child can usually obtain
sufficient air through the temporarily narrowed lumen. If, however, as
in cases of arachidic bronchitis, large amounts of purulent secretion
must be expelled, it will be found in certain cases that the decreased
glottic lumen and impaired laryngeal motility will render tracheotomy
necessary to drain the lungs and prevent drowning in the retained
secretions. Subglottic edema occurring in a previously normal larynx
may result from: 1. The use of over-sized tubes. 2. Prolonged
bronchoscopy. 3. Faulty position of the patient, the axis of the tube
not being in that of the trachea. 4. Trauma from undue force or
improper direction in the insertion of the bronchoscope. 5. The
manipulation of instruments. 6. Trauma inflicted in the extraction of
the foreign body.

_Diagnosis_ must be made without waiting for cyanosis which may never
appear. Pallor, restlessness, startled awakening after a few minutes
sleep, occurring in a child with croupy cough, indrawing around the
clavicles, in the intercostal spaces, at the suprasternal notch and at
the epigastrium, call for tracheotomy which should always be low. Such
a case should not be left unwatched. The child will become exhausted
in its fight for air and will give up and die. The respiratory rate
naturally increases because of air hunger, accumulating secretions
that cannot be expelled because of impaired glottic motility give
signs wrongly interpreted as pneumonia. Many children whose lives
could have been saved by tracheotomy have died under this erroneous
diagnosis.

_Treatment_.--Intubation is not so safe because the secretions cannot
easily be expelled through the tube and postintubational stenosis may
be produced. Low tracheotomy, the tracheal incision always below the
second ring, is the safest and best method of treatment.

[156] CHAPTER XIV--REMOVAL OF FOREIGN BODIES FROM THE LARYNX

_Symptoms and Diagnosis_.--The history of a sudden choking attack
followed by impairment of voice, wheezing, and more or less dyspnea
can be usually elicited. Laryngeal diphtheria is the condition most
frequently thought of when these symptoms are present, and antitoxin
is rightly given while waiting for a positive diagnosis. Extreme
dyspnea may render tracheotomy urgently demanded before any attempts
at diagnosis are made. Further consideration of the symptomatology and
diagnosis of laryngeal foreign body will be found on pages 128, 133
and 143.

_Preliminary