172 THE LARYNX, BRONCHI AND OESOPHAGUS
suturing of the wound and is not dangerous unless it leads to mediastinal
emphysema and cardiac tamponade.
2. Blockage of Tracheostomy Tube. This can occur if there is lack of humidifica-
tion or poor toilet. It is more likely to occur with Portex tubes than silver
tubes, but presents little problem if it is recognized in time. The tube should j,
be changed and if crusts have occurred down the trachea they must bef-
removed by bronchoscopy. ^
3. Tracheal Erosion and Haemorrhage. The initial erosion can be caused by
using a tube with the wrong curvature or by passing the tube anterior to the
tracheal opening to lie on the anterior tracheal wall. A tube in this position
may erode the innominate vein with almost invariably fatal results. ^
4. Dysphagia. This is fairly common in the first few days after tracheostomy.
In normal swallowing a positive subglottic pressure is created by the closing
of the vocal cords—which is why one cannot speak during swallowing. This
is not possible with a tracheostomy tube in place, and thus swallowing is
incoordinate. Another reason for dysphagia is that if an inflatable cuff is
blown up it will press on and obstruct the oesophagus.
5. Difficult Decanmilation. The problems of decannulating children have been
mentioned earlier; on occasion this is due to psychological factors* but on
other occasions it is due to -subglottic^oedemar'BJnfection andjigr.rngis nf_
rgrtijagfi occur the Cartilaginous tracheal rings softenTand when the tube is
removed the lumen^ollapses causing^respiratory obstruction and difficulty in
decannuiation. Another cause ^flMs"ls tracheal stenosis due to infection
becaus^locTmuch;anterior tracheal wall has"15een removed at the operation, or
to cricoid c^lla^sejollowing a high tracheostomy.
TRACHEOSTOMY VERSUS INTUBATION
If a patient requires assisted ventilation then either a tracheostomy tube or an
endotracheal tube supplies an adequate route for this. Similarly, if a patient
requires an airway to by-pass an obstruction then either method is equally
good, given the proviso that an endotracheal tube can be inserted past or
through the obstruction.
In spite of the relatively rare complication of tracheal stenosis due to an
indwelling endotracheal tube it is probably safer not to leave one in situ for
more than 72 hours. In considering this oft-repeated complication of intuba-
tion it is prudent to consider the list of complications of tracheostomy listed
In the emergency situation, which with careful patient care should not be
allowed to occur, given an equally skilled anaesthetist and surgeon, intubation
will be the quicker procedure. In the hands of unskilled doctors in the
emergency situation, both of the procedures are dangerous and a laryngo-
tomy is quicker and safer. Generally, however, the procedure adopted
depends upon which one the attending doctor can do better, more safely and
quicker, and this will usually be intubation.
The use of hydrocortisone in inflammatory states had decreased the need
for tracheostomy in an illness such as acute laryngotracheobronchitis. This is
an effective and safe method and occasionally has to be complemented by
intubation for a short time. Very few patients have died from an overdosage of
iiitravmo*is hydrocortisoee. Since this problem usually arises in children and