Remembering the classics: A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age
Myron Yaster MD, Melissa Brooks Peterson MD, Alan Jay Schwartz MD, MSEd
"What has been will be again, what has been done will be done again; there is nothing new under the sun" Ecclesiastes 1:9
Today’s PAAD authored by Peter Szmuk and colleagues1 may appeal primarily to history buffs but I found it to be a fascinating read that I think many of you will find entertaining and well worth the time to read in its entirety. This is also the article that I (MBP) referenced during my lecture at the October 2024’s SPA Annual Meeting “Tips for Trachs.” It describes the roots of airway management which span almost 4,000 years of human history. If you are an airway nerd (like us!), you will find it both informative and enjoyable. Melissa Brooks Peterson MD & Myron Yaster MD
Original article
Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Intensive Care Med. 2008 Feb;34(2):222-8. doi: 10.1007/s00134-007-0931-5. Epub 2007 Nov 13. PMID: 17999050
“Over the past 4,000 years, the development of increasingly effective airway devices, along with a better understanding of the pathophysiology of the upper airway, have formed the cornerstones of modern practice. Today’s appreciation of the value of tracheostomy and tracheal intubation was prefaced by two millennia of the intermittent rise and fall of their vogue. Advances made from antiquity until the middle of the twentieth century underpin the decrease in anesthetic mortality linked to failed airway management; and they form the foundation for modern management of the normal and difficult airway.”1
Tracheotomy with or without a tracheal tube has been a life-saving device for at least 4,000 years. It has been described in Hindu, Egyptian, Greek, Roman, and Judaic texts since 2,000 BC. Many texts describe opening the throat, others of placing a reed through the tracheostomy to provide ventilation. Ventilation by blowing into the reed or with the use of bellows “so that the lung may rise again, and the animal take in air.” became firmly established by the 1500s. “Fabricius of Aquapendente (1537–1619), an Italian anatomist, wrote this historic statement: “Of all the surgical operations which are performed in man ... the foremost [is] that by which man is recalled from a quick death to a sudden repossession of life ... the operation is the opening of the aspera arteria [“artery of air”], by which patients, from a condition of almost suffocating obstruction to respiration, suddenly regain consciousness, and draw that vital ether, the air, so necessary to life, and again resume an existence which had been all but annihilated.”1
Over the next 200+ years tracheotomy and tube insertion went in and out of favor. George Washington died of suffocation (and bloodletting) from an upper airway obstruction, probably epiglottitis, because his group of four physicians feared killing the first American president by doing the (unfavorable at the time) procedure. In the 1880s, tracheal intubation with preformed metal and later rubber tubes coincided with the development of inhalational general anesthesia.
Many of the devices we currently use, such as the Magill forceps, the laryngoscope and various blades including the Crawford curved blade, were all developed at the turn of the last century. “Chevalier Jackson, M.D. (1865-1958) is honored as the father of bronchoscopy and laryngoscopy. He is also credited with standardizing the modern technique of tracheotomy. Jackson invented numerous instruments for airway management, including the first modern laryngoscope.”2-4
Double lumen tubes to isolate a lung were first developed in the late 1930s first by Eric Carlens in Sweden and later by Robertshaw in 1962. The final step in this journey was the development by Kensuke Ikeda of Japan introduced flexible fiberoptic bronchoscopy into medical practice in 1968. Although not discussed in today’s article, 2 giants of pediatric anesthesia Robert Smith (against) and Digby Leigh (for) debated the routine use of endotracheal tubes into pediatric anesthesia practice well into the 1950s and 60s.
An incredible 4,000-year journey. Send your thoughts and comments to Myron who will post in a Friday reader response.
PS from Myron: We will have more to say about Dr. Chevalier Jackson next month. Dr. Alan Jay Schwarz a member of the PAAD’s executive council has an Anesthesiology Reflections piece highlighting some of his achievements in the May issue of Anesthesiology
References
1. Szmuk P, Ezri T, Evron S, Roth Y, Katz J. A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age. Intensive care medicine 2008;34(2):222-8. (In eng). DOI: 10.1007/s00134-007-0931-5.
2. Schwartz AJ. Chevalier Jackson, MD: Patient Safety Champion. Hektoen International 17(1) Winter 2025. https://hekint.org/2025/01/16/chevalier-jackson-md-patient-safety-champion/ (accessed 02/13/2025)
3. Wood Library Museum of Anesthesiology. Jackson Laryngoscope. https://www.woodlibrarymuseum.org/museum/jackson-laryngoscope/ (accessed 02/13/2025)
4. Wood Library Museum of Anesthesiology. Jackson Tracheostomy Tube. https://www.woodlibrarymuseum.org/museum/jackson-tracheotomy-tube/ (accessed 02/13/2025)