A Fatal, Post-Intubation, Tracheoesophageal Fistula

Abstract

Despite the use of safer tubes with high-volume, low-pressure cuffs, post-intubation injury is still the leading cause of benign, acquired, tracheoesophageal fistula (TEF). Cuff pressure, which is their primary pathogenetic driver, is not routinely monitored as a quality metric. To highlight the devastating consequences, we report this case of a fatal, iatrogenic fistula in a 64year-old Asian male. He had undergone tracheostomy due to amyotrophic lateral sclerosis (ALS) and had a series of hospitalizations due to recurrent episodes of pneumonia. A TEF was eventually diagnosed to be the underlying cause. Esophageal stenting was ineffective. We intend to present teaching points aimed at reducing the risk of TEF in ventilator-dependent patients.

Ineffective ventilation in a very low birth weight infant with H-type Tracheoesophageal Fistula with bilateral chemical pneumonitis. A lesson learned

“…Airway management and ventilatory strategies are the most critical aspects for TEF management, the goal of which should be to avoid insufflation of gas via fistula into the stomach, causing ineffective ventilation and abdominal distension, thereby pushing the diaphragm up, adding further to impair ventilation, aggravating hypoxemia. 7 We share this case to highlight the two most important aspects of management, i.e., diagnosis and mechanical ventilation. Diagnosis: The use of fiber-optic bronchoscopes to confirm and locate the fistula is critical to avoid complications.…”

“…Contrast-enhanced studies have the risk of aspiration pneumonia and pulmonary injury are not helpful in delineating the size and precise location. 7 If performed, all neonatal emergency resuscitation equipment must be ready if needed. 8 Since fiber-optic bronchoscopes are not available in our setting, one might need to delay diagnostic procedures if the baby is clinically stable to let the baby become more mature.…”

A rare case of acquired tracheo-esophageal fistula in adult

“…So monitoring the cuff pressures to ensure low cuff pressures routinely especially in long term ventilator dependent patient may reduce the risk. 3 Surgical approach for the treatment is successful in surgical units with specialized tracheal and esophageal surgery. 4…”