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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 86-88

Failed weaning due to acquired tracheo-oesophageal fistula and tracheal stenosis: a case report


Department of Anaesthesia and Critical Care, MDM Hospital under S.N. Medical College, Jodhpur, Rajasthan, India

Date of Submission02-Sep-2015
Date of Acceptance09-Apr-2016
Date of Web Publication6-Sep-2016

Correspondence Address:
Babita
Babita d/o Mahilal, Behind Tehsil, Chamad Gali, Ward No. 6, Nagar, Tehsil, Bharatpur 321205, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2356-9115.189785

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  Abstract 


Tracheo-oesophageal fistula is defined as abnormal connection between the oesophagus and the trachea. It is a life-threatening emergency that warrants urgent attention and treatment as the patent tract bypasses the normal protection offered by laryngeal reflexes. Pulmonary complications such as aspiration pneumonia and pneumonitis can follow. Tracheostomy tube cuffs seal against the tracheal wall and prevent leakage of air around the tube, assuring that the tidal volume is delivered to the lungs. Measures to prevent tracheal stenosis include inflation of cuffs when necessary, maintenance of intracuff pressures less than 20 cmH2O using properly sized tracheostomy tubes, and avoidance of excessive pressure of the tube tip on either the anterior or the posterior tracheal wall. We report a case of acquired tracheo-oesophageal fistula and tracheal stenosis secondary to high pressure in the cuff of the tracheostomy tube. This situation can present the anaesthetists with significant difficulties.

Keywords: intracuff pressure, tracheal stenosis, tracheo-oesophageal fistula, weaning


How to cite this article:
Babita, Kumar R, Singh B, Kamal M. Failed weaning due to acquired tracheo-oesophageal fistula and tracheal stenosis: a case report. Res Opin Anesth Intensive Care 2016;3:86-8

How to cite this URL:
Babita, Kumar R, Singh B, Kamal M. Failed weaning due to acquired tracheo-oesophageal fistula and tracheal stenosis: a case report. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2020 Jun 4];3:86-8. Available from: http://www.roaic.eg.net/text.asp?2016/3/2/86/189785




  Introduction Top


Tracheo-oesophageal fistula (TOF) is a rare but serious complication of airway instrumentation [1]. It is observed in less than 1% of patients undergoing endotracheal intubation or tracheostomy procedures [2]. Posterior wall perforation during the procedure or posterior wall erosion caused by excessive cuff pressure or abrasion by the tip of the tracheostomy tube cannula are responsible for the formation of TOF [3]. Furthermore, mucosal ischaemia due to systemic disorders in intubated patients triggers the formation of TOF. Bronchoscopy is the gold standard for the diagnosis of TOF.

Tracheostomy tube cuff volume and pressure require constant monitoring to avoid tracheal injury. Because cuff pressures more than or equal to 30 cmH2O compress the mucosal capillaries and impair blood flow, with total occlusion occurring at 50 cmH2O, it is generally recommended that cuff pressures not exceed 20 cmH2O. Cuff volumes should not exceed 6–8 ml ideally, and the need to inflate the cuff to more than or equal to 10 ml should raise concerns about tracheal injury [4].

Case report

A 25-year-old male patient was admitted to the ICU because of organophosphorus poisoning after being intubated for airway protection in the emergency unit.

Anticipating a long recovery time, elective surgical tracheostomy was performed. He was started on antibiotics, and supportive care was given and feeding was started by means of a nasogastric tube.

The general condition of the patient improved slowly. The patient became stable after 15 days. We planned to wean the patient but failed. On suctioning, a copious amount of secretion was expelled and tidal volume was not adequate; therefore, we decided to change the tracheostomy tube. We evaluated the patient and intracuff pressure was measured, which was found to be 40 cmH2O. We removed the tube to exchange it with a new one, but while inserting the new tube the patient became restless and saturation dropped to 70%. After removing the tube, the patient became comfortable and saturation increased to 90%. A smaller tube was tried, but failed. The ENT surgeon was referred who performed a bronchotelescopy, which revealed a large TOF and retrograde scarring with stenosis below the fistula.

An urgent computerized axial tomography was carried out, which showed a narrowing of the distal trachea with an opening that was only 3 mm in diameter. The TOF was present above this stenosed part and the rest of the visualized trachea and bronchi were unremarkable. The tube was repeatedly entering the wrong passage of the oesophagus, and hence the patient was becoming distressed on insertion of the tube as the small opening of the trachea was becoming occluded by the tube at the level of the stenosis.

The challenge was to secure the airway because below the fistula the tracheal diameter was only 3 mm. Tracheal dilatation was planned. The patient was taken into the operation theatre and all monitors were attached and oxygen was given through a face mask. Rigid dilators were used for dilatation of the stenosed part of the trachea for serial enlargement. Lignocaine 10% spray was used to numb the mouth and throat and 2% lignocaine jelly for the nose. An endoscope was placed through the patient’s nose to identify the area of narrowing. Serial dilators were placed through the tracheostomy opening and into the narrowed area. Oxygen was given through the tracheostoma by means of a small face mask. By this technique we were able to insert a 5 mm tracheostomy tube and ventilate the patient. Tracheal reconstruction was planned by the cardiac surgeon after stabilization of the patient [Figure 1].
Figure 1 Showing tracheo-oesophagial fistula.

