te cough if necessary to expel
secretions. An aspirating tube should be used, when necessary.
12. A patient with a properly fitted cannula free of secretions
breathes noiselessly. Any sound demands immediate attention.
13. If the respiratory rate increase it is much more likely to be
due to obstruction in, malposition of, or shortness of the cannula
than to lung complications.
14. Be sure that:
(a) The cannula is clear and clean.
(b) The cannula is long enough to reach well down into the
trachea. A cannula that was long enough when the operation was done
may be too short after the cervical tissues swell.
(c) The distal end of the cannula actually is deeply in the
trachea. The only way to be sure is, when inserting the cannula, to
spread the wound and the tracheal incision with a Trousseau dilator,
then _see_ the interior of the tracheal lumen and _see_ the cannula
enter therein.
15. If after attending to the above mentioned details there are
still signs of obstructive dyspnea, a bronchoscopy should be done for
finding and removal of the obstruction in the trachea or main bronchi.
16. If all the "pipes," natural and instrumental, are clear there
can be no such thing as obstructive dyspnea.
17. Pneumonia and pulmonary edema may exist before tracheotomy, but
they are rare sequelae.
18. Decannulation, in cases of tracheotomy done for temporary
conditions should not be attempted until the patient has slept at
least 3 nights with his cannula tightly corked. A properly fitted
cannula (i.e. one not larger than half the area of cross section of
the trachea) permits the by-passage of plenty of air. A partial cork
should be worn for a few days first for testing and "weaning" a child
away from the easier breathing through the neck. In cases of chronic
laryngeal stenosis a prolonged test is necessary before attempting
decannulation.
19. A tracheotomic case may be aphonic, hence unable to call for
help.
20. The foregoing rules apply to the post-operative periods. After
the wound has healed and a fistula is established, the patient, if not
a child, may learn to care for his own cannula.
[298] 21. Do not give cough-sedatives or narcotics. The cough reflex
is the watch dog of the lungs.

NOTES ON NURSING TRACHEOTOMIZED PATIENTS

Bedside tray should contain:
Duplicate cannula
Scalpel
Trousseau dilator
Hemostat
Dressing forceps
Sterile vaseline
Scissors
Tape
Probe
Gauze s