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Sexual selection
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This article is about the evolutionary concept. For the artificial selection of the sex of offspring, see sex selection.
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Sexual selection creates colourful differences between sexes (sexual dimorphism) in Goldie's bird-of-paradise. Male above; female below. Painting by John Gerrard Keulemans (d.1912)
Sexual selection is a form of natural selection where one sex prefers a specific characteristic in an individual of the other sex. Peafowls exhibit sexual selection in that peahens look for peacocks with more "eyes" on their tail feathers. This causes the peacocks with fewer eyes to die out and those with more to become more common.
Sexual selection is a mode of natural selection where members of one biological sex choose mates of the other sex to mate with (intersexual selection), and compete with members of the same sex for access to members of the opposite sex (intrasexual selection). These two forms of selection mean that some individuals have better reproductive success than others within a population, either from being more attractive or preferring more attractive partners to produce offspring.[1][2] For instance in the breeding season sexual selection in frogs occurs with the males first gathering at the water's edge and making their mating calls: croaking. The females then arrive and choose the males with the deepest croaks and best territories. Generalizing, males benefit from frequent mating and monopolizing access to a group of fertile females. Females have a limited number of offspring they can have and they maximize the return on the energy they invest in reproduction.
The concept was first articulated by Charles Darwin and Alfred Russel Wallace who described it as driving speciation and that many organisms had evolved features whose function was deleterious to their individual survival,[3] and then developed by Ronald Fisher in the early 20th century. Sexual selection can lead typically males to extreme efforts to demonstrate their fitness to be chosen by females, producing sexual dimorphism in secondary sexual characteristics, such as the ornate plumage of birds such as birds of paradise and peafowl, or the antlers of deer, or the manes of lions, caused by a positive feedback mechanism known as a Fisherian runaway, where the passing-on of the desire for a trait in one sex is as important as having the trait in the other sex in producing the runaway effect. Although the sexy son hypothesis indicates that females would prefer male offspring, Fisher's principle explains why the sex ratio is 1:1 almost without exception. Sexual selection is also found in plants and fungi.
The maintenance of sexual reproduction in a highly competitive world is one of the major puzzles in biology given that asexual reproduction can reproduce much more quickly as 50% of offspring are not males, unable to produce offspring themselves. Many non-exclusive hypotheses have been proposed,[4] including the positive impact of an additional form of selection, sexual selection, on the probability of persistence of a species.[5]
Contents
[hide]
1 History
1.1 Darwin
1.2 Ronald Fisher
2 Theory
2.1 Reproductive success
2.2 Modern interpretation
2.3 Toolkit of natural selection
2.4 Sexual dimorphism
3 In different taxa
4 References
4.1 Citations
4.2 Sources
5 External links
History[edit]
Darwin[edit]
Sexual selection was first proposed by Charles Darwin in The Origin of Species (1859) and developed in The Descent of Man and Selection in Relation to Sex (1871), as he felt that natural selection alone was unable to account for certain types of non-survival adaptations. He once wrote to a colleague that "The sight of a feather in a peacock's tail, whenever I gaze at it, makes me sick!" His work divided sexual selection into male-male competition and female choice.
... depends, not on a struggle for existence, but on a struggle between the males for possession of the females; the result is not death to the unsuccessful competitor, but few or no offspring.[6]
... when the males and females of any animal have the same general habits ... but differ in structure, colour, or ornament, such differences have been mainly caused by sexual selection.[7]
These views were to some extent opposed by Alfred Russel Wallace, mostly after Darwin's death. He accepted that sexual selection could occur, but argued that it was a relatively weak form of selection. He argued that male-male competitions were forms of natural selection, but that the "drab" peahen's coloration is itself adaptive as camouflage. In his opinion, ascribing mate choice to females was attributing the ability to judge standards of beauty to animals (such as beetles) far too cognitively undeveloped to be capable of aesthetic feeling.[8]
Ronald Fisher[edit]
Ronald Fisher, the English statistician and evolutionary biologist developed a number of ideas about sexual selection in his 1930 book The Genetical Theory of Natural Selection including the sexy son hypothesis and Fisher's principle. The Fisherian runaway describes how sexual selection accelerates the preference for a specific ornament, causing the preferred trait and female preference for it to increase together in a positive feedback runaway cycle. In a remark that was not widely understood[9] for another 50 years he said:
... plumage development in the male, and sexual preference for such developments in the female, must thus advance together, and so long as the process is unchecked by severe counterselection, will advance with ever-increasing speed. In the total absence of such checks, it is easy to see that the speed of development will be proportional to the development already attained, which will therefore increase with time exponentially, or in geometric progression. —Ronald Fisher, 1930
Male long-tailed widowbird
This causes a dramatic increase in both the male's conspicuous feature and in female preference for it, resulting in marked sexual dimorphism, until practical physical constraints halt further exaggeration. A positive feedback loop is created, producing extravagant physical structures in the non-limiting sex. A classic example of female choice and potential runaway selection is the long-tailed widowbird. While males have long tails that are selected for by female choice, female tastes in tail length are still more extreme with females being attracted to tails longer than those that naturally occur.[10] Fisher understood that female preference for long tails may be passed on genetically, in conjunction with genes for the long tail itself. Long-tailed widowbird offspring of both sexes inherit both sets of genes, with females expressing their genetic preference for long tails, and males showing off the coveted long tail itself.[9]
Richard Dawkins presents a non-mathematical explanation of the runaway sexual selection process in his book The Blind Watchmaker.[9] Females that prefer long tailed males tend to have mothers that chose long-tailed fathers. As a result, they carry both sets of genes in their bodies. That is, genes for long tails and for preferring long tails become linked. The taste for long tails and tail length itself may therefore become correlated, tending to increase together. The more tails lengthen, the more long tails are desired. Any slight initial imbalance between taste and tails may set off an explosion in tail lengths. Fisher wrote that:
The exponential element, which is the kernel of the thing, arises from the rate of change in hen taste being proportional to the absolute average degree of taste. —Ronald Fisher, 1932[11]
The peacock tail in flight, the classic example of a Fisherian runaway
The female widow bird chooses to mate with the most attractive long-tailed male so that her progeny, if male, will themselves be attractive to females of the next generation - thereby fathering many offspring that carry the female's genes. Since the rate of change in preference is proportional to the average taste amongst females, and as females desire to secure the services of the most sexually attractive males, an additive effect is created that, if unchecked, can yield exponential increases in a given taste and in the corresponding desired sexual attribute.
