Early postoperative displacement of a Montgomery T-tube: successful rescue with low-pressure bag mask ventilation

Abstract

Background: Airway compromise following tracheal reconstruction is uncommon but potentially catastrophic because of the vulnerability of the fresh tracheal anastomosis. Early displacement of a Montgomery T-tube may result in rapid hypoxaemia and presents a complex airway management challenge.

Case presentation: We report a detailed perioperative course of a 39-yr-old female with post-intubation tracheal stenosis who underwent elective tracheal resection with primary end-to-end anastomosis and Montgomery T-tube insertion. Within hours of ICU admission, she developed acute respiratory distress with oxygen saturation falling to 88% and less despite supplemental oxygen. Controlled low-pressure bag–mask ventilation (BMV) was instituted using a two-handed technique with inspiratory pressures limited to <20 cm H₂O.

Results: BMV resulted in rapid restoration of oxygenation (SpO₂ 100%) without haemodynamic compromise. Following stabilisation, the displaced T-tube was removed and a cuffed tracheostomy tube inserted through the existing stoma with minimal disturbance to the anastomosis. No evidence of anastomotic dehiscence or airway injury was observed, and the patient recovered uneventfully.

Conclusions: In early postoperative airway emergencies following tracheal reconstruction, oxygenation remains the primary priority. Carefully applied low-pressure BMV may provide a safe and effective bridging strategy to definitive airway management.

Keywords: airway emergency; bag–mask ventilation; Montgomery T-tube; tracheal resection; tracheal stenosis