TRACHEOSTOMY:
EVOLUTION OF AN AIRWAY

By Steven E. Sittig, RRT and James E. Pringnitz, RRT

It was a frigid afternoon that day in Virginia December 1799 as three physicians gathered around a dying man. The man kept shifting his position, as he gasped for air. The physicians gave the man sage tea with vinegar to gargle but it nearly caused the patient to choke to death. It was obvious the patients airway was severely compromised but poultices did little to help. It had only been a year since the medical literature of the time described a surgical procedure in which the trachea could be accessed in cases of airway obstruction. In 1799, even elective tracheotomy, let alone emergent tracheotomy were rarely performed.

The patients condition continued to deteriorate as he struggled for breath. One of the physicians was aware of the tracheotomy procedure but was reluctant to attempt it on such a famous person because the procedure was considered futile and irresponsible. Soon the patient became calm and relaxed. The patient took his finger and felt for his pulse as he had seen his physicians do many times. His attending physicians never learned the result as his fingers slipped from his wrist and he died. History buffs may recognize this story as the death of George Washington. While arguments still persist about the cause of Washingtons death, the most popular theory is that he died from an upper airway obstruction caused by bacterial epiglottitis.1

The surgical procedure of tracheostomy is actually a very ancient one. The procedure was portrayed on Egyptian tablets dating back to 3600 BC. The earliest known references to tracheostomy are made in the Rigveda, a sacred Hindu book, published around 2000 BC. The term tracheotomy was actually coined by Lorenz Heister in 1718.2,3

Before 1800 only 50 life-saving tracheostomies had been described in the literature. In the 19th century the tracheostomies performed for upper airway obstruction and those done for disorders of the lower airway were in the ratio of 90:10, nowadays the ratio is 20:80.4

 

Antique sterling silver tracheostomy tube, made in England in the late 1800s.
(left and right outer cannula, inner cannula in center)

Evolution of the Tracheostomy

Tracheostomy tube materials have certainly evolved since 160 AD when Galen wrote, "If you take a dead animal and blow air through its larynx (through a reed), you will fill its bronchi and watch its lungs attain the greatest dimension."5 Imagine discussing with your physician in the late 1800s about the necessity for a tracheostomy, and that your only option was similar to that pictured above. Notice that the physical characteristics of this early stainless steel tracheotomy tube is very similar to that of todays oral airway in regards to angle and shape of the lumen. While stainless steel tracheostomy tubes have proved to be a time honored airway adjunct for providing long-term airway management, there were serious compromises in size, shape, and application of early metal products. One can only imagine how uncomfortable these early tracheostomy tubes must have been. With developmental improvements of natural and synthetic materials such as silicone and polyvinyl chloride, allowances have been made over the years resulting in improved design more conducive to the anatomic airway eventually leading to the modern day tracheostomy tube.

Cuff evolution

In 1869, Trendelenburg first proposed the use of a cuffed tracheotomy tube.6 Many decades later with the development of positive pressure ventilation (PPV) an adaptation of the tracheotomy tube was required. Before the 1970s, cuffs for both tracheostomy and endotracheal tubes were of the low volume, high-pressure design. These were designed for short-term use in the operating room. The development of high-pressure cuffs fulfilled the need of this early application of PPV. In the late 1960s, complications of tracheal mucosal damage caused by the application of high-pressure cuffs were discovered. Alternatives such as double cuffed tubes, cylindrical tubes, spacers to vary the level of tracheal contact, flange seals, and intermittent cuff inflation techniques were examined.5 From these efforts, resulted the advent of the modern high volume low pressure cuffs. When inflated, these cuffs provide a larger surface area for contact with the trachea, therefore minimizing tracheal mucosa destruction. Other manufacturer attempts to minimize tracheal damage have resulted in various cuff products. The Kamen-Wilkinson Fome-Cuff contains polyurethane foam that expands when the pilot tube is open to the atmosphere, and automatically adjusts to unique contours and changes of the trachea.

Pressure limiting devices such as the pilot balloon pop-off valve limits tracheal pressure to 20-25 mmHg in attempts to reduce tracheal damage.

Modern technology has allowed manufacturers to craft improved products currently on the market. Todays thermosensitive PVC provides sufficient rigidity for initial insertion, and then softens at body temperature to accommodate individual patient anatomy with a 105 degree angle in situ for improved comfort as opposed to a metal tracheostomy tube. Other tubes are crafted of hydrophobic silicone making protein adhesion more difficult in attempts to reduce the opportunity for bacterial growth on the tube. For those patients with unique pathology or anatomical airway, manufacturers have developed flexible kink resistant wire reinforced silicone shafts that consist of an adjustable neck flange making this tube instantly customizable. Neck flanges have also advanced from stainless steel to transparent materials allowing for aesthetic acceptability.6 Modern day cuffs are being made of velvet soft material and even offer a tight to the shaft (TTS) cuff. These TTS cuffed tracheostomy tubes have the benefits of a cuffed tube while adding little dimension to the outer diameter of the tubes shaft when deflated.

