A brief history of clinical airway management

Given the remarkable advances that have occurred in clinical airway management in recent years it is only natural for clinicians to wonder how airway management was carried out in distant times. It turns out that the art of clinical airway management is as old as medicine itself. For instance, there is evidence that the tracheotomy operation was portrayed on Egyptian tablets dating back to 3,600 BC, while reference to the procedure can be found in ancient Hindu scriptures dating from 2000 BC(1,2). It is also said that Alexander the Great (356-323 BC) saved a soldier from suffocation by making a tracheal incision using the tip of his dagger(3). Later, in 100 AD, Antyllus described tracheotomy as a «horizontal incision between 2 tracheal rings to bypass upper airway obstruction»(4) while in 160 AD, the Roman physician Galen wrote, «If you take a dead animal and blow air through its larynx (through a reed), you will fill its bronchi and watch its lungs attain the greatest dimension»(5) (Figure 1) illustrates a description of the operation in a 17th century textbook. Despite such ancient reports, however, according to Sittig and Pringnitz(6), before 1,800 only 50 life-saving tracheotomies had been described in the entire medical literature; common clinical use of the procedure would have to wait until pioneers such as Trousseau and Trendelenburg refined and popularized the operation. In 1833 Trousseau reported on his experience with 200 diphtheria patients treated with tracheotomy(7). In 1871, Trendelenburg performed a tracheotomy to prevent blood inhalation during upper airway surgery(8). As experience with the tracheotomy operation grew, consideration to less invasive techniques arose. In 1880, in Scotland, William Macewen described how to relieve airway obstruction by passing an oral tube into the trachea(9). He practiced blind, digital intubation using cadaver models and eventually was able to use this technique clinically. A few years later, in the USA, Joseph O’Dwyer developed a metal tube system that could be passed blindly to relieve airway obstruction in children suffocating from the pseudo membrane formed with diphtheria infections(10) (Figure 2). Later, George Fell developed an apparatus that could be attached to the O’Dwyer tube system to allow for positive pressure ventilation(11). This combination was used by Fell and others to provide temporary respiratory support in some patients who were apneic from respiratory depressant drugs such as morphine. The combination was also used to treat patients with pneumothoraces and to allow for thoracic surgical procedures. Across the ocean in Germany, Hans Kuhn modified O’Dwyer’s tube system to create a flexometallic endotracheal tube with matching introducer intended for blind insertion(12).