52.2 Laryngotomy and tracheostomy

If a patient’s respiration is obstructed and you cannot relieve it by simpler methods or by intubation, you may occasionally have to open his respiratory tract below the obstruction. You can enter it through his cricothyroid membrane, or his trachea.

As a useful emergency method, you can pass two or more large (1.5 mm) short needles through his cricothyroid membrane, whatever age he is. In an adult (but not in a child) you have the additional possibility of opening his cricothyroid membrane (laryngotomy) with a sharp knife. If necessary, you can do this in 30 seconds or less—it may be so urgent that you do not have time to sterilize the knife. As an emergency procedure in an adult this is simpler and safer than the other alternative, which is an emergency tracheostomy. Permanent impairment of the patient’s voice or airway is unusual after a laryngotomy. But it is a temporary procedure only, so he will need a formal tracheostomy later.

Figure 52.2: A TRACHEOSTOMY SET. Always have this ready and sterile. You may need it in a hurry.

If possible anticipate the need for an emergency tracheostomy and do it as an elective procedure under local anaesthesia, ketamine, or tracheal anaesthesia. It will: (1) Provide immediate relief for a patient’s upper airway obstruction. (2) Reduce his dead space by 100 ml and nearly double his alveolar ventilation. (3) Provide an opening through which you can suck out secretions. (4) Provide him with an airway that can be continued indefinitely.

But, a tracheostomy will also: (1) Greatly diminish the effectiveness of his cough reflex. (2) Short circuit the humidifying effect of his upper respiratory tract, and so dry his tracheal mucosa and make his bronchial secretions more viscid. (3) Make infection of his lower respiratory tract much more likely, so careful aseptic procedures are essential. (4) Occasionally cause severe bleeding. (5) Carry the risk of tracheal stenosis later, especially in a child.

Intubation is almost always possible, so that tracheostomy is only very rarely necessary. Only do it if. (1) Intubation fails or is unsatisfactory, and there is no other way of maintaining an injured patient’s airway. Or, (2) intubation has to be prolonged for more than 48 hours. If his tracheostomy proves to be unnecessary later, you can close it. If it was necessary, you have saved his life. Even so, a tracheostomy has serious risks, especially when nursing care is poor. Here are two patients whose lives it saved.

OMARI (36) was crushed by some heavy scaffolding in a sugar works. He was dyspnoeic with paradoxical movement on the left side of his chest, which had no breath sounds and diminished vocal resonance. It was resonant anteriorly, and dull at the base posteriorly. His trachea and apex beat were shifted to the right. X-rays confirmed the diagnosis of multiple fractured ribs with a flail chest and a left haemopneunothorax.

A chest drain connected to an underwater seal was inserted in his left mid-axilla, and he was given oxygen. Much air and a litre of blood flowed into the drain bottle, but he remained distressed and cyanosed. His chest was too painful to allow him to cough. Secretions began to accumulate, so he was bronchoscoped and copious sputum sucked out. Unfortunately, bronchoscopy was too traumatic to be repeated. Further X-rays showed diffuse mottling throughout both his lung fields. A tracheostomy was done, and his trachea was repeatedly aspirated, after which his general condition improved and his cyanosis disappeared. Eight days later his tracheostomy tube was removed and 3 weeks after discharge, he returned to work.

HAMID heard a lion chasing his cows. He went out with his spear, but the lion leapt at him, biting his throat, and pe­ne­trat­ing his larynx. He arrived in hospital at the point of death, with blood bubbling from his mouth. It obscured his oede­ma­tous distorted larynx, so that intubation was impossible. A tracheostomy was done with some difficulty under local an­ae­sthe­sia. He immediately began to breathe normally. Much blood was sucked from his trachea, and blood stopped coming from his mouth. He recovered completely.

You will need tracheostomy equipment in a hurry, so have a set ready sterilized in the theatre. You will need it for other indications, besides trauma, and particularly for respiratory infections in children. Here is the equipment for it.

• DILATOR, tracheal, extra small for children, one only. Use this to dilate the trachea before inserting a tracheostomy tube.

• TUBE, tracheostomy, plain, uncuffed, reusable, with 15 mm termination, 15 Ch one, 18 Ch one, 21 Ch two, 24 Ch three, 27 Ch four, 30 Ch three, 36 Ch one, 42 Ch one one carton of 15 assorted tubes only. Traditionally a silver tracheostomy tube was used with an inner tube and obturator. Plastic ones are equally good, but they must be firm enough to hold their shape in the trachea.

• TUBE, tracheostomy, standard, cuffed and reusable com- plete with obturator and one way valve, 24 Ch two, 27 Ch two, 30 Ch two, 36 Ch two, 39 Ch one, 42 Ch one, one carton of 10 assorted tubes only.

• RETRACTOR, tracheostomy, single, sharp hook, blunt, one only.

• RETRACTOR, tracheostomy, double hook, blunt, two only. If you don’t have one of these, use a Langenbeck retractor instead.