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  Discussion Top


Acquired TOF is a rare but serious complication, mainly due to malignancy and trauma. Nowadays, malignancy comprises about 50% of acquired TOF cases, whereas more than 75% of nonmalignant TOFs are due to endotracheal cuff-related trauma. Other etiologies include thoracic trauma, granulomatous inflammation such as tuberculosis, foreign bodies, radiotherapy, caustic ingestion and in-dwelling oesophageal stent [5],[6].

Excessive motion of the tracheal tube during frequent dressing changes and respiratory care is another predisposing factor. Local infection worsens the mucosal damage, resulting in perforation. The duration of artificial ventilation by means of a tracheal tube in these patients has considerable impact on the occurrence of this complication.

Tracheal stenosis occurs in response to tube-related trauma at various levels of the trachea, including the suprastomal area, the stoma itself, the tube cuff and the distal tip of the tube tip. The cuff site was, at one time, a common location for stenosis; but after the advent of low-pressure, high-volume cuffs for both endotracheal and tracheostomy tubes the stoma site is now more frequently affected.

Patients are usually asymptomatic until the tracheal diameter is reduced to less than 5 mm, at which time they may present with dyspnoea, cough, stridor and inability to clear secretions. These symptoms may not be apparent until trials with speaking valves and full capping are undertaken.

Diagnosis of TOF is basically based on clinical signs and symptoms, imaging studies and endoscopy. Three main signs and symptoms have been described: cough while taking meals; recurrent pneumonia or respiratory infection; and periodic abdominal distention. Cough while taking meals is also known as Ono’s signs or swallow-cough complex [7]. For ventilated patients, signs suggestive of TOF are air leak [8], failure of weaning, sudden bout of increased secretions and recurrent chest infections. As for imaging studies, barium swallow can detect 70% of the lesions [5].Computed tomographic scan is being increasingly used as it helps evaluate luminal and extraluminal conditions such as lymph node status or mediastinal masses [9]. Nevertheless, endoscopy (bronchoscopy and oesophagoscopy) still remains the best diagnostic method. Benign TOFs are managed individually depending on cause, size and location [10].

In our reported case, TOF occurred as a result of high intracuff pressure, because the intracuff pressure after diagnosis of TOF was 40 cmH2O and the problem was failed weaning.


  Conclusion Top


Endotracheal tube cuff pressures should be routinely measured with a manometer to minimize trauma to the tracheal mucosa and surrounding structures. Failed weaning should not be taken lightly. It may be due to TOF. Management of patients who undergo tracheostomies involves minimizing complications by avoiding overinflation of the tube cuff.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Smith HM, Bacon DR, Sprung J. Difficulty assessing endotracheal tube placement in a patient with undiagnosed iatrogenic tracheoesophageal fistula. J Cardiothorac Vasc Anesth 2006;20:223–224.  Back to cited text no. 1
[PUBMED]    
2.
Mooty RC, Rath P, Self M, Dunn E, Mangram A. Review of tracheo-esophageal fistula associated with endotracheal intubation. J Surg Educ 2007;64:237–240.  Back to cited text no. 2
    
3.
Sue RD, Susanto I. Long-term complications of artificial airways. Clin Chest Med 2003;24:457–471.  Back to cited text no. 3
    
4.
Make BJ, Hill NS, Goldberg AI, Bach JR, Criner GJ, Dunne PE et al. Mechanical ventilation beyond the intensive care unit: report of a consensus conference of the American College of Chest Physicians. Chest 1998;113:289S–344S.  Back to cited text no. 4
    
5.
Diddee R, Shaw IH. Acquired trachea-oesophageal fistula in adults. Continuing education in anaesthesia. Crit Care Pain 2006;6:105–108.  Back to cited text no. 5
    
6.
Rekha P, Sajitha M, Pappachan JM, Babu A, Jayakumar TK, Sukumaran P. Acquired trachea-oesophageal fistula caused by a denture. Indian J Surg 2007;69:19–21.  Back to cited text no. 6
    
7.
Jacob R, Kunder S, Mathai J, Chacko J, John V. Traumatic tracheoesophageal fistula in a 5-year old. Paediatr Anaesth 2006;16:1068–1072.  Back to cited text no. 7
    
8.
Parker RJ, Rechner IJ, Parke TJ. Tracheo-oesophageal fistula and upper airway leak in the intensive care unit. Br J Anaesth 2008;100:139–140.  Back to cited text no. 8
    
9.
Darbari A, Suryavanshi A, Tandon S, Chandra G, Singh PK. Non-malignant tracheoesophageal fistula: our experience. Indian J Thorac Cardiovasc Surg 2012;21:272–276.  Back to cited text no. 9
    
10.
Richter GT, Ryckman F, Brown RL, Rutter MJ. Endoscopic management of recurrent tracheoesophageal fistula. J Pediatr Surg 2008;43:238–245.  Back to cited text no. 10
    


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