6. Memorize Jackson's tracheotomic triangle.

7. Incise exactly in middle line from Adam's apple to sternum.

8. Feel for tracheal corrugations with left index in pool of blood, following trachea with finger downward from superficial Adam's apple.

9. Pa.s.s knife along index and incise trachea (not too deeply, may cut posterior wall).

10. Don't mind bleeding; but keep middle line and keep head straight; keep head low; don't bother about thyroid gland.

11. Don't expect hiss when trachea is cut if patient has stopped breathing.

12. Start artificial respiration.

13. Amyl nitrite. Oxygen.

14. Practice palpation of the neck until the tracheal landmarks are familiar.

15. Practice above technic, up to point of incision, at every opportunity.

16. _Jackson's tracheotomic triangle_: A triangulation of the front of the neck intended to facilitate a proper emergency tracheotomy.

Apex at suprasternal notch.

Sides anterior edge sternomastoids.

Base horizontal line lower edge cricoid.

RESUME OF AFTER-CARE OF A TRACHEOTOMIC CASE

1. Always bear in mind that tracheotomy is not an ultimate object.

The ultimate object is to pipe air down into the lungs. Tracheotomy is only a means to that end.

2. Sterile tray beside bed should contain duplicate (exact) tracheotomy tube, Trousseau dilator, hemostat, thumb forceps, silver probe, scissors, scalpel, probe-pointed curved bistoury. Sterile gloves ready.

3. Special nursing necessary for safety.

4. Laxative.

5. Sponge away secretions before they are drawn in.

6. Cover wound with wide large gauze square slit so it fits around cannula under the tape holder. Pull off ravelings. Keep wet with 1 : 10,000 Bichloride solution.

7. Change dressing every hour or oftener.

8. Abundance of fresh air, temperature preferably about 70 degrees.

9. _Nurse should remove inner cannula as often as needed and clean it with pipe cleaner before boiling._ 10. Outer cannula should be changed every day by the surgeon or long-experienced tracheotomy nurse. A pilot should be used and care should be taken not to injure the cut ends of the tracheal cartilage.

11. A sterile, bent probe may be inserted downward in the trachea with both cannulae out to excite cough if necessary to expel secretions. An aspirating tube should be used, when necessary.

12. A patient with a properly fitted cannula free of secretions breathes noiselessly. Any sound demands immediate attention.

13. If the respiratory rate increase it is much more likely to be due to obstruction in, malposition of, or shortness of the cannula than to lung complications.

14. Be sure that: (a) The cannula is clear and clean.

(b) The cannula is long enough to reach well down into the trachea. A cannula that was long enough when the operation was done may be too short after the cervical tissues swell.

(c) The distal end of the cannula actually is deeply in the trachea. The only way to be sure is, when inserting the cannula, to spread the wound and the tracheal incision with a Trousseau dilator, then _see_ the interior of the tracheal lumen and _see_ the cannula enter therein.

15. If after attending to the above mentioned details there are still signs of obstructive dyspnea, a bronchoscopy should be done for finding and removal of the obstruction in the trachea or main bronchi.

16. If all the "pipes," natural and instrumental, are clear there can be no such thing as obstructive dyspnea.

17. Pneumonia and pulmonary edema may exist before tracheotomy, but they are rare sequelae.

18. Decannulation, in cases of tracheotomy done for temporary conditions should not be attempted until the patient has slept at least 3 nights with his cannula tightly corked. A properly fitted cannula (i.e. one not larger than half the area of cross section of the trachea) permits the by-pa.s.sage of plenty of air. A partial cork should be worn for a few days first for testing and "weaning" a child away from the easier breathing through the neck. In cases of chronic laryngeal stenosis a prolonged test is necessary before attempting decannulation.

19. A tracheotomic case may be aphonic, hence unable to call for help.

20. The foregoing rules apply to the post-operative periods. After the wound has healed and a fistula is established, the patient, if not a child, may learn to care for his own cannula.

[298] 21. Do not give cough-sedatives or narcotics. The cough reflex is the watch dog of the lungs.

NOTES ON NURSING TRACHEOTOMIZED PATIENTS

Bedside tray should contain: Duplicate cannula Scalpel Trousseau dilator Hemostat Dressing forceps Sterile vaseline Scissors Tape Probe Gauze sponges Gauze squares Probe-pointed curved bistoury.

1. Room should be abundantly ventilated, as free from dust and lint as possible, and the air should be moistened by steam in winter.

2. Keep mouth clean. Tooth brush. Rinse alcohol 1:10.

3. Sponge away secretion after the cough before drawn in.

4. Remove inner cannula (not outer) as often as needed. Not less often than every hour. Replace immediately. Never boil a cannula until you have thoroughly cleaned it.

5. Obstruction of cannula calling for cleaning indicated by: Blue or ashy color.

Indrawing at clavicles, sternal notch, epigastrium.

