Departeman Anestesiologi dan Reanimasi

Fakultas Kedokteran Universitas Airlangga

Anesthetic management of patients with tracheal

T-tubes

oleh :
Andri Subiantoro, dr.

Pembimbing :
Dr. Arie Utariani, dr., Sp. An-KAP

1
 Introduction
• Tracheal T-tubes  Stent for :
– patients who have undergone laryngotracheal reconstruction,
– in patients with airway collapse (particularly tracheomalacia),
– palliative stent for patients with tumors of the airway.
• Advantages Tracheal T tube  maintain airway patency while
allowing respiration and speech
• Patients with tracheal T-tubes  require anesthetic procedures
 rare  Anesthesiologist seldom have the opportunity to
manage patients with these stents
• T-tubes are sized according to the external diameter of the
superior and inferior limbs of the T-tube  5-18 mm

Christopher t. Wootten, michael j . rutter, john m. Dickson, paul J . Samuels. Anesthetic management of patients with tracheal T-
tubes. 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 349–357
2
Types of T- Tube

3
4
 Complications of T-tubes
• The lumen of the T-tube may become partly occluded by
dried secretions 
– patients who do not keep the anterior limb of their T-tube capped,
– not meticulous about T-tube care and cleaning
• The other potential complication is granulation tissue
formation at either end of the T-tube  airway obstruction
• Both crusting and granulation present with symptoms of
obstruction
• The level of obstruction is diagnosed by passing a flexible
endoscope through the anterior limb of the T-tube, and
inspecting both the superior and the inferior limbs
Christopher t. Wootten, michael j . rutter, john m. Dickson, paul J . Samuels. Anesthetic management of patients with tracheal T-
tubes. 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 349–357 5
 Complications of T-tubes
• Flexible endoscopic examination should be performed with
the patient awake and maintaining their own airway
• Crusting will usually respond rapidly to irrigation with
bicarbonate solution, suctioning and humidity
• Granulation tissue may respond to topical or systemic
steroids, but in some cases, the T-tube may require
replacement or removal  CIPRODEX Otic suspension
(ciprofloxacin ⁄ dexamethasone)

Christopher t. Wootten, michael j . rutter, john m. Dickson, paul J . Samuels. Anesthetic management of patients with tracheal T-
tubes. 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 349–357
6
 Elective anesthetic techniques
• Airway management represents an interesting challenge in
patients with T-tubes presenting for an operation.
• Preoperative :
– type and size of the T-tube present
– Consider whether the patient need requires positive pressure or
spontaneous ventilation
– From an anesthetic standpoint, it should not matter whether the
superior limb of the T-tube has its tip in the subglottis, or protrudes
through the vocal folds

Christopher t. Wootten, michael j . rutter, john m. Dickson, paul J . Samuels. Anesthetic management of patients with tracheal T-
tubes. 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 349–357
7
 Spontaneous ventilation
a. For a short procedure, a bag and mask (and oral airway) may
be used with the anterior limb of the T-tube plugged.
b. A laryngeal mask airway may be used with the anterior limb
of the T-tube plugged. It should not matter if the superior
limb of the T-tube protrudes into the supraglottis.
c. An anesthetic connector may be connected directly to the
anterior limb of the T-tube  for leakage ⁄ dilution of
anesthetic gas due to the open superior limb of the T-tube.

Christopher t. Wootten, michael j . rutter, john m. Dickson, paul J . Samuels. Anesthetic management of patients with tracheal T-
tubes. 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 349–357
8
12 mm T-tube before and after connection to 6.5 mm endotracheal 15 mm ISO connector.