It is important to notice that the conditions of relative stability brought about by these or other means, will be far longer duration than the process in which the ornaments are evolved. In most existing species the runaway process must have been already checked, and we should expect that the more extraordinary developments of sexual plumage are not due like most characters to a long and even course of evolutionary progress, but to sudden spurts of change. —Ronald Fisher, 1930
Since Fisher's initial conceptual model of the 'runaway' process, Russell Lande[12] and Peter O'Donald[13] have provided detailed mathematical proofs that define the circumstances under which runaway sexual selection can take place.
Theory[edit]
Reproductive success[edit]
Extinct Irish elk (Megaloceros giganteus). These antlers span 2.7 metres (8.9 ft) and have a mass of 40 kg (88 lb).
The reproductive success of an organism is measured by the number of offspring left behind, and their quality or probable fitness.
Sexual preference creates a tendency towards assortative mating or homogamy. The general conditions of sexual discrimination appear to be (1) the acceptance of one mate precludes the effective acceptance of alternative mates, and (2) the rejection of an offer is followed by other offers, either certainly, or at such high chance that the risk of non-occurrence is smaller than the chance advantage to be gained by selecting a mate.
The conditions determining which sex becomes the more limited resource in intersexual selection can be best understood by way of Bateman's principle which states that the sex which invests the most in producing offspring becomes a limiting resource over which the other sex competes", illustrated by the greater nutritional investment of an egg in a zygote, and the limited capacity of females to reproduce; for example in humans a woman can only give birth every ten months whereas in theory a male can become a father every day.
Modern interpretation[edit]
Male mountain gorilla, a tournament species
The sciences of evolutionary psychology, human behavioural ecology, and sociobiology study the influence of sexual selection in humans.
Darwin's ideas on sexual selection were met with scepticism by his contemporaries and not considered of great importance in the early 20th century, until in the 1930s biologists decided to include sexual selection as a mode of natural selection.[14] Only in the 21st century have they become more important in biology.[15] The theory however is generally applicable and analogous to natural selection.[16]
Flour beetle
Tungara frog
Research in 2015 indicates that sexual selection, including mate choice, "improves population health and protects against extinction, even in the face of genetic stress from high levels of inbreeding" and "ultimately dictates who gets to reproduce their genes into the next generation - so it's a widespread and very powerful evolutionary force." The study involved the flour beetle over a ten-year period where the only changes were in the intensity of sexual selection.[5]
Another theory, the handicap principle of Amotz Zahavi, Russell Lande and W. D. Hamilton, holds that the fact that the male is able to survive until and through the age of reproduction with such a seemingly maladaptive trait is taken by the female to be a testament to his overall fitness. Such handicaps might prove he is either free of or resistant to disease, or that he possesses more speed or a greater physical strength that is used to combat the troubles brought on by the exaggerated trait. Zahavi's work spurred a re-examination of the field, which has produced an ever-accelerating number of theories. In 1984, Hamilton and Marlene Zuk introduced the "Bright Male" hypothesis, suggesting that male elaborations might serve as a marker of health, by exaggerating the effects of disease and deficiency. In 1990, Michael Ryan and A.S. Rand, working with the tungara frog, proposed the hypothesis of "Sensory Exploitation", where exaggerated male traits may provide a sensory stimulation that females find hard to resist. Subsequently, the theories of the "Gravity Hypothesis" by Jordi Moya-Larano et al. (2002), invoking a simple biomechanical model to account for the adaptive value for smaller male spiders of speed in clmbing vertical surfaces,[17] and "Chase Away" by Brett Holland and William R. Rice have been added. In the late 1970s, Janzen and Mary Willson, noting that male flowers are often larger than female flowers, expanded the field of sexual selection into plants.[18]
In the past few years, the field has exploded to include other areas of study, not all of which fit Darwin's definition of sexual selection. These include cuckoldry, nuptial gifts, sperm competition, infanticide (especially in primates), physical beauty, mating by subterfuge, species isolation mechanisms, male parental care, ambiparental care, mate location, polygamy, and homosexual rape in certain male animals.
Focusing on the effect of sexual conflict, as hypothesized by William Rice, Locke Rowe et Göran Arnvist, Thierry Lodé argues that divergence of interest constitutes a key for evolutionary process. Sexual conflict leads to an antagonistic co-evolution in which one sex tends to control the other, resulting in a tug of war. Besides, the sexual propaganda theory only argued that mate were opportunistically lead, on the basis of various factors determining the choice such as phenotypic characteristics, apparent vigour of individual, strength of mate signals, trophic resources, territoriality etc. and could explain the maintenance of genetic diversity within populations.[19]
Several workers have brought attention to the fact that elaborated characters that ought to be costly in one way or another for their bearers (e.g., the tails of some species of Xiphophorus fish) do not always appear to have a cost in terms of energetics, performance or even survival. One possible explanation for the apparent lack of costs is that "compensatory traits" have evolved in concert with the sexually selected traits.[20]
Toolkit of natural selection[edit]
Protarchaeopteryx - skull based on Incisivosaurus and wings on Caudipteryx
Sexual selection may explain how certain characteristics (such as feathers) had distinct survival value at an early stage in their evolution. Geoffrey Miller proposes that sexual selection might have contributed by creating evolutionary modules such as Archaeopteryx feathers as sexual ornaments, at first. The earliest proto-birds such as China's Protarchaeopteryx, discovered in the early 1990s, had well-developed feathers but no sign of the top/bottom asymmetry that gives wings lift. Some have suggested that the feathers served as insulation, helping females incubate their eggs. But perhaps the feathers served as the kinds of sexual ornaments still common in most bird species, and especially in birds such as peacocks and birds-of-paradise today. If proto-bird courtship displays combined displays of forelimb feathers with energetic jumps, then the transition from display to aerodynamic functions could have been relatively smooth.[21]
Sexual selection sometimes generates features that may help cause a species' extinction, as has been suggested[21] for the giant antlers of the Irish elk (Megaloceros giganteus) that became extinct in Pleistocene Europe.[22] However, sexual selection can also do the opposite, driving species divergence - sometimes through elaborate changes in genitalia - such that new species emerge.[23][24][25]
Sexual dimorphism[edit]
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Main article: Sexual dimorphism
Sex differences directly related to reproduction and serving no direct purpose in courtship are called primary sexual characteristics. Traits amenable to sexual selection, which give an organism an advantage over its rivals (such as in courtship) without being directly involved in reproduction, are called secondary sex characteristics.
