Tracheotomy

“ Always bear in mind that tracheotomy is not an ultimate object. The ultimate object is to pipe air down into the lungs. Tracheotomy is only a means to that end. 2. Sterile tray beside bed should contain duplicate (exact) tracheotomy tube, Trousseau dilator, hemostat, thumb forceps, silver probe, scissors, scalpel, probe-pointed curved bistoury. Sterile gloves ready. 3. Special nursing necessary for safety. 4. Laxative. 5. Sponge away secretions before they are drawn in. 6. Cover wound with wide large gauze square slit so it fits around cannula under the tape holder. ”

“ The time for removal of the canula varies according to the condition. Thus, when tracheotomy is performed for a foreign body, the tube may be removed as soon as the object has been extracted; on the other hand, when treating stenosis of the larynx it may be necessary to advise permanent wearing of the canula.
Complications are less common than with tracheotomy for diphtheria. Under favourable conditions there is little danger of pneumonia unless the wound becomes infected, as may happen when the operation is undertaken for the relief of septic inflammations. ”

“ Whereas in high tracheotomy practically the whole operation is best done by clean cutting, in the lower operation this is more dangerous, and the deep dissection must be performed partly with forceps or blunt director; if an artery be divided or venous bleeding occurs, it should be controlled immediately. No attempt should be made to perform this operation rapidly owing to the relations of the parts; nor should the trachea be opened before its rings are exposed thoroughly, as complications may arise after imperfect division of the pretracheal fascia. ”

“ The sooner the serum is injected the better the prognosis with tracheotomy. A large dose should be given, 8,000 to 18,000 units, irrespective of age, and the dose may be repeated on the second day if required. Improvement generally commences between twelve and twenty-four hours after injection; the swelling of the mucosa subsides, and secretion is diminished; false membrane is not so copious, and rarely extends to the trachea and bronchi; crusts become less adherent, and are expelled by the patient. ”

“ About the middle of the nineteenth century tracheotomy--that is, the surgical opening of the trachea, or wind-pipe, below the larynx, for the purpose of admitting air to the lungs through such artificial opening--had been introduced by Trousseau, of Paris. In many cases this afforded relief; {330} at least the little patients did not die the awful death by asphyxiation, though not many recovered from the diphtheria or the results of the operation. ”

“ Usually an emetic suffices to open up the hole at once; but tracheotomy is often necessary to supply air to the patient, the attacks of suffocation are so frequent, and since he is already voiceless, he loses nothing by the operation. ”

“ But when the first alarm has quieted down, the attacks are likely to be only occasional, as when the article, drawn up with the expired air, comes in contact with the under aspect of the vocal cords. It may be that in a violent fmt of coughing it will be expelled, but, if not, the surgeon must be at hand ready to perform tracheotomy when the urgency of the symptoms demands it. Tracheotomy is the making of an opening into the trachea, the air-tube below the larynx. It is unsafe to leave a child with a foreign body loose in its windpipe, on account of the risk of sudden and fatal asphyxia. ”

“ Not only does tracheotomy obviate immediate danger of suffocation, but by removing the source of irritation in the continuous and forcible rush of air through the narrowed and inflamed tube, and in securing for the blood a freer æration and a purer constitution it often induces a rapid change for the better in the character of the inflammatory action. ”

“ If the body remains movable in the trachea, it is apt to be displaced when the patient moves or coughs, and it may be driven up and become impacted in the glottis, setting up violent attacks of coughing and spasmodic dyspnœa.
Tracheotomy should be performed at once, and the edges of the tracheal wound held widely open with retractors, the patient being inverted, or coughing induced by tickling the mucous membrane with a feather. The foreign body is usually expelled, but it may be inhaled into one of the bronchi. ”

“ Champneys30 was the first writer to call attention to this complication of tracheotomy. After a large number of observations and experiments, he was of opinion that emphysema of the anterior mediastinum occurs in a certain proportion of tracheotomies and is of frequent occurrence in cases that are fatal; that it may be associated with pneumothorax; and that the conditions which favour its production are a low division of the deep cervical fasciæ in the neighbourhood of the sternum, combined with obstruction of the air-passages and strong inspiratory efforts ”

“ TRACHEOTOMY AND INTUBATION.—The operation of tracheotomy, opening of the wind-pipe, is performed where there is choking from a foreign body in the wind-pipe or when it has become suddenly closed in diseases such as croup and diphtheria. It is always an emergency operation and is only resorted to when it is evident that unless severe measures are taken the patient will choke to death. Intubation is more frequently practised in disease when the breathing has become difficult owing to the growth of membrane in the larynx. ”

“ Surgical treatment alone suggests itself. Before attempting an operation tracheotomy should be performed and a metal canula inserted. The animal having been cast, and the upper laryngeal region anæsthetised by means of cocaine, a vertical incision is made in the median line below the larynx, passing through the skin, the vertical junction between the neck muscles and the three first circles of the trachea, and access is thus obtained to the larynx and subglottal region. ”

“ In tracheotomy, the incision of the tracheal rings can be extended with much less injury than can division of the laryngeal cartilages, when the largeness of the foreign body, its being firmly fixed, or other circumstances, require that the wound be of considerable size. The risk or danger in the one operation is not much greater than in the other. Division of the crico-thyroid membrane and skin is effected by one incision; there is nothing important in the way of the knife. ”

“ When possible, a tampon canula is inserted into the lower part of the trachea. When the growth is low down, the patient is placed in the Trendelenburg position in order to prevent the inspiration of blood. Should the diagnosis be uncertain, a portion of the tumour can be excised and a frozen section made. If proved to be innocent, the growth can then be freely excised with scissors or galvano-cautery. The bleeding is arrested, and the tracheotomy tube is retained for several days. ”

