A Lesson on Human Factors in Airway Management Learnt From the Death of George Washington.

On December 14, 1799, 3 prominent physicians-Craik, Brown, and Dick-gathered to examine America's first president, George Washington. He was complaining of severe throat symptoms and was being treated with bloodletting, blistering, and enemas. Dick advised performing an immediate tracheotomy to secure the airway. Both Craik and Brown were not keen on trying tracheotomy and overruled that proposal. Washington was not involved in making that decision. He most likely had acute epiglottitis that proved to be fatal at the end. If Dick had prevailed, a tracheotomy could have saved Washington's life. Human factors analysis of these events shows that his physicians were totally fixated on repeating futile treatments and could not comprehend the need for a radical alternative, like tracheotomy. That was aggravated by an impaired situational awareness and significant resistance to change. Leadership model was also based on hierarchy instead of competency, which might have also contributed to Washington's death.

Glottic Stenosis: An Anatomic Analysis and New Treatment With a Self-Retaining Interarytenoid Spring.

INTRODUCTION:: Endotracheal (ET) intubation is a common cause of acquired glottic stenosis. Severe cases often require an irreversible arytenoidectomy/cordectomy, which typically results in poor voice quality. Adult human cadaver larynges were studied to gain insights about ET tube-induced posterior glottic injuries, hoping to create a less invasive remedy. STUDY DESIGN:: Human cadaver investigation and case reports. METHODS:: Microlaryngeal assessments were done on 10 human cadaver larynges (5 men, 5 women) with and without ET tubes. After supracricoid soft tissue resection, measurements were obtained, including the distance between the outer diameter of the ET tube and the medial aspect of the cricoarytenoid joint facet. Additionally, measurements of the circumferential arc of differently sized ET tubes were made alongside both cricoarytenoid joint capsules. This information was used to design a silastic stent that would function as a self-retaining interarytenoid spring to treat posterior glottic stenosis in 5 patients. Four of 5 patients included in the clinical study were tracheotomy dependent, primarily because of glottic stenosis. The human surgical technique is described in detail. RESULTS:: The shortest distance between the outer diameter of the ET tube to the medial cricoid facet averaged 5.02 mm in men and 3.62 mm in women. On the basis of the diameter of the intralaryngeal component of the initially round stent, and the position of the cricoarytenoid joint facets, the interarytenoid spring would have a subtended arc between 110° and 175°. These data helped fashion parameters for modifying a conventional T-tube to form a new self-retaining silastic interarytenoid spring. The first 5 human cases have been successful, allowing effective tracheotomy tube decannulation and excellent voice quality. CONCLUSIONS:: The anatomic investigation herein provided key insights into ET tube-induced glottic stenosis and facilitated a new straightforward procedure to surgically improve the airway yet preserve excellent vocal function in patients with acquired glottic stenosis. Level of Evidence: NA.

Birth of Airway Surgery and Evolution over the Past Fifty Years.

Significant developments in airway surgery occurred following the introduction of mechanical ventilators and intubation with cuffed endotracheal tubes during the poliomyelitis epidemic of the 1950s. The resulting plethora of postintubation injuries provided extensive experience with resection and reconstruction of stenotic tracheal lesions. In the early 1960s, it was thought that no more 2 cm of trachea could be removed. By the late 1960s, this was challenged owing to better knowledge of airway anatomy and blood supply, tension-releasing maneuvers, and improved anesthetic techniques. Currently, about half of the tracheal length can be safely removed and continuity restored by primary anastomosis.

History of Mechanical Ventilation. From Vesalius to Ventilator-induced Lung Injury.

Mechanical ventilation is a life-saving therapy that catalyzed the development of modern intensive care units. The origins of modern mechanical ventilation can be traced back about five centuries to the seminal work of Andreas Vesalius. This article is a short history of mechanical ventilation, tracing its origins over the centuries to the present day. One of the great advances in ventilatory support over the past few decades has been the development of lung-protective ventilatory strategies, based on our understanding of the iatrogenic consequences of mechanical ventilation such as ventilator-induced lung injury. These strategies have markedly improved clinical outcomes in patients with respiratory failure.

