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Eur J Cardiothorac Surg 2001;20:1037-1039
© 2001 Elsevier Science NL
How-to-do-it |
Department of Thoracic and Cardiovascular Surgery, Korea University Medical Center, 126-1 Anam-dong, Sungbuk-gu, Seoul 136-705, South Korea
Received 17 May 2001; received in revised form 24 July 2001; accepted 25 July 2001.
Corresponding author. Tel.: +82-2-920-5559; fax: +82-2-927-3104
e-mail: ksunmd{at}kumc.or.kr
Abstract
We describe a simple and secure technique for the insertion of a long Montgomery type T-tube in patients with tracheal stenosis. An endotracheal tube is placed into the lumen of the T-tube and by maintaining the airway during insertion, the technique has been found to be safe and it can prevent the kind of tracheal damage occurring with blind techniques.
Key Words: Intubation • Intratracheal • Trachea • Tracheal Stenosis • Tracheostomy
1. Introduction
Since the Montgomery T-tube was introduced in 1965 [1], it has been widely used as a long-term palliation for stenotic tracheal lesions untreatable by surgical procedures [2]. The T-tube can be inserted by a standard technique of direct insertion or by modified techniques using rigid bronchoscopy or a reversed T-tube [3]. However, the flexibility of silicone frequently prohibits the tube from passing through the stenotic segment especially when the lesion involves a long segment or is located in the distal trachea. Also, this complicated procedure tends to block the airway for a long time. We herein describe a simple and safe technique for the insertion of T-tube in patients with tracheal stenosis.
2. Insertion technique
It is important to select a T-tube with appropriate length and diameter. Routine preoperative chest CT and bronchoscopy should be performed to obtain precise information regarding the nature and location of the tracheal stenosis lesion including the diameter of the stenotic segment (DIAMETER), the distance from the tracheostomy opening to the vocal cord (PROXIMAL), and the depth of the tracheostomy wound from the skin surface (DEPTH). When the lesion is distally located, it is also important to determine the distance from the tracheostomy opening to the distal end of the stenosis lesion (DISTAL). When a T-tube is selected and modified, a smaller sized endotracheal tube is placed into the T-tube lumen. The external diameter of the T-tube should be 2 mm bigger than the DIAMETER, the upper arm of the T-tube 10 mm shorter than the PROXIMAL, the lower arm 2 mm longer than the DISTAL, and the side arm 5 mm longer than the DEPTH.
The patient is positioned supine with the neck extended slightly. The tracheostomy wound is infiltrated with 2% lidocaine. An endotracheal tube is inserted through the side arm of the T-tube and advanced until the balloon portion has passed 5 mm beyond the distal end of the T-tube. The balloon is slightly inflated, only enough to cover the distal tip of the T-tube (Fig. 1). After application of a lubricant, both tubes are held together and gently inserted as a unit into the trachea through the tracheostomy opening (Fig. 2). During insertion, an endotracheal tube stylet can be used to overcome resistance if required. When all T-tube segments including the upper arm are placed into the distal tracheal lumen, both tubes are pulled back until the upper arm is located in the upper tracheal lumen. Then, the balloon is deflated and the endotracheal tube is removed. During insertion of the distal arm, oxygenation is maintained through the endotracheal tube. Once the distal arm is placed in the tracheal lumen, insertion of the proximal arm can also be safely done as oxygenation is still maintained through the endotracheal tube in place. Following this procedure, fiberoptic bronchoscopic examination is performed routinely to ascertain T-tube positioning and luminal patency.
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The above described procedure was performed a total of 17 times on eleven patients, six females and five males, 5–66 years old, between February 1993 and October 1999, and all cases are succeeded with this procedure. All of the patients required a prolonged tracheal intubation due to long tracheal stenosis, with associated conditions including various intracranial pathologies with hemiplegia in six patients, high cervical spine injuries with quadriplegia in two, tracheal tumor in one, tuberculosis tracheobronchitis in one, and respiratory failure after pneumonectomy in one. Three of them had previously undergone tracheal reconstruction surgery. The procedures were performed in the operating room or at the bedside in the intensive care unit. The outer diameter of the T-tube used ranged from 7 to 11 mm. The entire time required for insertion of both the distal and proximal arms was less than a minute and there has been no morbidity related to the procedure. Most patients did not require predilatation procedures. In a few patients with tight or recurrent stenosis, laser predilatation was done. Additional balloon dilatation was not necessary because the stenting effect of the endotracheal tube could overcome resistance of residual tracheal stenosis.
During the early period of performing the procedure, an endotracheal tube was placed through the upper arm of the T-tube [4]. When the distal arm of the T-tube was placed into the tracheal lumen, the endotracheal tube was removed and the upper arm was inserted proximally by using a hemostat clamp. One patient suffered from airway obstruction due to a difficulty of insertion. Following this experience, the technique was changed by inserting the endotracheal tube through the side arm of the T-tube as described above.
In conclusion, the technique presented here has several advantages over standard techniques with respect to ease of operation and safety. The airway can be maintained throughout the procedure which reduces risk of hypoxia. The stenting effect of the endotracheal tube assists the T-tube in passing resistant tracheal lesions more easily without kinking. Furthermore, by covering the distal tip of the T-tube with the endotracheal tube balloon, the tracheal mucosa is less prone to traumatic injury. Finally, the procedure does not require general anesthesia or additional invasive instrumentation, and it lessens the patient's discomfort.
References
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