Anesthetic management of T tube: A simple approach.

Sir,

We read with great interest the case report “Anesthetic management of a patient with Montgomery t-tube in situ for direct laryngoscopy.”

The authors were able to achieve an induction with 3-4% sevoflurane in 100% oxygen.[1] This appears to be technically difficult in view of considerable loss of gases through the open laryngeal end of the intraluminal limb. An appropriate sized red rubber suction catheter inserted trans-laryngeally into the open intraluminal limb could have hastened the process of induction. However this could prove to be technically difficult.

Alternate maneuvers which could have been used include keeping the oral cavity closed tightly with slight jaw retraction and pinching of nostrils to prevent escape of gases.

Inability to ventilate due to the proximal air-leak with ventilation via the extraluminal limb using standard endotracheal tube connector, as well as failure of bag-valve-mask ventilation while occluding the extraluminal limb with a stopper has been described recently.[2] The emergency case required removal of the T-tube and insertion of orotracheal tube.

Another method we have successfully used is the insertion of a small appropriate sized endotracheal tube, either 4 or 4.5 mm ID, through the extraluminal limb into the tracheal end of the intraluminal limb [Figures 1 and 2]. This obviates the laryngeal leak sufficiently. The use of Fogarty's catheter, which can introduce technical difficulties as rightly pointed out by the authors, is thus avoided. The resistance offered by the length that requires to be inserted is slightly higher as compared to use of number four universal connector used by the authors but acceptable.

Figure 1

Plain endotracheal tube through T-tube

Figure 2

Assembly in situ

Similar technique has been successfully used for mechanical ventilation in ventilator dependent patient as reported by Wu et al.[3]

Considering the increasing use of T-tubes and as yet relative unfamiliarity of this device, we feel that the above simple techniques would prove useful in managing patients with T-tube in situ coming for anesthesia.