9
• Technique (C) may be optimized if the nose and mouth are
blocked. This may be easily accomplished by strapping an
occluded anesthetic mask to the patient

Patient with occluded mask strapped to the face to allow closed circuit spontaneous ventilation
through the T-tube.
10
 To be continued,..
d. The patient may be intubated with an uncuffed
endotracheal tube through the superior limb of the T-tube
 need lubricant  to avoid risk of dislodging the T-tube
during endotracheal tube placement
e. The patient may be intubated with an uncuffed endotracheal
tube through the anterior limb of the T-tube
– the main difference that there is a smaller available lumen than is
provided by an anesthetic adapter
– To help the endotracheal tube negotiate the curve between anterior
and inferior limbs it is helpful to lubricate it well, and to insert it with
the anterior limb of the T-tube angled superiorly

Christopher t. Wootten, michael j . rutter, john m. Dickson, paul J . Samuels. Anesthetic management of patients with tracheal T-
tubes. 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 349–357
11
 Positive pressure ventilation
a. A laryngeal mask airway may be used with the anterior limb
of the T-tube plugged  It should not matter if the superior
limb of the T-tube protrudes into the supraglottis in most
cases.
b. Jet ventilation through the superior limb (with the anterior
limb occluded) or the anterior limb (with the superior limb
occluded) is effective.
– jet ventilation should be used with caution in children  risk of
pneumothorax or pneumomediastinum.

Christopher t. Wootten, michael j . rutter, john m. Dickson, paul J . Samuels. Anesthetic management of patients with tracheal T-
tubes. 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 349–357
12
Jet Ventilation via T Tube

13
 To be continued,..
c. An anesthetic connector may be connected directly to the
anterior limb of the T-tube
– To prevent a marked loss of pressure (and anesthetic gases) via the
superior limb, it is necessary to occlude the mouth and nose.
– However this may allow the stomach to inflate in some cases.
– An alternative is to occlude the upper limb with a balloon catheter
placed transorally or transnasally.

14
 To be continued,..
d. The patient may be intubated through the superior limb of
the T-tube (whether it lies above the vocal cords or not)
– An uncuffed endotracheal tube should be a snug fit
– A cuffed endotracheal tube will provide a better pressure seal, but a
smaller working lumen  Usually the cuff will require minimal or no
inflation
e. The patient may be intubated through the anterior limb of
the T-tube
– However as the anterior limb is of smaller dimensions than the
inferior limb in most T-tubes  potential for pressure escape through
the superior limb
– An alternative is placing a cuffed endotracheal tube through the
anterior limb (small size) or use ballon cathether

15
 To be continued,..
f. While it is feasible to remove the T-tube altogether and
intubate the trachea with a cuffed endotracheal tube placed
through the stoma,
– Removal and replacement of the T-tube is difficult enough.
– Discourage this technique when other options exist.

Christopher t. Wootten, michael j . rutter, john m. Dickson, paul J . Samuels. Anesthetic management of patients with tracheal T-
tubes. 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 349–357
16
 Emergency T-tube care
• Life threatening airway compromise may occur with crusting,
granulation tissue, or a foreign body occluding the T-tube.
• Whenever possible  inspect the lumen of the T-tube with a
flexible endoscope prior to intervention.
• Severe crusting  respond to irrigation and suctioning,
• While intubation through the T-tube may risk displacing the crust
into the distal airway  requiring emergency ‘foreign body’
removal
• Granulation  require steroid treatment & continuous
humidification via a tracheostomy collar.
• In a true emergency, the T-tube may be removed at the bedside,
and replaced with a tracheostomy tube or endotracheal tube

Christopher t. Wootten, michael j . rutter, john m. Dickson, paul J . Samuels. Anesthetic management of patients with tracheal T- 17
tubes. 2009 Blackwell Publishing Ltd, Pediatric Anesthesia, 19, 349–357
Laporan Kasus

Tn. Fauzan/ 24 th/ 40 kg/12463414

Stenosis Trakea Post Rekonstruksi dengan T Tube
Diagnosa
+ Granulasi Korda Vokalis Sinistra
PS ASA 2 (Airway Sulit)
Tindakan Ekstraksi Granulasi
Jenis Anestesi General Anestesi

