Extraanatomic percutaneous access to the trachea is performed in one of two settings: As life-saving stat procedure in acute airway obstruction cephalad of the larynx, ideally penetrating the cricothyroid ligament between the thyroid and cricoid cartilages (coniotomy).
Or, in most cases, as an elective procedure in intensive care for prolonged mechanical ventilation through a tracheal tube, bypassing the oropharynx, hypopharynx and larynx.
Access to the trachea is gained either by percutaneous dilatational tracheotomy, as detailed in the webop article Percutaneous dilatational tracheotomy, or as open tracheostomy.
Tracheotomy is one of the oldest surgical procedures known to man.
Historical medical reports include those of the Rig-Veda in Hinduism (1) two thousand years BC and by Galen.
Andreas Vesalius praised it because “it suddenly saved a life which already seemed lost” (8).
With the publications by Armand Trousseau on his treatment of numerous diphtheria cases in childhood (6,7) the procedure became standardized in the first half of the 19th century.
Today, tracheostomy in patients on prolonged ventilation is a routine procedure in surgery and intensive care. Numerous descriptions of the actual technique, its modifications, possible complications and the postoperative care have been published. Following is a list of selected references on this topic.
As early as 1966, A. Potondi from Budapest, Hungary, and O. Pribilla from Kiel, Germany jointly published an impressive paper in the “Deutsche Zeitschrift für gerichtliche Medizin” on the few fatal complications of this procedure. In those days, the overall complication rate of this procedure in the literature was about 30%, without differentiating between elective and emergency surgery: The paper also included three reports by Billroth of fatal postoperative bleeding with the patients still at home (9).
As expected, the current rates have improved significantly: For example, while the “Tracheotomie bei Intensivpatienten” review article by A. Valentin from Vienna, Austria, listed a rate of 2.9% to 5.4% for subsequent tracheal stenosis, it also emphasized the importance of correct timing for this procedure: “The positive results for extremely early tracheotomy in patients on mechanical ventilation expected for > 14 days, as demonstrated in the randomized trial by Rumbak (Crit Care Med 2004; 32: 1689), are countered by the argument that perhaps many of these patients actually did not require tracheotomy. Indeed, in the control group (planned tracheotomy on day 14-16) 13% of patients had already been extubated before the tracheotomy” (11):
And a 2007 meta-analysis by Higgins KM of about 1,000 patients, studying events such as minor and major bleeding, subglottic stenosis and mortality – particularly comparing open and percutaneous dilatational tracheostomy – noted a pooled odds ratio of 0.75 for all complications, with a confidence interval of 0.56 to 1.0.