These guidelines are intended to support practitioners caring for a child or young person with a Montgomery T-tube.
A Montgomery T-tube is an artificial airway made of soft silicone tube that is shaped like a ‘T’. T-tubes are used for many reasons; to support a diseased upper airway or to support the upper airway after surgery. The distinctive shape of the T-tube allows part of the tube to support (or stent) the upper airway, whilst the lower parts act like a tracheostomy tube, allowing the child to breathe easily and expel secretions.
The T tube is an artificial airway and the child must be supervised at all times by someone fully competent in its care. T tubes can be life-saving, but can become life-threatening unless the airway is kept clear from secretions 24 hours/day. The default in an emergency is to remove the T Tube and insert a tracheostomy tube into the stoma.
Paediatric Montgomery T-tubes
Paediatric Montgomery T-tubes are available in various sizes and the surgeon will determine the appropriate size for the individual child at the time of surgery. This will be documented in the health care record.
The Montgomery T-tube has five parts:
1. External limb
The external limb can be seen protruding from the child’s neck. This limb is connected to the upper and lower limbs. It is from here that facilitates breathing and removing of secretions either by suctioning or coughing.
2. Upper limb
The upper limb rests in the child’s upper part of the Trachea. The upper limb extends to an area just below, at, or above the vocal cords. The length will vary so it is essential that practitioners know the exact length of the upper limb for suctioning purposes.
The upper aspect can be stitched together to minimise aspiration, especially if it passes through the vocal cords. If this is the case Practitioners must be aware that the child has NO upper airway and therefore the upper limb must NEVER be occluded. This information will be on the operation note within the child’s health care record, and must be communicated to all health care professionals involved in the child/young person’s care both in hospital and in the community.
3. Lower limb
The lower limb extends down the trachea allowing the child to breathe, and facilitates the removal of secretions from the lower airways. As above, this length will vary, so it is essential that practitioners are aware of the length for suctioning purposes.
The ring sits on the external limb between grooves; they support and position the T-tube by minimising its movement back and forth. The ring should not be pushed flush to the skin, as this pressure may cause skin irritation/pain.
The occlusion cap can be inserted into the external limb and can be used when children are able to breathe through their (normal) upper airways.
However for the majority of children and where the upper limb is stitched together, the occlusion cap is left off the external limb and the child breathes through the lower and external limb much like a tracheostomy.
Preparation of equipment and environment
Appropriate resuscitation and suction equipment (with correct Portex T-tube fitting male to female portex adapter) and correct size face mask in full working order should be available as well as a portex swivel connector. (Rationale 1)
The child must have a dedicated airway trolley (Rationale 2) by the bedside, containing the following equipment:
- suction catheters - correct size
- clean gauze
- Personal Protective Equipment (PPE) - Protective eye wear, gloves, face mask and apron
- clean receiver containing bottled water
- a 2ml syringe and ampoule 0.9 per cent sodium chloride for cleaning/ irrigation
- orange waste bag for disposal of waste in line with the waste management policy
- an emergency tracheostomy box should be prepared with:
- Blue locking clamps (to remove the T Tube)
- A spare tracheostomy tube (same internal diameter as the T Tube; the size should be indicated on the operation note). T Tubes are measured in FG where tracheostomy tubes are measured in mm- Practitioners can refer to the sizing chart for reference or contact the NP Tracheostomies/ ENT team for advice.
- a Shiley tracheostomy tube (one size smaller than above)
- a water based lubricant such as Aqua lube® or K-Y jelly®
- round-ended scissors
- spare tracheostomy tapes
- a suction catheter (of the correct size)
Initial care of Montgomery T-tube formation
Following on from the initial insertion of a Montgomery T-tube, the initial care requirements include:
- Maintaining the patency of the new tube
- Stoma care
- Parental training.
The majority of children/young people with a T-tube will have had a tracheostomy formed prior to the T Tube insertion so parents would be familiar with caring for their child with an ‘artificial airway’.
During the first few days, the child/young person must be supervised at all times by someone who is competent to:
- Suction the upper and lower limb
- Remove the T-tube in an emergency situation
- Insert and secure and care for a tracheostomy tube.
