[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to asphyxiate, though some air is heard passing through the tracheal opening, H, after the cannula has been partially withdrawn by swelling of the tissues, T.]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.]
Anesthesia.—No dyspneic patient should be given a general anesthetic; because any patient dyspneic enough to need a tracheotomy for dyspnea is depending largely upon the action of the accessory respiratory muscles. When this action is stopped by beginning unconsciousness, respiration ceases. If the trachea is not immediately opened, artificial respiration instituted, and oxygen insufflated, the patient dies on the table. Skin infiltration along the line of incision with a very weak cocaine solution (1/10 of 1 per cent), apothesine (2 per cent), novocaine, Schleich's fluid or other local anesthetic, suffices to render the operation painless. The deeper structures have little sensation and do not require infiltration. It has been advocated that an interannular injection of cocaine solution with a hypodermic syringe be done just prior to incision of the trachea for the purpose of preventing cough after the incision of the trachea and the insertion of the cannula. It would seem, however, that this introduces the risk of aspiration pneumonia and pulmonary abscess, by permitting the aspiration and clotting of blood in small bronchi, followed by subsequent breaking down of the clots. As the author has so often said, "The cough reflex is the watch dog of the lungs," and if not drugged asleep by local or general anesthesia can safely be relied upon to prevent all possibility of the blood or the pus which nearly always is present in acute or chronic conditions calling for tracheotomy, being aspirated into the deeper air-passages. Cocaine in any form, by any method, and in any dosage, is dangerous in very young children.
Technic.—The patient should be placed in the recumbent position, with the extended head held in the midline by an assistant. The shoulders, not the neck, should be slightly raised with a sand bag. The head should be somewhat lower than the feet, to lessen the danger of aspiration of blood. A midline incision dividing the skin and fascia is made from the thyroid notch to just above the suprasternal notch. The cricoid is now located, and the deeper dissection is continued from below this point. The ribbon muscles are separated with dissecting scissors or knife, and held apart with retractors. If the isthmus of the thyroid gland is in the way, it may be retracted upward; if large, however, it should be divided and ligated, for it is apt to slip over the tracheal incision afterward, and render difficult the quick finding of the incision during after-care. This covering of the tracheal incision by the slipping back of the drawn-aside thyroidal isthmus is one of the most frequent avoidable causes of mortality, because it deflects the cannula off into the tissues when it is replaced after cleaning during the early postoperative period. The corrugated surface of the trachea can be felt, and its exact location can be determined by the index finger. If the tracheotomy is proceeding in an orderly manner, all bleeding points should be caught and tied with plain catgut (No. 1) before the trachea is opened. Because of distension of vessels during cough, all but the tiniest vessels should be ligated. Side-cut veins are particularly treacherous. They should be freed of tissue, cut across and the divided ends ligated.
The incision in the trachea should be as low as possible, and should never be made through the first ring. The incision should be through the third, fourth and fifth rings. Only in cases of laryngoptosis will it be necessary to incise the trachea higher than this. The incision must be made in the midline, and in the long axis of the trachea, and care must be exercised that the point of the knife does not perforate the posterior tracheal wall. Stab incisions are always to be avoided. If the incision in the trachea is found to be of insufficient length, the original incision must be found and elongated. A second incision must not be made, for the portion of cartilage between the two incisions will die and will almost certainly make a site of future tracheal stenosis. The cricoid should never be cut, for stenosis is almost sure to follow the wearing of a cannula in this position. A Trousseau dilator should now be inserted in the tracheal incision, its blades gently separated. With the tracheal lumen thus opened, a cannula of proper size is introduced with absolute certainty of its having entered the trachea. A quadruple-folded square of gauze in the form of a pad about four inches square is moistened with mercuric chloride solution (1:10,000) and is slit from the lower border to its midpoint. This pad is slipped from above downward under the tape holder of the cannula, the slit permitting the tubal part of the cannula to reach the central part of the pad (Fig. 108), and completely covers the wound. No attempt should be made to suture the skin wound, for this tends to form a pocket in which lodge the bronchial secretions that escape alongside the tube, resulting in infection of the wound. Furthermore it renders the daily changing of the tube much more difficult. In fact it prevents the attendant from being certain that the tube is actually placed in the trachea. Suturing of the skin to the trachea should never be done, for the sutures soon tear out and often set up a perichondritis of the tracheal cartilages, with resulting difficult decannulation.
[FIG. 105.—Schema of practical gross anatomy to be memorized for emergency tracheotomy. The middle line is the safety line, the higher the wider. Below, the safety line narrows to the vanishing point VP. The upper limit of the safety line is the thyroid notch until the trachea is bared, when the limit falls below the first tracheal ring. In practice the two-dark danger lines are pushed back with the left thumb and middle finger as shown in Fig. 106, thus throwing the safety line into prominence. This is generally known as Jackson's tracheotomic triangle.]
[FIG. 106.—Schema showing the author's method of rapid tracheotomy. First stage. The hands are drawn ungloved for the sake of clearness. The upper hand is the left, of which the middle finger (M) and the thumb are used to repress the sterno-cleido-mastoid muscles, the finger and thumb being close to the trachea in order to press backward out of the way the carotid arteries and the jugular vein. This throws the trachea forward into prominence, and one deep slashing cut will incise all of the soft tissues down to the trachea.]
Emergency Tracheotomy.—Stabbing of the cricothyroid membrane, or an attempted stabbing of the trachea, so long taught as an emergency tracheotomy, is a mistake. The author's "two stage, finger guided" method is safer, quicker, more efficient, and not likely to be followed by stenosis. To execute this promptly, the operator is required to forget his textbook anatomy and memorize the schema (Fig. 105). The larynx and trachea are steadied by the thumb and middle finger of the left hand, which at the same time push back the important nerves and vessels which parallel the trachea, and render the central safety line more prominent (Fig. 106). A long incision is now made from the thyroid notch almost to the suprasternal notch, and deep enough to reach the trachea. This completes the first stage.
[FIG. 107.—Illustrating the author's method of quick tracheotomy. Second stage. The fingers are drawn ungloved for the sake of clearness. In operating the whole wound is full of blood, and the rings of the trachea are felt with the left index which is then moved slightly to the patient's left, while the knife is slid down along the left index to exactly the middle line when the trachea is incised.]
Second stage. The entire wound is full of blood and the trachea cannot be seen, but its corrugations can be very readily felt by the tip of the free left index finger. The left index finger is now moved a little to the patient's left in order that the knife shall come precisely in the midline of the trachea, and three rings of the trachea are divided from above downward (Fig. 107). The Trousseau dilator should now be inserted, the head of the table should be lowered, and the patient should be turned on the side to allow the blood to run away from the wound. If respiration has ceased, a cannula is slipped in, and artificial respiration is begun. Oxygen insufflation will aid in the restoration of respiration, and a pearl of amyl nitrite should be crushed in gauze and blown in with the oxygen. In all such cases, excessive pressure of oxygen should be avoided because of the danger of producing ischemia of the lungs. Hope of restoring respiration should not be abandoned for half an hour at least. One of the author's assistants, Dr. Phillip Stout, saved a patient's life by keeping up artificial respiration for twenty minutes before the patient could do his own breathing.