Tracheostomy Health Dictionary

Choking is the process which results from an obstruction to breathing situated in the larynx (see AIR PASSAGES). It may occur as the result of disease causing swelling round the glottis (the entrance to the larynx), or of some nervous disorders that interfere with the regulation of the muscles which open and shut the larynx. Generally, however, it is due to the irritation of a piece of food or other substance introduced by the mouth, which provokes coughing but only partly interferes with breathing. As the mucous membrane lining the upper part of the latter is especially sensitive, coughing results in order to expel the cause of irritation. At the same time, if the foreign body is of any size, lividity of the face appears, due to partial su?ocation (see ASPHYXIA).

Treatment The choking person should take slow, deep inspirations, which do not force the particle further in (as sudden catchings of the breath between the coughs do), and which produce more powerful coughs. If the coughing is weak, one or two strong blows with the palm of the hand over either shoulder blade, timed to coincide with coughs, aid the e?ect of the coughing. If this is ine?ective, the Heimlich manoeuvre may be used. This involves hugging the person from behind with one’s hands just under the diaphragm. A sudden upward compressive movement is made which serves to dislodge any foreign body. In the case of a baby, sit down with left forearm resting on thigh. Place the baby chest-down along the forearm, holding its head and jaw with the ?ngers and thumb. The infant’s head should be lower than its trunk. Gently deliver three or four blows between the shoulder blades with the free hand. The resuscitator should not attempt blind ?nger-sweeps at the back of the mouth; these can impact a foreign body in the larynx.

If normal breathing (in adult or child) cannot be quickly restored, seek urgent medical help. Sometimes an emergency TRACHEOSTOMY is necessary to restore the air supply to the lungs. (See APPENDIX 1: BASIC FIRST AID.)... choking

Cutting of the trachea. (See also tracheostomy.)... tracheotomy

Once known as infantile paralysis, this disease is caused by a viral infection involving the BRAIN and SPINAL CORD. Since the development of e?ective vaccines in the 1950s (see IMMUNISATION), polio has been practically eliminated in most developed countries. People who have not been fully vaccinated, however, may get the disease: it remains a serious risk for unvaccinated travellers to Africa, Asia or southern Europe. Most reported cases are now from sub-Saharan Africa.

Pathology There are three types of virus, infection spreading by the stools-contaminated hands-mouth route. Children are most susceptible.

One attack usually produces permanent immunity, and second attacks are rare. The virus typically affects the anterior horn cells of the spinal cord, especially those in the lumbar region; the grey matter of the brain stem and cortex may also be damaged.

Vaccination is given to infants at two, three and four months: a booster dose is given at around the age of ?ve. The vaccine contains all three types of polio virus. Two types of vaccine are available: inactivated polio virus (IPV) contains dead virus and is administered by injections; oral polio vaccine (OPV) contains live, harmless strains. The latter is used in the United Kingdom.

Symptoms The incubation period is around 7–14 days, the onset being marked by a mild fever and headache which improves after a few days. In around 85 per cent of infected children there is no further progression, but in some – after approximately one week – the symptoms recur, together with neck sti?ness and signs of meningeal irritation (see MENINGES). Weakness of individual muscle groups is common, and may progress – to a variable extent, depending on the distribution of the virus – to widespread PARALYSIS. Involvement of the diaphragm and intercostal muscles may lead to respiratory failure and rapid death unless arti?cial respiration is provided. Involvement of the cranial nerves and brain may lead to nystagmus (see under EYE, DISORDERS OF), hoarseness and di?culty in swallowing, and CONVULSIONS may occur in young children. The CEREBROSPINAL FLUID shows an early increase in lymphocytes, followed by a rise in protein concentration.

