Bridging with “silicone lifeline”: Anaesthetic management for montgomery T- tube placement in a complex laryngotracheal stenosis

T. Mohana Rangam*, Niveditha. A, Vijayakumar, Sankararaman, Arul

Department of Anesthesiology, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu

Abstract

The silicone T- tube was developed and originally described by Dr. William Montgomery in 1968 for the stenting of airway after subglottic stenosis. The Montgomery Tracheal tube (T- Tube) is a uncuffed silicone T tube that is inserted with a long limb into trachea and short limb protruding through the tracheostomy stoma. This device used as a combined tracheal stent and airway for patients with tracheal stenosis and can present various challenges to anaesthesiologists during its placement which includes acute airway compromise, inadequate administration of inhalation agents, inadequacy of controlled mechanical ventilation and surgical plane of anaesthesia. The present case is a successful airway management with help of laryngeal mask airway with Injection Propofol, Fentanyl, Rocuronium in the insertion of Tracheal tube after multiple tracheal dilation of recurrent subglottic stenosis.

Case Presentation

A 65-year male patient had a medical history of left sided multiteritorial infarct and internal carotid artery complete occlusion and right sided hemiplegia months earlier with associated hospital acquired pneumonia with respiratory distress requiring ventilatory support with tracheostomy tube in a week later with the total duration of 8 days and weaned off from ventilator. Patient was discharged with Shiley’s tube and got de-cannulated 4 months later.

A month after de-cannulation patient complained of exertional dyspnea and bronchoscopy was done which revealed subglottic stenosis for which serial balloon dilation done consecutively in July, August and treated simultaneously for post tracheal infection elsewhere in private hospital, Chennai.

Following that patient presented to our hospital with complaints of severe shortness of breath and noisy breathing at rest with associated severe cough with mild expectoration since last dilation procedure. He was  known to have Diabetes and Hypertension, and was on Tab . Levolin QID, Tab. Syndopa plus 125 BD, Tab. Atorvas 20mg HS, Tab. Brivacetam 50mg BD, Tab. Aspirin 75mg OD, Tab. Torasemide+ Tab. Spironolactone OD, with emaciated build, pale, dehydration, and aphasia, He was in a bedridden state.

On examination

PR – 65 bpm

BP – 160/100 mmHg

SpO2 – 96% room air

RR – 26 /min

BMI – 19.1kg/m2 weight 41kgs Temp- 97.4F

Systemic Examination

CVS – S1S2 + ESM +

RS – Bilateral air entry + bilateral wheeze +

CNS – conscious, oriented, Right upper limb, lower limb hemiplegia power 3/10

P/A – soft, bowel sounds +

Airway examination

MPG – GRADE 3

Mouth opening – 2fingers

Restricted neck extension

TMD >6 cm

TMJ – normal

Investigations revealed:

Normocytic normochromic blood picture with Hb 9.6, PCV – 30, TLC – 8960,

Platelets- 532000, urea- 41, creatinine -0.6 Na – 133, K – 5.6, Cl – 92, HCO3-28,

Albumin-3.2, negative HIV, HbsAg, HCV.

ECG showed normal sinus rhythm, left axis deviation, left atrial enlargement, left ventricular hypertrophy, ST elevation in V2-V3, T inversion in V5-V6

ECHO revealed EF – 50%, concentric LVH, mild global dyskinesia, mild TR/MR. CXR- showed increased Broncho vascular markings, congestion present bilateral middle and inferior zones

This ASA-3, RCRI-3 patient was planned for Montgomery T-tube insertion with high cardiac risk in Bronchoscopy suite.

Anaesthetic Management

Plan: General Anesthesia; airway secured with supraglottic airway device (I-Gel -size 3) and anaesthetic drugs were tailored to patient hemodynamic variations.

The patient was monitored with noninvasive measurement of blood pressure, electrocardiogram, pulse oximetry, end tidal carbon dioxide monitoring Preoperative vital signs were maintained within normal limits.

Induction of anaesthesia is carried out with Inj. Midazolam 0.1mg/kg, Inj. Glycopyrrolate 10mcg/kg, Inj. Ondansetron 0.1mg/kg, Inj. Fentanyl 1mcg/kg, Inj. Etomidate 0.2 mg/kg, Inj. Ketamine 0.5mg / kg, Inj. Rocuronium 1mg/kg and airway is secured with supraglottic airway

(I-gel ®) size 3 and patient is connected on mindray® ventilator with pressure control mode initially with inspiratory driving pressure of 18 mmHg, RR 18, PEEP 5, surgeon introduced fibre optic bronchoscope through the catheter mount connected to proximal end 15mm connector site. With the advancement of bronchoscope, the pinhole type subglottic segment is electrocauterized and serial dilatation with CRE balloon upto 12mm.

