Tracheotomy


Categories: TRACHEOTOMY
Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

Indications.--Tracheotomy is indicated in dyspnea of laryngotracheal

origin. The cardinal signs of this form of dyspnea are:

1. Indrawing at the suprasternal notch.

2. Indrawing around the clavicles.

3. Indrawing of the intercostal spaces.

4. Restlessness.

5. Choking and waking as soon as the aid of the voluntary

respiratory muscles ceases in falling to sleep.

6. Cyanosis is a dangerously late symptom.



As a therapeutic measure in diseases of the larynx its place has been

thoroughly established. Marked improvement of the laryngeal lesions

has been observed to follow tracheotomy in advanced laryngeal

tuberculosis, and in cancer of the larynx. It has proven, in some

cases, a useful adjunct in the treatment of luetic laryngitis, though

it cannot be regarded as indicated, in the absence of dyspnea.

Perichondritis and other inflammations are benefited by tracheotomy. A

marked therapeutic effect on multiple laryngotracheal papillomata in

children has been noted by the author in hundreds of cases.



Tracheotomy for foreign body is no longer indicated either for the

removal of the intruder, or for the insertion of the bronchoscope.

Tracheotomy may be urgently indicated for foreign body dyspnea, but

not for foreign body removal.



Subcutaneous rupture of the trachea from external trauma may produce

dyspnea and generalized emphysema, both of which will be relieved by

tracheotomy.



[280] Acromegalic stenosis of the larynx is a rare but urgent

indication for tracheotomy.



Contraindications.--There are no contraindications to tracheotomy

for dyspnea.



The instruments required for an orderly tracheotomy are:

Headlight

Scalpels

2 Retractors

Trousseau dilator

6 Hemostats

Scissors (dissecting)

Tracheal cannulae (six sizes)

Curved needles

Needle holder

Hypodermic syringe for local anesthesia

No. 1 plain catgut ligatures

Linen tape

Gauze sponges



These are sterilized and kept in a sterile copper box ready for

instant use. Beside the patient's bed following the tracheotomy the

following sterile materials are placed:

Sterile gloves

1 Hemostat

Sterile new gauze

Trousseau dilator

Scissors

Duplicate tracheotomy tube

Silver probe

Basin of Bichloride of mercury solution, 1 : 10,000



Tracheotomy is one of the oldest operations known to surgery, yet

strange to say, it is probably more often improperly performed today,

and more often followed by needless mortality, than any other

operation. The two chief preventable sequelae are death from improper

routine surgical care and wrongly fitted tube, and stenosis from too

high an operation. The classical descriptions of crico-thyroidotomy

and high and low tracheotomy have been handed down to generations of

medical students without revision. Every medical graduate has been

taught that there are two kinds of tracheotomy, high and low, the low

operation being very difficult, the high operation very easy. When he

is suddenly called upon to do an emergency tracheotomy, this erroneous

teaching is about all that remains in the dim recesses of his memory;

consequently he makes sure of doing the operation high enough, and

goes in through the larynx, usually dividing the cricoid cartilage,

the only complete ring in the trachea. As originally made the

distinction between high and low as applied to tracheotomy referred to

operations above and below the isthmus of the thyroid gland, in a day

when primitive surgery attached too much importance to operations upon

the thyroid gland. The isthmus is entitled to absolutely no

consideration whatever in deciding the location at which to incise so

vital a structure as the trachea. Students are taught different short

skin incisions for these two operations, and it is no wonder that

they, as did their predecessors, find tracheotomy a difficult, bloody,

and often futile operation. The trachea is searched for at the bottom

of a short, deep wound filled with blood, the source of which is

difficult to find and impossible to control.



Tracheotomic cannulae should be made of sterling silver. German

silver plated with pure silver is good enough for temporary use, but

the plating soon wears off under the galvanic action set up between

the two metals. Aluminum becomes roughened by boiling and contact with

secretions, and causes the formation of granulations which in time

lead to stenosis. Hard rubber tubes cannot be boiled, the walls are so

thick as to leave too little lumen, and the rubber is irritating to

the tissues. All tracheotomy tubes should be fitted with pilots. Many

of the tubes furnished to patients have no pilots to facilitate the

introduction, and the tubes are inserted with somewhat the effect of a

cheese tester, and with great pain and suffering on the part of the

patient. Most of the the tubes in the shops are too short to allow for

the swelling of the tissues of the neck following the operation. They

may reach the trachea at the time of the operation, but as soon as the

reactionary swelling occurs, the end of the tube is pulled out (Fig.

103) of the tracheal incision; the air hissing along the tube is

considered by the attendant to indicate that the tube is still in

place, and the increasing dyspnea and accelerated respiratory rate are

attributed to supposed pneumonia or edema of the lungs, under which

erroneous diagnosis the patient is buried. In all cases in which it is

reported that in spite of tracheotomy the dyspnea was only temporarily

relieved, the fault is the lack of a plumber. That is, an attendant

who will make sure that there is at all times a clear airway all the

way down to the lungs. With a bronchoscope and aspirator he will see

that the airway is clear. To begin with, a proper sized cannula must

be selected. The series of different sized, full curved tubes, one of

which is illustrated in Fig. 104, will under all conditions reach the

trachea. If the tube seems to be too long in any given case, it will

usually be found that the tracheotomy has been done too high, and a

lower one should be done at once. If the operation has not been done

too high, and the cannula is too long, a pad of gauze under the shield

will take up the surplus length. In cases of tracheal compression from

new growth, thymus or other such cases, in which the ordinary tube

will not pass the obstruction, the author's long cane-shaped cannula

(see Fig. 104) can be inserted past the obstruction, and if necessary

into either bronchus. The fenestrum placed in the cannula in many of

the older tubes, with the supposed function of allowing partial

breathing through the larynx, is a most pernicious thing. A properly

fitted tube should not take up more than half of the cross section of

the trachea, and should allow the passage of sufficient air for free

laryngeal breathing when it is completely corked. The fenestrum is,

moreover, rarely so situated that air can pass through it; the

fenestral edges act as a constant irritant to the wound, producing

bleeding and granulation tissue.



[FIG. 103.--Schema showing thick pad of gauze dressing, filling the

space, A, and used to hold out the author's full-curved cannula when

too long, prior to reactionary swelling, and after subsidence of the

latter. At the right is shown the manner in which the ordinary cannula

of the shops permits a patient to asphyxiate, though some air is heard

passing through the tracheal opening, H, after the cannula has been

partially withdrawn by swelling of the tissues, T.]



[FIG. 104.--The author's tracheotomic cannulae. A, shows cane-shaped

cannula for use in intrathoracic compressive or other stenoses. B,

shows full curved cannula for regular use. Pilots are made to fit the

outer cannula; the inner cannula not being inserted until after

withdrawal of the pilot.]





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