“ The growth usually occurs about the inner edges of the tracheal wound, extending thence inward and upward or downward, as the case may be, and is most frequently met with, perhaps, after tracheotomies undertaken for diphtheria, although it may occur as a result of the ulcerations mentioned above, and develop even from the cicatrix in an old and perfectly-closed tracheotomy wound. ”

“ But if no medication will have proved successful, the symptoms of stenosis, dyspnoea, cyanosis, and the supra- and intraclavicular and epigastric recension increase steadily to an alarming extent. When the pulse becomes frequent and intermitting, even without the presence of asphyxia and anæsthesia, air ought to be introduced into the lungs by tracheotomy. No positive rules can be laid down as to the length of time one ought to wait before performing it. No subdivision of the disease into several stages is of any benefit in selecting the exact period in which the trachea must or may be opened. ”

“ When stenosis is extreme there is no alternative, and the open wound allows of the constant passage of graduated bougies, which is more easily accomplished from below than from above. If treatment be persistent the prospect of a good result is not unfavourable, and there is every reason to believe that in the future the number of cases which require a permanent tracheotomy tube will be reduced to a minimum. ”

“ Anyone skilled in the introduction of the bronchoscope can do bronchoscopy in a few seconds, and it is especially easy in cases of respiratory arrest, because of the limp condition of the patient.
The foregoing applies to cases in which a pulmotor would be used, such as apnea from electric shocks, etc. For obstructive dyspnea and asphyxia, tracheotomy is the procedure of choice, and the skillful tracheotomist would be justified in preferring tracheotomy for the other class of cases, insufflating the oxygen and amyl nitrite through the tracheotomic wound. ”

“ In addition to the fact, that the carotid arteries lie farther apart from each other and from the median place—viz., the crico-thyroid interval, which is the seat of laryngotomy—than they do lower down on either side of the trachea, it should also be noticed that the tracheal tube being more moveable than the larynx, is hence more liable to swerve from the cutting instrument, and implicate the vessels. Tracheotomy on the infant is a far more anxious proceeding than the same operation performed on the adult ”

“ These dangers constitute shoals and quicksands to the anatomist and surgeon, that has made many a one shudder at their approach. The six or eight vessels to tie, before daring to open the trachea, causes delay dangerous to life, as well as to the success of the operation, and brings into question the propriety of the operation, and sometimes the skill of the physician. In the upper operation, laryngo-tracheotomy, you can enlarge the opening upward whenever necessary, with but little risk, by cutting through the thyroid cartilage. ”

“ The fact remains that the first essential is the safety of the patient, and, if the dyspnœa is urgent, relief must be afforded. When a foreign substance has been inhaled the surgeon must always be prepared for tracheotomy, and it is not advisable for him to leave the patient, even for a short interval, without proper supervision. In addition, the operation has been advocated as the proper treatment for all cases of foreign bodies in the lower air-passages: nevertheless, removal by Killian’s method gives far better results (see p. 559) . ”

“ Excision of the larynx has found its chief indication in carcinoma, but has been employed in sarcoma, polyps, tuberculosis, enchondroma, stenosis, and necrosis. Whatever the procedure chosen for the operation, preliminary tracheotomy is a prerequisite. It should be made well below the isthmus of the thyroid gland, and from three to fifteen days before the laryngectomy. This affords time for the lungs to become accustomed to the new manner of breathing, and the trachea becomes fixed to the anterior wall of the neck. ”

“ Your purpose is to make a hole in the windpipe sufficiently large to admit the tracheotomy tube. It is quickly manifested when the windpipe is severed; the hot air rushes out, and when air is taken in it is sucked in with a noise. A slight hemorrhage may result (it never amounts to much) , which is easily controlled by washing the wound with a sponge and cold water, but use care not to get any water in the windpipe. ”

“ The lady pupils are not obliged to do night duty, as they are only here for one year; but Matron was short of senior probationers, and asked me if I would like it, and I thought I would. Part of the time I have been an "extra," just helping wherever they were busy, and helping in the theatre for any night operations. Then I was put on as "special" with a tracheotomy (diphtheria) in a men's medical ward—such a nice boy, called Albert, aged eight. And, when he was getting better, another little chap of three came in, so desperately bad that they had to do tracheotomy in the receiving room ”

“ In such cases skilful technique is of far greater value than haste. The high operation is preferred, because the trachea is more superficial, less movable, and easier to find; it has less complicated relations, the blood-vessels are less numerous, the fasciæ are not so loose, the tube is easier to fit and unlikely to slip out, healing of the wound is more rapid, and complications seldom occur. In cases where the isthmus is very broad or highly placed, so that the upper parts of the trachea and cricoid are covered, a median operation is recommended. Low tracheotomy is rarely necessary. ”

“ Such a method of procedure is preferable to the passage of probes, forceps, sponges, and other articles through the larynx, in the hope that any obstruction may be removed. If ulceration or necrosis of cartilage be discovered, it is impossible to relieve the condition by surgical means without prolonged treatment with tubes and the constant use of antiseptics. Under these conditions it is advisable to consider the removal of the tracheotomy tube in favour of intubation. ”

“ Tracheotomy was at one time used in certain cases in order to give complete rest to the larynx, but this has been abandoned as unsatisfactory; it should not be performed unless there is urgent laryngeal obstruction, since ‘it has many and grave disadvantages. It materially diminishes the efficiency of the cough, the secretion from the lungs is apt to accumulate in the bronchi and alveoli, and set up miliary tuberculosis. Again, the patient can often ill withstand even this slight operation; his power of speaking is diminished or lost and his mental anxiety is increased. ”