Noisy breathing. (Learn sound.) 6. Surgeon (in our cases) will change outer cannula once daily or oftener.

7. Duplicate cannulae.

8. Be careful in cleaning cannulae not to damage.

9. Watch for loose parts on cannula.

10. Change dressing (in our cases) as often as soiled. Not less often than every hour. Large squares. Never narrow strips.

11. Watch color of lips and ears and face.

[299] 12. Report at once if food or water leaks through wound.

(Coughing and choking).

13. Never leave a tracheotomized patient unwatched during the first days or weeks, according to case.

14. Remember Trousseau dilator or hemostat will spread the tracheal wound or fistula when cannula is out.

15. Remember life depends on a clear cannula if the patient gets no air through the mouth.

16. Remember it takes very little to clog the small cannula of a child.

17. Remember a tracheotomized patient cannot call for help.

18. Decannulation. Testing by corking partially. Watch corks not too small, or broken. Attach them by braided silk thread. Pure rubber cord ground down makes best cork.

[300] CHAPTER x.x.xVIII--CHRONIC STENOSIS OF THE LARYNX AND TRACHEA

The various forms of laryngeal stenosis for which tracheotomy or intubation has been performed, and the difficulties encountered in restoring the natural breathing, may be cla.s.sified into the following types: 1. Panic 2. Spasmodic 3. Paralytic 4. Ankylotic (arytenoid) 5. Neoplastic 6. Hyperplastic 7. Cicatricial (a) Loss of cartilage (b) Loss of muscular tissue (c) Fibrous

_Panic_.--Nothing so terrifies a child as severe dyspnea; and the memory of previous struggles for air, together with the greater ease of breathing through the tracheotomic cannula than through even a normal larynx, incites in some cases so great a degree of fear that it may properly be called panic, when attempts at decannulation are made.

Crying and possibly glottic spasm increase the difficulties.

_Spasmodic stenosis_ may be a.s.sociated with panic, or may be excited by subglottic inflammation. Prolonged wearing of an intubation tube, by disturbing the normal reciprocal equilibrium of the abductors and adductors, is one of the chief causes. The treatment for spasmodic stenosis and panic is similar. The use of a special intubation tube having a long antero-posterior lumen and a narrow neck, which form allows greater action of the musculature, has been successful in some cases. Repeated removal and replacement of the intubation tube when dyspnea requires it may prove sufficient in the milder cases. Very rarely a tracheotomy may be required; if so, it should be done low.

The wearing of a tracheotomic cannula permits a restoration of the muscle balance and a subsidence of the subglottic inflammation.

Corking the cannula with a slotted cork (Fig. 111) will now restore laryngeal breathing, after which the tracheotomic cannula may be removed.

[PLATE V--PHOTOPROCESS REPRODUCTIONS OF THE AUTHOR'S OIL-COLOR DRAWINGS FROM LIFE--LARYNGEAL AND TRACHEAL STENOSES:

1, Indirect view, sitting position; postdiphtheric cicatricial stenosis permanently cured by endoscopic evisceration. (See Fig. 5.) 2, Indirect view, sitting position; posttyphoid cicatricial stenosis.

Mucosa was very cyanotic because cannula was re-moved for laryngoscopy and bronchoscopy. Cured by laryngostomy. (See Fig. 6.) 3, Indirect view, sitting position; posttyphoid infiltrative stenosis, left arytenoid destroyed by necrosis. Cured by laryngostomy; failure to form advent.i.tious band (Fig. 7) because of lack of arytenoid activity.

4, Indirect view, rec.u.mbent position; posttyphoid cicatricial stenosis. Cured of stenosis by endoscopic evisceration with sliding punch forceps. Anterior commissure twice afterward cleared of cicatricial tissue as in the other case shown in Fig. 15. Ultimate result shown in Fig. 8. 5, Same patient as Fig. 1; sketch made two years after decannulation and plastic. 6, Same patient as Fig. 2; sketch made four years after decannulation and plastic. 7, Same patient as Fig. 3; sketch made three years after decannulation and plastic. 8, Same patient as Fig. 4; sketch made one year after decannulation, fourteen months after clearing of the anterior commissure to form advent.i.tious cords. 9, Direct view, rec.u.mbent patient; web postdiphtheric (?) or congenital (?). "Rough voice" since birth, but larynx never examined until stenosed after diphtheria. Web removed and larynx eviscerated with punch forceps; recurrence of stenosis (not of web). Cure by laryngostomy. This view also ill.u.s.trates the true depth of the larynx which is often overlooked because of the misleading flatness of laryngeal ill.u.s.trations. 10, Direct laryngoscopic view; postdiphtheric hypertrophic subglottic stenosis. Cured by galvanocauterization. 11, Direct laryngoscopic view; postdiphtheric hypertrophic supraglottic stenosis. Forceps excision; extubation one month later; still well after four years. 12, Bronchoscopic view of posttracheotomic stenosis following a "plastic flap" tracheotomy done for acute edema. 13, Direct laryngoscopic view; anterolateral thymic compression stenosis in a child of eighteen months. Cured by thymopexy. 14, Indirect laryngoscopic (mirror) view; laryngostomy rubber tube in position in treatment of post-typhoid stenosis. 15, Direct view; posttyphoid stenosis after cure by laryngostomy. Dotted line shows place of excision for clearing out the anterior commissure to restore the voice. 16, Endoscopic view of posttracheotomic tracheal stenosis from badly placed incision and chondrial necrosis. Tracheotomy originally done for influenzal tracheitis. Cured by tracheostomy.]

