A prolonged attempt at introducing the tube should be avoided. Many brief trials characterized by gentleness will do much less harm. If during the first at tempt the tube passes into the cesopha o b'7) ns the instrument and the finger should be removed from the throat, and the pa tient be allowed to recover his breath for a moment. A new trial is then made. Entrance of the tube into the larynx is indicated by violent coughing and by easy respiration, if the tube is not blocked by membrane below it.
To ascertain whether the tube is in position the child, sitting upright, is al lowed to drink a small quantity of water from a glass; if the tube is in the larynx violent coughing will result. If it is in the oesophagus there will be no violent coughing, no relief from the threatening suffocation, and there will also be a gradual shortening of the loop as the tube gravitates toward the stomach.
newed. The operator should wait a few minutes to make sure that the tube is in position, and to allow the cough to expel the mucus and softened membrane. He should then replace the gag, cut the loop near the mouth and introduce the index finger of the left hand until it reaches the head of the tube. This is held down If the operator is quite certain that the tube has entered the larynx the gag should be removed and the loop placed backward over the ear. While doing this, the hands of the patient should be held firmly by the nurse, otherwise the child will grasp the thread, pull out the tube, and the procedure will have to be re while the thread is removed by pulling on one end of the loop.
The string should be permitted to remain in place, being passed over the left ear, until quiet breathing is restored, from fifteen minutes to half an hour, and should then be removed by cutting one side of the loop close to the mouth, taking hold of the long end, and with drawing while the left forefinger is making gentle pressure down on the head of the tube. Never, under any cir cumstances, should the string be removed without making pressure on the head of the tube, as the string becomes twisted in the mouth and will be caught in the eyelet of the tube and the latter itself withdrawn unless the counter-pressure is made. Another very important pre caution is that the person holding the child should never release the child's hands until the string is removed by the surgeon. W. K. Simpson (Med. News,
Mar. 19, '98).
If, in introducing the tube, membrane is crowded down ahead of it and respira tion is difficult or impossible, as a conse quence, the patient should be encour aged to cough violently. As be does this the tube should be quickly jerked by means of the thread still attached. Fre quently a large mass of membrane will be expelled. If this does not occur stim ulants and water should be given and violent coughing encouraged.
It will occasionally happen that in spite of all efforts a patient is unable to expel the offending and obstructing membrane. In such a case it is necessary to employ a long pair of tracheal forceps and, as the child coughs, endeavor to grasp the membrane and remove it. If still unsuccessful our last resort is to per form tracheotomy and extract the mem brane. This, however, is rarely neces sary.
Out of two hundred cases in only two has the membrane been crowded down sufficiently to produce asphyxiation, and in both of these it was immediately coughed out on removal of the tube. O'Dwyer (Med. News, June 23, 'SS).
Pushing down of the psendomembrane by intubation is seldom observed, and only in rare cases ends fatally. The asphyxia caused by it can be relieved by extubation, and the loosened mem brane will be expectorated. If no ex pectoration follows extubation, artificial respiration must be performed, and, if this has no effect, tracheotomy should be performed. The later obstruction of the tube by pseudomembrane rarely occurs. The thread should be fixed to the child's neck, so that extubation could be per formed by the nurse if necessary. 13okay (Pester med.-chir. Presse, No. 12, '94).
Of 498 intubation cases, an immediate tracheotomy became necessary in 3 '/2 per cent. on account of detachment of pseudomembrane. Tracheotomy failed to relieve the asphyxia in only 2 of these cases, and these patients died from the pushing down of pseudomembrane. immediate extubation leads, in most eases, to the result that the loosened pseudomembrane is ejected by violent coughing, either simultaneously with the After the tube has been successfully introduced the patient experiences entire relief. The change in the appearance of the patient is not only immediate, but remarkable.