INDICATIONS/CONTRAINDICATIONS

Severe tracheal obstruction that is not correctable by surgical or endoscopic means requires some form of tracheal stenting or bypass for safe and comfortable breathing. A tracheal T-tube is an effective tool to stent airway obstruction that avoids some of the disadvantages associated with a tracheostomy tube or tracheal stent. A T-tube preserves airflow through the nasopharynx, unlike a tracheostomy tube, and allows efficient humidification of the breath and speech. Moreover, a T-tube, by virtue of its sidearm, is not prone to migration and displacement as with a tracheal stent. A T-tube is also less injurious to the trachea and does not extend the tracheal injury as a tracheal stent is prone to do.

A T-tube is temporarily placed for a variety of indications. Temporary stenting of an airway while edema and inflammation resolve sometimes allows eventual decannulation without further intervention. This is more often the exception than the rule as airway obstruction that is severe enough to require intervention is usually not a reversible process. Temporary T-tube placement is also appropriate as a bridge to definitive resection and reconstruction as patients wean from high doses of corticosteroids or recover from reversible conditions such as Guillain–Barré syndrome.

A T-tube also definitively treats airway obstruction in a patient with insufficient normal trachea remaining for reconstruction. It is also effective for palliation of tracheal obstruction by primary or secondary tracheal neoplasms, after conventional modalities have been exhausted. A T-tube is the ideal palliation of tracheal obstruction due to progressive inflammatory disorders such as Wegener’s and relapsing polychondritis, which are not surgically correctable.

The last major indication is management of an anastomotic complication after tracheal or laryngotracheal reconstruction. A T-tube either stabilizes the airway until healing is complete, or it is a bridge to another attempt at repair in several months. Rarely, a T-tube is a permanent solution to a failed tracheal reconstruction.

A T-tube is not appropriate for a patient requiring mechanical ventilation, as the tube does not provide a definitive airway for positive pressure ventilation. A T-tube is also problematic in a patient with obstructive sleep apnea, who may not tolerate closure of the side port at night. A T-tube is generally not appropriate for children or a patient with a small habitus, as the tube is either tolerated poorly or is associated with increased risk of complication. Finally, a patient with a T-tube requires periodic replacement of the tube, as it deteriorates or accumulates endoluminal material. A T-tube must not be placed in a patient with poor access to expert caregivers.

PREOPERATIVE PLANNING

Preoperative computed tomography provides an estimate of the degree and length of tracheal obstruction and what size of T-tube is necessary. Bronchoscopy at the time of T-tube placement is required to directly measure the lesion and confirm what size of T-tube will be accommodated. The proximal limb of the T-tube must be seated below the conus elasticus, when the obstruction extends into the subglottis. A T-tube may be inserted into a pre-existing mature stoma or into a newly constructed stoma.

SURGERY

Positioning

Patients are positioned supine with a bag or roll underneath the shoulders to extend the neck.

Technique

A tracheostomy, if not previously performed, is constructed to lie in the midst of the narrowed and diseased trachea. This is important if future reconstruction is planned, as ideally no normal trachea would be violated during creation of the tracheostomy. Even when there is a pre-existing mature tracheostomy, T-tube insertion is best performed under general anesthesia. Rigid bronchoscopy is performed to dilate any stenosis or to core-out endoluminal tumor and to make precise measurements regarding the location of the stoma, distance between the glottis and the top of the lesion, and the distance between the bottom of the lesion and carina. The tracheal diameter determines the size of T-tube (Fig. 33.1

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