Treatment There is no e?ective drug treatment for the infection. Treatment involves early bed rest, followed by PHYSIOTHERAPY and orthopaedic measures as required. At the onset of respiratory diffculties a TRACHEOSTOMY and arti?cial ventilation should be started. (In the 1950s, when polio epidemics were occurring, respiratory diffculties were treated by placing patients in an ‘iron lung’ – a large, airtight, cylindrical container in which the air pressure was raised and lowered to simulate normal breathing.) In cases of severe paralysis with persistent wasting of the limbs, surgery may be necessary to minimise the resulting disability.... poliomyelitis

A bacterial infection that causes a sore throat, fever, and sometimes serious or fatal complications. It is caused by CORYNEBACTERIUM DIPHTHERAE. During infection, the bacterium may multiply in the throat or skin. In the throat, bacterial multiplication gives rise to a membrane that may cover the tonsils and spread up over the palate or down to the larynx and trachea, causing breathing difficulties. Other symptoms are enlarged lymph nodes in the neck, increased heart rate, and fever. Sometimes, infection is confined to the skin. Life-threatening symptoms develop only in nonimmune people and are caused by a toxin released by the bacterium. A victim may collapse and die within a day of developing throat symptoms. More often the person is recovering from diphtheria when heart failure or paralysis of the throat or limbs develops.

Diphtheria is treated with antibiotics.

An antitoxin is also given if diphtheria affects the throat.

If severe breathing difficulties develop, a tracheostomy may be needed.

Mass immunization has made diphtheria rare in developed countries.... diphtheria

A condition that needs urgent medical care. Examples include life-threatening injuries involving blood loss or damage to major organs, cardiac arrest or sudden loss of consciousness from, say, a blow or an epileptic ?t. Emergency is a term also applied to any resuscitative procedure that must be undertaken immediately – for instance, cardiopulmonary resuscitation (see APPENDIX 1: BASIC FIRST AID – Cardiac/respiratory arrest) or TRACHEOSTOMY. Patients with an emergency condition may initially be treated on the spot by suitably quali?ed paramedical sta? before being transported by road or air ambulance to a hospital Accident and Emergency department, also known as an A&E or Casualty department. These departments are sta?ed by doctors and nurses experienced in dealing with emergencies; their ?rst job when an emergency arrives is to conduct a TRIAGE assessment to decide the seriousness of the emergency and what priority the patient should be given in the context of other patients needing emergency care.

As their title shows, A&E departments (and the 999 and 112 telephone lines) are for patients who are genuine emergencies: namely, critical or life-threatening circumstances such as:

unconsciousness.

serious loss of blood.

suspected broken bones.

deep wound(s) such as a knife wound.

suspected heart attack.

di?culty in breathing.

suspected injury to brain, chest or abdominal organs.

•?ts. To help people decide which medical service is most appropriate for them (or someone they are caring for or helping), the following questions should be answered:

Could the symptoms be treated with an overthe-counter (OTC) medicine? If so, visit a pharmacist.

Does the situation seem urgent? If so, call NHS Direct or the GP for telephone advice, and a surgery appointment may be the best action.

Is the injured or ill person an obvious emergency (see above)? If so, go to the local A&E department or call 999 for an ambu

lance, and be ready to give the name of the person involved, a brief description of the emergency and the place where it has occurred.... emergency

The origin of this important branch of medicine lies in the e?ective use of positive-pressure VENTILATION of the lungs to treat respiratory breathing failure in patients affected by POLIOMYELITIS in an outbreak of this potentially fatal disease in Denmark in 1952. Doctors reduced to 40 per cent, the 90 per cent mortality in patients receiving respiratory support with the traditional cuirass ventilator by using the new technique. They achieved this with a combination of manual positive-pressure ventilation provided through a TRACHEOSTOMY by medical students, and by looking after the patients in a speci?c area of the hospital, allowing the necessary sta?ng and equipment resources to be concentrated in one place.

The principle of one-to-one, 24-hours-a-day care for seriously ill patients has been widely adopted and developed for the initial treatment of many patients with life-threatening conditions. Thus, severely injured patients – those with serious medical conditions such as coronary thrombosis or who have undergone major surgery, and individuals suffering from potentially lethal toxic affects of poisons – are treated in an INTENSIVE THERAPY UNIT (ITU). Patients whose respiratory or circulatory systems have failed bene?t especially by being intensively treated. Most patients, especially post-operative ones, leave intensive care when their condition has been stabilised, usually after 24 or 48 hours. Some, however, need support for several weeks or even months. Since 1952, intensive medicine has become a valued specialty and a demanding one because of the range of skills needed by the doctors and nurses manning the ITUs.... intensive care medicine