_Paralysis_.--Bilateral abductor laryngeal paralysis causes severe stenosis, and usually tracheotomy is urgently required. In cadaveric paralysis both cords are in a position midway between abduction and adduction, and their margins are crescentic, so that sufficient airway remains. Efforts to produce the cadaveric position of the cords by division or excision of a portion of the recurrent laryngeal nerves, have been failures. The operation of _ventriculocordectomy_ consists in removing a vocal cord and the portion or all of the ventricular floor by means of a punch forceps introduced through the direct laryngoscope. Usually it is better to remove only the portion of the floor anterior to the vocal process of the arytenoid. In some cases monolateral ventriculocordectomy is sufficient; in most cases, however, operation on both sides is needed. An interval of two months between operations is advisable to avoid adhesions. In almost all cases, ventriculocordectomy will result in a sufficient increase in the glottic c.h.i.n.k for normal respiration. The ultimate vocal results are good. Evisceration of the larynx, either by the endoscopic or thyrotomic method, usually yields excellent results when no lesion other than paralysis exists. Only too often, however, the condition is complicated by the results of a faultily high tracheotomy. A rough, inflexible voice is ultimately obtained after this operation, especially if the arytenoid cartilage is unharmed. In recent bilateral recurrent paralysis, it may be worthy of trial to suture the recurrent to the pneumogastric. Operations on the larynx for paralytic stenosis should not be undertaken earlier than twelve months from the inception of the condition, this time being allowed for possible nerve regeneration, the patient being made safe and comfortable, meanwhile, by a low tracheotomy.

_Ankylosis_.--Fixation of the crico-arytenoid joints with an approximation of the cords may require evisceration of the larynx.

This, however, should not be attempted until after a year's lapse, and should be preceded by attempts to improve the condition by endoscopic bouginage, and by partial corking of the tracheotomic cannula.

_Neoplasms_.--Decannulation in neoplastic cases depends upon the nature of the growth, and its curability. Cicatricial contraction following operative removal of malignant growths is best treated by intubational dilatation, provided recurrence has been ruled out. The stenosis produced by benign tumors is usually relieved by their removal.

_Papillomata_.--Decannulation after tracheotomy done for papillomata should be deferred at least 6 months after the discontinuance of recurrence. Not uncommonly the operative treatment of the growths has been so mistakenly radical as to result in cicatricial or ankylotic stenoses which require their appropriate treatments. It is the author's opinion that recurrent papillomata const.i.tute a benign self-limited disease and are best treated by repeated superficial removals, leaving the underlying normal structures uninjured. This method will yield ultimately a perfect voice and will avoid the unfortunate complications of cicatricial hypertrophic and ankylotic stenosis.

_Compression Stenosis of the Trachea_.--Decannulation in these cases can only follow the removal of the compressive ma.s.s, which may be thymic, neoplastic, hypertrophic or inflammatory. Glandular disease may be of the Hodgkins' type. Thymic compression yields readily to radium and the roentgenray, and the tuberculous and leukemic adenitides are sometimes favorably influenced by the same agents.

Surgery will relieve the compression of struma and benign neoplasms, and may be indicated in certain neoplasms of malignant origin. The possible coexistence of laryngeal paralysis with tracheal compression is frequently overlooked by the surgeon. Monolateral or bilateral paralysis of the larynx is by no means an uncommon postoperative sequel to thyroidectomy, even though the recurrent nerves have been in no way injured at operation. Probably a localized neuritis, a cicatricial traction, or inclusion of a nerve trunk accounts for most of these cases.

_Hyperplastic and cicatricial chronic stenoses_ preventing decannulation may be cla.s.sified etiologically as follows: 1. Tuberculosis 2. Lues 3. Scleroma 4. Acute infectious diseases (a) Diphtheria (b) Typhoid fever (c) Scarlet fever (d) Measles (e) Pertussis 5. Decubitus (a) Cannular (b) Tubal 6. Trauma (a) Tracheotomic (b) Intubational (c) Operative (d) Suicidal and homicidal (e) Accidental (by foreign bodies, external violence, bullets, etc.)

Most of the organic stenoses, other than the paralytic and neoplastic forms, are the result of inflammation, often with ulceration and secondary changes in the cartilages or the soft tissues.