Then ventilator settings are tailored to PS- 12mmhg RR 14mm hg and patient is made spontaneous airway is anaesthetised with Lignocaine 4% spray and airway blocks performed, Inj Fentanyl 1mcg /kg given and Rigid scope of 14mm is passed through the glottis, and under sterile aseptic precautions through anterior and lateral aspect of cricoid arch exposed under vision with the help of artery forceps the proximal part of T-tube is inserted and placed in position which guided the placement of distal part of T-tube in trachea after multiple failed attempts.

Patient ABG revealed pH 7.52, pCO2-34, pO2-100, HCO3-27.9, Lac-1.1, and patient was ventilated spontaneously and supraglottic airway device was uneventfully extubated shifted to intensive care for observation for 4 days and patient discharged home after education regarding care of T -tube and psychological counselling.

Discussion

The device is an uncuffed silicone T-tube that is inserted with a long limb into the trachea and a short limb protruding through the tracheostomy stoma. The tube is available in sizes ranging from 4.5-16 mm external diameter. Main indications of its use are post-laryngotracheoplasty (to keep the lumen open and to prevent mucosal laceration from scarring), tracheomalacia, relapsing polychondritis, post-tubercular bronchostenosis, amyloidosis, tracheobronchial trauma, postanastamotic bronchial stenosis and extrinsic airway compression. In contrast to a tracheotomy tube, the T-tube has advantages of preservation of the voice and normal respiration and minimal generation of cough. It avoids mucosal abrasion and the formation of granulation tissue associated with maintenance of a tracheotomy tube.

Silicone has little or no tissue reaction. It does not harden with prolonged contact with body temperature and secretion. The Montgomery T-tube suffers from the disadvantage of not accommodating a standard catheter mount connector. To circumvent this, a short laryngeal portion or extratracheal segment must be occluded for ventilation. The attending anaesthesiologist, therefore, should seek ways of delivering volatile agent and carrier gases. After insertion of a Montgomery T-tube, airway management can be done in two ways.

First, the extratracheal stem of T-tube can be blocked with a spigot, allowing the patient to maintain ventilation through the intratracheal part. Second, the airway can be maintained by inserting the endotracheal tube through the extratracheal portion. Or insertion of supraglottic airway device and the extratracheal part of the Montgomery T-tube was blocked with a spigot and ventilation was maintained.

In addition to this case, there are other ways to maintain breathing after T-tube insertion. A Fogarty embolectomy catheter can be passed through the short laryngeal part to obstruct the upper intraluminal limb of the T-tube followed by insertion of the endotracheal tube into the extratracheal portion. The flow of gas is then delivered through the endotracheal tube to the distal airway.

This procedure is complex and was not appropriate in the present case because of the absence of a connection to the extra tracheal portion.

Another method maintains ventilation via the extra tracheal part of T-tube, after the occlusion of the top of the LMA. Although LMA insertion is simple, this method was also presently inappropriate for the same reason.

A third method is jet ventilation. In this method, the attending anesthesiologist positions the tip of a jet catheter into the short laryngeal portion to maintain ventilation.

The fourth method is use of Bain’s breathing system, in which a Y-connector is connected at the end of the circuit, and fresh gas flow is delivered to the extra tracheal part of the T-tube and the face mask. This method carries the risk of aspiration.

In the present case, LMA-mediated blockage of the extratracheal part of Montgomery T-tube with a spigot as a means of maintaining ventilation was both appropriate and successful.

An anaesthesiologist may not be familiar with anaesthetic airway control via a Montgomery T-tube. Therefore, prior to its use, the attending anaesthesiologist must understand the structure and characteristics of the Montgomery T-tube, and must have various options available for use before initiating anaesthesia.

Conclusion

The judicious premedication and preoperative anaesthetic upper airway preparation combined with spontaneous breathing using either inhalational or IV agents with strict hemodynamic monitoring is a tailored successful anaesthesia technique for this procedure.

Abbreviation

LMA – laryngeal mask airway

This report has no conflict of interest.

References

  • Ling Peng, Wei Wei. Tube-in-tube airway management in a patient with Montgomery T-tube in situ -a case report-The Montgomery T-tube: anaesthetic problems and solutions. Korean Journal of Anesthesiology. 2021;74(2):165-168.
  • Guha, S. M. Mostafa, J. B. Kendall, The Montgomery T‐tube: anaesthetic problems and solutions, BJA: British Journal of Anaesthesia, Volume 87, Issue 5, 1 November 2001, Pages 787–790,
  • Ahlawat M, Anshul, Ahlawat G, Kulsaurabh, Kumar S, Nair A. Anaesthetic Management in Patient with Montgomery T-Tube in-Situ- A Case Report. Ann. Int. Med. Den. Res. 2019; 5(5):AN11-AN13.

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