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Montgomery T-tube: anesthetic management
Journal of Clinical Anesthesia (2007) 19, 135 – 137
Case report
Montgomery T-tube: anesthetic management Sanjay Agrawal MD (Assistant Professor)a,*, Y.S. Payal MD (Senior Resident)a, J.P. Sharma MD (Professor)a, Ravi Meher MD (Assistant Professor)b, Saurabh Varshney MD (Professor)b a
Department of Anesthesia, Himalayan Institute of Medical Sciences, Dehradun, 248140 India Department of ENT, Himalayan Institute of Medical Sciences, Dehradun, 248140 India
b
Received 11 January 2006; revised 27 June 2006; accepted 28 June 2006
Keywords: Montgomery T-tube; Anaesthetic management; Laryngotracheoplasty
Abstract The Montgomery T-tube is a device used as a combined tracheal stent and airway after laryngotracheoplasty. It is a valuable option in the management of upper and mid–tracheal lesions. Because its use is sporadic, many anesthesiologists may not be familiar with this device, and its anesthetic management may pose a challenge. Safe management of such patients requires careful planning. We describe different techniques of anaesthetic management in two cases of injuries to the throat, for which this tube was inserted as a tracheal stent. D 2007 Elsevier Inc. All rights reserved.
1. Introduction The Montgomery T-tube (Fig. 1) was introduced in 1960 to support trachea during laryngotracheoplasty. The device is an uncuffed silicone T-tube that is inserted with a long tube into trachea and short limb protruding through the tracheostomy stoma. The tube is available in sizes ranging from 4.5 to 16-mm external diameter [1]. Main indications of its use are post–laryngotracheoplasty (to keep the lumen open and to prevent mucosal laceration from scarring), tracheomalacia, relapsing polychondritis, posttubercular bronchostenosis, amyloidosis, tracheobronchial trauma, postanastamotic bronchial stenosis, and extrinsic airway compression. The tube is soft, and misplacement of the upper or lower limb during insertion is possible. In addition, there may be difficulty in maintaining controlled ventilation as the upper end of the intratracheal position of tube has to be occluded to prevent loss of inspired gas. The Montgomery T-tube has the disadvantage of not taking a standard catheter connector. * Corresponding author. Department of Anesthesiology, Himalayan Institute of Medical Sciences, Dehradun, India. E-mail address: [email protected] (S. Agrawal). 0952-8180/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2006.06.007
The anesthesiologist must devise ways of delivering volatile agents and carrier gases for general anesthesia.
2. Case report 2.1. Case 1 A 60-year-old man presented with a history of suicide attempt by throat slashing. Immediately after injury, he underwent tracheostomy, and the neck wound was repaired. The patient developed postoperative infection due to uncontrolled diabetes leading to wound dehiscence and laryngeal cartilage necrosis. He was then referred to our hospital for further management one month later. On examination, there was a loss of cricoid cartilage and lower half of thyroid cartilage (Fig. 2). After controlling blood sugar, laryngotracheoplasty with rib cartilaginous graft, along with tracheal stenting with the Montogomery T-tube. Preoperative examination showed that the patient was diabetic—and taking oral hypoglycemic agents. The rest of the systemic examination was within normal limits. Premedication included oral diazepam 10 mg the night before surgery, with a repeat dose on the morning two hours
136
S. Agrawal et al.
Fig. 3 Intraoperative photograph of case 1 showing the Montgomery T-tube in situ.
Fig. 1 Photograph of the Montgomery T-tube and its different parts: short laryngeal part (1), long tracheal part (2), extratracheal part (3), spigot (4), and standard endotracheal tube connector (5).
before surgery as anxiolytic and glycopyrrolate 0.2 mg given intramuscularly (IM). The dose of oral hypoglycemic agent was omitted on the day of surgery. After institution of noninvasive monitoring, anesthesia was induced with intravenous (IV) thiopental sodium and vecuronium 0.1 mg/kg and maintained with 66% nitrous oxide in oxygen (N2O and O2), isoflurane, and IV morphine (0.15 mg/kg). Costal cartilage graft was harvested, followed by removal of tracheostomy tube and insertion of the Montgomery T-tube of 11-mm size with a well-fitting standard endotracheal connector attached to the extratracheal limb of T-tube. After insertion of the Montgomery T-tube, the anesthesia breathing circuit was fastened to the tube connector (Fig. 3), while simultaneously, an assistant did a tight pharyngeal
Fig. 2
Clinical photograph of case 1.
packing to prevent the leakage of anesthetic gases through upper end of T-tube. Ventilation was checked by capnography and auscultation. The rest of the surgery was uneventful. At the end of surgery, anesthesia was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. The patient was comfortable, the pharyngeal pack was removed, and patient was transferred to the Postanesthesia Care Unit (PACU).