The rhinoceros beetle is a classic case of sexual dimorphism. Plate from Darwin's Descent of Man, male at top, female at bottom
In most sexual species the males and females have different equilibrium strategies, due to a difference in relative investment in producing offspring. As formulated in Bateman's principle, females have a greater initial investment in producing offspring (pregnancy in mammals or the production of the egg in birds and reptiles), and this difference in initial investment creates differences in variance in expected reproductive success and bootstraps the sexual selection processes. Classic examples of reversed sex-role species include the pipefish, and Wilson's phalarope. Also, unlike a female, a male (except in monogamous species) has some uncertainty about whether or not he is the true parent of a child, and so is less interested in spending his energy helping to raise offspring that may or may not be related to him. As a result of these factors, males are typically more willing to mate than females, and so females are typically the ones doing the choosing (except in cases of forced copulations, which can occur in certain species of primates, ducks, and others). The effects of sexual selection are thus held to typically be more pronounced in males than in females.
Differences in secondary sexual characteristics between males and females of a species are referred to as sexual dimorphisms. These can be as subtle as a size difference (sexual size dimorphism, often abbreviated as SSD) or as extreme as horns and colour patterns. Sexual dimorphisms abound in nature. Examples include the possession of antlers by only male deer, the brighter coloration of many male birds in comparison with females of the same species, or even more distinct differences in basic morphology, such as the drastically increased eye-span of the male stalk-eyed fly. The peacock, with its elaborate and colourful tail feathers, which the peahen lacks, is often referred to as perhaps the most extraordinary example of a dimorphism. Male and female black-throated blue warblers and Guianan cock-of-the-rocks also differ radically in their plumage. Early naturalists even believed the females to be a separate species. The largest sexual size dimorphism in vertebrates is the shell dwelling cichlid fish Neolamprologus callipterus in which males are up to 30 times the size of females. Many other fish such as guppies also exhibit sexual dimorphism. Extreme sexual size dimorphism, with females larger than males, is quite common in spiders and birds of prey.
In different taxa[edit]
SEM image of lateral view of a love dart of the land snail Monachoides vicinus. The scale bar is 500 μm (0.5 mm).
Sexual selection in birds - mammals - humans -scaled reptiles - amphibians - insects - spiders - major histocompatibility complex
Human spermatozoa can reach 250 million in a single ejaculation
Sexual selection has been observed to occur in plants, animals and fungi.[26] In certain hermaphroditic snail and slug species of molluscs the throwing of love darts is a form of sexual selection.[27] Certain male insects of the lepidoptera order of insects cement the vaginal pores of their females.[28]
A male bed bug (Cimex lectularius) traumatically inseminates a female bed bug (top). The female's ventral carapace is visibly cracked around the point of insemination.
Today, biologists say that certain evolutionary traits can be explained by intraspecific competition - competition between members of the same species - distinguishing between competition before or after sexual intercourse.
Illustration from The Descent of Man showing the tufted coquette Lophornis ornatus: female on left, ornamented male on right
Before copulation, intrasexual selection - usually between males - may take the form of male-to-male combat. Also, intersexual selection, or mate choice, occurs when females choose between male mates.[29] Traits selected by male combat are called secondary sexual characteristics (including horns, antlers, etc.), which Darwin described as "weapons", while traits selected by mate (usually female) choice are called "ornaments". Due to their sometimes greatly exaggerated nature, secondary sexual characteristics can prove to be a hindrance to an animal, thereby lowering its chances of survival. For example, the large antlers of a moose are bulky and heavy and slow the creature's flight from predators; they also can become entangled in low-hanging tree branches and shrubs, and undoubtedly have led to the demise of many individuals. Bright colourations and showy ornamenations, such as those seen in many male birds, in addition to capturing the eyes of females, also attract the attention of predators. Some of these traits also represent energetically costly investments for the animals that bear them. Because traits held to be due to sexual selection often conflict with the survival fitness of the individual, the question then arises as to why, in nature, in which survival of the fittest is considered the rule of thumb, such apparent liabilities are allowed to persist. However, one must also consider that intersexual selection can occur with an emphasis on resources that one sex possesses rather than morphological and physiological differences. For example, males of Euglossa imperialis, a non-social bee species, form aggregations of territories considered to be leks, to defend fragrant-rich primary territories. The purpose of these aggregations is only facultative, since the more suitable fragrant-rich sites there are, the more habitable territories there are to inhabit, giving females of this species a large selection of males with whom to potentially mate.[30]
After copulation, male–male competition distinct from conventional aggression may take the form of sperm competition, as described by Parker[31] in 1970. More recently, interest has arisen in cryptic female choice,[32] a phenomenon of internally fertilised animals such as mammals and birds, where a female can get rid of a male's sperm without his knowledge.
Victorian cartoonists quickly picked up on Darwin's ideas about display in sexual selection. Here he is fascinated by the apparent steatopygia in the latest fashion.
Finally, sexual conflict is said to occur between breeding partners,[33] sometimes leading to an evolutionary arms race between males and females. Sexual selection can also occur as a product of pheromone release, such as with the stingless bee, Trigona corvina.[34]
Female mating preferences are widely recognized as being responsible for the rapid and divergent evolution of male secondary sexual traits.[35] Females of many animal species prefer to mate with males with external ornaments - exaggerated features of morphology such as elaborate sex organs. These preferences may arise when an arbitrary female preference for some aspect of male morphology — initially, perhaps, a result of genetic drift — creates, in due course, selection for males with the appropriate ornament. One interpretation of this is known as the sexy son hypothesis. Alternatively, genes that enable males to develop impressive ornaments or fighting ability may simply show off greater disease resistance or a more efficient metabolism, features that also benefit females. This idea is known as the good genes hypothesis.
Darwin conjectured that heritable traits such as beards and hairlessness in different human populations are results of sexual selection in humans. Geoffrey Miller has hypothesized that many human behaviours not clearly tied to survival benefits, such as humour, music, visual art, verbal creativity, and some forms of altruism, are courtship adaptations that have been favoured through sexual selection. In that view, many human artefacts could be considered subject to sexual selection as part of the extended phenotype, for instance clothing that enhances sexually selected traits. Some argue that the evolution of human intelligence is a sexually selected trait, as it would not confer enough fitness in itself relative to its high maintenance costs.[36]
References[edit]
Citations[edit]
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^ Jump up to: a b Population benefits of sexual selection explain the existence of males phys.org May 18, 2015 Report on a study by the University of East Anglia
Jump up ^ Darwin, Charles (1859). On the Origin of Species (1st edition). Chapter 4, page 88. "And this leads me to say a few words on what I call Sexual Selection. This depends ..." http://darwin-online.org.uk/content/frameset?viewtype=side&itemID=F373&pageseq=12
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^ Jump up to: a b c Dawkins, Richard (1986). The Blind Watchmaker. Longman, London. Published in Penguin Books 1988, 1991, and 2006. Chapter 8, Explosions and Spirals.
