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DecannulationCategory: TRACHEOTOMY Source: A Manual Of Peroral Endoscopy And Laryngeal Surgery When the tracheal incision is placed below the first ring, no difficulty in decannulation should result from the operation per se. When by temporarily occluding the cannula with the finger it is evident that the laryngeal aperture has regained sufficient size to allow free breathing, a smaller-sized tracheotomic tube should be substituted to allow free passage of air around the cannula in the trachea. In doing this, the amount of secretion and the handicap of impaired glottic mobility in the expulsion of thick secretions must be borne in mind. Babies labor under a special handicap in their inefficient bechic expulsion and especially in their small cannulae which are so readily occluded. If breathing is not free and quiet with the smaller tube; the larger one must be replaced. If, however, there is no trouble with secretions, and the breathing is free and quiet, the inner cannula should be removed, and the external orifice of the outer cannula firmly closed with a rubber cork. If the laryngeal condition has been acute, decannulation can usually be safely done after the patient has been able to sleep quietly for three nights with a corked cannula. If free breathing cannot be obtained when the cannula is corked, the larynx is stenosed, and special work will be required to remove the tube. Children sometimes become panic stricken when the cannula is completely corked at once and they are forced to breathe through the larynx instead of the easier shortcut through the neck. In such a case, the first step is partially to cork the cannula with a half or two-thirds plug made from a pure rubber cord fashioned in the desired shape by grinding with an emery wheel (Fig. 112). Thus the patient is gradually taught to use the natural air-way, still feeling that he has an anchor to windward in the opening in the cannula. When some swelling of the laryngeal structures still exists, this gradual corking has a therapeutic effect in lessening the stenosis by exercising the muscles of abduction of the cords and mobilizing the cricoarytenoid articulation during the inspiratory effort. The forced respiration keeps the larynx freed from secretions, which are more or less purulent and hence irritating. After removing the cannula, in order that healing may proceed from the bottom upward, the wound should be dressed in the following manner: A single thickness of gauze should be placed over the wound and the front of the neck, and a gauze wedge firmly inserted over this to the depths of the tracheotomic wound, all of this dressing being held in place by a bandage. If the skin-wound heals before the fibrous union of the tracheal cartilages is complete, exuberant granulations are apt to form and occlude the trachea, perhaps necessitating a new tracheotomy for dyspnea. It is so important to fix indelibly in the mind the cardinal points concerning tracheotomy that I have appended to this chapter the teaching notes that I have been for years giving my classes of students and practitioners, hundreds of whom have thanked me for giving them the clear-cut conception of tracheotomy that enabled them, when their turn came to do an emergency tracheotomy, to save human life. Next: Resume Of Tracheotomy Previous: Bronchial Aspiration
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