Respiratory Insufficiency with Tracheotomy_1
Short Summary

72-yaer-old female was hospitalized due to bronchopneumonia complicated by septic shock. Her complicated diagnosis was: acute respiratory insufficiency with recent results of right mediobasal bronchopneumonic foci with respiratory distress, Hypertensive hypertrophic heart disease, Renal insufficiency, Anemia, Drained left PNX, Tracheomalacia, and Gastritis, and various medical procedures were performed, including Tracheostomy. Following the development of serious respiratory depression (post tracheotomy tracheal stenosis), she underwent Montgomery T-tube insertion, and after 2 weeks developed distal obstruction with dense mucous secretions, and was changed to a Bivona trach. tube. About 2 weeks later it was switched back to a Montgomery tube.


Patient's Questions
In consideration of the 2 failed attempts at Montgomery T-tube insertion, we ask:
1)    How is it possible to resolve the post-tracheotomy tracheal stenosis?

2) Can you indicate a center of excellence in Italy for Montgomery T-tube insertion or another effective surgical technique with the highest guarantee of success?

3) Prognosis?
Medical Background

72 years old, Female
Past Medical History:
Common childhood exanthems.
Arterial hypertension. Dysthymia.
Depressive syndrome for about 25 years.
Hypothyroidism for about 5 years.
Surgery for extrauterine pregnancy, gallstones and bilateral cataracts.
The patient was hospitalized on February 2008 in the Intensive Care Unit of the Santi Antonio e Biagio e Cesare Arrigo Hospital in Alessandria due to bronchopneumonia complicated by septic shock. The patient was then transferred on February 2008 to the department of Pulmonary Medicine of the same hospital with the complicated diagnosis of: acute respiratory insufficiency with recent results of right mediobasal bronchopneumonic foci with respiratory distress. Hypertensive hypertrophic heart disease. Renal insufficiency (Dialysis). Anemia. Drained left PNX. Tracheomalacia. Gastritis with petechial hemorrhage of the gastric fundus.
Over the course of hospital stay various medical procedures were performed, among which: transfusions; dialysis; pleural drainage. Tracheostomy tube replacement. Bronchial biopsy. Bronchoscopy. Esophagogastroduodenoscopy. 
When the patient's clinical conditions stabilized, she was transferred on May 2008 to the Rehabilitation unit of the Alexandria Hospital. Following the development of serious respiratory depression (post tracheotomy tracheal stenosis), the patient was again transferred to the department of Pulmonary Medicine on June 2008.
On June 2008, Montgomery T-tube insertion, which was placed with the help of endoscopic forceps. On June 2008, the Montgomery T-tube was found to be distally obstructed with dense mucous secretions. After repeated attempts to remove the obstruction, the stent was removed and a Bivona no. 7 tracheostomy tube was inserted. Another Montgomery T-tube with 15 mm proximal arm was inserted on July 2008, which was removed on July 2008 because it was obstructed by secretions with onset of acute dyspnea and cyanosis.
On July 2008, the patient was transferred to the ENT department. During her stay in that department, she developed pericarditis.
From August 2008 to October 2008, the patient was hospitalized in the rehabilitation unit of the Alexandria Hospital: at admittance fair general conditions, the patient was alert, oriented to place and time, cooperative, with tracheostomy tube in place. Hypertrophy and global hyposthenia of the 4 limbs from lack of use, primarily the lower limbs. Postural changes possible with assistance. During hospitalization, rehabilitation therapy was performed to improve muscle tone and trophism, postural changes and walking resistance.

Expert's Opinion

1. The best way to resolve post-tracheotomy tracheal stenosis would be for a thoracic surgeon to remove the stenotic portion of the trachea – which may or may not be possible depending on the location/length of the stenosis. Another possible option is for an interventional pulmonologist evaluate her for placement of a tracheal stent – which would again depend on the location/length of the stenosis.
2. I do not know of surgeons in Italy who perform this, or centers of excellence in Italy for Montgomery T-tube insertion. I believe Dr. John Wain, a thoracic surgeon at Massachusetts General Hospital in Boston, MA has performed that type of surgery.
3. I would not expect the tracheal stenosis to improve with time, and it could slowly worsen.
There are some options to try to optimize management if she can not have surgery, or to try while waiting evaluation for surgery.
I assume she currently has an open tracheostomy tube, and that a main consideration is to allow speech.
One option is seeing if she would tolerate a speaking valve on the tracheostomy tube. Measuring tracheostomy tube manometry (see my recently published paper Tracheostomy tube manometry: evaluation of speaking valves, capping and need for downsizing. Clinical Respiratory Journal 2009;3:8-14) can help determine whether a speaking valve would be tolerated. The expiratory pressure can be checked with her current tracheostomy tube. In general if the expiratory pressure is 0 to 5 cm H2O, a speaking valve is well tolerated. If the pressures are high with the current tube (?#7 Bivona tight-to-shaft), I’d suggest trying a #6 Bivona TTS and recheck the pressures. If pressures are 0 to 5, see how she does with the speaking valve on all the time. If pressures 5 to 10, suggest allowing short periods with speaking valve, and see if they improve. If still too high (>10) to allow speech, then suggest change back to a #7 tube to allow more patent airway.
Another option would be to place another Montgomery T-tube, but with other efforts to reduce mucous and mucous plugging. These include treating any infection/bronchitis; instilling acetylcysteine (e.g. 3 cc of 10%) directly into the tube or acetylcysteine neb treatments via mouth (3 cc of 10%) and acetylcysteine po (e.g. 600 mg BID) may help. If she has a weak/ineffective cough with the T-tube in place, could try MIE (mechanical in-exsufflator) via face mask.