18
 Time line

2015 2016 2018

Pasien KLL, lehernya Dilakukan revisi Trakeostomi Paien mengeluh agak

terjerat oleh kabel derek dengan T-Tube  Post sesak, dilakukan FOL
mobil, awalnya tidak ada pemasangan T Tube, oleh TS THT Hasilnya
keluhan selang ebberapa awalnya pasien masih didapatkan Granulasi di
bulan pasien mengeluh bernafas melalui T tube Korda Vokalis
sesak, dan semakin dengan lubang anteriornya
memberat  di bawa ke di buka (lubang superior
RSUD Dr. Soetmo, masih tertutup)  pada Direncanakan BLM
didiagnosa Stenosis perjalannya pasien bahkan ekstraksi Granulasi
Trakea dilakukan dapat berbicara bila T tube
Trakeostomi bagian depannya di tutup
 Laboratorium RSDS

Hematologi 30/07/2018

Hb 14,6 Na 142 BUN 9 OT 26

Hct 45,4 K 3.9 SK 0,62 PT 36
L 13,16 Cl 100 APTT 28,1 (27.2) Alb 3.9
T 433 HbsAg (-) PPT 10,2 (10,7) GDA 108

20
Foto Thoraks

21
FOL

22
 Assesment
• Diagnosa :
Stenosis Trakea Post Rekonstruksi dengan T Tube + Granulasi Korda
Vokalis Sinistra

• PS ASA 2 :
– Airway Sulit
 Konsultasi
• Konsultasi dengan dr. Agustina Salinding,
SpAn-KIC
– Advis
• Siapkan peralatan airway sulit, ETT non kink berbagai
ukuran dan ETT biasa berbagai ukuran, LMA, Glidescope,
Jangan sampai apnea dan siapkan needle krikotiroid dan
Jet Insuflasi
• Konsultasi dengan dr. Lucky, Sp.An-KAP
– Advis
• Acc. sesuai advis konsultan bidang minat.
 Persiapan Anestesi
1. Siap pasien (pastikan puasa cukup, inform concent)
2. Siap obat (obat emergency dan obat anestesi)
3. Siap mesin anestesi  cek mesin anestesi apakah berfungsi
dengan baik
4. Pasang monitor : EKG, NIBP, pulse oksimetri, stetoskop prekordial
dua buah, Temperature
5. Syringe Pump untuk TIVA Propofol
6. Peralatan Airway Sulit hingga Jet Insuflasi
7. Siap Suction
8. Evaluasi ulang hemodinamik pasien sebelum induksi

25
 Prosedur Anestesi
• Sebelum induksi, buka ujung anterior dari T tube pada pasien
dan sambungkan dengan ujung connector dari ETT biasa
disesuaikan dengan ukuran T tube.

26
 Prosedur Anestesi
• Setelah ujung T tube disambungkan connector dari ETT 
sambungkan ke sirkuit
• Preoksigenasi dan Suction

27
 Prosedur Anestesi
• Induksi :
– Preoksigenasi dengan O2 100% selama 3-5 menit,
evaluasi hemodinamik dan SpO2
– Injeksi Fentanyl 50 mcg i.v
– Injeksi Propofol 40 mg i.v
– Pasien dijaga tetap ada nafas spontan sambil di
assist ventilasinya
– Karena ada resiko kebocoran ventilasi ke arah
lumen superior dari T tube  untuk maintenance
kami gungakan dengan TIVA Propofol

28
Post Induksi

29
 Durante Op
Hemodinamik
• TD : 80-140/52-82
• Nadi : 90-105 x/menit,
• SpO2 : 99-100%
Ditemukan :
• Granulasi di Korda Vokalis sebelah kiri

Dilakukan : Ekstraksi granulasi dengan BLM

Balans cairan :

Input Output
Ringer Laktat 200 ml Darah 30 ml
Urine Spontan
TERIMA KASIH

31