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Jump up ^ Ronald Fisher in a letter to Charles Galton Darwin, 22 November 1932, cited in Fisher, R. A., Bennett, J. H. 1999. The genetical theory of natural selection: A complete variorum edition, Oxford University Press, Oxford, p. 308
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Jump up ^ Miller, Geoffey, The Mating Mind, p.24
Jump up ^ Sexual Selection and the Mind
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Jump up ^ Moya-Laraño, J. (2007). "Gravity still matters". Functional Ecology. 21: 1178–1181. doi:10.1111/j.1365-2435.2007.01335.x.
Jump up ^ Wilson, Mary F (June 1979). "Sexual Selection In Plants". The American Naturalist. 113, No. 6: 777–790.
Jump up ^ Thierry Lodé (2006). "La guerre des sexes chez les animaux " Eds Odile Jacob, Paris. ISBN 2-7381-1901-8
Jump up ^ Sexual Selection Costs & Compensations
^ Jump up to: a b Miller, Geoffrey (2000). The Mating Mind. Anchor Books, a division of Random House, Inc. (First Anchor Books Edition, April 2001). New York, NY. Anchor ISBN 0-385-49517-X
Jump up ^ Gould, Stephen J. (1974). "Origin and Function of 'Bizarre' Structures - Antler Size and Skull Size in 'Irish Elk', Megaloceros giganteus". Evolution. 28 (2): 191–220. doi:10.2307/2407322.
Jump up ^ Hosken, David J., and Paula Stockley. "Sexual selection and genital evolution." Trends in Ecology & Evolution 19.2 (2004): 87-93.
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Jump up ^ Eberhard, W. G. (1985). Sexual Selection and Animal Genitalia. Harvard University Press, Cambridge, Mass.
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Jump up ^ Tales of two snails: sexual selection and sexual conflict in Lymnaea stagnalis and Helix aspersa Oxford Journals
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Jump up ^ Campbell, N. A.; J. B. Reece (2005). Biology. Benjamin Cummings. p. 1230. ISBN 0-8053-7146-X.
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Sources[edit]
Andersson, M. (1994) Sexual selection. Princeton University Press. ISBN 0-691-00057-3
Arnqvist, G. & Rowe, L. (2013) Sexual conflict. Princeton University Press
Lande, C. F. R. (1981). "Models of speciation by sexual selection on polygenic traits" (PDF). Proc. Natl. Acad. Sci. U.S.A. 78 (6): 3721–5. doi:10.1073/pnas.78.6.3721. PMC 319643  . PMID 16593036. Archived from the original (PDF) on 2007-09-27.
Cronin, H. (1991) The ant and the peacock: altruism and sexual selection from Darwin to today. Cambridge University Press.
Darwin, C. (1871) The Descent of Man and Selection in Relation to Sex. John Murray, London.
Eberhard, W. G. (1996) Female control: Sexual selection by cryptic female choice. Princeton, Princeton University Press.
Fisher, R. A. (1930) The Genetical Theory of Natural Selection. Oxford University Press, ISBN 0-19-850440-3, Chapter 6 Memeoid.net
Lodé, T. (2006) La guerre des sexes chez les animaux. Eds Odile Jacob. ISBN 2-7381-1901-8
Miller, G. F. (1998) How mate choice shaped human nature: A review of sexual selection and human evolution. In: C. Crawford & D. Krebs (Eds.) Handbook of evolutionary psychology: Ideas, issues, and applications. Lawrence Erlbaum, pp. 87–129
Miller, G. F. (2000) The Mating Mind: How sexual choice shaped the evolution of human nature. Heinemann, London. ISBN 0-434-00741-2
Rosenberg, J. & Tunney, R. J. (2008). Human vocabulary use as display. Evolutionary Psychology, 6, 538-549
External links[edit]
Wikimedia Commons has media related to Sexual selection.
Natural & Sexual Selection Videos by the Cornell Lab of Ornithology
Sexual Selection: Stanford University
The Great Debate: Sexual Selection
Intralocus Sexual Conflict Diminishes the Benefits of Sexual Selection
A New Interpretation of Natural Beauty and Sexual Selection
Review of GF Miller's The Mating Mind
Why Sex Evolved
"The sexual propaganda theory"
"Sexual Selection Theory and Human Reproductive Behaviour "
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text:
Tracheotomy
From Wikipedia, the free encyclopedia
Jump to: navigation, search
This article is about the surgical procedure called a tracheotomy. For a similar procedure, see Cricothyrotomy.
Tracheotomy
Completed tracheotomy:
1 – Vocal folds
2 – Thyroid cartilage
3 – Cricoid cartilage
4 – Tracheal rings
5 – Balloon cuff
ICD-10-PCS
0B110F4
ICD-9-CM
31.1
MeSH
D014140
MedlinePlus
002955
[edit on Wikidata]
Tracheotomy (US: /ˌtreɪkiˈɒtəmi/ tray-kee-AW-tə-mee) or tracheostomy, is a surgical procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea (windpipe). The resulting stoma (hole), can serve independently as an airway or as a site for a tracheal tube or tracheostomy tube[1] to be inserted; this tube allows a person to breathe without the use of the nose or mouth.
Contents
[hide]
1 Etymology and terminology
2 Indications
2.1 Long term ventilation
2.2 Bypassing upper airway blockages
3 Parts
4 Surgical procedure
4.1 Instruments
4.2 Percutaneous tracheotomy
4.3 The translaryngeal tracheostomy TLT Fantoni method
5 Complications
6 Alternatives
7 Routine care
7.1 Suctioning
8 History
8.1 Prior to 16th century
8.2 16th–18th centuries
8.3 19th century
8.4 20th century
9 See also
10 References
11 External links
Etymology and terminology[edit]
The etymology of the word tracheotomy comes from two Greek words: the root tom- (from Greek τομή tomḗ) meaning "to cut", and the word trachea (from Greek τραχεία tracheía).[2] The word tracheostomy, including the root stom- (from Greek στόμα stóma) meaning "mouth," refers to the making of a semi-permanent or permanent opening, and to the opening itself. Some sources offer different definitions of the above terms. Part of the ambiguity is due to the uncertainty of the intended permanence of the stoma at the time it is created.[3]
Indications[edit]
Long term ventilation[edit]
Main article: Mechanical ventilation
Tracheotomy tubes and endotracheal tubes are often attached to ventilators to assist in breathing.
