Emergency airway management in a patient with a Montgomery T-tube in situ

Abstract

Editor —We report a case of successful airway management during cardiorespiratory arrest in a patient with a Montgomery T-tube in situ and make suggestions for the management of similar cases. The patient was a 38-yr-old male with background medical history of quadriparesis after a cervical spinal cord injury who had multiple intensive care admissions for pneumonia. At the age of 35, he developed subglottic tracheal stenosis and had a long-term Montgomery T-tube inserted. On this admission, the patient was treated for bronchopneumonia on a medical ward. He subsequently developed type 2 respiratory failure and rapidly progressed to respiratory arrest. The extratracheal lumen of the Montgomery T-tube was occluded with the stopper attached, and ventilation with a bag-valve face mask was attempted but proved difficult. The patient developed pulseless electrical activity and standard advanced life support management was initiated. Attempted ventilation via the extratracheal lumen with the aid of a standard tracheal tube connector resulted in a large air leak from the proximal airway with insufficient ventilation. The Montgomery T-tube was removed via the stoma by grasping it with haemostatic forceps and applying firm steady withdrawal. The patient’s trachea was intubated via the oral route and the lungs were ventilated with high oxygen concentration. Return of spontaneous circulation occurred shortly afterward. The patient was transferred to the intensive care unit where he required ventilatory support for 10 days. He was then discharged to the respiratory ward with tracheostomy tube in situ having made full neurological recovery. The Montgomery T-tube is an uncuffed silicone tube that serves as both tracheal stent and tracheostomy. It consists of a long (intratracheal) limb and a short (extratracheal) limb projecting through the tracheostomy stoma (Fig. 1). The extratracheal lumen can be occluded with an attached stopper plug to allow phonation.1Montgomery WW Silicone tracheal cannula.Ann Otol Rhinol Laryngol. 1980; 89: 521-528Crossref PubMed Scopus (18) Google Scholar, 2Montgomery WW Manual for care of Montgomery silicone tracheal T-tube.Ann Otol Rhinol Laryngol Suppl. 1980; 89: 1-8Crossref PubMed Google Scholar, 3Guha A Mostafa SM Kendall JB The Montgomery T-tube: anaesthetic problems and solutions.Br J Anaesth. 2001; 87: 787-790doi:10.1093/bja/87.5.787Crossref PubMed Scopus (36) Google Scholar Emergency airway management of a patient with a Montgomery T-tube has not been reported before. There are various case reports of airway and anaesthetic management for patients undergoing insertion of the Montgomery T-tube or for patients with Montgomery T-tube in situ undergoing anaesthesia for various procedures.2Montgomery WW Manual for care of Montgomery silicone tracheal T-tube.Ann Otol Rhinol Laryngol Suppl. 1980; 89: 1-8Crossref PubMed Google Scholar, 3Guha A Mostafa SM Kendall JB The Montgomery T-tube: anaesthetic problems and solutions.Br J Anaesth. 2001; 87: 787-790doi:10.1093/bja/87.5.787Crossref PubMed Scopus (36) Google Scholar, 4Wu C-Y Liu Y-H Hsieh M-J Ko P-J Use of the Montgomery T tube in ventilator-dependent patients.Eur J Cardiothorac Surg. 2006; 29: 122-124doi:10.1016/j.ejcts.2005.10.024Crossref PubMed Scopus (5) Google Scholar Our case illustrates the difficulties posed by the Montgomery T-tube in an emergency setting. Unlike standard tracheostomy tubes, the majority of Montgomery T-tubes do not take standard catheter mount connectors due to the variable internal diameter and thickness of the tube. Attempted ventilation via the extratracheal limb is likely to be ineffective due to the air leak via the open upper end of the intratracheal limb. When bag-valve face mask ventilation is attempted, the extratracheal lumen should be occluded to prevent air leak.5Kulkarni VR Kelkar VS Salunkhe SA Anaesthetic challenges of the Montgomery T-tube insertion in a patient with fascioscapulohumeral dystrophy.Indian J Anaesth. 2005; 49: 502-504Google Scholar The relative rarity of the Montgomery T-tube and the associated unfamiliarity of the device present challenges during emergency airway management. We present a guide for emergency airway care in such situations. We suggest occluding the extratracheal limb and attempting ventilation via a bag-valve face mask or a laryngeal mask airway. If no adequate ventilation is achieved, the Montgomery T-tube should be removed via the stoma. A definitive airway may be established by inserting an appropriately sized cuffed tracheostomy or tracheal tube into the trachea via the stoma or alternatively the patient trachea could be intubated via standard laryngoscopy. The advice of an anaesthetist and otorhinolaryngology surgeon should be sought whenever an acute admission of a patient with a Montgomery T-tube occurs in order to formulate an airway management plan in the case of an emergency. We also recommend that such patients carry a tube identical to the one they have in situ, compatible airway equipment such as appropriately sized tracheal tube connector could be tested and identified in advance. None declared. Download .zip (.0 MB) Help with zip files