2.2. Case 2 A 24-year-old man presented with slash injury to the throat and underwent tracheostomy. He was subsequently scheduled for laryngotracheoplasty with insertion of a Montgomery T-tube. Preoperative systemic examination was within normal limits. Premedication included oral diazepam 10 mg on the night before surgery and two hours before surgery, and IV glucopyrolate 0.2 mg anesthesia was induced with thiopental and vecuronium 0.1 mg/kg. Maintenance of anesthesia with 66% N2O in O2, isoflurane, and IV morphine
Fig. 4
Postoperative clinical photograph of case 2.
Montgomery T-tube: anesthetic management (0.15 mg/kg) was done. After performing tracheoplasty, a size 4 Laryngeal Mask Airway (LMA) was inserted in the usual manner and secured in place. The upper end of the LMA was blocked, and controlled ventilation was continued through tracheostomy until the surgeon replaced it with a size 10 Montgomery T-tube. After insertion of T-tube, its extratracheal lumen was occluded by spigot, and the breathing circuit was connected to the LMA. Ventilation was checked by capnography. At the end of the procedure, residual neuromuscular block was antagonized with IV neostigmine 0.05 mg/kg and IV glycopyrrolate 0.02 mg/kg, the LMA removed and patient transferred to the PACU (Fig. 4).
3. Discussion The Montgomery T-tube is an uncuffed T-tube that is inserted with its long limb in trachea and short limb projecting through tracheotomy stoma. The standard method of inserting the tube is to grasp it with curved forceps and place the long intratracheal lumen through the tracheostomy. The extratracheal lumen is then tugged anteriorly to straighten the tube in the trachea, thus, positioning the upper intratracheal portion. Problems encountered during insertion include the following: (a) the airway is not fully under the control of the anesthesiologist during the time of insertion, and (b) during insertion, there may be a kinking in the T-tube, usually at the junction of the extratracheal and intratracheal part, leading to complete obstruction. Various methods have been advocated by different authors for correct placement [2-5] of the T-tube, but these methods are either too complicated or do not ensure correct placement. Additional problems encountered are: 1.
2.
Maintenance of anesthesia to a desired depth of anesthesia is a problem. Because the extratracheal lumen does not accept a standard-size, 15-mm endotracheal tube connector, fitting of the anesthesia breathing circuit may be a problem. Loss of anesthetic gases and vapors through the open intratracheal upper end of the T-tube leads to dilution and inadequate depth of anesthesia.
Montgomery [1] suggested passing a Fogarty embolectomy catheter through the extratracheal lumen up to the upper stem of T-tube and occluding the open upper end by inflating the balloon. A suitable size tracheal tube could then be placed in the extratracheal lumen adjacent to the catheter and ventilation continued. Guha et al [6] advocated insertion of the LMA before insertion of the T-tube. Thus, they had the advantage of airway control before T-tube insertion. Subsequently, they continued the ventilation through the LMA and by the occluding the extratracheal lumen by the spigot. Uchiyama and Yoshino [7] also inserted the LMA before insertion of the T-tube, but they occluded the
137 upper end of the LMA and maintained ventilation though the extratracheal lumen. The Hebeler T-tube [8] (Boston Medical Products, Westborough, MA) is a modified T-tube that contains an internal balloon located in the proximal portion of the intraluminal limb. The balloon can be transiently inflated to achieve ventilation of the distal airways. In cases of emergency or loss of airways, an endotracheal tube size of 6.0 cm can be passed through the intraluminal limb of most T-tubes used in adults (a second operator grasps the extraluminal limb while the endotracheal tube is being inserted so as to prevent accidental dislodging of the T-tube). In the first case, we inserted the T-tube, during which the airway was not in our control. However, effective ventilation was achieved by occluding the upper lumen by pharyngeal pack and maintaining ventilation through the extratracheal lumen. This had the disadvantage, of airway loss and leak around the pack. Reviewing the literature, the use of LMA for airway control and maintenance prompted us to try this technique in our second case. The advantages of this technique included airway control and maintenance during T-tube insertion. The use of fiberoptic laryngoscope via the LMA to confirm the correct position of Montgomery T-tube also can be done. It is also important to choose the correct size of T-tube. Ideally, it should be a snugly fitting tube in the tracheal lumen and of adequate length so as to cover the whole of the involved tracheal length. In addition, the edges of the tube must be smooth and should not come in contact with the undersurface of the vocal folds.