An endotracheal tube (above) used in acute settings requires sedation. For longer term settings a tracheostomy tube is used instead.
In the chronic (long term) setting, indications for tracheotomy include the need for long-term mechanical ventilation and tracheal toilet (e.g. comatose patients, or extensive surgery involving the head and neck). Tracheotomy may result in a significant reduction in the administration of sedatives and vasopressors, as well as the duration of stay in the intensive care unit.[4] In extreme cases, the procedure may be indicated as a treatment for severe obstructive sleep apnea (OSA) seen in patients intolerant of continuous positive airway pressure (CPAP) therapy. The reason tracheostomy works well for OSA is because it is the only surgical procedure that completely bypasses the upper airway. This procedure was commonly performed for obstructive sleep apnea until the 1980s, when other procedures such as the uvulopalatopharyngoplasty, genioglossus advancement, and maxillomandibular advancement surgeries were described as alternative surgical modalities for OSA.
Bypassing upper airway blockages[edit]
In the acute (short term) setting, indications for tracheotomy include such conditions as severe facial trauma, tumors of the head and neck (e.g., cancers, branchial cleft cysts), and acute angioedema and inflammation of the head and neck. In the context of failed orotracheal or nasotracheal intubation, either tracheotomy or cricothyrotomy may be performed.
Parts[edit]
An outer cannula (top item) with inflatable cuff (top right), an inner cannula (center item) and an obturator (bottom item)
A tracheostomy tube consists of an outer cannula or main shaft, an inner cannula, and an obturator. The obturator is used when inserting the tracheostomy tube to guide the placement of the outer cannula and is removed once the outer cannula is in place. The outer cannula remains in place but, because of the buildup of secretions, there is an inner cannula that may be removed for cleaning or replaced. Tracheostomy tubes may have cuffs, inflatable balloons at the end of the tube to secure it in place. A tracheostomy tube may be fenestrated with one or several holes to let air through the larynx, allowing speech.[5]
Surgical procedure[edit]
Instruments[edit]
As with most other surgical procedures, some cases are more difficult than others. Surgery on children is more difficult because of their smaller size. Difficulties such as a short neck and bigger thyroid glands make the trachea hard to open.[6] There are other difficulties with patients with irregular necks, the obese, and those with a large goitre. The many possible complications include hemorrhage, loss of airway, subcutaneous emphysema, wound infections, stomal cellulites, fracture of tracheal rings, poor placement of the tracheostomy tube, and bronchospasm".[7]
By the late 19th century, some surgeons had become proficient in performing the tracheotomy procedure. The main instruments used were:
“Two small scalpels, one short grooved director, a tenaculum, two aneurysm needles which may be used as retractors, one pair of artery forceps, haemostatic forceps, two pairs of dissecting forceps, a pair of scissors, a sharp-pointed tenotome, a pair of tracheal forceps, a tracheal dilator, tracheotomy tubes, ligatures, sponges, a flexible catheter, and feathers”.[6]
Haemostatic forceps were used to control bleeding from separated vessels that were not ligatured because of the urgency of the operation. Generally, they were used to expose the trachea by clamping the isthmus thyroid gland on both sides. To open the trachea physically, a sharp-pointed tentome allowed the surgeon easily to place the ends into the opening of the trachea. The thin points permitted the doctor a better view of his incision. Tracheal dilators, such as the “Golding Bird”, were placed through the opening and then expanded by “turning the screw to which they are attached.” Tracheal forceps, as displayed on the right, were commonly used to extract foreign bodies from the larynx. The optimum tracheal tube at the time caused very little damage to the trachea and “mucus membrane”.[6]
The best position for a tracheotomy was and still is one that forces the neck into the biggest prominence. Usually, the patient was laid on his back on a table with a cushion placed under his shoulders to prop him up. The arms were restrained to ensure they would not get in the way later.[6] The tools and techniques used today in tracheotomies have come a long way. The tracheotomy tube placed into the incision through the windpipe comes in various sizes, thus allowing a more comfortable fit and the ability to remove the tube in and out of the throat without disrupting support from a breathing machine. In today’s world general anesthesia is used when performing these surgeries, which makes it much more tolerable for the patient. Special tracheostomy tube valves (such as the Passy-Muir valve[8]) have been created to assist people in their speech. The patient can inhale through the unidirectional tube. Upon expiration, pressure causes the valve to close, redirecting air around the tube, past the vocal folds, producing sound.[9]
Significant improvements to surgical instruments for tracheotomy include the direct suction tracheotomy tube invented by Josephine G. Fountain (RN); she was awarded patent no. 3039469 in 1962 for the direct suction tracheotomy tube, which improved the ways mucus could be cleared from the trachea and increased patient breathing and comfort.[10]
Percutaneous tracheotomy[edit]
While there were some earlier false starts, the first widely accepted percutaneous tracheotomy technique was described by Pat Ciaglia, a New York surgeon, in 1985. This technique involves a series of sequential dilatations using a set of seven dilators of progressively larger size.[11] The next widely used technique was developed in 1989 by Bill Griggs, an Australian intensive care specialist. This technique involves the use of a specially modified pair of forceps with a central hole enabling them to pass over a guidewire enabling the performance of the main dilation in a single step.[12] Since then a number of other techniques have been described. In 1995, Fantoni developed a translaryngeal approach of percutaneous tracheostomy which involves passing a guidewire through the larynx and over it railroading a tracheostomy tube with a cone shaped structure. It is also known as the In-and-out procedure. A variant of the original Ciaglia technique, using a single tapered dilator known as a "blue rhino", is the most commonly used of these newer techniques and has largely taken over from the early multiple dilator technique. Ambesh SP (2005) introduced a T-Trach kit (T-Dagger) which contains a T-shaped dilator with an elliptical shaft. The shaft of the dilator is marked in its length according to the sizes of tracheostomy tube to be introduced and has a number of holes. This T-shaped dilator provides better grip during its introduction and its elliptical shaft forms a calibrated tracheal stoma between two tracheal rings and minimizes tracheal ring fracture.[13] The Griggs and Ciaglia Blue Rhino techniques are the two main techniques in current use. A number of comparison studies have been undertaken between these two techniques with no clear differences emerging[14]
The translaryngeal tracheostomy TLT Fantoni method[edit]
The translaryngeal tracheostomy is a percutaneous technique characterized by the exclusive procedure to carry out the stoma. A cone of soft plastic material, welded to a flexible cannula, is passed into trachea through the glottis, and then extracted outside of the neck through the pretracheal layers. The direction of this dilational manoeuvre is from the inside of the tracheal lumen to the outside of the neck (In/Out) and therefore completely opposite to the Out/In of other traditional percutaneous tracheostomies. The cone is then separated from the cannula, which results in it being positioned in the trachea. This method ensures considerable advantages, two of which are of particular importance: the abolition of the risk of perforation of the posterior wall and the reduction of local trauma to a level that is unlikely to be further lowered. The use of a ventilation catheter during the time of the procedure allows full control of the airway and to extend the indications of the technique to patients with severe respiratory failure.
