The patient, during, especially, the first few days after the opening into the trachea has been made, should be kept in a well-ventilated room with a uniform temperature. There is rarely any occasion, except in cases of croup and diphtheria, when it may be advisable, to envelop him in steam. Some surgeons place a small wad, two or three layers of gauze, wrung out frequently in hot water, over the mouth of the tube for the first day or two. A large, coarse sponge answers the same purpose; and the precaution seems to me to be a good one, preventing, as it does, air of a low temperature from entering the lungs, and rendering it moist and free from adventitious particles. The difficulty is in keeping it in place.
The question as to the final removal of the canula is a difficult one to answer here, depending as it does upon the various causes for which the operation was originally performed. In certain cases, as will be seen from what has been said, its sojourn in the trachea will only be from a few moments to a few hours; while, on the other hand, in cases, for instance, of severe syphilitic disease of the larynx, with cicatricial stenosis of its cavity, the tube, once introduced, has to be worn during the lifetime of the patient. Between these extreme limits the period varies greatly. As a general rule—perhaps from the fourth or fifth day to the end of the first week—an attempt to cause the patient to breathe through the natural passages, the outer end of the outer fenestrated tracheal tube being closed, will partially succeed. Each day will now make success greater; the voice in part returns, and a period is soon reached when the outer tube may be closed with a cork (at first during the daytime only) and respiration carried on entirely through the larynx. The speedy removal of the tube and the closure of the tracheal wound then follow as a matter of course. I have never found it necessary to employ any of the various forms of after-treatment canulas, and believe them to be unnecessary. The original tube, preferably a fenestrated one, as heretofore described, is to be worn until convalescence is established, then permanently withdrawn.
The tube should be removed at the earliest safe and practicable moment. Its lengthened sojourn is not devoid of danger, as will be shown; and an atrophy of the laryngeal muscles, especially the abductors of the vocal cords, may follow their prolonged disuse, or at least inactivity, thus giving rise to a narrowing of the glottic opening perhaps inconsistent with respiration.
The wound, covered by granulation-tissue if the tracheotomy-tube has been worn for any length of time, quickly closes, when the latter is removed, and needs to ensure this but a few narrow strips of adhesive plaster to be passed across it and attached to the side of the neck, to prevent the air being forced out through it during the first day or two when the patient coughs or attempts to speak.
In cases where the tube has been worn for a long period, and the edges of the opening have firmly cicatrized, their freshening by the knife or scissors is a necessary preliminary to their being brought together by means of a suture or two.
The wound in the trachea closes not by the formation of a cartilaginous, but rather of a dense connective tissue, and the cicatrix is so smooth and small as to be with difficulty discernible. The cicatrix remaining externally upon the neck need be but slight and linear, and cause no disfigurement, especially if the wound have been properly treated and watched during the healing process.
Among the complications and accidents which may occur after a tracheotomy successfully performed,5 none is commoner, and none, perhaps, is more to be feared, than the broncho-pneumonia which may develop at any time within the first three or four days, and especially in those cases where the operation has been rendered necessary by a diphtheritic inflammation of the throat or air-passages. Bronchitis is common when much blood has escaped into the trachea during the operation. The periodical and careful auscultation of the chest is therefore desirable, in order that the earliest physical signs of these morbid conditions may be detected.
5 See Parker, "On Some Complications of Tracheotomy, with Illustrative Cases," Lancet, Jan. 24, Jan. 31, and Feb. 7, 1885.
Secondary hemorrhage is rare: should it occur, the wound must be opened, enlarged if necessary, and the bleeding vessel sought for and secured. A slight hemorrhage may be checked by pressing the parts firmly about the tracheal tube and the use of styptics locally.
When the pathological condition of the parts has demanded that the canula be worn for a long time, and in cases where sufficient care has not been taken to select one suited to the age of the patient or to the particular form of operation that has been chosen, perhaps to the needs of the special case, an ulceration of the anterior or posterior wall of the trachea, the result of the pressure of the lower edge of the tube or of its upper posterior and convex side, may occur. Usually, it happens on the anterior wall, rarely on both, and the main trouble to which they give rise lies in the repeated hemorrhages that proceed from the laceration of granulation-tissue, in changing the canula, for instance, and the descent of the blood into the trachea and lungs. Cases of extensive ulceration, with erosion of the large vessels at the root of the neck, and fatal hemorrhage, have been reported. Considerable care should then be exercised in so adapting a canula to a special case that it will lie as free as possible within the lumen of the trachea. Ulceration of the tracheal walls, it is claimed, never occurs with the right-angled canula of Durham. Occasional change of form in the canula or the use of canulas with rounded extremities (perforated with numerous slits) is often advisable when the tube is worn for a length of time.