The after-care of the tracheotomic wound is of the utmost importance. A special day and night nurse are required. The inner tube of the cannula must be removed and cleaned as soon as it contains secretion. Secretion coughed out must be wiped away quickly, but gently, before it is again aspirated. The gauze dressing covering the wound must be changed as soon as soiled with secretions from the wound and the air-passages. Each fresh pad should be moistened with very weak bichloride of mercury solution (1:10,000). The outer tube must be changed every twenty-four hours, and oftener if the bronchial secretion is abundant. Student-physicians who have been taught my methods and who have seen the cases in care of our nurses have often expressed amazement at the neglect unknowingly inflicted on such cases elsewhere, in the course of ordinary routine surgery. It is not unusual for a patient to be sent to the Bronchoscopic Clinic who has worn his cannula without a single changing for one or two years. In some cases the tube had broken and a portion had been aspirated into the trachea.
[FIG. 108.—Method of dressing a tracheotomic wound. A broad quadruple, in-folded pad of gauze is cut to its centre so that it can be slipped astride of the tube of the cannula back of the shield. No strings, ravellings or strips of gauze are permissible because of the risk of their getting down into the trachea.]
If the respiratory rate increases, instead of attributing it to pulmonary complications, the entire cannula should be removed, the wound dilated with the Trousseau forceps, the interior of the trachea inspected, and all secretions cleaned away. Then the tracheal mucosa below the wound should be gently touched with a sterile bent probe, to induce cough to rid the lower air passages of accumulated secretions. In many cases it is a life-saving procedure to insert a sterile long malleable aspirating tube to remove secretions from the lower air-passages. When all is clear, a fresh sterile cannula which has been carefully inspected to see that its lumen has been thoroughly cleaned, is inserted, and its tapes tied. Good "plumbing," that is, the maintenance at all times of a clear, clean passage in all the "pipes," natural and artificial, is the reason why the mortality in the Bronchoscopic Clinic has been less than half of one per cent, while in ordinary routine surgical care in all hospitals collectively it ranges from 10 to 20 per cent.
Bronchial Aspiration.—As mentioned above, bronchial aspiration is often necessary. When the patient is unable to get up secretions, he will, as demonstrated by the author many years ago, "drown in his own secretions." In some cases bronchoscopic aspiration is required (Peroral Endoscopy, p. 483). Occasionally, very thick secretions will require removal with forceps. Pus may become very thick and gummy from the administration of morphin. Opiates do not lessen pus formation, but they do lessen the normal secretions that ordinarily increase the quantity and fluidity of the pus. When to this is added the dessicating effect of the air inhaled through the cannula, unmoistened by the upper air-passages, the secretions may be so thick as to form crusts and plugs that are equivalent to foreign bodies and require removal with forceps. Diphtheritic membrane in the trachea may require removal with bronchoscope and forceps. Thinner secretions may be removed by sponge-pumping. In most cases, however, secretions can be brought up through an aspirating tube, connected to a bronchoscopic aspirating syringe (Fig. 11), an ordinary aspirating bottle, or preferably, a mechanical aspirator such as that shown in Fig. 12. In this, combined with bronchoscopic oxygen insuflation (q.v.), we have a life-saving measure of the highest efficiency in cases of poisoning by chlorine and other irritant and asphyxiating gases. An aspirating tube for insertion into the deeper air passages should be of copper, so that it can be bent to the proper curve to reach into the various parts of the tracheobronchial tree, and it should have a removable copper-wire core to prevent kinking, and collapse of the lumen. The distal end should be thickened, and also perforated at the sides, to prevent drawing-in of the mucosa and trauma thereto. A rubber tube may be used, but is not so satisfactory. The one shown in Fig. 10 I had made by Mr. Pilling, and it has proved very satisfactory.
Decannulation.—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.
RESUME OF TRACHEOTOMY
Instruments.
Headlight
Sandbag
Scalpel
Hemostats
Small retractors
Tenaculum
Tracheotomic cannulae (proper kind)
Long.
Half area cross-section trachea.
Proper curve: Radius too short will press ant. tracheal wall; too
long, post. wall.
Sterling Silver
Tracheobronchial aspirator.
Probe.
Tapes for cannulae
Trousseau dilator
Sponges
Infiltration syringe and solution
Oxygen tank.
Indications: Laryngeal dyspnea.
(Indrawing guttural and clavicular fossae and at epigastrium.
Pallor. Restlessness. Drowning in his own secretions.)
Do it early. Don't wait for cyanosis.
[294] Never use general anesthesia on dyspneic patient.
Forget about "high" and "low" distinctions until trachea is exposed.
Memorize Jackson's tracheotomic triangle.
Patient recumbent, sand bag under shoulders or neck. Nose to zenith.
Infiltration, _Intra_dermatic.
Incise from Adam's apple to guttural fossa.
Hemostasis.
Keep in middle line.
Feel for trachea.
Expose isthmus of thyroid gland.
Draw it upward or downward or cut it.
Ligature, torsion, etc. before incising trachea.
Hold trachea with tenaculum.
Incise trachea below first ring.
Avoid cutting cricoid or first ring. Cut 3 rings vertically. Don't
hack. Don't cut posterior wall which almost touches the anterior wall
during cough. Spread carefully, with Trousseau dilator.
Insert cannula; see it enter tracheal lumen; remove pilot; tie
tapes.
Don't suture wound. Dress with large squares.
Don't give morphine.
Decannulation by corking partially, after changing to smaller
cannula.
Do not remove cannula permanently until patient sleeps without
indrawing with corked cannula.