Complications[edit]
A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10–15% and a procedural mortality of 0%,[15] which is comparable to those of other series reported in the literature from the Netherlands[16][17] and the United States.[18][19]
A 2003 American cadaveric study identified multiple tracheal ring fractures with the Ciaglia Blue Rhino technique as a complication occurring in 100% of their small series of cases.[20] The comparative study above also identified ring fractures in 9 of 30 live patients[14] while another small series identified ring fractures in 5 of their 20 patients.[21] The long term significance of tracheal ring fractures is unknown.[citation needed]
But the main complication of this procedure is obstruction of the hole due to accumulation of mucus produced by respiratory normal flora, which in turn will lead to hypoxia and further complications due to reduced level of oxygen received by lungs.[22]
Alternatives[edit]
Biphasic cuirass ventilation is a form of non-invasive mechanical ventilation that can in many cases allow patients an alternative mode of respiratory support, allowing patients to avoid an invasive tracheostomy and its many complications. While this method has not been proven to help in every case, it has been shown to be an effective alternative for many.[citation needed]
Routine care[edit]
Suctioning[edit]
Caring for a tracheotomy mostly includes suctioning to prevent occlusions and replacing supplies. Because of the lack of filtering and humidifying by the nose and the ineffective cough mechanism, there is a buildup of secretions. Suctioning is only performed when clinically necessary because there are many potential risks. Risks include hypoxia and so suctioning is limited to 10 to 20 seconds at a time and the patient is hyperoxygenated just before and after suctioning. Risks also include atelectasis, or collapsing lung tissue from high suction pressure, and so pressure is limited to 80–120 mm Hg. Risks also include tissue damage. The suction catheter is inserted no more than 1 cm past the length of the tube to avoid contact with trachea tissue. Suctioning is only done during withdrawing the catheter at least 1/2 inch. Risks also include infection.[5]
History[edit]
A tracheostomy from prior to the 20th century
Prior to 16th century[edit]
Tracheotomy was first depicted on Egyptian artifacts in 3600 BC.[23] Hippocrates condemned the practice of tracheotomy as incurring an unacceptable risk of damage to the carotid artery. Warning against the possibility of death from inadvertent laceration of the carotid artery during tracheotomy, he instead advocated the practice of tracheal intubation.[7]
Despite the concerns of Hippocrates, it is believed that an early tracheotomy was performed by Asclepiades of Bithynia, who lived in Rome around 100 BC. Galen and Aretaeus, both of whom lived in Rome in the 2nd century AD, credit Asclepiades as being the first physician to perform a non-emergency tracheotomy. Antyllus, another Roman physician of the 2nd century AD, supported tracheotomy when treating oral diseases. He refined the technique to be more similar to that used in modern times, recommending that a transverse incision be made between the third and fourth tracheal rings for the treatment of life-threatening airway obstruction.[7]
In 1000, Abu al-Qasim al-Zahrawi (936–1013), an Arab who lived in Arabic Spain, published the 30-volume Kitab al-Tasrif, the first illustrated work on surgery. He never performed a tracheotomy, but he did treat a slave girl who had cut her own throat in a suicide attempt. Al-Zahrawi (known to Europeans as Albucasis) sewed up the wound and the girl recovered, thereby proving that an incision in the larynx could heal. Circa AD 1020, Avicenna (980–1037) described tracheal intubation in The Canon of Medicine in order to facilitate breathing.[24] The first correct description of the tracheotomy operation for treatment of asphyxiation was described by Ibn Zuhr (1091–1161) in the 12th century. According to Mostafa Shehata, Ibn Zuhr (also known as Avenzoar) successfully practiced the tracheotomy procedure on a goat, justifying Galen's approval of the operation.[25]
16th–18th centuries[edit]
The European Renaissance brought with it significant advances in all scientific fields, particularly surgery. Increased knowledge of anatomy was a major factor in these developments. Surgeons became increasingly open to experimental surgery on the trachea. During this period, many surgeons attempted to perform tracheotomies, for various reasons and with various methods. Many suggestions were put forward, but little actual progress was made toward making the procedure more successful. The tracheotomy remained a dangerous operation with a very low success rate,[quantify] and many surgeons still considered the tracheotomy to be a useless and dangerous procedure. The high mortality rate[quantify] for this operation, which had not improved, supported their position.
From the period 1500 to 1832 there are only 28 known reports of tracheotomy.[26] In 1543, Andreas Vesalius (1514–1564) wrote that tracheal intubation and subsequent artificial respiration could be life-saving. Antonio Musa Brassavola (1490–1554) of Ferrara treated a patient suffering from peritonsillar abscess by tracheotomy after the patient had been refused by barber surgeons. The patient apparently made a complete recovery, and Brassavola published his account in 1546. This operation has been identified as the first recorded successful tracheostomy, despite many ancient references to the trachea and possibly to its opening.[26] Ambroise Paré (1510–1590) described suture of tracheal lacerations in the mid-16th century. One patient survived despite a concomitant injury to the internal jugular vein. Another sustained wounds to the trachea and esophagus and died.