4. Conclusion The Montgomery T-tube is invaluable in stenting lesions that are too long and multisegmental. Its application often remains the only possible solution for patients with tracheal stenosis.
References [1] Montgomery WW. Manual for care of Montgomery silicone tracheal T tube. Ann Otol Laryngol 1980;89:1 - 7. [2] Mather CM, Sinclair R, Gurr P. Tracheal stents: the Montgomery T tube. Anesth Analg 1993;77:1282 - 4. [3] Cooper JD, Todd TRJ, Ives IR, et al. Use of silicone tracheal T tube for management of complex tracheal injuries. J Thorac Cardiovasc Surg 1981;82:559 - 68. [4] Ni Chonchubhair A, O’Connor T, O’Hagan C. A novel approach to insertion of Montgomery T tube. Anaesthesia 1994;49:605 - 7. [5] Sichel JY, Elisashan R, Dono I, Braveman I. Insertion of Montgomery T tube. Laryngoscope 1998;108:1107 - 8. [6] Guha A, Mostafa SM, Kendall JB. The Montgomery T tube: anaesthetic problems and solutions. Br J Anaesth 2001;87:787 - 90. [7] Uchiyama M, Yoshino A. Insertion of Montgomery T tube. Anaesthesia 1995;50:476. [8] Wahidi MM, Ernst A. The Montgomery T tube tracheal stent. Clin Chest Med 2003;24:437 - 43.
Case report
Montgomery T-tube: anesthetic management Sanjay Agrawal MD (Assistant Professor)a,*, Y.S. Payal MD (Senior Resident)a, J.P. Sharma MD (Professor)a, Ravi Meher MD (Assistant Professor)b, Saurabh Varshney MD (Professor)b a
Department of Anesthesia, Himalayan Institute of Medical Sciences, Dehradun, 248140 India Department of ENT, Himalayan Institute of Medical Sciences, Dehradun, 248140 India
b
Received 11 January 2006; revised 27 June 2006; accepted 28 June 2006
Keywords: Montgomery T-tube; Anaesthetic management; Laryngotracheoplasty
Abstract The Montgomery T-tube is a device used as a combined tracheal stent and airway after laryngotracheoplasty. It is a valuable option in the management of upper and mid–tracheal lesions. Because its use is sporadic, many anesthesiologists may not be familiar with this device, and its anesthetic management may pose a challenge. Safe management of such patients requires careful planning. We describe different techniques of anaesthetic management in two cases of injuries to the throat, for which this tube was inserted as a tracheal stent. D 2007 Elsevier Inc. All rights reserved.
1. Introduction The Montgomery T-tube (Fig. 1) was introduced in 1960 to support trachea during laryngotracheoplasty. The device is an uncuffed silicone T-tube that is inserted with a long tube into trachea and short limb protruding through the tracheostomy stoma. The tube is available in sizes ranging from 4.5 to 16-mm external diameter [1]. Main indications of its use are post–laryngotracheoplasty (to keep the lumen open and to prevent mucosal laceration from scarring), tracheomalacia, relapsing polychondritis, posttubercular bronchostenosis, amyloidosis, tracheobronchial trauma, postanastamotic bronchial stenosis, and extrinsic airway compression. The tube is soft, and misplacement of the upper or lower limb during insertion is possible. In addition, there may be difficulty in maintaining controlled ventilation as the upper end of the intratracheal position of tube has to be occluded to prevent loss of inspired gas. The Montgomery T-tube has the disadvantage of not taking a standard catheter connector. * Corresponding author. Department of Anesthesiology, Himalayan Institute of Medical Sciences, Dehradun, India. E-mail address: [email protected] (S. Agrawal). 0952-8180/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.jclinane.2006.06.007
The anesthesiologist must devise ways of delivering volatile agents and carrier gases for general anesthesia.
