Airway

CASE REPORT
Year
: 2019  |  Volume : 2  |  Issue : 2  |  Page : 103--105

Anaesthetic management of a patient with difficult airway for T-tube insertion


Bhavna Gupta1, Bharti Wadhwa2, Prachi Gaba2, Kirti Nath Saxena2,  
1 Department of Anaesthesia, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Anaesthesia, MAMC and Lok Nayak Hospital, New Delhi, India

Correspondence Address:
Dr. Bhavna Gupta
4/4, AIIMS Campus, Rishikesh, Uttarakhand
India

Abstract

A 60-year-old male, case of benign oesophageal stricture and unresectable carcinoma bucco-alveolar mucosa had suffered tracheal injury during oesophagectomy for refractory oesophageal stricture. Tracheal repair was done with rectus sheath graft over tracheostomy tube and he was now posted for T-tube insertion. There are various techniques reported for this procedure. Anaesthesiologists should be aware of surgical technique, limitations of T-tube, loss of depth of anaesthesia during tube change, and should be vigilant during all the steps of the procedure. We used total intravenous anaesthesia (TIVA) as a technique with propofol and dexmedetomidine for providing safe and effective anaesthesia during this procedure. Perioperative period was uneventful.



How to cite this article:
Gupta B, Wadhwa B, Gaba P, Saxena KN. Anaesthetic management of a patient with difficult airway for T-tube insertion.Airway 2019;2:103-105


How to cite this URL:
Gupta B, Wadhwa B, Gaba P, Saxena KN. Anaesthetic management of a patient with difficult airway for T-tube insertion. Airway [serial online] 2019 [cited 2020 Feb 28 ];2:103-105
Available from: http://www.arwy.org/text.asp?2019/2/2/103/265613


Full Text



 Introduction



Montgomery T-tube is a silicone T-tube which was introduced in 1965 to support the trachea during laryngotracheal surgeries. It is shaped like a T with its long limb placed in the trachea and the short limb protruding through the tracheostome. T-tube insertion poses a lot of challenges to the anaesthesiologist as loss of airway can occur, there may be dilution of gases, awareness and hypoventilation. Our case describes intraoperative challenges and its management.

 Case Report



A 60-year-old male with benign oesophageal stricture and unresectable carcinoma involving bucco-alveolar mucosa had suffered tracheal injury during oesophagectomy for refractory oesophageal stricture. Tracheal repair was done with rectus sheath graft over a tracheostomy tube and he was now posted for T-tube insertion. On examination, the patient was grossly emaciated and anaemic and had reduced mouth opening (1.5 finger-breadths) and a low tracheostomy with 6.5 mm ID tracheostomy tube in situ. In view of potential airway difficulty, we decided on a management strategy wherein spontaneous breathing would be preserved under total intravenous anaesthesia (TIVA). The difficult airway cart was kept ready in the event of urgent need to secure the airway. Local anaesthesia of the upper airway was accomplished with lignocaine nebulisation, and the patient was given antisialogogue and antiaspiration prophylaxis. Anaesthesia was induced with injection propofol titrated to loss of consciousness and maintained with infusion of propofol and dexmedetomidine. The tracheostomy tube was connected to the breathing circuit and 100% oxygen administered. After ensuring adequate depth of anaesthesia, the surgeons removed the tracheostomy tube and gently inserted the silicon T-tube. During this time, the breathing circuit was disconnected from the tracheostomy tube and attached to the mask placed over the patient's face with the patient breathing spontaneously. The T-tube placement was confirmed by checking mask ventilation after occluding the extraluminal segment of the T-tube. The optimal placement of the T-tube was further confirmed by direct visualisation of the airway using a fibreoptic bronchoscope inserted through the T-tube. All along, the patient was administered 100% oxygen via face mask connected to the breathing circuit. At the end of procedure, dexmedetomidine and propofol infusions were stopped. Postoperative recovery was uneventful. [Figure 1] shows the patient in the postoperative ward with T-tube in situ and limited mouth opening.{Figure 1}

 Discussion



Our patient was a known case of carcinoma buccal mucosa who underwent multiple cycles of chemotherapy and radiotherapy. This combined with the burden of malignancy not only resulted in gross emaciation, anaemia and hypoproteinaemia but also resulted in gross fibrosis in the neck and reduced mouth opening, leading to a difficult airway. Problems anticipated during insertion of T-tube were the possibility of misplacement of upper and lower limb of T-tube leading to complete loss of airway in the presence of an existing difficult airway (reduced mouth opening and neck mobility).[1] Providing controlled ventilation through a supraglottic airway device or endotracheal tube during the exchange is difficult as the gases can escape from the stoma site and the extraluminal portion of the T-tube. Ventilation through the extraluminal portion may not be feasible as external connectors do not fit snugly on it, leading to escape of gases through the upper airway rather than ventilation of the lungs.[2] The other option was securing the airway with either a supraglottic airway device or an endotracheal tube with jet ventilation during the period of change over from tracheostomy tube to T-tube. We did not opt for a supraglottic airway device or intubation beforehand as T-tube insertion is a relatively short procedure. Jet ventilation facility was available to us, and we were confident of our ability to mask ventilate our patient during T-tube insertion, which is a relatively short procedure. We had checked the ability to mask ventilate shortly after induction of TIVA. The preoperative preparation of airway with lignocaine not only prepared the patient for fibreoptic intubation in case the need arose but also helped reduce the laryngeal stimulation during the exchange. TIVA was preferred over inhalational anaesthesia as the delivery of inhalation agent would have been hampered during the change of T-tube, leading to an inadequate depth during this period. It also provided adequate depth, lesser hypercapnia and desaturation with early recovery, haemodynamic stability and reduced anaesthetic and analgesic requirement.[3] The use of spontaneous ventilation provided a margin of safety in the event of any tube misplacement or obstruction as a result of kinking of the lumen of T-tube at the junction of external and internal sections. Backup methods to secure the airway in our case included the placement of laryngeal mask airway (LMA) Supreme or intubation via King Vision videolaryngoscope. Fibreoptic bronchoscope was another option should placement of LMA Supreme or intubation via videolaryngoscope fail. Our last resort was to reintroduce the tracheostomy tube through the already formed tracheostomy track.

T-tube insertion in case of difficult airway is a meticulous task requiring constant vigilance while controlling the airway and at the same time ensuring the maintenance of adequate depth of anaesthesia. TIVA is a promising approach in these patients as it not only provides adequate depth of anaesthesia during the period when airway control is lost but also achieves adequate analgesia and haemodynamic stability.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Guha A, Mostafa SM, Kendall JB. The Montgomery T-tube: Anaesthetic problems and solutions. Br J Anaesth 2001;87:787-90.
2Kerai S, Gupta R, Wadhawan S, Bhadoria P. Anesthetic management of a patient with Montgomery T-tube in-situ for direct laryngoscopy. J Anaesthesiol Clin Pharmacol 2013;29:105-7.
3Ramaswamy AH, Kurdi MS, Sindhupriya. TIVA-A promising approach to anaesthetic management of Montgomery T-tube insertion. J Clin Diagn Res 2015;9:UD03-4.