Origin of the cannula for tracheotomy during the middle ages and Renaissance.

The purpose of this article was to trace the historical origin of the inserted cannula during tracheotomy. Tracheotomy is mentioned in most ancient medical texts, but the origin of cannula insertion into the windpipe is unclear. We reviewed the incunabula and Renaissance texts reporting the utilization of surgical cannulas and tracheotomy. The incunabula disclosed extended use of surgical cannulas during the middle ages and Renaissance. Although tracheotomy was advocated in acutely suffocating patients for a disease of the throat termed squinantia or angina, the first report of the procedure was found only at the end of the middle ages and a second during the middle Renaissance. The introduction of cannula use in tracheotomy was supported by a semantic misinterpretation by Antonio Musa Brasavola. The historical origin for tracheotomy in the middle ages and Renaissance is conflicting. Antonio Brasavola wrongly interpreted Avicenna's oral cannula introduced into the windpipe for angina. This misinterpretation allowed Giulio Casserio to draw the first curved cannula introduced for used during tracheotomy.

Tracheotomy: historical review.

The authors review the ancient history of tracheotomy and bring the subject up to date (2008) by including the modern history of this procedure. In the past 60 years, there have been many advances in the knowledge of respiratory function that have been utilized to expand applications of the tracheotomy procedure. Improvements in the care of tracheotomized patients and the application of modifications in the available variety of tubes and ancillary equipment and procedures have made this a much more effective and widely utilized way of caring for the pulmonary cripple as well as utilizing it in the classical fixed obstruction of the upper airway.

[Cancer or syphilis laryngis, politics or diagnostic failure--problems of Emperor Frederick's III disease]. / Rak czy kila krtani, polityka czy bledna diagnoza--problem choroby cesarza Fryderyka III.

The case history of the German emperor Frederick III, who died of laryngeal cancer in 1888, is briefly reported. In spite of fact, that the German laryngologists the patient's pathologic changes diagnosed as laryngeal cancer in early stage, the ultimate diagnosis was made too late for surgery to have any effect. This delay was due to the differences in opinions between the attending laryngologists; particularly between that of the English prominent laryngologist Morell Mackenzie and the Germans, prof. Gerhardt and prof. Bergmann. The roles of the British Queen Victoria as well as her daughter, the wife of Prince Frederick, the princess Victoria, in decisions about the treatment of the disease, are discussed. The behavior and the personality of Sir Morell Mackenzie played also a very important role in the course of the disease. Some medical facts and symptoms render it probable that syphilis was the underlying reason for the development of cancer. Crown Prince Frederick was a pipe smoker for at least 30 years before he died at the age of 57 years, so it may be possible, that the Emperor's laryngeal cancer was induced by tobacco. There are some suggestions, that the premature death of the King of Prussia and German Emperor Frederick III could be a critical turning point in European's history.

19th century pioneers of intensive therapy in North America. Part 1: George Edward Fell.

For three decades after Marshall Hall's 1856 strictures against "forcing methods" and bellows for artificial ventilation (AV), human "forced respiration" (equivalent to intermittent positive pressure ventilation) was virtually abandoned. Various arm-chest manoeuvres often proved inadequate to save life. After doctor and engineer George Fell, of Buffalo (New York) (1849-1918), failed to save the life of an opiate-poisoned patient using Silvester's popular method, he resolved to try his animal laboratory AV method (bellows and tracheotomy). Following his first success in a landmark case (1887), he better adapted the apparatus for human use and soon succeeded with further difficult cases, but was unable to raise enthusiasm for his "Fell method" of AV. His reports of successful rescues to prestigious Washington Congresses met derision (1887) and indifference (1893), although by then they detailed 28 "human lives saved", mostly after opiate poisoning, and a switch from tracheotomies to face masks (simpler, but with a few complications). Continuing with rescues throughout the 1890s, Fell personally achieved recoveries after AV for as long as 73.5 hours (1896), and over 78 hours (1899). He argued for his method repeatedly with many talks, much documentation, and pleas for its use in other ventilatory crises. Despite his endeavours and successes, Fell was unable to secure widespread uptake of forced respiration, but others adopted his principles. Joseph O'Dwyer modified Fell's face mask-tracheotomy system by incorporating an intralaryngeal tube, and this "Fell-O'Dwyer apparatus" was used for neurosurgical cases (1894), also revolutionising intrathoracic surgery (1899).

