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In reference to Removal of obstructing T‐tube and stabilization of the airway

2012; Wiley; Volume: 122; Issue: 4 Linguagem: Inglês

10.1002/lary.23177

1531-4995

Jeremy D. Richmon,

Voice and Speech Disorders

Recently, Athavale et al.1 described a method by which a patient can secure their airway should their T-tube become obstructed. I agree with the authors that T-tube obstruction is a rare event, and education on daily T-tube hygiene and what to do if airway problems develop is of prime importance. Because T-tubes lack an inner cannula and are left as indwelling devices, obstruction can present a life-threatening emergency. However, I do not agree with their method of securing the airway should the T-tube become obstructed and fear that this may actually result in further airway compromise. Anyone who has removed a T-tube from an anesthetized patient in the controlled situation of the operating room knows the considerable force necessary to remove it. The force must overcome the intrinsic rigidity of both the upper and lower limbs of the Silastic T-tube to pull both limbs through the tracheostoma. As one who has yet to have a resident who did not need a bit of encouragement to pull harder to remove the T-tube, I find it hard to fathom that a patient in respiratory distress will completely occlude the outer limb of the T-tube with a Kelly clamp and be able to self-extract their own tube. One fear is that they will partially extract the tube until the upper and lower limbs fold and stop midway, given the force necessary or the resultant pain, and lose whatever airway they had. This could make a bad situation worse as it is very challenging to replace a partially extruded T-tube. However, giving the patient the benefit of the doubt and assuming that he has successfully removed his T-tube, I find it improbable that he will be able to self-cannulate himself with a tracheotomy tube. Trach tube changes, albeit routine for us otolaryngologists, are complex maneuvers that require dedicated training from nurse educators and respiratory technicians. I worry that an obstructing patient would not be able to successfully perform their first trach tube placement under such challenging circumstances. Nonetheless, provided that the distressed patient has the wherewithal to rotate the obturated trach into their stoma, remove the obturator, and place the inner cannula does not guarantee a stable airway as the authors suggest. Distal obstruction of the T-tube by tumor mass, granulation tissue, or stenosis may not be relieved by the above technique. The lower limb of a T-tubes ranges from 23 to 75 mm.2 The length of a Shiley tracheotomy tube ranges from 62 to 79 mm including the bend and the portion of the tube that will sit in the tracheotomy tract.3 It is therefore conceivable that a partially obstructed T-tube, if removed, can lead to complete airway obstruction that would not be relieved by a standard tracheotomy tube (especially with the smaller tube that the authors send home with their patients). Although “How I Do It” articles do not require data to support expert advice, it would be helpful to know whether Athavale et al.'s recommendations have ever been used by their patients, and if so with what success and complication rate. Although I surely do not contend that an evidence base is necessary for every intervention, especially life-threatening ones, without any data to support this intervention and the fear of exacerbating an already tenuous airway, it is only under absolute airway obstruction that I can support the authors' technique. We continue to rely on providing our patients with meticulous T-tube hygiene practices and instructions to call our clinic or on-call resident at the earliest signs of airway compromise. Jeremy D. Richmon MD*, * Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland.