Eur J Cardiothorac Surg 2006;29:122-124
© 2006 Elsevier Science NL
Use of the Montgomery T tube in ventilator-dependent patients
Ching-Yang Wu,
Yun-Hen Liu,
Ming-Ju Hsieh,
Po-Jen Ko
*
Division of Thoracic & Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, 5, Fushing Street, Gueishan Shiang, Taoyuan 333, Taiwan, ROC
Received 28 June 2005;
received in revised form 23 September 2005;
accepted 3 October 2005.
* Corresponding author. Tel.: +886 3 3281200x2118; fax: + 886 3 3285818. (Email: pjko{at}cgmh.org.tw).
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Abstract
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Tracheal stenosis of ventilator-dependent patient is generally managed via dilation and long trachesostomy tube. This study reports four ventilator patients with tracheal stenosis managed with Montgomery T tube via rigid bronchoscopy. The respiratory symptoms improved in all patients. Three of the patients were weaned from ventilator shortly following treatment.
Key Words: Montgomery T tube • Tracheal stenosis • Ventilator-dependent patient
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1. Introduction
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Montgomery T tube has been proposed as a good method of managing airway stenosis in cases with high risks for surgery [1,2]. However, T tube is rarely used when patients are ventilator dependent. The authors recently used Montgomery T tube in four ventilator patients associated with airway stenosis. Three of the four patients were successfully weaned off the ventilator following stent insertion.
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2. Patients and methods
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Patient 1 was an 82-year-old male with kyphoscoliosis, respiratory failure, and a 7-year history of using a mechanically ventilated tracheostomy tube. The patient suffered tracheal stenosis and underwent bronchoscopic procedures (dilation and laser ablation) to treat the lesions. The respiratory symptoms were temporally relieved, but worsened progressively because of re-stenosis of the airway. Bronchoscopy revealed a stenotic trachea (length 1.5 cm) and copious sputum causing an 80% obstruction immediately above the distal end of the tracheostomy tube. Computed tomography revealed severe distortion of the trachea and major bronchus. The blunt tips of Dumon scopes were used to manipulate and dilate the stricture region. The no. 15 Montgomery safe T tube (15 mm x 119 mm) was introduced over the stricture segment to maintain a patent airway. The 5.0 mm cuffed endotracheal tube was inserted via the extraluminal limb of the T tube to facilitate mechanical ventilation. The procedure provided satisfactory ventilation, and the patient was discharged in good condition and remained healthy and using a home ventilator at 1 year follow-up (Fig. 1 ).
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Fig. 1. (A) CXR revealed kyphoscoliosis and severe chest wall deformity. (B) Bronchoscopy revealed tracheal distortion and stenosis over the distal tracheal region. (C) The stenosis was relieved following dilation with rigid bronchoscope. (D) Patent airway lumen following Montgomery safe T tube insertion.
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Patient 2 was 81-year-old female with subarachnoid hemorrhage who underwent tracheostomy followed by 6 months of nocturnal mechanical ventilation. The patient was referred to our hospital with dyspenea and airway obstruction. Flexible bronchoscopy and CT scan found airway stenosis with 90% luminal obstruction located at the tip of the tracheostomy tube. The patient received multiple fiberoptic bronchoscopic ballon dilation but this resulted in re-stenosis of the airway. A rigid bronchoscopy procedure was performed. The therapeutic procedure involved dilating the airway stricture, removing granulation tissue, and placing the no. 13 Montgomery safe T tube (13 mm x 116 mm) across the stenotic segment. The symptoms improved following stent placement, and the patient was weaned off the ventilator the same day. The patient was doing well at 6 months follow-up.
Patient 3 was 69-year-old male with traumatic subarachnoid and sub-dural hemorrhage. The patient suffered respiratory failure that required tracheostomy and mechanical ventilation. The patient was transferred following the onset of stridor and progressive respiratory distress. Flexible bronchoscopy showed severe stricture at the middle lower trachea and a huge granuloma with 90% airway obstruction located 2 cm above the carina. The 5.5 mm endotracheal tube was inserted through the airway stricture to maintain a patent airway. However, poor ventilation and CO2 retention persisted despite aggressive respiratory management. The no. 14 Montgomery safe T tube (14 mm x 119 mm) was inserted via the tracheal stoma using a rigid bronchoscope, and normal caliber was restored without significant residual stenosis. The patient was weaned from the ventilator the day after surgery, and was discharged to home 5 days after surgery. Six months following surgery, the patient was doing well and had no respiratory symptoms (Fig. 2 ).
