**5. Tracheostomy and oxygenation**

To prevent or reverse hypoxemia and provide oxygen to the tissues during acute respiratory failure, airway access is often provided by translaryngeal endotracheal tube. When mechanical ventilation is expected to be prolonged, TQT tube is frequently chosen as part of the airway management care plan [86–88].

Earlier TQT records were found in the Edwin Smith Papyrus (1600 BC), whereas an emergency airway was performed after a trauma [89]. The first surgical description of successful case of TQT was performed by Antonio Musa Brasavola (1546) [90] and a full book dedicated to this procedure, previously known as bronchotomy, was published in 1620 [91] by Nicolas Habicot, who pictured it as demonstrated in **Figure 4**.

#### **Figure 4.**

*[92] Patient's tracheostomy by Nicolas Habitot. A: the patient; B: the larynx; C: bronchotomy insertion; D: bronchotomy's instrument; E: the cannula; F: cannula's strap; G: a band to apply over the cannula to control the air leakage; H: the needle to suture the wound when needed.*

During the Second World War, TQT grown relevance in chest trauma patients [93] and since then, it is expanding its role in airway management, as well improvement of the surgical techniques, instruments and cannulas.

Prolonged/impractical intubation, ventilation support for weaning, pulmonary hygiene management and airway protection are main indications for TQT placement [86–88, 94]. Patients can benefit from tracheostomy that is performed by open surgical (OST) or percutaneous dilatory (PDT) techniques.

Patient's individual aspects assist the medical team to decide whether to use PDT or OST. PDT is recommended for patients who can hyperextend the neck, tolerate hypercarbia and hypoxemia, and present at least 1-cm distance between the inferior cricoid cartilage and the suprasternal notch (in case of needed re-intubated after accidental extubation) [86–88]. PDT relative contraindications are emergency airway access, anatomical incompatibility, coagulopathies, higher levels for support oxygenation (e.g. positive end-expiratory pressure ≥ 10 mm Hg or fraction of inspired oxygen ≥0.7), and infection at insertion site surroundings [86–88].

Studies were carried out to establish advantages and preferences between techniques. A Cochrane review did not find statistical difference for mortality and serious life-threatening adverse events between techniques [95]. However, PDT presented significantly reduced rate for wound infections/stomatitis and unfavorable scaring. Other systematic reviews and meta-analysis confirmed the same result trend: no difference in mortality and life-threatening complications [96–100]. Significant positive outcomes for PDT was cited as less infection rate [97–100] and less procedure time [96, 100–102]. Besides these results, OST could also impact hospital expenditures, since the procedure can require an operatory room and staff [88, 103, 104].
