The procedure was also performed in the ancient Hindu culture and described in the Rig Veda, the sacred Hindu book of medicine written between 2000 and 1000 B.C. Alexander III of Macedon more commonly known as Alexander the Great (356–323 B.C.) reportedly performed a tracheotomy on one of his soldiers and “opened the trachea of a choking soldier with the point of his sword.” The prominent Roman surgeon Galen of Pergamon (130–200 B.C.) wrote that his colleague Asclepiasds of Bithynia performed the first elective tracheotomy. Early evidence of the procedure surfaced again in the medical text Epitome written by Paul of Aeginas (625–690 B.C.) with this description of tracheotomy: “In cases of inflammation of the mouth or palate, it is reasonable to use tracheotomy (pharyngotomy) in order to prevent suffocation. We cut the trachea below the upper part at the level of the third or fourth ring. For a better exposure of the trachea, the head needs to be reclined. A transverse incision is made in between two tracheal rings, so it is not the cartilage that is incised, but the tissue in between.” The procedure was deemed a success by “a wheezing noise escaping from the hole in the trachea and the loss of the patient’s voice.” For unknown reasons, the procedure fell out of favor during the fifth century, and its use was rarely documented over the next millennium. tracheotomy reemerged in the medical literature in 1546 when the Italian surgeon Antonia Musa Brasavola is credited with reintroducing the procedure on a patient dying from asphyxiation from an upper airway obstruction and is quoted as saying, “when there is no other possibility, in angina, of admitting air to the heart, we must incise the larynx below the abscess.” Hieronymus Fabricus (1537–1619) is credited with first using a cannula which was short and straight so as to reduce the risk of posterior tracheal wall puncture and flanges to prevent aspiration of the instrument.

In 1626, another Italian surgeon, Sanctorio Sanctorius, performed the first percutaneous approach to tracheotomy and described the procedure by using a “ripping needle” to introduce a silver cannula into the tracheal lumen and then removed the needle. Despite the technical improvements in regard to the procedural approach to tracheotomy, it remained a highly morbid procedure leading to the majority of practicing surgeons to shy away from performing it. This most famously occurred on the evening of December 14, 1799, when a patient was fatally struck with “cynanche trachealis” presumed to be bacterial epiglottitis. He was surrounded at the bedside by 3 prominent physicians, Dr. James Craik, Dr. Gustav Brown, and Dr. Elisha Dick. At the time, bloodletting was a mainstay treatment and tracheotomy was still considered experimental. Dr. Dick had recently been trained in tracheotomy and reportedly a debate ensued between Dr. Dick and Dr. Craik in regard to the appropriate treatment. As the senior physician on the team, Dr. Craik vetoed this suggestion by Dr. Dick and continued to pursue bloodletting which was ineffective. Although tracheotomy would have likely saved his life, it was not performed, and at 10:20 pm that evening, George Washington, the first president of the United States of America, died with his wife Martha at his bedside (Fig. 66.3).

During the diphtheria epidemic of 1833, Pierre Bretonneau and his student Armand Trousseau were the first physicians to document using tracheotomy on a routine basis. During this epidemic, Dr. Trousseau was quoted as stating, “Today gentleman, I have performed this operation more than 200 times and I am reasonable happy to have a success in more than 25% of cases.” Trousseau was also the first to use a spreader to keep the trachea open during the procedure. In 1869, Trendelenburg developed the first cuffed tracheotomy tube, and although this was an improvement, due to its high operative mortality, tracheotomy continued to be used in limited circumstances at only a few institutions worldwide. The tracheotomy procedure further declined during the late 1800s. During that time, Dr. Joseph O’Dwyer joined the ­hospital staff at the Foundling Asylum of the Sisters of Charity in New York after completing his training at the College of Physicians and Surgeons in New York City. At that time, there continued to be a very high mortality of patients with laryngotracheal croup. From the period of 1869–1880, every patient who underwent a tracheotomy at the Foundling Asylum had died. Dr. O’Dwyer decided to make it his life’s work to discover a treatment to prevent suffocation without surgical intervention and, as a result, pioneered the orotracheal tube. In 1894, he presented his data at the National Sciences Research Workers Meeting in Nuremberg that 40% of the 1,324 cases he had treated had fully recovered.

It was not until the early twentieth century that tracheotomy regained popularity due to the standardization of open surgical tracheotomy by the famous American surgeon Chevalier Jackson. Jackson is credited with reducing the operative mortality associated with tracheotomy at that time from 25% to 1%. He recognized and emphasized the importance of adequate oxygenation during the procedure as well as airway control. He also further advanced all surgical techniques by recognizing the importance of postoperative care. In the 1930s, tracheotomy was advocated as an effective way to provide bronchopulmonary toilet in patients with polio. Due to the continued modern track record of safety associated with the placement of tracheotomy tubes along with the widespread use of positive pressure ventilation in the 1950s, there was considerable effort focused on the development of tracheotomy tubes as a means of providing long-term ventilatory support.

In 1955, Shelden introduced the first modern-day percutaneous tracheotomy set which closely resembled the approach fist described by Sanctorius 500 years earlier. The procedure used a trocar over a needle that resulted in multiple deaths secondary to airway and vascular injury and was abandoned. In 1967, Toye and Weinstein first used the Seldinger technique to safely introduce a cannula into the tracheal lumen. The technique was further refined by Pasquale Ciaglia in 1985 in what has now become one of the most popular techniques for percutaneous dilatational tracheotomy (PDT).