Modifications of Tubes and Placement

Modifications of the silicone tracheal T tube are useful for special circumstances. Westaby and colleagues fashioned a T-Y tube for lesions involving the carina and main bronchi (Figure 39-6).8 The T-Y tube may be inserted over two ureteral catheters, which pass through the tube and its right and left bronchial limbs into the tracheal stoma, and by bronchoscopic placement, into right and left main bronchi. A simpler alternative is to squeeze the right and left limbs together, with a bronchoscopic foreign body forceps placed through the T-Y tube, and insert the tube directly into the stoma. The proximal end of the tube is snapped upward into the proximal trachea. The placement is confirmed by a flexible bronchoscopy.

Because the angles of the bronchi are not the same in all patients, it is necessary in some cases to design a tube with special dimensions and angles. The length of the tube and the point at which the external sidearm emerges may also need to be specified. In general, the T-Y tube is designed so that the sidearm enters at an angle which is obtuse distally. An advantage of the T-Y tube over a Y stent is that the carinal Y will not be displaced upward because of the fixation by the sidearm. Furthermore, access for suctioning is always available and the tube can be extracted with ease emergently and a tracheostomy tube replaced. In special cases, we have removed one of the sidearms of the T-Y tube, converting it to a T-L tube. If necessary, a bronchial limb may extend into the bronchus intermedius, and a further side hole is cut out for the right upper lobe bronchial orifice.

With patients who have had a right pneumonectomy, but have airway obstruction of the carina or left main bronchus, a very long tube has been fashioned, using a segment of a Hood Montgomery silicone salivary tube (Figure 39-7). The next larger size of the standard T tube is cut to produce a short collar attached to a sidearm. A side opening is made at the appropriate level of the salivary tube segment and the collar with the sidearm is slipped over the tube and cemented in place. For long-term management, special tubes may be designed and ordered individually. Bronchial stents may be preferred for some patients (see Chapter 40, "Tracheal and Bronchial Stenting").

In the special case of a subglottic stenosis that extends close to the vocal cords, the T tube must pass through the vocal cords to be effective. If placed directly beneath the cords, irritation may produce granulation tissue or edematous obstruction. Subglottic and upper tracheal inhalation burns are similarly man-aged.9 A tube placed in this fashion should end between the false and true cords and not impinge on the epiglottis. Because of the small size of the glottic aperture, Robert H. Lofgren has designed a T tube with a proximal upward tapering vertical limb that traverses the glottis (see Chapter 35, "Laryngologic Problems Related To Tracheal Surgery"). A tube through the glottis interferes with the voice, leaving the patient with n

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