P059: WHY IS HE SO DISTENDED? MANAGEMENT OF A PATIENT WITH LARGE TRACHEOESOPHAGEAL FISTULA
Maksym Doroshenko, MD, MS1, Oleg Turkot, MD2, Sripad Rao, MD1; 1Jackson Memorial Hospital / University of Miami, 2Johns Hopkins Hospital
Introduction: Acquired tracheoesophageal fistula is rare, occurring in 0.3 to 3% of patients with prolonged mechanical ventilation or tracheostomies. Cuff-related tracheal injury is the second most common etiology of it. Most significant risk factors are high cuff pressure (above 30 cm H2O) and prolonged duration of intubation. We would like to present a case of large TEF and discuss possible treatment options.
Case report: 41-year-old male was found in cardiac arrest after being electrocuted. He was intubated and resuscitated by paramedics with return of spontaneous circulation upon arrival to trauma center, yet with remaining generalized tonic-clonic seizures, resistant to initial abortive treatment. After Trauma ICU admission and seizure control, patient was found difficult to wean off ventilator due to persistent MSSA pneumonia and resulting hypoxia. After 9 days in the unit, air leak developed, followed by significant small bowel and gastric distension (despite properly suctioned nasogastric tube), copious thick bronchial drainage and severe P. Aeruginosa pneumonia with sepsis in the following week, causing frequent episodes of hypoxia. He required increasing cuff balloon pressures and high ventilatory support. Given above concerns, bronchoscopy and upper GI endoscopy were performed in the OR with identification of a 3 cm tracheoesophageal fistula with lower margin 4 cm above carina. ETT was repositioned with tip 2 cm above carina, which was the minimum depth at which ventilation parameters and leak improved significantly. Further bronchoscopies found evidence of worsening tracheomalacia. Following thoracic surgery consultation and multidisciplinary discussion, the following treatment was proposed: obtaining custom made tracheostomy tube with cuff position below fistula and performing open TEF repair once pneumonia and inflammation around fistula resolves. Custom tracheostomy tube was placed within next two weeks. Patient gradually improved, started PT and was weaned off mechanical ventilation. Eventually, complicated open TEF repair was performed and tracheostomy decanulated 4 month after accident.
Discussion: This case describes symptoms and treatment of a complicated tracheoesophageal fistula. It also presents challenges that occur with large TEF and tracheomalacia, mostly related to establishing control of ventilation and optimizing the airway design to allow for proper organ healing, as some of commonly employed fistula repair techniques (e.g. segmental resection of trachea, stenting, endoscopic repair) could not be performed.
Conclusion: Post-intubation tracheoesophageal fistula presents multiple diagnostic and treatment challenges. It is usually managed surgically, yet in cases of large fistula that cause subsequent severe respiratory complications, there may be a need to delay primary repair while optimizing ventilation and employing longer tracheostomy tubes to bypass TEF.
1. Couraud L, Ballester ML, Delaisement C. Acquired tracheoesophageal fistula and its management. Semin Thorac Cardiovasc Surg. 1998;8:392–399.
2. Diaz E, Rodriguez AH, Rello J. Ventilator-associated pneumonia: issues related to the artificial airway. Respir Care. 2005;50:900–906.