Hieronymus Fabricius
Towards the end of the 16th century, anatomist and surgeon Hieronymus Fabricius (1533–1619) described a useful technique for tracheotomy in his writings, although he had never actually performed the operation himself. He advised using a vertical incision and was the first to introduce the idea of a tracheostomy tube. This was a straight, short cannula that incorporated wings to prevent the tube from advancing too far into the trachea. He recommended the operation only as a last resort, to be used in cases of airway obstruction by foreign bodies or secretions. Fabricius' description of the tracheotomy procedure is similar to that used today. Julius Casserius (1561–1616) succeeded Fabricius as professor of anatomy at the University of Padua and published his own writings regarding technique and equipment for tracheotomy. Casserius recommended using a curved silver tube with several holes in it. Marco Aurelio Severino (1580–1656), a skillful surgeon and anatomist, performed multiple successful tracheotomies during a diphtheria epidemic in Naples in 1610, using the vertical incision technique recommended by Fabricius. He also developed his own version of a trocar.[27]
In 1620 the French surgeon Nicholas Habicot (1550–1624), surgeon of the Duke of Nemours and anatomist, published a report of four successful "bronchotomies" which he had performed.[28] One of these is the first recorded case of a tracheotomy for the removal of a foreign body, in this instance a blood clot in the larynx of a stabbing victim. He also described the first tracheotomy to be performed on a pediatric patient. A 14-year-old boy swallowed a bag containing 9 gold coins in an attempt to prevent its theft by a highwayman. The object became lodged in his esophagus, obstructing his trachea. Habicot suggested that the operation might also be effective for patients suffering from inflammation of the larynx. He developed equipment for this surgical procedure which displayed similarities to modern designs (except for his use of a single-tube cannula).
Sanctorius (1561–1636) is believed to be the first to use a trocar in the operation, and he recommended leaving the cannula in place for a few days following the operation.[29] Early tracheostomy devices are illustrated in Habicot’s Question Chirurgicale[28] and Julius Casserius' posthumous Tabulae anatomicae in 1627.[30] Thomas Fienus (1567–1631), Professor of Medicine at the University of Louvain, was the first to use the word "tracheotomy" in 1649, but this term was not commonly used until a century later.[31] Georg Detharding (1671–1747), professor of anatomy at the University of Rostock, treated a drowning victim with tracheostomy in 1714.[32][33][34]
19th century[edit]
In the 1820s, the tracheotomy began to be recognized as a legitimate means of treating severe airway obstruction. In 1832, French physician Pierre Bretonneau employed it as a last resort to treat a case of diphtheria.[35] In 1852, Bretonneau's student Armand Trousseau reported a series of 169 tracheotomies (158 of which were for croup, and 11 for "chronic maladies of the larynx")[36] In 1858, John Snow was the first to report tracheotomy and cannulation of the trachea for the administration of chloroform anesthesia in an animal model.[37] In 1871, the German surgeon Friedrich Trendelenburg (1844–1924) published a paper describing the first successful elective human tracheotomy to be performed for the purpose of administration of general anesthesia.[38] In 1880, the Scottish surgeon William Macewen (1848–1924) reported on his use of orotracheal intubation as an alternative to tracheotomy to allow a patient with glottic edema to breathe, as well as in the setting of general anesthesia with chloroform.[39][40] At last, in 1880 Morrell Mackenzie's book discussed the symptoms indicating a tracheotomy and when the operation is absolutely necessary.[7]
20th century[edit]
In the early 20th century, physicians began to use the tracheotomy in the treatment of patients afflicted with paralytic poliomyelitis who required mechanical ventilation. However, surgeons continued to debate various aspects of the tracheotomy well into the 20th century. Many techniques were described and employed, along with many different surgical instruments and tracheal tubes. Surgeons could not seem to reach a consensus on where or how the tracheal incision should be made, arguing whether the "high tracheotomy" or the "low tracheotomy" was more beneficial. The currently used surgical tracheotomy technique was described in 1909 by Chevalier Jackson of Pittsburgh, Pennsylvania. Jackson emphasised the importance of postoperative care, which dramatically reduced the death rate. By 1965, the surgical anatomy was thoroughly and widely understood, antibiotics were widely available and useful for treating postoperative infections, and other major complications had also become more manageable.
See also[edit]
Cricothyrotomy
Laryngotomy
List of surgeries by type
References[edit]
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Jump up ^ US patent 3039469
Jump up ^ Ciaglia P, Firsching R, Syniec C (June 1985). "Elective percutaneous dilatational tracheostomy. A new simple bedside procedure; preliminary report". Chest. 87 (6): 715–9. doi:10.1378/chest.87.6.715. PMID 3996056.
Jump up ^ Griggs WM, Worthley LI, Gilligan JE, Thomas PD, Myburg JA (June 1990). "A simple percutaneous tracheostomy technique". Surgery, Gynecology & Obstetrics. 170 (6): 543–5. PMID 2343371.
Jump up ^ Ambesh SP, Tripathi M, Pandey CK, Pant KC, Singh PK (July 2005). "Clinical evaluation of the 'T-Dagger': a new bedside percutaneous dilational tracheostomy device". Anaesthesia. 60 (7): 708–11. doi:10.1111/j.1365-2044.2005.04236.x. PMID 15960723.
^ Jump up to: a b Ambesh SP, Pandey CK, Srivastava S, Agarwal A, Singh DK (December 2002). "Percutaneous tracheostomy with single dilatation technique: a prospective, randomized comparison of Ciaglia blue rhino versus Griggs' guidewire dilating forceps". Anesthesia and Analgesia. 95 (6): 1739–45, table of contents. doi:10.1097/00000539-200212000-00050. PMID 12456450.
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Jump up ^ van Heurn LW, van Geffen GJ, Brink PR (July 1996). "Clinical experience with percutaneous dilatational tracheostomy: report of 150 cases". The European Journal of Surgery. 162 (7): 531–5. PMID 8874159.
Jump up ^ Polderman KH, Spijkstra JJ, de Bree R, et al. (May 2003). "Percutaneous dilatational tracheostomy in the ICU: optimal organization, low complication rates, and description of a new complication". Chest. 123 (5): 1595–602. doi:10.1378/chest.123.5.1595. PMID 12740279.
Jump up ^ Hill BB, Zweng TN, Maley RH, Charash WE, Toursarkissian B, Kearney PA (August 1996). "Percutaneous dilational tracheostomy: report of 356 cases". The Journal of Trauma. 41 (2): 238–43; discussion 243–4. doi:10.1097/00005373-199608000-00007. PMID 8760530.
Jump up ^ Powell DM, Price PD, Forrest LA (February 1998). "Review of percutaneous tracheostomy". The Laryngoscope. 108 (2): 170–7. doi:10.1097/00005537-199802000-00004. PMID 9473064.
Jump up ^ Hotchkiss KS, McCaffrey JC (January 2003). "Laryngotracheal injury after percutaneous dilational tracheostomy in cadaver specimens". The Laryngoscope. 113 (1): 16–20. doi:10.1097/00005537-200301000-00003. PMID 12514375.