An uncommon bacterial infection affecting the ?oor of the mouth. It can spread to the throat and become life-threatening. Usually caused by infected gums or teeth, it causes pain, fever and swelling, resulting in di?culty in opening the mouth or swallowing. Urgent treatment with ANTIBIOTICS is called for, otherwise the patient may need a TRACHEOSTOMY to relieve breathing problems.... ludwig’s angina

severe inflammation caused by infection of both sides of the floor of the mouth, resulting in massive swelling of the neck. If untreated, it may obstruct the airways, necessitating tracheostomy. [W. F. von Ludwig (1770–1865), German surgeon]... ludwig’s angina

n. temporary *tracheostomy using a needle or fine-bore tube inserted through the skin.... minitracheostomy

Also known as croup. An acute infection of the respiratory tract in infants and young children, usually caused by parain?uenza virus. The onset is variable but the croupy cough and stridulous breathing usually occur a few days after the onset of a viral upper-respiratory-tract infection. A harsh barking cough is typical of the condition. The majority of affected children can be treated with HUMIDIFICATION and a single dose of inhaled corticosteroid (budesonide – see CORTICOSTEROIDS) or a single day’s treatment with oral prednisolone. Severe croup can cause serious breathing problems when the child should be referred for urgent specialist assessment, and hospitalisation is preferable in all cases. Rarely, some form of intervention is necessary and this will either be in the form of endotracheal intubation or of a tracheostomy.... laryngo-tracheo-bronchitis

Obstruction of the larynx is potentially dangerous in adults but can sometimes be life-threatening in infants and children. Stridor – noisy, di?cult breathing – is a symptom of obstruction. There are several causes, including congenital abnormalities of the larynx. Others are in?ammatory conditions such as acute laryngitis (see below), acute EPIGLOTTITIS and laryngo-tracheo-bronchitis (croup – see below); neurological abnormalities; trauma; and inhalation of foreign bodies.

Laryngitis In?ammation of the mucous membrane of the larynx and vocal chords may be acute or chronic. The cause is usually an infection, most commonly viral, although it may be the result of secondary bacterial infection, voice abuse or irritation by gases or chemicals. ACUTE LARYNGITIS may accompany any form of upper-respiratory-tract infection. The main symptom is hoarseness and often pain in the throat. The voice becomes husky or it may be lost. Cough, breathing diffculties and sometimes stridor may occur. Acute airway obstruction is unusual following laryngitis but may occasionally occur in infants (see laryngotracheo-bronchitis, below).

Treatment Vapour inhalations may be soothing and reduce swelling. Usually all that is needed is rest and analgesics such as paracetamol. Rarely, airway intervention – either ENDOTRACHEAL INTUBATION or TRACHEOSTOMY – may be necessary if severe airway obstruction develops (see APPENDIX 1: BASIC FIRST AID). A?ected patients should rest their voice and avoid smoking.

Chronic laryngitis can result from repeated attacks of acute laryngitis; excessive use of the voice – loud and prolonged, singing or shouting; tumours, which may be benign or malignant; or secondary to diseases such as TUBERCULOSIS and SYPHILIS.

Benign tumours or small nodules, such as singer’s nodules, may be surgically removed by direct laryngoscopy under general anaesthetic; while cancer of the larynx may be treated either by RADIOTHERAPY or by SURGERY, depending on the extent of the disease. Hoarseness may be the only symptom of vocal-chord disturbance or of laryngeal cancer: any case which has lasted for six weeks should be referred for a specialist opinion.

Laryngectomy clubs are being established

A laryngoscopic view of the interior of the larynx.

throughout the country to support patients following laryngectomy. Speech therapists provide speech rehabilitation.... larynx, disorders of

The rash produced by the sudden release of HISTAMINE in the skin. It is characterised by acute itching, redness and wealing which subsides within a few minutes or may persist for a day or more. Depending upon the cause, it may be localised or widespread and transient or constantly recurrent over years. It has many causes.