Observe and record for any signs of increased respiratory effort. Observations should be undertaken as dictated by the child’s condition and these recorded on the CEWS chart, nerve centre or carevue.
Should complications arise, or the child’s condition deteriorates, follow the Observation and CEWS Policy to escalate concerns.
Post insertion complications
Initial complications are largely avoidable with careful and effective post-operative management. Early recognition of complications is essential and practitioners can contact the Tracheostomy Nurse Practitioner (NP) or the ENT team for advice, but should never delay escalation of concerns in line with the CEWS escalation policy while this advice is sought.
Initial post insertion complications include:
- Haemorrhage: this may be primary, reactionary or secondary: observe and record the child’s vital signs and where there are concerns or visible haemorrhage occurs, follow the CEWS escalation policy (Rationale 3-4). The Ear/Nose/Throat (ENT) medical team or Tracheostomy NP can also be contacted for advice if any bleeding is evident from the tube, but do not delay escalation of concerns in line with the CEWS escalation policy while this advice is sought.
- Tube blockage: Perform suction at least half hourly to one hourly for the first 12-24 hours. (Rationale 4)
- Accidental decannulation/tube displacement: This is a clinical emergency, Phone x2222 to alert the clinical emergency team, a tracheostomy tube must be inserted into the stoma to facilitate breathing.
- Infection (chest/stoma site). Observe the stoma site recording any changes and record temperature.
- Surgical emphysema: An air may leak around the tube into the surrounding tissue. Palpate neck area and check for swelling. If any swelling occurs, contact ENT medical team, Tracheostomy NP or CSP for advice. Again, do not delay escalation of concerns in line with the CEWS escalation policy while this advice is sought.
Oral dietary intake
If there have been no previous feeding concerns, the child may recommence their normal feeds after a specified time of being ‘nil orally’. Practitioners must confirm this with the operation notes. If there were difficulties with oral feeding prior to the T Tube insertion, or the child doesn’t tolerate feeding, and for example begins coughing or feed/fluid comes out of the T Tube, STOP feeding, refer to the ENT Team/Tracheostomy NP The child will then be referred to the speech and language therapists (SALT) for assessment.
The nose and naso-pharynx space provides an optimum environment within which inspired air is maintained at a temperature of 37°C in 100% relative humidity. The T-tube bypasses this space and, instead, rests within the lower airway structures, which fail to provide the optimum environment. The natural warming, humidification and filtering of air, that usually takes place in the upper airway, is lost and, instead must be achieved artificially.
Without appropriate humidification, secretions can become increasingly thick and tenacious, making their retrieval difficult. This may lead to blockage of the tube or retention of secretions in the lower airways. (Rationale 5-6)
To reduce these risks, artificial humidification is recommended and can be given in many ways;
- A home nebuliser with a tracheostomy mask (over the T Tube external limb) should be considered for these children prior to discharge. Nebulisers provide aerosol droplets in a saturated vapour helping to keep the airway humidified and secretions loose so that are easily retrievable on suctioning. For more information about nebulisers, see the nebuliser guideline.
- After any anaesthetic the child should receive continuous humidity until such time the secretions are loose, is coughing well and able to maintain their own hydration. This can be delivered via elephant tubing from a cold/warmed water system. Any child under 1 year must have warmed humidity. (Ref 6). (Rationale 6)
- It is also important that a child/young person with an artificial airway remains systemically hydrated, this again helps with keeping secretions loose and retrievable by suctioning, preventing tube blockages. Practitioners should consider increasing the child/young person’s fluid intake during times of illness such as respiratory disease, vomiting, diarrhoea, pyrexia, etc.
- The traditional heat and moisture exchangers (HME) cannot be used, as the termination is not a standard 15mm fitting, so children must wear a Buchannan bib at all times.
- The Buchannan bib is simply a modified heat and moisture exchanger that looks like ‘a bib’ and can be placed over the external limb and tucked into clothing,
- The Buchannan bib should be changed daily or more frequently if soiled.
- If the child is to be discharged with the external limb blocked, then the child should be able to humidify their airway in the normal way with supplementary facial nebulisers as required.
