figure 39-3 Modification of existing tracheostomy tract for T tube placement. A, Oblique tract in a longstanding tracheostomy. The dotted line shows the modifying incision. B, Corrected stomal tract with a T tube in place through the dilated stenosis.
tube is sanded smooth with sterile emery paper to produce a rounded end similar to that of the original manufacture. Excess bits of silicone produced by the grinding process are, of course, washed off with saline. This process can be speeded a bit by trimming the sharp outer circumference of the freshly cut edge with scissors on a 45o obliquity and then sanding the resulting rough cut. The precise lengths of proximal and distal vertical limbs of the final tube and its total length are measured and recorded. This will facilitate later changes and revisions. When a tube that has been trimmed in this fashion is changed, it provides a template for a replacement tube. During final bronchoscopic examination of the tube's position, an adaptor from an endotracheal tube may be slipped into the sidearm of the T tube and adequate ventilation carried out with high flow directly through the tube, despite proximal loss of gases.
The technique of insertion is done according to Montgomery's description (Figure 39-4). The distal end of the tube is grasped with Kelly forceps. I prefer to invert the distal portion of the tube into a U-shape and grasp it from either side, thereby compressing the tube into a relatively small leading diameter (see Figure 39-4A). With liberal use of a water-soluble surgical lubricant, the tube is passed through the existing stoma into the distal trachea. A second Kelly clamp grasps the tube higher up, close to the sidearm, thrusting the tube distally as the first Kelly clamp is released and withdrawn carefully (see Figure 39-4B). The tube is now pushed distally so that the upper limb is inserted into the distal trachea first and then permitted to snap up into the upper trachea above the stoma (see Figure 39-4C). Passage of a suction catheter distally, to clear out secretions and blood, is facilitated by angulating the sidearm upward towards the chin with a finger.
If great difficulty is encountered in seating the upper end of the tube, then it may be overcome by a technique described by Cooper and colleagues.6 A long tracheostomy tape is passed through the sidearm of the tube, out through the proximal vertical limb, and thence into the stoma, where it is grasped by forceps through the rigid bronchoscope and pulled out through the bronchoscope proximally (Figure 39-5A). The distal tube is pushed downward into the distal trachea and a clamp is placed across the sidearm, fixing the tape firmly in the T tube (Figure 39-5B). The bronchoscopist next pulls firmly and tightly on the portion of the tape that passes through the bronchoscope, which serves to snap the proximal limb into the tracheal lumen (Figure 39-5C). The clamp on the sidearm is removed and the tape withdrawn. Cooper and colleagues described passing a T tube over a bronchoscope perorally, using an occlusive balloon on the bronchoscope.6 We have not found this technique necessary. Once the T tube is seated, ventilation continues through the sidearm. If strenuous manipulation is necessary, then Decadron is frequently given intra-operatively and for a short period postoperatively. Racemic epinephrine can also be considered.
The final position of the tube is always checked bronchoscopically. A further check on its effectiveness is whether ventilation through the sidearm is satisfactory. Where pathology permits, and where the patient can tolerate it and breathes well, I prefer to cap the sidearm of the tube immediately. The patient leaves the operating room breathing spontaneously through a normal route across the pharynx. It is almost impossible to ventilate satisfactorily through a T tube even if a Fogarty or Pruitt catheter is placed in the proximal vertical limb figure 39-4 Technique of insertion of T tube. A, Folding the distal end of the T tube on itself and grasping it with a curved clamp close to its tip produces a "probe," which is easily directed into the stoma and distal trachea.
and an adaptor is placed in the sidearm of the T tube. The T tube is too flexible to be a safe conduit for ventilation except briefly in the operating room, even though the lesion itself provides a seal around the distal tube.
In patients who have undergone multiple prior tracheal procedures (failed reconstruction, several tracheostomies at different levels, lasering, etc) with destruction of long lengths of trachea, and in whom proximal and distal tracheal remnants are wholly separated by scar, cervical exploration may be necessary in order to insert a tracheal T tube. In others, an extent of injury precluding safe end-to-end reconstruction only becomes evident after exploration. In several patients with tracheoesophageal fistula in addition to extended tracheal stenosis, the fistula was reparable but a T tube was used to restore a functional airway. Pedicled strap muscles are used to cover the bridging T tubes in these patients. The results can be very satisfactory.
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