Part 6 — CHAPTER XLI. THE RESPIRATORY PASSAGES PROPER. (continued 2)

The procedure is by no means a simple nor necessarily easy one, and it should be practised with the instruments upon the cadaver before resorting to it on the living child.

The tube being placed it will remain to be decided by the subsequent course of events how long it should be allowed to remain—in some cases a few hours, in others a few days. With young children it should remain for at least a week. The time having arrived for its removal, the procedure is similar to that required for its introduction. The assistants hold the child in the same position as before, while the operator substitutes the extractor, guiding its tip again by the sense of touch along the left index finger, which, passed down into the pharynx, is made to discover and identify the upper end of the metallic tube. So soon as the point of the extractor is engaged within the tube the blades are separated and it is then drawn out, while the finger is withdrawn along with it in order to make its removal easier and to prevent its loss should it slip off the instrument. Unless the patient struggles violently the whole procedure should be conducted so as to scarcely cause the slightest staining of the expectoration with blood.

Various causes may require abrupt removal of the tube. Thus it is possible for its caliber to be become occluded with tenacious secretion. This may produce a violent fit of coughing, during which there may occur spontaneous expulsion of the tube. At any time, when it is seen that asphyxia is increasing, or when violence of respiratory effort would indicate obstruction within the tube, it should be removed, cleaned, and re-introduced. After its introduction and removal the operator should remain within easy reach for a short time, to be sure that no unpleasant effects result and that no re-introduction may be suddenly required. Should obstructive efforts occur the child should be held head downward and be slapped vigorously upon the chest. This may loosen membrane or it may permit dislodgement of the tube and its spontaneous expulsion. The latter may also occur during the act of vomiting.

The above description is meant especially to apply to intubation as performed upon young children for the relief of the laryngeal obstruction consequent upon diphtheria. It has given better results than tracheotomy, which was the only resort previous to O’Dwyer’s device. It is usually performed easily, and is devoid of the horrors frequently attendant upon an emergency tracheotomy. But intubation is not necessarily limited to children nor to cases of diphtheria. The emplacement of such a tube may be called for at any time in cases of threatening or actual edema of the glottis, as, for instance, from inhalation of steam or flame. It may be advisable in other forms of intralaryngeal disease, both acute and chronic, while individuals suffering from laryngeal stricture or stenosis find that they can wear an O’Dwyer tube almost constantly, not only with relief, but that they are thereby saved from the more serious measure of opening the trachea or removing the larynx.

Impending suffocation having been relieved by intubation, the question of feeding arises. The principal disadvantage attendant upon the use of the tube is partial or complete inability to swallow, for the epiglottis does not always easily close over the tube and prevent entrance of fluid into the larynx. It is necessary to feed patients, especially the young, with extreme care. For this purpose there is no food better than ice-cream, while little children should be placed upon their backs, with the head lower than the body, and made to swallow in this position, at least until they have been accustomed to the presence of the tube and instinctively learn how to avoid irritation by involuntary regulation of the act of swallowing.