Airway management in a patient with Montgomery T-tube in situ

Abstract

Introduction/Background: The airway management of a patient with a Montgomery T-tube poses challenges. Unlike standard tracheostomy tubes or endotracheal tubes, t-tubes are not provided with standard connectors to fit with anesthesia breathing circuits and cause loss of inspired gases. Unfamiliarity of the tube presents challenges as well. We describe the successful anesthetic management of a case with a T- tube in situ. Case Description: 58 yo M with subglottic stenosis s/p complex airway reconstruction with placement of size 13 T-tube, DM2, NASH cirrhosis, s/p TIPS procedure for GI bleed with subsequent TIPS failure and recurrent ascites with MELD score 9. He presents for TIPS revision due to thrombosis of the stent. The airway plan was to proceed with LMA after the removal of ascites. The backup plan was a size 4 ETT through his T-tube. ENT was at bedside to remove T-tube and place tracheostomy if needed. Extratracheal limb was occluded and oxygen was given by nasal canula. Sedation was started with propofol infusion at 75mcg/kg/min for paracentesis with 2.3L fluid removal. Then the induction with propofol 100mg was performed for LMA 4 insertion. It didn't provide a good seal. Subsequently ETT 4.0 insertion through T-tube was performed. The tube position was confirmed with fiberoptic scope and taped 11cm at stoma. Good TV and end tidal CO2 achieved. Ventilation was managed with pressure support. The case was finished safely. Discussion: Many anesthesiologists may not be familiar with T-tube. T-tube's unique design presents challenges in addition to the fact that T-tube does not have standard connectors. Removal of T-tube may cause bleeding or loss of airway control. It is very important to formulate the airway plan when a patient with T-tube shows up at the hospital. Conclusion: In our case, insertion of LMA was performed, but not good seal probably due to deformed anatomy from the previous surgery. We successfully utilized a backup plan and inserted ETT 4.0 through T-tube. ENT surgeon was at patient's bedside in case if needed. The judicious anesthetic plan and airway preparation should be tailored for safe management of such patients.