[Armand Trousseau, laryngologist]. / Armand Trousseau laryngologiste.

Trousseau's contribution to laryngology was considerable, but it was eclipsed by his reputation in other fields. His work in the field was not limited to the diffusion of tracheotomy for the treatment of croup, despite opposition from certain surgeons. He totally transformed the intervention, which up until then had been undertaken without any specific methodology, into a controlled procedure with principles that still apply today. He undertook the study of chronic diseases of the larynx and wrote the first work dedicated to this pathology, before the arrival of laryngoscopy. He reported the first recorded and illustrated case of laryngeal cancer for which he himself performed a tracheotomy. Laryngeal pathology was an important centre of interest throughout his career. With the arrival of laryngoscopy at the end of his professional life, Armand Trousseau had left a lifetime's work that facilitated the expansion of the new generation of laryngology. He could be considered as the first medico-surgical laryngologist, mastering both an in-depth knowledge of the organ, its medicine, and surgery, which at that time was limited to tracheotomy.

[History of tracheotomy]. / Historia tracheotomii.

The present notion - tracheotomy, originates from the Latin words trachea - windpipe, which comes from the combination of Latin "tracheia" and Greek "arteria" indicating an uneven road, and "tome" - cut. Procedures of pharyngotomy have a long-lasting history. First similar operations were found on the ancient Egyptian clay tablets dating back to 3600 BC. Mentions of pharyngotomy operations were found in the papyrus called Ebers's Papyrus dating back to about 1550 BC, which can obviously be treated as an encyclopaedia of the medical knowledge that the ancient Egyptians possessed. Guidelines for the person performing pharyngotomy were described in Rig Veda - the holy scriptures of Hindi medicine, about 2000 BC. Asclepiads of Prussia in Bithynia (124-156 BC), a Greek physician practising in Rome, is commonly considered the father of pharyngotomy. In the 1st century BC he documented an operation similar to pharyngotomy. Procedures similar to pharyngotomy were conducted by Claudius Galenus of Pergamon (about 130-200 AD) who was treating gladiators at the beginning of his medical career. A precise description of the technique in pharyngotomy performed by the method adopted from Antilla (3rd century AD) was presented by Paulos Aeginata (625-690 AD), whereas in modern times the first surgical pharyngotomy was performed by Antonio Brasavola (1490-1554) in 1546. In those times pharyngotomy operations were applied as life saving procedures and were associated with a desperate fight for life. The best example is given by Sanctorio Santorius (1561-1636) who pierced the trachea lumen with a trocar. All the experiences connected with the pharyngotomy technique were collected by Lorenz Heister (1683-1758) and published in his work "Surgery" in 1716. Until the end of 18th century the work finally established views about performing pharyngotomy operations. In 1856 Eugeniusz Bonchut conducted the first pharyngotomy in a child with passing an intubation tube into the trachea lumen. The operation was performed according to theoretical assumptions by Armando Trausseau (1801-1867), whose contributions to emergency pharyngotomy methods are enormous. Finally, at the beginning of the 20th century Chevalier Jackson (1865-1958) set principles for surgical techniques in pharyngotomy that still remain in force. The return to Sanctorius's method and also adaptation of Selinger's method (1953) of cannulation of blood vessels turned out to be fundamental for the further development of transdermal pharyngotomy. The first set for multistage, dilatation pharyngotomy was provided by P. Ciaglia et al. in 1985. A one-stage pharyngotomy by special forceps was described by W. M. Griggs et al. in 1990. A technique of transdermal pharyngotomy from inside the trachea was presented in 1995 by A. Fantoni with his group. Modern methods of transdermal pharyngotomy are good complementary techniques for classical methods of pharyngotomy in both emergency and chronic cases.