Anaesthesia management in an obese patient with a broken Montgomery tube – A case report

Montgomery T-tubes are used for stenting and maintaining airway patency, especially in cases of tracheal stenosis. However, these tubes pose unique anesthetic challenges for the anesthesiologist, particularly in cases such as a fractured tube. Obesity adds another layer of complexity due to increased oxygen requirements and decreased functional residual capacity. This case presented significant anesthetic challenges due to the patient's morbid obesity (BMI 48 kg/m 2 ) and severe grade 4 subglottic stenosis, compounded by the presence of a fractured Montgomery T-tube. Airway management was particularly difficult due to the risk of obstruction, air leak and risk of loss of ventilation. Induction was done by keeping a careful balance between maintaining spontaneous respiration and achieving adequate anaesthesia, using inhalational and intravenous ketamine. Preventing gas leak from the proximal airway was critical and was managed by sealing the oral cavity with gauze and pursing the lips. Ventilation was further complicated by the non-standard airway anatomy; a 15 mm endotracheal tube (ETT) connector of 6.5 mm internal diameter (ID) was used to connect the T-tube to the circuit, and a flexometallic tube was temporarily inserted to allow controlled ventilation during surgical manipulation. This case demonstrates strategic airway planning in a complex stenotic and obese airway, emphasising the importance of maintaining oxygenation with unconventional airway devices, preserving spontaneous respiration during induction in high-risk airways and close coordination between surgical and anesthetic teams. Hence, anticipation and preparation for a difficult airway is crucial to avoid life-threatening complications.