Conventional surgical tracheostomy as the preferred method of airway management

Abstract

Tracheostomy was first described in the early Christian era.’ In 1909, Jackson standardized tracheostomy as we know it today.2 Although many modifications have been introduced since that time, Jackson’s conventional surgical technique has remained the gold standard, having been used in elective and emergent cases, in the operating room (OR) and in the intensive care unit (ICU).3-8 Indications for tracheostomy are the same regardless of the technique, including airway access for prolonged mechanical ventilation, facilitation of removal of tracheobronchial secretions, and elimination of upper airway obstruction. The last decade has seen a shift toward performing tracheostomy via Ciaglia et al’s percutaneous dilational technique,9 because studies have shown it to be safe, relatively easy to learn, and cost-effective when performed in the ICU (compared with conventional surgical tracheostomy in the operating room).10-28 However, surgeons should recognize that variability in performing a given technique adds error to any clinical comparison and potential bias to the literature. For example, in one trial, conventional surgical tracheostomies were performed by 18 different surgeons.18 This discussion supports conventional surgical tracheostomy as a safe technique that can be performed in the ICU, questions the trend away from conventional surgical tracheostomy toward percutaneous techniques for reasons of greater cost, suggests that conventional surgical tracheostomy is simple and can be performed quickly, and asserts that it is a fundamental surgical skill that should be mastered before performing alternative tracheostomy techniques.