Hermes C Grillo MD

The T Tube and Its Placement Immediate Care

Modifications of Tubes and Placement Tube Management Experience with T Tubes Conclusions

Critical stenosis of the upper airway not amenable to surgical resection often requires a tracheostomy, either as a temporary measure or for long-term relief. Transient airway obstruction after operative reconstruction may also require temporary intubation. Although tracheostomy tubes have the virtue of simplicity in insertion, management, and change, they divert the airflow from the nose, mouth, and larynx. Speech is then possible only when air passes around the tube or through a fenestration in the tube, and then only with a flutter valve or an occluding finger. Because of these disadvantages and the potential of additional injury to the trachea from quite rigid tubes, an alternative solution to maintenance of a patent airway was desirable. The tracheal T tube lies halfway between a tracheostomy tube and an internal airway stent. It has advantages and disadvantages relative to both and so merits its own chapter.

In 1891, Bond devised a tracheal T tube made of two rigid parts, a proximal half and a distal half, divided horizontally along the line of the sidearm which emerged from the tracheal stoma.1 The two were held together with a collar (Figure 39-1). The T tube in its present incarnation was developed by William Montgomery, at the Massachusetts Eye and Ear Infirmary, and introduced in 1965.2,3 Although an initial model consisted of a two-part rigid tube, the present design, which is now widely used, is made of flexible medical silicone rubber. It was originally hoped that the tube would provide definitive treatment for tracheal stenosis. Because of the innate cicatricial tendency of scar tissue, this has rarely been successful, but the Silastic T tube tracheal stent has found extensive use. If the sidearm of the T tube remains occluded, except during treatment, then humidity is maintained in the tube by the normal upper airway protective mechanisms. The airway remains open and the patient breathes normally through the mouth and nose. When the tube spans an obstructing tracheal lesion, normal glottic speech is maintained. Excellent long-term acceptance with absence of injury to the tracheal wall makes this a preferable way to maintain airway patency. The T tube has been used for long-term management of many problems.4-6 Modifications have been made to deal with special problems at the laryngeal and carinal ends of the airway.

The T tube has been used at Massachusetts General Hospital since 1968 for three general indications: 1) for temporary stenting of the airway, 2) as a definitive procedure for palliation of airway obstruction, and

3) for complications of airway reconstruction. Gaissert and colleagues described the use of the T tube or its modifications in 140 patients from the ages of 7 months to 95 years, between 1968 and 1991.7 Tempo rary airway support was provided in 31 patients, either prior to tracheal resection or as the only procedure. In 49 patients, the T tube was the definitive procedure for airway palliation. Obstruction following operative reconstruction led to placement in 32 patients.

The T tube can provide temporary airway support while determination is made as to whether all or part of a complex injury will stabilize, where, for example, cartilages are partly intact. Time is also gained for severe inflammation to subside prior to resection at a safe stage, for a patient's medical status to improve, as in Guillain-Barre syndrome, for reduction in corticosteroid medication, or for completion of other procedures (such as orthopedic repairs) prior to tracheal reconstruction. If the stenosis is severe— and indeed in most cases, resolution after T tube splinting is illusory and the stricture will reassert itself— then either resection or permanent splinting is required.

The T tube may be the definitive airway where insufficient trachea remains for adequate reconstruction or where irresectable tumor obstructs after other modalities have been used, especially extrinsic tumor, or where other severe disease precludes tracheal repair. Some malacic or inflammatory processes, such as relapsing polychondritis, may also be so palliated. Severe inhalation burns may be palliated by prolonged intubation but may eventually resolve sufficiently to allow extubation.

A T tube can provide a satisfactory airway following failure of tracheal anastomosis, until such time as reoperation is appropriate, or permanently if reconstruction can not be repeated.

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