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84 Journal of The Association of Physicians of India Vol. 64 December 2016
Tracheoesophageal Fistula following Endotracheal Intubation for Organophosphorus PoisoningShailaja V Rao1, Ajay K Boralkar2, Prabhakar S Jirvankar3, Mangala V Sonavani4, Varsha Rotte Kaginalkar5, Chimu Chinte6
AbstractTracheoesophageal fistula (TEF) is an abnormal communication between the trachea and esophagus. Iatrogenic TEF can be due to endotracheal intubation, rigid bronchoscopy or tracheostomy. Tracheostomy tube cuff volumes and pressures require constant monitoring to avoid tracheal injury. Acquired TEF which occurs after prolonged intubation, usually develops after 15-200 days of mechanical ventilation. We report a case of a large TEF secondary to endotracheal intubation for organophosphorus poison-induced respiratory failure. Patient presented with dysphagia and recurrent aspiration pneumonia after extubation. She underwent trachea-esophageal fistulectomy and closure with a sternocleidomastoid muscle flap.
1Associate Professor, Department of Medicine, 2Associate Professor, Department of Surgery, 3Associate Professor, 4Professor, Department of Medicine, 5Professor and Head, Department of Radiology, 6Chief Resident, Department of Medicine, Government Medical College, Aurangabad, MaharashtraReceived: 07.04.2016; Accepted: 27.06.2016
Ac q u i r e d n o n m a l i g n a n t t r a c h e o e s o p h a g e a l f i s t u l a is very rare disease and dif f icul t to manage.1,2 High cuff pressure or direct mechanical t rauma during mechanical ventilation are considered as the main causes of TEF.3 TEF is an abnormal communication between the trachea and esophagus. Esophageal malignancy is the most common cause of TEF in adults; other benign causes are induced by endotracheal tubes, tracheostomies and thoracic surgery. Onos sign4 i.e. cough while swallowing is an important clinical sign of TEF. Increase in tracheal secretions and aspiration during swallowing results in paroxysms of cough and recurrent pneumonia. Patients may have food particles in expectorated material.
two months ago and had been on ventilator support for 12 days, with an endotracheal tube. The patient developed dysphagia and recurrent fever after extubation. She had cough every time during food intake, more so with liquids.
On in i t ia l evaluat ion, she was pale, cachexic, febrile, weighing 30 kg, with Pulse rate- 110/min, blood pressure 100/70 mmHg, had bilateral crepitations, more in right base. Her hemoglobin was 8.5 gm%, TLC 15000/cu m, platelet counts were normal, other routine biochemical investigations were normal.
The chest radiography revealed patchy heterogeneous opacities in both lung fields. Her CECT chest showed large TEF in upper esophagus (Figure 1). Esophagus was seen containing air and communicating with the trachea, with Ryles tube in situ (Figure 2). OGD-scopy also confirmed the presence of fistula.
A s p a t i e n t wa s n u t r i t i o n a l l y d e b i l i t a t e d a n d h a d r e c u r r e n t aspirations, a feeding jejunostomy was done and she was also put on partial parenteral nutrition for 4 weeks along
The incidence of TEF following endotracheal in tubat ion i s < 1%. Usually TEF develops after prolonged mechanical ventilation, with a mean period of 42 days.5 In this case patient had underwent mechanical ventilation for 12 days , a f ter extubat ion she developed dysphagia and further evaluation revealed large TEF.
A 25 year o ld lady came with complaints of dysphagia, fever and cough. She had history of consumption o f o r g a n o p h o s p h o r u s c o m p o u n d
Fig. 1: TEF in upper part of esophagus
Fig. 2: Esophagus containing air with Ryles tube in situ
Fig. 3: Intraoperative localization of fistula
85Journal of The Association of Physicians of India Vol. 64 December 2016
with chest physiotherapy. I n t r a o p e r a t i v e e n d o s c o p i c
localization of the fistula showed it to be 2 cm in diameter, 3 cm below cricopharynx. The esophagus is seen with Ryles tube in situ. (figure 3). Neck exploration was done with a L shaped anterolateral incision and the fistula was localized and divided. The edges were refreshened. The esophageal and tracheal defects were closed with interposition of sternocleidomastoid between the two closure lines. The patient was extubated uneventfully. The leak stopped after three weeks.
Endotracheal tube cuff volumes a n d p r e s s u r e s r e q u i r e c o n s t a n t monitoring to avoid tracheal injury. Past literature recommended routine inflation and deflation of cuffs every few hours ; but this has not been shown to reduce the risk of tracheal injury, it actually increases the risk for aspiration. Ischemic damage of the trachea depends on the balance between mucosal perfusion pressure and the pressure exerted by the cuff.
When the cuff pressure exceeds tracheal mucosal perfusion pressure, induction of ischemia and/or necrosis will just be question of time. Cuff pressures > 30 cm HO compress mucosal capillaries and impair blood flow, with total occlusion occurring at 50 cm HO, it is generally recommended that cuff pressures should not exceed 20 cm HO. However, monitoring cuff pressure alone is insufficient, because tracheal damage and increases in cuff volume can occur even when cuff pressures are maintained within the desired range. Cuff volumes should not
exceed 6 to 8 ml.6
Predisposing factors for development of TEF include prolonged intubation ranging from 15-200 days (with mean of 42 days), traumatic intubation attempts, presence of a wide bore gastric tube and excess ive motion of t racheal tube during dressing change. Local infection, anaemia, shock, metabolic acidosis, diabetes and steroid therapy cause decrease in mucosal b lood flow hence increase the likelihood of fistula formation.7 Problems during endotracheal intubation may cause iatrogenic trauma to of the upper airways. The direct cause of rupture is difficult tracheal intubation particularly with a stylet inside the tube.8
I n t h e s t u d y b y K a l a u d a n d colleagues, use of stylet in intubation in 4 of 12 TEF cases has been mentioned. The size of endotracheal tube and swelling of cuff may contribute to the trauma. Many researchers assert that prevalence of iatrogenic tracheal rupture is higher in females and this assertion leads to conclusion that the membranous trachea is less firm in women and children as compared to men.9
I n t h e p r e s e n t c a s e d i f f i c u l t /traumatic intubation seem to be the cause of iatrogenic TEF, as the total duration for which the patient was intubated i .e. 12 days, is not very long. The exact mechanism remains uncertain , but the most probable explanation is direct laceration from endotracheal tube tip caught in the fold of flaccid posterior tracheal membrane while advancing the tube.
A p a t i e n t w i t h a c q u i r e d T E F should be preoperatively given good
supportive therapy, measures should be taken to prevent aspiration and p u l m o n a r y i n f e c t i o n s s h o u l d b e aggressively managed. A spontaneously breathing and nutritionally fit patient is prerequisite for success of the therapy.Conclusion
Proper selection of an appropriate size endotracheal tube, use of low pressure high volume cuf fs with frequent cuff pressure monitoring (keeping cuff pressure < 20 mm of HO and cuff volume < 6-8 ml), minimal endotracheal tube movement during posi t ioning/suct ioning and using flexible nasogastric tube can prevent the occurrence of TEF. This case reinforces the need for a high index of clinical suspicion for an early diagnosis and treatment of a tracheoesophageal fistula.
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