PEDIATRIC TRACHEOSTOMY

One of the first references to tracheostomy in the pediatric population occurred in 1650 in a case report by the pathologic anatomist Theophilus Bonetus. He presented a case study in which he proposed a tracheostomy for a 7-year old boy who had aspirated a bone. His recommendation was overruled as too risky and contradictory to standard medical practice of the time. The child subsequently died. It was common in the early 1800s that children received tracheostomies in their treatment of diphtheria. Little changed in the indication for tracheostomy until in 1932 Wilson first suggested the proposed prophylactic and therapeutic use of a tracheostomy with poliomyelitis. Up until this time tracheostomies were performed exclusively for patients with upper airway obstruction.4,7 Early tracheostomy tubes were made of sterling silver or stainless steel. These early airways had inherent problems associated with their use. These tracheostomy tubes did not conform well to the airway, which lead to complications such as formation of granulomas in the airway from repeated irritation, potential tracheal wall erosion and tracheostomy tube occulusion against the tracheal wall.8

While granuloma formation is tolerated in the adult population, any process that decreases an already narrow airway can have serious consequences in pediatrics.

With the advent of improved neonatal care, more premature infants were surviving only to develop acquired subglottic stenosis from prolonged tracheal intubation and mechanical ventilation. In 1972, only 30% of children who required tracheostomy were under the age of 1 year. This percentage increased to 45% by 1983 and in 1996 this figure climbed to 70% with over half of these children being under three months of age. These statistical changes placed increased need for surgeons to become more skilled as they performed tracheostomies on smaller and smaller patients. This new patient population required specialized tracheostomy tubes in special sizes and lengths that were at that time never before been needed.9

Specialized tracheostomy tubes made from synthetic materials soon replaced most applications of the metal tracheostomy tube. The newer generation tracheotomy tubes are now better designed for children of all ages. The curvature of the modern cannula is now designed to be co-linear and concentric with the trachea to better conform to the airway leading to less abrasion by the tracheostomy tube.

There are now many options available in the pediatric population. Specialized lengths and wider range of sizes, plus thermo-sensitive materials that soften slightly at body temperature are some of the many options available. Typically smaller pediatric tracheostomy tubes do not have cuffs but there are cuffs that when deflated are tight to the shaft of the cannula. This decreases tracheal irritation but the cuff may be inflated as needed to protect the airway or help assure effective positive pressure ventilation.

Bronchoscopic Ward 

Children with tracheostomies in a bronchoscopic ward

Not all that long ago children who had tracheostomy tubes were kept in the hospital, as there was no formal home going education program to allow them to transition to home. During my research for this article a lady who had a tracheostomy as a young child in the mid 1950s told a story to me. She was allowed to go home only occasionally because a nurse lived next door and that her mother developed a crude alarm to monitor her daughter as she lay in the crib. The alarm system consisted of a small bell tied to the child's toe and the mother slept on a mattress on the floor next to the crib. Today there are many advances in technology and education that make it possible for the child with a tracheostomy tube to safely and effectively transition to the home setting.

While children who receive a tracheostomy have a relatively high mortality (19%), their deaths are usually related to the underlying disease, not the tracheostomy itself.

The improvement in design/materials of tracheostomy tubes, medical management and education of parents/caregivers has significantly decreased pediatric mortality.10 A better understanding of the pathophysiology that can occur to the pediatric airway when even routine tracheostomy care is completed has led to important new tracheostomy care guidelines. The use of measured suction depths dependent on the size of the pediatric tracheostomy tube has helped decreases the formation of granulomas caused from suction catheter irritation. It is imperative that caregivers of pediatric tracheostomy patients are educated to manage the two most serious complications of mucous plugging and inadvertent decannulation.7 Fortunately advances in corrective surgery for pediatric airways disorders has continued to improve, allowing more children to be decannulated without complications. Thus allowing them to lead more normal lives.10

It is important that we as respiratory care professionals be involved in all aspects of tracheostomy issues from routine care, patient/family education and home going care plan. Airway management is a forte of the respiratory care practitioner; our expertise can be a valuable asset to the healthcare team, the family, and especially the patient. The one constant thing about those of us who work in the field of medicine and patient care is that there is always an evolution in technology and knowledge. As we help care for patients with tracheostomy, we become part of the history that has been illustrated here.

REFERENCES

  1. Morens DM: Death of a President, The New England Journal of Medicine, Volume 341(24), December pages 1845-1849.
  2. Pahor AL: Ear, Nose and Throat in Ancient Egypt. Journal of Laryngology and Otology, Volume 106(9), September 1992, Pages 773-779.
  3. Stock CR: What is past is prologue: A short history of the development of the tracheostomy. Ear, Nose and Throat Journal, Volume 66(4). April 1987 pages 166-169.
  4. Graamans K., Pirsig W., Biefel K: The shift in the indications for the tracheostomy between 1940 and 1955: an historical review. The Journal of Laryngology and Otology 113(7): July 1999. pages 624-627.
  5. Stoller JK: The history of intubation, tracheotomy and airway appliances. Respiratory Care Volume 44(6) June 1999. Pages 595-603.
  6. Harrell M: Clinical Perspectives. Developing an effective care plan for the tracheostomized individual.  AARCTimes 23(3), March 1999 pages 45-47, 65.
  7. Myer CM, Cotton RT, Shott SR: The Pediatric Airway: An Interdisciplinary Approach. Chapter 9 , page JB Lippincott Co Philadelphia.
  8. Branson RD, Hess DR, Chatburn RL: Respiratory Care Equipment , Chapter 6 page 127-128, JB Lippincott , Philadelphia.
  9. Shinkwin CA, Gibbon KP: Tracheostomy in children. Journal of the Royal Society of Medicine 89(4) April 1996. pages188-192.
  10. Carronn JD, Dekay CS, et al: Pediatric tracheostomies: Changing Indications and outcomes. Laryngoscope 110(7), July 2000. pages 1099-1104.

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