Using Bronchoscopy to Detect Acquired Tracheoesophageal Fistula in Mechanically Ventilated Patients

Abstract

IntroductionAn acquired Tracheoesophageal fistula (TEF) is commonly caused by a malignancy or trauma, with pulmonary infection or aspiration being the presenting symptom. However, in the critical care setting the presentation can be subtle and may present with difficult ventilation. High endotracheal tube cuff pressures can lead to tracheal erosions and thus increasing the chances for developing a TEF. Prolonged intubation in the presence of other risk factors like poor general state of health, episodic hypotension, nasogastric tubes, and repeated intubations can increase the likelihood of developing an acquired TEF. Angioedema of the airway is a rare but potentially devastating complication of angiotensin converting enzyme inhibitors (ACE-I) that could further add insult to the tracheal mucosa, predisposing to an acquired TEF.Case PresentationAn elderly woman with multiple comorbidities and requiring mechanical ventilation, developed angioedema following intake of ACE inhibitor for hypertension. The ensuing airway edema made weaning off mechanical ventilation difficult. After repeated attempts at extubation, tracheostomy was performed. With the loss of airway after tracheostomy, the possibility of TEF was considered given her multiple risk factors and intra-operative findings of the tracheal mucosa.ConclusionsWhile it may be difficult to predict who will actually develop a TEF, it is prudent to identify those at risk and take precautionary measures to prevent one. Emphasis should be placed on daily endotracheal cuff manometric pressure check to prevent ischemic changes of the tracheal mucosa resulting from high cuff pressures. Also, bronchoscopy could be used after extubating susceptible patients to detect an acquired TEF.

Evaluation of the Incidence and Potential Mechanisms of Tracheal Complications in Patients With COVID-19

“…Tracheal damages associated with life-threatening complications occurred in almost half of patients with COVID-19 treated with prolonged invasive MV, with a marked increase in incidence compared with non-COVID-19 matched controls and previous case series . Several mechanisms specifically related to COVID-19 treatment and pathophysiology may explain the greater incidence of tracheal complications in mechanically ventilated patients with COVID-19:…”

“…Full-thickness tracheal lesions (FTTLs) and tracheoesophageal fistulas (TEFs) are serious but rare (0.3%-3%) complications of prolonged invasive mechanical ventilation (MV) . With the coronavirus disease 2019 (COVID-19) outbreak, however, we experienced an unprecedented increase in the incidence of FTTLs and TEFs in ventilated patients with COVID-19, the reasons for which are unknown.…”

Diagnosis and Treatment of Tracheoesophageal Fistula in Tetraplegic-Ventilator Dependent Patient, Case Report

“…Beraberinde rijit-geniş nazogastrik sonda kullanımı yüksek basınçlı kafla birlikte trakea arka duvarı ve özofagus ön duvarının arada sıkışarak hasarlanmasına yol açar ve TÖF oluşumunu hızlandırır. Malnutrisyon, hipotansiyon, hipoksemi, anemi, diyabet, steroid tedavisi ve gastroözofageal reflü (GÖR) diğer tetikleyici nedenlerdendir (1,7) .…”

“…Yüksek hacim-düşük basınçlı kaflı tüplerin kullanımına geçilmesi, kaf basıncına bağlı komplikasyon sıklığını azaltsa da özellikle yoğun bakım ünitelerinde düzenli kaf basınç monitorizasyonu yapılması, kaf basıncının <20 mm-H 2 O tutulması ve kaf hacminin 6-8 mL ile sınırlandırılması önerilmektedir (1,8) .…”

“…Edinilmiş trakeaözofageal fistül (TÖF) nadir görülen bir durum olmasına karşın, yoğun bakım ünitelerinde unutulmaması gereken, tedavi yönetimi zor, ölümcül bir olaydır. Edinilmiş TÖF'ün %50'si malignite nedeniyle oluşurken, benign nedenler arasında en yaygın olanı kaf ilişkili trakeal tüp hasarıdır (1,2) . İyatrojenik yaralanmalar, özofagus/trakea cerrahisi öyküsü, yabancı cisim/kostik maddeye maruziyet veya kalıcı trakeaözofageal stentler diğer benign nedenlerdendir (2) .…”