgical tools used to perform tracheostomy during 1700s-1900s(Courtesy: Archives of Anatomy Library, University of Greifswald, Germany)
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Fig. 1.8: Chevalier Q Jackson (1865–1958) who described step by step account of surgical tracheostomy
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Fig. 1.9: Metallic tracheostomy tube with plain and fenestrated inner cannulas
Until mid 1970s, the cuffs of endotracheal as well as the tracheostomy tubes were low-volume, high-pressure and were indicated for short-term use during the operative procedures under general anesthesia. In 1960s, a number of tracheal mucosal injuries were reported with these tubes, if used for longer duration. This led to the development of high-volume, low-pressure cuffs in polyvinyl chloride or silicone tubes (Fig. 1.10). These cuffs when inflated provide larger surface area for contact with the trachea, therefore minimizing tracheal mucosa ischemia and destruction.
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Fig. 1.10: Different types of cuffed tracheostomy tubes
In the last three decades, while emergency tracheostomy has become a rarity, elective tracheostomy has become more common due to the increasing awareness of complications caused by prolonged translaryngeal intubation for long-term airway access.
 
EVOLUTION OF PERCUTANEOUS TRACHEOSTOMY
With the passage of time the extensive surgical procedures are being replaced with minimally invasive or keyhole surgical procedure and the tracheostomy cannot remain an exception. Historically, various devices were available for rapid formation of tracheostomy through percutaneous approach; however, such devices were inherently unsafe due to their design and never achieved widespread usage. Since late 1980s a number of percutaneous tracheostomy devices have been introduced in clinical practice with excellent results. A review of historical aspects of percutaneous tracheostomy is presented below:
Seldinger (1953) introduced the technique of guide wire needle replacement in percutaneous arterial catheterization; and soon after the technique became popular as Seldinger technique.9 This technique has been adapted to various procedures, including percutaneous tracheostomy.7
Shelden (1957) was first to introduce percutaneous tracheotomy in an attempt to reduce the incidence of complications that followed open surgical tracheostomy and to obviate the need to move potentially unstable intensive care patients to the operating theater. Shelden and colleagues gained airway access with a slotted needle then that was used to guide a cutting trocar into the trachea (Fig. 1.11).10 Unfortunately, the method caused multiple complications; and fatalities were reported secondary to the trocar's laceration of vital structures adjacent to the airway.
Toye and Weinstein (1969) used a tapered straight dilator that was advanced into the tracheal airway over a guide catheter. This tapered dilator had a recessed blade that was designed to cut tissue as the dilator was forced into the trachea over a guiding catheter.11 However, this device too was associated with complications like peritracheal insertion, tracheal injuries, esophageal perforation and hemorrhage; and is therefore now obsolete.
Ciaglia P (1985) thoracic surgeon ((Fig. 1.12), described a technique that relies on progressive blunt dilatation of a small initial tracheal aperture created by a needle using series of graduated dilators over a guide wire that had been inserted into the trachea.12 A formal tracheostomy tube is passed into the trachea over an appropriately sized dilator. He modified percutaneous nephrostomy set to facilitate percutaneous tracheostomy in a series of 26 patients. As early results of percutaneous tracheostomy were favorably comparable with surgical tracheostomy, by 1990 the technique became quite popular. The kit is being manufactured by Cook Critical Care, Bloomington, IN, USA (Fig. 1.13) Ciaglia is regarded as father of modern bedside percutaneous tracheostomy and whose approach rejuvenated the interest in the art and clinical utility of tracheostomy.
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Fig. 1.11: Cutting trocar and cannula(Courtesy: Archives of Anatomy Library of University of Greifswald, Germany)
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Fig. 1.12: Pasquale (Pat) Ciaglia (1912–2000)
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Fig. 1.13: Ciaglia's percutaneous dilatational tracheostomy introducer set (Cook Inc, Bloomington, IN, USA)
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Schachner A (1989) developed a kit (Rapitrach, Fresenius) that consisted of a cutting edged dilating forceps (Fig. 1.14) with a beveled metal conus designed to advance forcibly over a guide wire and opened, allowing a tracheostomy tube to be inserted between the open jaws of the device.13 Rapitrach kit, as the name suggests, was originally designed for emergency use to gain airway access to trachea through percutaneous approach but the kit was associated with a number of posterior tracheal wall injury reports and even death.
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Fig. 1.14: Rapitrach dilating forceps (Surgitech, Sydney, Australia)
Griggs WM (1990) reported a guide wire dilating forceps (GWDF) marketed by Portex, Hythe Kent, UK (Fig. 1.15).14 The device is like a pair of modified Kelly's forceps but does not have a cutting edge of the Rapitrach. The GWDF is passed into the trachea after initial dilation over a guide wire. Griggs forceps is quite popular in European countries and Australia.