- Oxygen can be delivered in two ways, either by nasal cannula (only if the external limb is occluded by the cap) or with a tracheostomy mask with a supply of Oxygen placed over the T-tube if the external limb is to remain open.
Suctioning a Montgomery T-tube
It will be determined early on whether or not the child is to have the exterior limb occluded. If they do, then the child should be encouraged to cough and clear their own secretions in the normal way up through the mouth.
If this is not the case, suctioning will have to be performed in both the upper and lower limbs of the T Tube, to remove secretions from the child's respiratory tract. Both the upper and lower limbs must be kept clear, especially if the child is to have periodic exterior limb occlusion (Rationale 7).
Suctioning is associated with potential complications, and is only recommended when there are clear indications that the patency or ventilation of the children is compromised (Ref 6,7,12,13,14,15,16,17,18,19,20) Potential complications include:
- formation of distal granulation tissue/ulceration
- cardiovascular changes
- bacterial infection
- intracranial changes
The GOSH clinical guideline on airway suction is a useful resource.
Practitioners must be competent in respiratory assessment, indications for suctioning and suction technique, Basic Life Support (BLS); this will minimise complications and maximise treatment (Ref 21).
The procedure should be explained to the child/ parent / carer (Rationale 8) and the following equipment prepared:
- suction catheters of the correct size
- suction unit with variable vacuum control
- PPE: gloves, face mask, protective eye wear and apron (in accordance with the local infection control policy.
- Bottled water (in clean container)
- orange waste bag for disposal of waste in line with waste management policy
Distal tracheal damage and hypoxia are potential complications, particularly related to the paediatric airway. Suctioning should not be a painful procedure. If the child becomes distressed during suctioning, then practitioners should revise their technique and equipment.
The following measures help to reduce complications but maximise effect:
- Suction catheters must meet the following criteria:
- A suction catheter that is double the internal diameter of the Tracheostomy Tube (Ref 7,20,22,23), for example a Tracheostomy Tube size 4.0, use a suction catheter sized 8.0 (Rationale 9).
- Have one distal and two lateral ports with rounded ends (Ref 20). This allows secretions to be collected distally and from the sides of the tube. Catheters with more than three lateral holes weaken the catheter.
- Have a lateral port that is smaller than the distal ports, so that mucosal adhesion and biopsy do not occur.
- Have an integrated valve for vacuum control. Suction should be applied only on withdrawal. Catheters should not be kinked prior to insertion, in an effort to control the vacuum. In infants and children while there is little evidence to support the optimal negative pressure to be applied, the lowest pressure that will effectively clear secretions should always be used (Ref 7).
- Have numbered graduations for accurate insertion lengths
- The use of an effective technique for suctioning:
- Do not rotate the catheter on withdrawal, as both the distal and lateral holes on the new design of catheter allows for circumferential suctioning.
- Suctioning should not be carried out on a routine basis (the only exception is if the T-Tube / tracheostomy is new (i.e. before first tube change). The need for suction should be established each time the patient is assessed; thereby ensuring suction is performed only as necessary. Suctioning should be quick but effective enough to remove secretions and minimise complications especially atelectasis, hypoxia and cardiovascular changes (Ref 6,12,13).
- Practitioners must know the lengths of both the upper and lower limbs and the length of the external limb, all are cut to pre-determined lengths which vary. Suctioning should remain within the tube and not go further (Rational 10)
- Practitioners should only touch the proximal end of the catheter to minimise contamination being introduced into the tube. Catheters should be dis-guarded prior to use if the distal end is contaminated. Catheters can be re-used during the same episode of suctioning if the distal end is clear from secretions.
- Repeat the procedure only as necessary.
- Suction procedure for T Tubes (see Suction guideline for further information).
- Accurate Angulation of the external limb of the T Tube, either upwards or downwards, is required to facilitate suctioning in the upper or lower limb. Care must be taken to ensure that you are suctioning the correct way as the lengths of the upper and lower limb lengths may differ.
- To suction the upper limb, angulate the external limb downwards and pass the catheter in and up, if suctioning the lower limb angulate the external limb upwards and pass the catheter in and down.
- Installation of Saline drops, is a contentious area and there is little evidence to support this practice so should not be used routinely. (Ref 24,25,26,27,28). This should be done on an individualised basis and only by experienced practitioners (Rationale 11).
