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Source: 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

[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:
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
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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