Bronchoscopy and Esophagoscopy / A Manual of Peroral Endoscopy and Laryngeal Surgery

by Chevalier Jackson

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.