The decision by the pope's doctors to perform a tracheostomy -- an incision in the neck directly into the trachea, or windpipe -- is a strong indication that John Paul II's condition is quite serious, medical specialists said yesterday.
"It's a major development," said Martin J. Blaser, chairman of medicine at New York University Medical Center in Manhattan and president-elect of the Infectious Diseases Society of America. "This is not a good sign."
The operation allows a patient to breathe through that new opening instead of through the nose and mouth. It is commonly used to provide an alternative airway for patients with a breathing obstruction, a reason cited by the pope's physicians. Doctors said a tracheostomy is used for three other common purposes:
• Suction: At a minimum, a tracheostomy allows easy access to the trachea so doctors and nurses can periodically suction from the airway the fluids that accumulate as a result of pneumonia -- an infection in the lungs, which the pope appears to have.
• Preventing reinfection: The elderly and the frail often develop pneumonia as a result of aspirating bacteria from their mouth or nasal passages into their lungs. That is especially true of patients with Parkinson's disease, the progressive neurological disorder that has long afflicted the pope. Such patients lose control over their epiglottis, the fleshy barrier that separates their food-carrying esophagus from the trachea, which when healthy should remain sterile. By bypassing the upper respiratory tract, a tracheostomy offers a cleaner air supply. And its need suggests that the pope has been suffering not from influenza or a cold but from repeated aspiration pneumonias, perhaps the most common cause of death for Parkinson's patients.
• Emergency airway access: If the pope should stop breathing on his own and it becomes necessary to place him on a mechanical ventilator, a tracheostomy will make the procedure easier. Otherwise it is necessary to perform an emergency intubation through the mouth, which can be difficult and traumatic in a patient as frail as the pope.
Tracheostomies are often temporary, but this instance is likely to be longer term, doctors said, because the pope will have more difficulty keeping his lungs clear with Parkinson's. And although people can live a long time with tracheostomies, the artificial openings carry risks, including infections from bacteria that can colonize the incision.
"People with trachs get complications from trachs," Blaser said.
For the pope, whose power is so vested in the spoken word, a tracheostomy also raises profound issues of communication. It is impossible to speak with an open tracheostomy. Valves and other devices can temporarily close the artificial opening so that air can be redirected upward through the vocal cords, allowing understandable, albeit distorted, speech.
One question that remained yesterday was whether the pope's doctors would be willing to have the tracheostomy closed for even short periods to allow speech, as that would pose a renewed risk of lung infection from the upper respiratory tract.
