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, 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