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Fig. 1.15: Griggs guide wire dilating forceps kit with tracheostomy tube (SIMS Portex Ltd, Hythe, Kent, UK)
Fantoni A (1993) described a technique of tracheostomy through translaryngeal approach whose main feature was the passage of a dilator as well as the tracheostomy tube from inside of the trachea to the outside of the neck (an in and out technique).15 The tracheostomy tube is pulled from inside the trachea to the outside and rotated. The initial version of the kit was later modified in 1997 (Mallinckrodt, Europe) (Fig. 1.16).16
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Fig. 1.16: Fantoni's translaryngeal tracheostomy kit (Mallinckrodt Medical GmbH, Hennef, Germany)
Ciaglia P (1999) developed a modification of his own technique wherein a series of dilators was replaced with a single, sharply tapered dilator with a hydrophilic coating that looks like Rhino's horn and therefore appropriately named Blue Rhino (Cook Critical Care, Bloomington, IN, USA) (Fig. 1.17). The device permits formation of tracheal stoma in one step for insertion of a tracheostomy tube using Seldinger guide wire technique.
Ciaglia P (2000) shortly before his death at the age of 88 years, came up with an idea of balloon facilitated percutaneous tracheostomy (BFPT). His preliminary vision was translated into the reality by Michael Zgoda, a pulmonologist at the University of Kentucky (USA) and published his experience using this kit in 2003 (Fig. 1.18).17
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Fig. 1.17: Ciaglia's Blue Rhino percutaneous dilatational tracheostomy introducer set (Cook Critical Care, Bloomington, IN, USA)
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Fig. 1.18: Ciaglia's Blue Dolphin Balloon Dilatation percutaneous tracheostomy introducer (Cook Critical care, Bloomington, IN, USA)
Frova G (2002) Professor of Anesthesia and Intensive Care at Brescia Hospital, Italy (Fig. 1.19) developed a screw like device (PercuTwist®, Rüsch) that utilizes a self-tapering screw dilator to form tracheal stoma over the guide wire.18 The screw like dilator (Fig. 1.20) is claimed to offer more controlled dilation of the trachea without causing anterior tracheal wall compression.
Ambesh SP (2005) Professor of Anesthesiology at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow (India) (Fig. 1.19) introduced a modification to Ciaglia Blue Rhino by developing a T-shaped tracheal dilator “T-Trach” (formerly known as T-Dagger). Unlike Ciaglia's rounded dilator, the shaft of T-Trach is elliptical in shape with tapered edges, and has a number of oval holes (Fig. 1.21).19 Like other techniques of PDT, T-Trach too utilizes Seldinger guide wire technique. As this is a very recent addition to the range of percutaneous tracheostomy kits, only few studies are available at the moment.
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Fig. 1.19: (Left to Right): A Fantoni, WM Griggs, G Frova and SP Ambesh. 1st International Symposium “Tracheostomy- Past and Present” at University of Greifswald, Germany (11–13 May 2006)
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Fig. 1.20: Different sizes of Frova's PercuTwist dilators (Ruüsch, Kernen, Germany)
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Fig. 1.21: Ambesh's T-Trach percutaneous tracheostomy introducer (Eastern Medikit Limited, Delhi, India)
However, it has been claimed that the T-trach has a potential of minimizing tracheal injuries and cartilaginous rings fracture while causing creation of tracheal stoma between the two tracheal rings, in one step.
A large number of studies have been conducted with various commercially available PDT kits. Many authors are proponents of the technique for the formation of elective tracheostomy in intensive care unit patients for long-term ventilation, isolation of airway and weaning from ventilator.20 Other authors have reported no significant superiority of PDT over traditional surgical tracheostomy. Recently, Paw and Turner in their survey reported that percutaneous tracheostomy is being performed in 75% of intensive care units of England and Wales and has almost replaced the surgical tracheostomy. The most commonly used percutaneous tracheostomy kit was Ciaglia's multiple serial dilators (46.6%) followed by Ciaglia's Blue Rhino kit (31.3%).21 However, irrespective of the techniques used the most common thing is the use of guide wire. The most important and major modification to the technique is the increasing use of the fiberoptic bronchoscope to visualize the placement of tracheal puncture needle, the guide wire and the tracheostomy tube. A detailed description on commonly used percutaneous tracheostomy kits and the techniques is presented in the succeeding chapters of the book.
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