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Sources: A Manual Of Peroral Endoscopy And Laryngeal Surgery

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, th
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