As noted, the tube should be kept capped at all times except as described. A few cc's of saline are instilled once or twice a day.11 The patient usually clears secretions with a cough. Suctioning should be available, especially initially, even at home, using a portable machine. The patient and family are taught to instill saline and also to pass the suction catheter distally by angling the protruding tube upward or proximally, if necessary, by angling it downward. Proximal suctioning, which will tickle the undersurface of the vocal cords, is likely to produce cough and sometimes gagging. If the catheter is passed too far distally, it produces cough from carinal reflex. Saline instillation may be used more frequently, if necessary.
Acetylcysteine instillation for care of a T tube is not routinely necessary. In some patients, acetyl-cysteine appears to produce more irritation and cough. The stoma itself is cared for in the usual manner.
figure 39-7 Fabrication of a very long T tube in the operating room. The tube is fashioned from a Montgomery silicone "salivary tube," shown at the left, by removing the funnel and cutting it to the desired length. The cut edge is sanded smooth. A side opening is cut out at the level desired for the sidearm. The sidearm is constructed from a standard T tube of next larger size (at the center of the illustration), by cutting off the proximal and distal vertical limbs to produce a short collar. The collar is then cemented into place, as seen on the right.
Swabs with hydrogen peroxide or saline are used to clean the peritubal area daily, or more frequently, as needed. No dressing is required. Granulation tissue around the stoma is treated by removal and cautery with silver nitrate sticks.
Patients have kept T tubes in place for years without difficulty. In general, however, we recommend that the tube be changed about once a year. Silicone rubber ages, and eventually, the sidearm may crack or even separate from the vertical tube. Inspissated material inevitably sludges inside the tube after long periods of time. The rate of formation of such sludge, even with the best of care, will vary from patient to patient. Patients should also be instructed that if they experience shortness of breath on exercise or hear wheezing, then their tube patency should be examined promptly by a physician. This is easily done with a flexible bronchoscope through the sidearm.
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