External injuries to the skin such as the sting of a nettle (‘nettle-rash’) or an insect bite cause histamine release from MAST CELLS in the skin directly. Certain drugs, especially MORPHINE, CODEINE and ASPIRIN, can have the same e?ect. In other cases, histamine release is caused by an allergic mechanism, mediated by ANTIBODIES of the immunoglobulin E (IgE) class – see IMMUNOGLOBULINS. Thus many foods, food additives and drugs (such as PENICILLIN) can cause urticaria. Massive release of histamine may affect mucous membranes – namely the tongue or throat – and can cause HYPOTENSION and anaphylactic shock (see ANAPHYLAXIS) which can occasionally be fatal.

Physical factors can cause urticaria. Heat, exercise and emotional stress may induce a singular pattern with small pinhead weals, but widespread ?ares of ERYTHEMA, activated via the AUTONOMIC NERVOUS SYSTEM (CHOLINERGIC urticaria) may also occur.

Rarely, exposure to cold may have a smiilar e?ect (‘cold urticaria’) and anaphylactic shock following a dive into cold water in winter is occasionally fatal. The diagnosis of cold urticaria can be con?rmed by applying a block of ice to the arm which quickly induces a local weal.

Transient urticaria due to rubbing or even stroking the skin is common in young adults (DERMOGRAPHISM or factitious urticaria). More prolonged deep pressure induces delayed urticaria in other subjects. IgE-mediated urticaria is part of the atopic spectrum (see ATOPY, and SKIN, DISEASES OF – Dermatitis and eczema). Allergy to peanuts is particularly dangerous in young atopic subjects. Notwithstanding the many known causes, chronic urticaria of unknown cause is common and may have an autoimmune basis (see AUTOIMMUNE DISORDERS).

Treatment Causative factors must be removed. Topical therapy is ine?ective except for the use of calamine lotion, which reduces itching by cooling the skin. Oral ANTIHISTAMINES are the mainstay of treatment and are remarkably safe. Rarely, injection of ADRENALINE is needed as emergency treatment of massive urticaria, especially if the tongue and throat are involved, following by a short course of the oral steroid, prednisolone.

Angio-oedema is a variant of urticaria where massive OEDEMA involves subcutaneous tissues rather than the skin. It may have many causes but bee and wasp stings in sensitised subjects are particularly dangerous. There is also a rare hereditary form of angio-oedema. Acute airway obstruction due to submucosal oedema of the tongue or larynx is best treated with immediate intramuscular adrenaline and antihistamine. Rarely, TRACHEOSTOMY may be life-saving. Patients who have had two or more episodes can be taught self-injection with a preloaded adrenaline syringe.... urticaria

Machinery used to provide arti?cial ventilation. Also called a respirator or life-support machine, it is an electric pump linked to a supply of air which it pumps into the patient through an endotracheal tube passed through the nose or mouth into the trachea (see ENDOTRACHEAL INTUBATION). Sometimes the air is pumped straight into the trachea through an arti?cial hole called a TRACHEOSTOMY. During ventilation the patient’s blood gases are closely monitored and other bodily activities such as pulse and heart pressure are regularly measured. Some patients need to be kept on a ventilator for several days or even weeks if their medical condition is serious. (See also ARTIFICIAL VENTILATION OF THE LUNGS.)... ventilator

A type of reaction caused by allergy. Angioedema is characterized by large, well-defined swellings, of sudden onset, in the skin, larynx (voicebox), and other areas.

The most common cause is a sudden allergic reaction to a food. Less commonly, it results from allergy to a drug (such as penicillin), a reaction to an insect bite or sting, or from infection, emotional stress, or exposure to animals, moulds, pollens, or cold conditions. There is also a hereditary form of the disease.

Angioedema may cause sudden difficulty in breathing, swallowing, and speaking, accompanied by swelling of the lips, face, and neck, depending on the area of the body affected. Angioedema that affects the throat and the larynx is potentially life-threatening because the swelling can block the airway, causing asphyxia.