- Record in the child’s health care records if the secretions are bloody, purulent, foul smelling or unusually thick. Take samples for analysis as required.
Practitioners must be aware that some pre-term, vulnerable infants may require pre-oxygenation prior to suctioning (Ref 7).
- A T-tube is held in place only by the upper and lower limbs. Applying undue pressure or pulling of the T-tube should be discouraged and this may cause dislodgement.
- Stomal cleaning is normally performed at least daily more often if needed, with normal saline and gauze. Ensure the ring is pulled away from the stoma and the skin cleaned well, always replace the ring close to the stoma. Observe for skin breakdown and granulation tissue and treat accordingly.
- Crusting may also need to be removed from the T-tube and/or cap.
- Only one person is usually needed to clean the stoma. Older children may sit, smaller ones may have to lie down and be swaddled.
The basics of cardio-pulmonary resuscitation (CPR) and basic life support (BLS) are universal to all protocols for emergency care.
Starting BLS quickly is extremely important. If in any doubt about child's condition, concerns regarding the T Tube and there is deterioration in CEWS, call for clinical emergency team immediately (x2222).
Airway management aspects of BLS will require modification for children with a T tube. Practitioners caring for children with T-tubes must have had both routine and tracheostomy BLS training and must familiarise themselves with the T-tube/tracheostomy resuscitation.
Patients with a Montgomery T-tube must always have their own emergency equipment correctly assembled and easily accessible. In an emergency:
- Stimulate the child and call their name, taking care to support their head and body.
- Open and check the child’s airway by placing the child supine on a flat firm surface. It may be helpful to put a folded towel under the shoulders, but only if this is immediately available. Do not waste time collecting this equipment.
- Expose the tube, inspecting for kinks, blockages or dislodgement.
- Shout for assistance from colleagues, and call the emergency team
- If the cap is on the external limb then remove it immediately.
- Suction the T-tube both inferiorly and superiorly to clear any secretions. This will determine whether the tube is blocked or if the airway is clear. If the tube is partially blocked and the child is still breathing take time to clear the tube rather than change it, (Changing the T Tube can be difficult, dangerous and distressing for the child). A member of the ENT team or the Tracheostomy NP/Emergency Team should be called prior to its removal if there is time. Removal of the T-tube is a decision that should not be taken lightly or undertaken by inexperienced practitioners, it must be only removed if all attempts to clear it have failed and it is a clinical emergency.
- If the tube is clear but the child is not breathing, then ventilation can be administered via the T-tube using the Bag Valve Mask attached to the swivel and male to female connector (appropriate size) giving 5 rescue ventilations (ensure the external limb is angled upwards.) auscultate and observe for chest movement.
- If the decision has been made to remove the T tube then practitioners must prepare the tracheostomy tube to be inserted first, and ensure that the child is lying flat and supported appropriately as this will not be a pleasant procedure for them. Remove the T Tube by grasping the external limb either with fingers or blue plastic clamps, once this is done the child cannot breathe. The T Tube is then gently and slowly pulled upwards out of the stoma until either the upper or lower limb is pulled from free , then gently assist the other limb from the stoma.
- On removal of the T-tube, a tracheostomy tube is inserted into the stoma and resuscitation can continue via this. See appendices 3 and 4.
- If there is any difficulty in inserting the tracheostomy tube, or difficulty in inserting the same size tube, try to insert the one that is a size smaller.
- If the stoma closes and the smaller tube cannot be inserted, remove the obturator from the smaller tracheostomy tube and pass a suction catheter through this tube. Attempt to insert the end of the catheter through the stomal opening and then guide the tracheostomy tube along the catheter and through the stoma (Seldinger technique). (Ref 29).
- If this is also unsuccessful, ventilation can be attempted by placing a mask over the stomal opening or by conventional rescue breaths (e.g. mouth-to-mouth or BVM/ intubation, if the child’s overall clinical diagnosis would allow this).
- Supporting the T-tube or the new tracheostomy tube, place the side of your face over the top listen and feel for any breathing. At the same time look at the child’s chest to observe any chest movement. Take up to a maximum of ten seconds to do this.
