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compound. Alternatively, the drug can be given subcutaneously of o-i per cent solution
in doses of 0-2 ml to 0-5 ml. Isoprenaline is another drug for immediate effect, which can
be given by inhalation of a nebulized solution of 1-2 per cent isoprenaline sulphate but
may also be given by mouth in doses of 10-20 mg tablets which are dissolved under the
tongue. However, undesirable side effects of this drug are tachycardia and dizziness.
Recently, Lustman (1970) and Choo-Kang
et al.
(1970) found Salbutamol (Ventolin-A
and H) more effective than Isoprenaline. The bronchodilator action of 200 meg of
Salbutamol was found to be equal in effect to 1,000 meg of Isoprenaline without its
tachycardia. Aminophylline (neutrophylline) is either administered as suppository per
rectum or is most effective as intravenous infusion in doses of 250-500 mg. Finally,
corticosteroid drugs (prednisone by mouth in doses of 10 mg every 6 hr) are also
used but should be controlled by repeated measurements of the forced expiratory volume.
In patients with tension pneumothorax and haemopneumothorax, thoracocemtesis,
which has to be repeated, especially in haemopneumothorax, is indicated and has proved
a life saving procedure. The technique adopted at Stoke Mandeville for the treatment of
pneumothorax is intercostal drainage connected to an underwater seal, and we found the
risks of tube drainage slight. Haemothorax is usually treated by aspiration through a wide
bore needle which can be repeated if necessary. This procedure was found to be a lesser
risk of infection than an intercostal drain. Needle aspiration can be repeated if at the first
session all blood could not be removed.
Tracheostomy—Tracheal Stenosis—Strictures.
There is no doubt that tracheostomy
has proved a life saving measure, both in patients with severe head injuries and cervical
injuries suffering from respiratory distress, and this applies also to thoracic lesions with
associated injuries such as fractures of ribs, xiphosternum and haemopneumothorax.
However, it should not be used indiscriminately, having regard to the great advances
made in physiotherapy. If, in certain cases with airway obstruction, tracheal catheteriza-
tion is contemplated, intubation with a naso-tracheal tube should be tried first, in the
technique of which an experienced anaesthetist could be of great help. However, pro
longed intubation must be avoided as it may lead to excoriation and ulceration in the
cricoid region. This has been found to occur, especially in children. Fearon (1966)
reported an incidence of 8 per cent in 72 children who had been intubated for more
than 8 hours. Pressure sores involving the cartilage may occur within 30 hr (Hard-
castle, 1966), especially through constant movement by intermittent positive pressure
ventilation (IPPV) occurring between the tube and the mucosa.
There are many observations of serious risks reported following tracheostomy, the
most important being the laryngeal and bronchial stenosis resulting in strictures with
dense fibrosis. A variety of stenosis may occur following insertion of a non-cuffed and, in
particular, a cuffed tube which has recently been reviewed by Harley (1971) who has
given a classification of air-way obstruction following tracheostomy with assisted ventila
tion. It is true that, as a result of Jackson's work (1921, 1954), high tracheostomy has
been abandoned because of the danger of producing laryngeal stenosis as a result of
perichondritis and cartilage necrosis, but infracricoid and, in particular, tracheal stenosis
still not infrequently occur, and many workers consider stenosis after tracheostomy and