2. Case report 2.1. Case 1 A 60-year-old man presented with a history of suicide attempt by throat slashing. Immediately after injury, he underwent tracheostomy, and the neck wound was repaired. The patient developed postoperative infection due to uncontrolled diabetes leading to wound dehiscence and laryngeal cartilage necrosis. He was then referred to our hospital for further management one month later. On examination, there was a loss of cricoid cartilage and lower half of thyroid cartilage (Fig. 2). After controlling blood sugar, laryngotracheoplasty with rib cartilaginous graft, along with tracheal stenting with the Montogomery T-tube. Preoperative examination showed that the patient was diabetic—and taking oral hypoglycemic agents. The rest of the systemic examination was within normal limits. Premedication included oral diazepam 10 mg the night before surgery, with a repeat dose on the morning two hours
136
S. Agrawal et al.
Fig. 3 Intraoperative photograph of case 1 showing the Montgomery T-tube in situ.
Fig. 1 Photograph of the Montgomery T-tube and its different parts: short laryngeal part (1), long tracheal part (2), extratracheal part (3), spigot (4), and standard endotracheal tube connector (5).
before surgery as anxiolytic and glycopyrrolate 0.2 mg given intramuscularly (IM). The dose of oral hypoglycemic agent was omitted on the day of surgery. After institution of noninvasive monitoring, anesthesia was induced with intravenous (IV) thiopental sodium and vecuronium 0.1 mg/kg and maintained with 66% nitrous oxide in oxygen (N2O and O2), isoflurane, and IV morphine (0.15 mg/kg). Costal cartilage graft was harvested, followed by removal of tracheostomy tube and insertion of the Montgomery T-tube of 11-mm size with a well-fitting standard endotracheal connector attached to the extratracheal limb of T-tube. After insertion of the Montgomery T-tube, the anesthesia breathing circuit was fastened to the tube connector (Fig. 3), while simultaneously, an assistant did a tight pharyngeal
Fig. 2
Clinical photograph of case 1.
packing to prevent the leakage of anesthetic gases through upper end of T-tube. Ventilation was checked by capnography and auscultation. The rest of the surgery was uneventful. At the end of surgery, anesthesia was reversed with neostigmine 0.05 mg/kg and glycopyrrolate 0.01 mg/kg. The patient was comfortable, the pharyngeal pack was removed, and patient was transferred to the Postanesthesia Care Unit (PACU).
2.2. Case 2 A 24-year-old man presented with slash injury to the throat and underwent tracheostomy. He was subsequently scheduled for laryngotracheoplasty with insertion of a Montgomery T-tube. Preoperative systemic examination was within normal limits. Premedication included oral diazepam 10 mg on the night before surgery and two hours before surgery, and IV glucopyrolate 0.2 mg anesthesia was induced with thiopental and vecuronium 0.1 mg/kg. Maintenance of anesthesia with 66% N2O in O2, isoflurane, and IV morphine
Fig. 4
Postoperative clinical photograph of case 2.
Montgomery T-tube: anesthetic management (0.15 mg/kg) was done. After performing tracheoplasty, a size 4 Laryngeal Mask Airway (LMA) was inserted in the usual manner and secured in place. The upper end of the LMA was blocked, and controlled ventilation was continued through tracheostomy until the surgeon replaced it with a size 10 Montgomery T-tube. After insertion of T-tube, its extratracheal lumen was occluded by spigot, and the breathing circuit was connected to the LMA. Ventilation was checked by capnography. At the end of the procedure, residual neuromuscular block was antagonized with IV neostigmine 0.05 mg/kg and IV glycopyrrolate 0.02 mg/kg, the LMA removed and patient transferred to the PACU (Fig. 4).