Jump up ^ Byhahn C, Lischke V, Halbig S, Scheifler G, Westphal K (March 2000). "Ciaglia Blue Rhino: Ein weiterentwickeltes Verfahren der perkutanen Dilatationstracheotomie" [Ciaglia blue rhino: a modified technique for percutaneous dilatation tracheostomy. Technique and early clinical results]. Der Anaesthesist (in German). 49 (3): 202–6. doi:10.1007/s001010050815. PMID 10788989.
Jump up ^ university of Jordan. Faculty of medicine, department of anesthesia.
Jump up ^ Steven E. Sittig; James E. Pringnitz (February 2001). "Tracheostomy: evolution of an airway" (PDF). AARC Times: 48–51.
Jump up ^ Patricia Skinner (2008). "Unani-tibbi". In Laurie J. Fundukian. The Gale Encyclopedia of Alternative Medicine (3rd ed.). Farmington Hills, Michigan: Gale Cengage. ISBN 978-1-4144-4872-5. External link in |publisher= (help)
Jump up ^ Mostafa Shehata (April 2003). "The Ear, Nose and Throat in Islamic Medicine" (PDF). Journal of the International Society for the History of Islamic Medicine. 2 (3): 2–5. ISSN 1303-667X.
^ Jump up to: a b Goodall, E.W. (1934). "The story of tracheostomy". British Journal of Children's Diseases. 31: 167–76, 253–72.
Jump up ^ Armytage WHG (1960). "Nova et Vetera". British Medical Journal. 1 (5179): 1129–1130. doi:10.1136/bmj.1.5179.1129. PMC 1966956  .
^ Jump up to: a b Nicholas Habicot (1620). Question chirurgicale par laquelle il est démonstré que le Chirurgien doit assurément practiquer l'operation de la Bronchotomie, vulgairement dicte Laryngotomie, ou perforation de la fluste ou du polmon (in French). Paris: Corrozet. p. 108.
Jump up ^ Sanctorii Sanctorii (1646). Sanctorii Sanctorii Commentaria in primum fen, primi libri canonis Avicennæ (in Latin). Venetiis: Apud Marcum Antonium Brogiollum. p. 1120. OL 15197097M.
Jump up ^ Julius Casserius (Giulio Casserio) and Daniel Bucretius (1632). Tabulae anatomicae LXXIIX ... Daniel Bucretius ... XX. que deerant supplevit & omnium explicationes addidit (in Latin). Francofurti: Impensis & coelo Matthaei Meriani.
Jump up ^ Cawthorne T, Hewlett AB, Ranger D (1959). "Discussion: Tracheostomy To-Day". Proceedings of the Royal Society of Medicine. 52 (6): 403–405. PMC 1871130  . PMID 13667911.
Jump up ^ Georges Detharding (1745). "De methodo subveniendi submersis per laryngotomiam (1714)". In Von Ernst Ludwig Rathlef; Gabriel Wilhelm Goetten; Johann Christoph Strodtmann. Geschichte jetzlebender Gelehrten, als eine Fortsetzung des Jetzlebenden. Zelle: Berlegts Joachim Undreas Deek. p. 20.
Jump up ^ Price JL (1962). "THE EVOLUTION OF BREATHING MACHINES". Medical History. 6 (1): 67–72. doi:10.1017/s0025727300026867. PMC 1034674  . PMID 14488739.
Jump up ^ Wischhusen HG, Schumacher GH (1977). "Curriculum vitae des Rostocker Professors für Anatomie, Botanik und der höheren Mathematik" [Curriculum vitae of the professor of anatomy, botany and higher mathematics Georg Detharding (1671–1747) at the University of Rostock]. Anatomischer Anzeiger (in German). 142 (1–2): 133–40. PMID 339777.
Jump up ^ Armand Trousseau (1833). "Mémoire sur un cas de tracheotomie pratiquée dans la période extrème de croup". Journal des connaissances médico-chirurgicales. 1 (5): 41.
Jump up ^ Armand Trousseau (1852). "Nouvelles recherches sur la trachéotomie pratiquée dans la période extrême du croup". In Jean Lequime and J. de Biefve. Annales de médecine belge et étrangère. Brussels: Imprimerie et Librairie Société Encyclographiques des Sciences Médicales. pp. 279–288.
Jump up ^ Snow, J (1858). "Fatal cases of inhalation of chloroform, Treatment of suspended animation from chloroform". In Richardson, BW. On chloroform and other anaesthetics: their action and administration. London: John Churchill. pp. 120–200, 251–62.
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Jump up ^ Macewen, W (1880). "General Observations on the Introduction of Tracheal Tubes by the Mouth, Instead of Performing Tracheotomy or Laryngotomy". British Medical Journal. 2 (1021): 122–4. doi:10.1136/bmj.2.1021.122. PMC 2241154  . PMID 20749630.
Jump up ^ Macewen, W (1880). "Clinical Observations on the Introduction of Tracheal Tubes by the Mouth, Instead of Performing Tracheotomy or Laryngotomy". British Medical Journal. 2 (1022): 163–5. doi:10.1136/bmj.2.1022.163. PMC 2241109  . PMID 20749636.
External links[edit]
Wikimedia Commons has media related to Tracheotomy.
Look up tracheotomy, pharyngotomy, laryngotomy, or tracheostomy in Wiktionary, the free dictionary.
Plotnikow GA, Roux N, Feld V, et al. (October 2013). "Evaluation of tracheal cuff pressure variation in spontaneously breathing patients". International Journal of Critical Illness and Injury Science. 3 (4): 262–8. doi:10.4103/2229-5151.124148. PMC 3891193  . PMID 24459624.
Tracheotomy Info (A Community For Tracheotomy-wearers and the people who love them) at tracheotomy.info
Tracheostomy Products and Support (Online resource for tracheostomy products, supplies and support) at trachs.com
Aaron's tracheostomy page (Caring for a tracheostomy) at tracheostomy.com
(Pictures with video clipping) at drtbalu.com
[1]
[2]
"Tracheotomy" at Dorland's Medical Dictionary
Smiths Medical Tracheostomy Training Videos
A Video of Rescue Breathing for Laryngectomees and Neck Breathers
"Book of Simplification Concerning Therapeutics and Diet", is a manuscript from 1497 that discusses tracheotomies
Site and blog with information about tracheostomies
Global Tracheostomy Collaborative. International collaborative with resources for hospitals, caregivers, and patients about tracheostomies, including international research
[3]
Dilatational Tracheostomy On An Intensive Care Unit
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