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A New Technique for T-Tube Insertion in Tracheal Stenosis Located Above the Tracheal Stoma

2005; Elsevier BV; Volume: 80; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2004.06.069

1552-6259

Benoit Jacques Bibas, Roberto A. Bibas,

Head and Neck Surgical Oncology

Tracheal stenosis is one of the main complications of long-term intubation. The Montgomery T-tube is a safe way to treat patients with tracheal stenosis who are unable to undergo surgical procedures. We describe a simple and practical technique for the insertion of the T-tube in tracheal stenosis located above the tracheostomy, while maintaining ventilation throughout the whole procedure. Tracheal stenosis is one of the main complications of long-term intubation. The Montgomery T-tube is a safe way to treat patients with tracheal stenosis who are unable to undergo surgical procedures. We describe a simple and practical technique for the insertion of the T-tube in tracheal stenosis located above the tracheostomy, while maintaining ventilation throughout the whole procedure. Ever since its development in 1968 by Montgomery [1Montgomery W.W. The surgical management of supraglottic and subglottic stenosis.Ann Otol Rhinol Laryngol. 1968; 77: 534-546PubMed Google Scholar], the T-tube has been used to maintain patency of the upper airway in both benign and malignant diseases for therapeutic or palliative procedures. Indications for the insertion of a T-tube will usually fall into three major categories: (1) temporary stenting of the airway, (2) definitive procedure for palliation, and (3) complications of airway reconstruction [2Gaissert H.A. Grillo H.C. Mathisen D.J. Wain J.C. Temporary and permanent restoration of airway continuity with the tracheal T-tube.J Thorac Cardiovasc Surg. 1994; 107: 600-606Abstract Full Text PDF PubMed Scopus (73) Google Scholar]. The insertion of the T-tube can turn out to be a difficult and time-consuming procedure if the stricture is located above the tracheostomy, especially in individuals with short, obese necks. Therefore we believe that the maintenance of ventilation is the key to minimize complications during the procedure. We describe an easy and useful technique for the insertion of the T-tube for tracheal stenosis located above the tracheal stoma while sustaining ventilation during the whole process. We present the case of a 23-year-old man involved in a motorcycle accident that resulted in severe brain trauma who needed mechanical ventilation. He remained intubated for 15 days. After extubation he had a sudden onset of dyspnea, and a tracheostomy was urgently performed. Flexible bronchoscopy revealed a near-total stricture of the tracheal lumen. A computed tomographic scan showed a subglottic stenosis, located approximately 1 cm below the vocal cords, extending downwards to the opening of the tracheostomy. The diameter of the airways, the distance from the carina to the vocal cords, carina to lower end of stenotic segment, lower end of stricture to tracheostoma, upper end of lesion to tracheostoma, and upper end of lesion to the vocal cords were measured by chest computed tomography with 3-dimensional reconstruction. As the stenosis was located too close to the vocal cords, we chose the Montgomery T-tube as the definitive treatment, instead of a primary tracheal resection,. The patient was placed under general anesthesia, ventilated through the tracheostomy, and was submitted to successive rigid bronchoscopies with progressive dilation of the tracheal stenosis. We managed to dilate the stricture to about 8 mm and then proceeded with the insertion of the T-tube, which was previously cut to meet the patient‘s requirements. The patient was intubated with a 6-French cuffed endotracheal tube. As this is a short tube, we connected it with an additional long segment of uncuffed endotracheal tube of the same caliber. This way we have a long and thin endotracheal tube that can be easily pulled out through the tracheostomy. The tracheostomy tube was removed and the distal tip of the endotracheal tube was pulled out through the tracheal stoma. The tip of the endotracheal tube was inserted into the proximal portion of the vertical limb of the Montgomery T-tube (Fig 1). The cuff of the endotracheal tube was inflated so that both tubes would be tightly connected and could be pulled together. The distal tip of the vertical limb of the T-tube was inserted back into the trachea through the tracheal stoma (Fig 2). At this moment, while occluding the horizontal limb of the T-tube, the patient could be ventilated through the endotracheal tube. With combined movement of pushing the T-tube and pulling the oral tube, the vertical limb of the T-tube smoothly slided into its correct position (Fig 3). The cuff of the endotracheal tube was deflated, and while holding the T-tube, the endotracheal tube was removed. Ventilation could be assessed through the horizontal limb of the T-tube.Fig 2The endotracheal tube is pulled upwards while the T-tube is pushed towards the carina. The T-tube smoothly slides into position.View Large Image Figure ViewerDownload (PPT)Fig 3With the T-tube in its correct position, the cuff of the endotracheal tube is deflated and the endotracheal tube is removed.View Large Image Figure ViewerDownload (PPT) The method proposed by Cooper and colleagues [3Cooper J.D. Todd T.R. Ilves R. Pearson F.G. Use of silicone tracheal T-tube for the management of complex tracheal injuries.J Thorac Cardiovasc Surg. 1981; 82: 559-568PubMed Google Scholar] is very useful for strictures located below the tracheal stoma, as the surgeon can easily push the tube downwards through the tracheostomy. Nevertheless, sometimes by using this technique it can be challenging to pull the tube upward if there is a long and irregular stenotic segment located above the tracheostomy; to do this the surgeon needs to pass a long umbilical tape through the horizontal and upper limb of the T-tube and guide it into the stoma, where it can be grasped by a rigid bronchoscope. By pulling the upper part of the umbilical tape while keeping the lower part steady, the surgeon pulls the tube upward. Although this procedure is easy when the upper trachea is normal, it can be difficult to push the upper limb of the T-tube through a long stenotic and irregular trachea. Besides, the technique does not allow ventilation, and it can be troublesome if the procedure takes too long, especially in patients with impaired lung function. Lin and colleagues [4Lin C.D. Tan C.T. Cheng Y.K. Lee S.Y. Ventilation silicone T-shaped tube insertion.Laryngoscope. 2001; 111: 361-363Crossref PubMed Scopus (4) Google Scholar] modified this technique by introducing a small endotracheal tube into the horizontal limb of the T-tube and out through the distal portion of the vertical limb, maintaining the airway during the entire procedure. Nevertheless, there is still the need to use an umbilical tape or suction tube to manipulate the T-tube. In conclusion, the technique described herein can be very useful for tracheal stenosis located above the tracheostomy. The technique provides easy manipulation of the T-tube without the need of other instruments, besides the T-tube itself and a long and thin endotracheal tube. As ventilation is maintained throughout the entire process, the chances of complications regarding ventilation are diminished. We believe that this is a simple and practical technique, and it can become an important option for the general thoracic surgeon.