Severe cases are treated with injections of adrenaline (epinephrine) and may require intubation (passage of a breathing tube via the mouth into the windpipe) or tracheostomy (surgical creation of a hole in the windpipe) to prevent suffocation. Corticosteroid drugs may also be given. In less severe cases, antihistamine drugs may relieve symptoms.... angioedema

n. acute inflammation and obstruction of the respiratory tract, involving the larynx and the main air passages (trachea and bronchi), in young children (usually aged between six months and three years). The usual cause is a virus infection but bacterial secondary infection can occur. The symptoms are those of *laryngitis, accompanied by signs of obstruction – harsh difficult breathing (see stridor), a characteristic barking cough, a rising pulse rate, restlessness, and *cyanosis. Treatment is by reassurance and humidification of the inspired air. In severe cases the obstruction may require treatment by steroid nebulizers, *intubation, or *tracheostomy. See also epiglottitis.... croup

n. surgical removal of the larynx in the treatment of laryngeal carcinoma. Postoperatively the patient breathes through a *tracheostomy. Speech is lost following the operation but can be restored by teaching the patient to swallow air and then belch it in a controlled fashion. Alternatively, a battery-powered vibrating device can be held in the mouth or underneath the chin to produce speech (see electrolarynx). Speech can also be facilitated by a one-way valve surgically implanted between the tracheostomy and the upper oesophagus, allowing the patient to divert air into the throat. Partial laryngectomy conserves part of the larynx and allows patients to breathe and speak normally. However, it is only suitable for a few patients with small tumours.... laryngectomy

(OSA, obstructive sleep apnoea syndrome, OSAS) a serious condition in which airflow from the nose and mouth to the lungs is restricted during sleep, also called sleep apnoea syndrome (SAS). It is defined by the presence of more than five episodes of *apnoea per hour of sleep associated with significant daytime sleepiness. Snoring is a feature of the condition but it is not universal. There are significant medical complications of prolonged OSA, including heart failure and high blood pressure. Patients perform poorly on driving simulators, and driving licence authorities may impose limitations on possession of a driving licence. There are associated conditions in adults, the *hypopnoea syndrome and the upper airways resistance syndrome, with less apnoea but with daytime somnolence and prominent snoring. In children the cause is usually enlargement of the tonsils and adenoids and treatment is by removing these structures. In adults the tonsils may be implicated but there are often other abnormalities of the pharynx, and patients are often obese. Treatment may include weight reduction or nasal *continuous positive airways pressure (nCPAP) devices, *mandibular advancement splints, or noninvasive ventilation. Alternatively *tonsillectomy, *uvulopalatopharyngoplasty, *laser-assisted uvulopalatoplasty, or *tracheostomy may be required.... obstructive sleep apnoea

(lockjaw) n. an acute infectious disease, affecting the nervous system, caused by the bacterium Clostridium tetani. Infection occurs by contamination of wounds by bacterial spores. Bacteria multiply at the site of infection and produce a toxin that irritates nerves so that they cause spasmodic contraction of muscles. Symptoms appear 4–25 days after infection and consist of muscle stiffness, spasm, and subsequent rigidity, first in the jaw and neck then in the back, chest, abdomen, and limbs; in severe cases the spasm may affect the whole body, which is arched backwards (see opisthotonos). High fever, convulsions, and extreme pain are common. If respiratory muscles are affected, a *tracheostomy or intubation and ventilation is essential to avoid death from asphyxia. Mortality is high in untreated cases but prompt treatment is effective. An attack does not necessarily confer complete immunity. Immunization against tetanus is effective but temporary. —tetanic adj.... tetanus

n. 1. the passage of air into and out of the respiratory tract. The air that reaches only as far as the conducting airways cannot take part in gas exchange and is known as dead space ventilation – this may be reduced by performing a *tracheostomy. In the air sacs of the lungs (alveoli) gas exchange is most efficient when matched by adequate blood flow (*perfusion). Ventilation/perfusion imbalance (ventilation of underperfused alveoli or perfusion of underventilated alveoli) is an important cause of *anoxia and *cyanosis. 2. the use of a *ventilator to maintain or support the breathing movements of patients. Invasive ventilation involves the insertion of an endotracheal tube (see intubation), through which air is blown into the lungs; patients need to be paralysed and anaesthetized. This need can be eliminated by using techniques of *noninvasive ventilation.... ventilation