Bronchoscopy and Esophagoscopy Part 20

_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 cla.s.sical 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 As originally made the distinction between high and low as applied to tracheotomy referred to operations above and below the isthmus of the thyroid gland, in a day when primitive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 ent.i.tled 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, b.l.o.o.d.y, 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 ill.u.s.trated 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 pa.s.s 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 pa.s.sage of sufficient air for free laryngeal breathing when it is completely corked. The fenestrum is, moreover, rarely so situated that air can pa.s.s through it; the fenestral edges act as a constant irritant to the wound, producing bleeding and granulation tissue.

[FIG. 103.--Schema showing thick pad of gauze dressing, filling the s.p.a.ce, 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 pa.s.sing 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 inst.i.tuted, 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-pa.s.sages.

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 rec.u.mbent position, with the extended head held in the midline by an a.s.sistant. 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.--Ill.u.s.trating 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 a.s.sistants, Dr. Phillip Stout, saved a patient's life by keeping up artificial respiration for twenty minutes before the patient could do his own breathing.

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-pa.s.sages. 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 pa.s.sages of acc.u.mulated 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-pa.s.sages. 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 pa.s.sage 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 quant.i.ty 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-pa.s.sages, 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 pa.s.sages 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 subst.i.tuted to allow free pa.s.sage 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 cla.s.ses of students and pract.i.tioners, 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 rec.u.mbent, 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.

RESUME OF EMERGENCY TRACHEOTOMY

The following notes should be memorized.

1. Essentials: Knife and pair of hands (but full equipment better).

[295] 2. Don't do a laryngotomy, or stabbing.

3. "Two stage, finger guided" operation better.

4. Sand bag or subst.i.tute.

5. Press back danger lines with left thumb and middle finger, making safety line and trachea prominent.