3. Discussion The Montgomery T-tube is an uncuffed T-tube that is inserted with its long limb in trachea and short limb projecting through tracheotomy stoma. The standard method of inserting the tube is to grasp it with curved forceps and place the long intratracheal lumen through the tracheostomy. The extratracheal lumen is then tugged anteriorly to straighten the tube in the trachea, thus, positioning the upper intratracheal portion. Problems encountered during insertion include the following: (a) the airway is not fully under the control of the anesthesiologist during the time of insertion, and (b) during insertion, there may be a kinking in the T-tube, usually at the junction of the extratracheal and intratracheal part, leading to complete obstruction. Various methods have been advocated by different authors for correct placement [2-5] of the T-tube, but these methods are either too complicated or do not ensure correct placement. Additional problems encountered are: 1.
2.
Maintenance of anesthesia to a desired depth of anesthesia is a problem. Because the extratracheal lumen does not accept a standard-size, 15-mm endotracheal tube connector, fitting of the anesthesia breathing circuit may be a problem. Loss of anesthetic gases and vapors through the open intratracheal upper end of the T-tube leads to dilution and inadequate depth of anesthesia.
Montgomery [1] suggested passing a Fogarty embolectomy catheter through the extratracheal lumen up to the upper stem of T-tube and occluding the open upper end by inflating the balloon. A suitable size tracheal tube could then be placed in the extratracheal lumen adjacent to the catheter and ventilation continued. Guha et al [6] advocated insertion of the LMA before insertion of the T-tube. Thus, they had the advantage of airway control before T-tube insertion. Subsequently, they continued the ventilation through the LMA and by the occluding the extratracheal lumen by the spigot. Uchiyama and Yoshino [7] also inserted the LMA before insertion of the T-tube, but they occluded the
137 upper end of the LMA and maintained ventilation though the extratracheal lumen. The Hebeler T-tube [8] (Boston Medical Products, Westborough, MA) is a modified T-tube that contains an internal balloon located in the proximal portion of the intraluminal limb. The balloon can be transiently inflated to achieve ventilation of the distal airways. In cases of emergency or loss of airways, an endotracheal tube size of 6.0 cm can be passed through the intraluminal limb of most T-tubes used in adults (a second operator grasps the extraluminal limb while the endotracheal tube is being inserted so as to prevent accidental dislodging of the T-tube). In the first case, we inserted the T-tube, during which the airway was not in our control. However, effective ventilation was achieved by occluding the upper lumen by pharyngeal pack and maintaining ventilation through the extratracheal lumen. This had the disadvantage, of airway loss and leak around the pack. Reviewing the literature, the use of LMA for airway control and maintenance prompted us to try this technique in our second case. The advantages of this technique included airway control and maintenance during T-tube insertion. The use of fiberoptic laryngoscope via the LMA to confirm the correct position of Montgomery T-tube also can be done. It is also important to choose the correct size of T-tube. Ideally, it should be a snugly fitting tube in the tracheal lumen and of adequate length so as to cover the whole of the involved tracheal length. In addition, the edges of the tube must be smooth and should not come in contact with the undersurface of the vocal folds.
4. Conclusion The Montgomery T-tube is invaluable in stenting lesions that are too long and multisegmental. Its application often remains the only possible solution for patients with tracheal stenosis.
References [1] Montgomery WW. Manual for care of Montgomery silicone tracheal T tube. Ann Otol Laryngol 1980;89:1 - 7. [2] Mather CM, Sinclair R, Gurr P. Tracheal stents: the Montgomery T tube. Anesth Analg 1993;77:1282 - 4. [3] Cooper JD, Todd TRJ, Ives IR, et al. Use of silicone tracheal T tube for management of complex tracheal injuries. J Thorac Cardiovasc Surg 1981;82:559 - 68. [4] Ni Chonchubhair A, O’Connor T, O’Hagan C. A novel approach to insertion of Montgomery T tube. Anaesthesia 1994;49:605 - 7. [5] Sichel JY, Elisashan R, Dono I, Braveman I. Insertion of Montgomery T tube. Laryngoscope 1998;108:1107 - 8. [6] Guha A, Mostafa SM, Kendall JB. The Montgomery T tube: anaesthetic problems and solutions. Br J Anaesth 2001;87:787 - 90. [7] Uchiyama M, Yoshino A. Insertion of Montgomery T tube. Anaesthesia 1995;50:476. [8] Wahidi MM, Ernst A. The Montgomery T tube tracheal stent. Clin Chest Med 2003;24:437 - 43.