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Fig. 2. Schematic representation the techniques of T tube insertion: (A) Severe stricture over middle and lower trachea. (B) The strictured area is dilated with rigid bronchoscope. (C) Lower portion of the T tube is inserted down into the distal trachea. (D) Upper portion of the T tube is grasped with alligator forceps and pulled upward to manipulate the tube into proper position. (E) Appropriate placement of the T tube.
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Patient 4 was a 17-year-old male with traumatic hemothroax and sub-dural hemorrhage. The patient underwent tracheostomy for ventilation support and airway secretion management. The patient was transferred to our hospital with progressive shortness of breath and apnea, and required aggressive ventilation and cardiopulmonary resuscitation. Bronchoscopic examination showed tracheal granulation with 90% airway obstruction over the distal end of the tracheostomy tube. The patient received no. 13 Montgomery safe T tube (13 mm x 116 mm) to keep the airway patent following rigid bronchoscope dilation. The patient was extubated the next day. Bronchoscopy performed 2 weeks later revealed no residual granulation. At 3 months follow-up, the patient remained well without any respiratory symptoms.
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3. Discussion
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Long tracheostomy tube is generally used in mechanically ventilated patients with distal airway stenosis and provides an easy method of airway establishment. However, Fairshter et al. [3] reported the complications of impingement of the tracheal tube on the carina and intubation of the right main stem bronchus with left lung atelectasis. Meanwhile, necrosis and ulceration at the cuff region were occasionally encountered in our patients.
The use of long Montgomery T tube has various advantages. The T tube provides a patent airway with vertical limb and prevents tracheal re-stenosis following dilation. The horizontal limb permits normal respiration. The endotracheal tube can be introduced via the horizontal limb into the vertical limb when patients require mechanical ventilation. We believe that it provides an acceptable long-term therapeutic option for mechanically ventilated patients with tracheal obstruction.
Gaissert et al. [4] studied 140 patients who underwent T tube placement over a 23-year period, and found long-term airway patency in 80% of these patients. Puma et al. [5] reported 45 patients with benign tracheal stenosis who achieved immediate respiratory symptomatic improvement. In patients with severe underlying disease reported in this study, the T tube insertion can lead to an immediate decrease in need for care (three of the four patients were weaned off ventilators) and relief of respiratory symptoms. Furthermore, the procedures could reduce costs and provide better quality of life. The therapeutic results of this study indicate that Montgomery T stent is useful for relieving tracheal stenosis and can be considered a treatment option for tracheal stenosis in ventilator-dependent patients.
Surgical resection of stenotic segment and anastomosis remains the preferred treatment for tracheal stenosis. However, conventional surgery involving dissection of the stenotic segment followed by resection and an end-to-end anastomosis is technically demanding and time consuming. The patients in this study were considered unfit for conventional surgery because of underlying disease. The long Montgomery T tube was extremely useful and successfully established a patent airway in the patients. At 7 months (range 94–353 days) follow-up, all T tubes were functioning well without migration and major complications.
The results of this study suggest that Montgomery T tube is useful for relieving tracheal stenosis and can be considered a treatment option for tracheal stenosis in ventilator-dependent patients.
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Appendix A
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Clinical presentation and result of the treatment
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References
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- Montgomery WW. T-tube tracheal stent. Arch Otolaryngol 1965;82:320-321.[Medline]
- Wahidi MM, Ernst A. The Montgomery T-tube tracheal stent. Clin Chest Med 2003;24:437-443.[CrossRef][Medline]
- Fairshter RD, Liff MO, Wilson AF. Complications of long tracheostomy tubes. Crit Care Med 1976;4:271-273.[Medline]
- Gaissert HA, Grillo HC, Mathisen DJ, Wain JC. Temporary and permanent restoration of airway continuity with the tracheal T-tube. J Thorac Cardiovasc Surg 1994;107:600-606.[Abstract/Free Full Text]
- Puma F, Ragusa M, Aventia N, Urbani M, Droghetti A, Daddi N, Daddi G. The role of silicone stents in the treatment of cicatricial tracheal stenoses. J Thorac Cardiovasc Surg 2000;120:1064-1069.[Abstract/Free Full Text]
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Abstract
1. Introduction