- If the child is breathing adequately, give oxygen and keep their airway open by regular suction and wait for the clinical emergency team.
- If the child is not breathing (or only making agonal gasps), commence artificial respiration with a bag-valve system directly connected to the T-tube/ tracheostomy tube, and administer five breaths. This is best achieved with a Portex 15mm swivel connector attached to the ambu bag. If you are delivering breaths via the T Tube then ensure the male-female connector is placed into the T tube first then connect the BVM + swivel connector.
- Ensure that the breaths are effective by observing chest movement.
Look for signs of life and proceed with cardiac support and monitoring in line with resuscitation guidelines.
The insertion of the Montgomery T-tube is usually a planned procedure allowing for adequate preparation for discharge to be completed in advance. Placement of the T Tube and information about the on-going care requirements must be confirmed with all professionals involved in the child’s care as soon as possible following n admission and confirmed ahead of discharge.
Most children would have had a tracheostomy prior to insertion of a T Tube and so would be familiar in its care and techniques. Specific attention must be directed in providing training to the parents / carers in the following areas:
- Competence in tracheostomy / T Tube care.
- Suctioning of both the upper and lower limbs.
- Stoma care and removal of cap.
- Advice on occluding the outer limb (if applicable).
- Resuscitation skills/emergency care - including resuscitation via the T-tube using the portex adapter, mouth to T tube resuscitation, checking for blockages and action to take with a blocked T Tube and removal of T-tube. Parents must receive training from the Tracheostomy NP, a resuscitation clinical trainer or other professional competent with the care of tracheostomies and Montgomery T-tubes. The Tracheostomy NP has a training podcast that is available for parents to watch.
- Parents must be given the appropriate tracheostomy and T-tube resuscitation booklets to support their training (see appendix 1 and 2).
- All training received must be recorded on the child’s discharge planner and kept in their health record for future reference.
Appropriate tracheostomy equipment and consumables need to be provided to the family prior to discharge, including a Smiths catheter mount 15mm female, disconnection wedge, blue clamps and emergency Velcro® tapes.
The local community teams must be aware of the equipment and consumables required to support the family at home.
An eight-week ENT outpatient appointment must be arranged prior to discharge.
- To ensure correct equipment is available to support/ maintain an airway
- To facilitate immediate access to equipment to support/maintain an airway, If the T Tube blocks or decannulates then a tracheostomy must be placed into the stoma.
- A large haemorrhage could be fatal therefore appropriate and timely escalation is paramount
- The presence of an artificial airway impairs the cough reflex and may increase mucus production (Ref 1,2,3,4,5,6,7) the T tube must be kept clear of secretions at all times. T Tubes can be difficult to remove if they block, and can only be reinserted in theatre. Regular suctioning confirms patency especially until which time the child is fully awake from the anaesthetic and able to manage their secretions independently.
- Lower airways are not designed to effectively humidfiy secretions. Impairment and destruction of cilia reduces the proximal transportation of mucus (Ref 6, 9)
- Cold inspired air increases heat loss from the respiratory tract and is a particular problem for the small infant who struggles to manage temperature changes anyway.
- A child with a Montgomery T-tube may find it difficult to clear their secretions effectively; secretions can get trapped in the join between the upper/lower limbs and the external limb therefore suction is an essential aspect of their care.
- Lifting the exterior limb can be uncomfortable in the beginning therefore explaining how/why will aid compliance and understanding from the child/parents.
- To minimise the potential for hypoxia and atelectasis by not occluding more than half of the diameter of the tube, allowing the child to breathe around the catheter whilst carrying out suctioning.
- The T Tubes are cut to specific lengths so vary from child to child, tube to tube, suctioning beyond either the upper or lower limb will cause trauma to surrounding tissue, increasing the risk of granulation formation/ trauma to vulnerable structures possibly occluding the distal airway. Practitioners must stay within the tube during suctioning only allowing the distal/lateral holes to pass through to retrieve secretions.
- There is little evidence to support the installation of saline into an artificial airway tTo loosen and mobilise secretions, however if experienced practitioners wish to use this as a last resort in an attempt to try and clear the tube rather than change it then they could consider it. It should NOT be routinely used.
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