Acquired Nonmalignant Tracheoesophageal Fistula

Abstract

Introduction: Acquired tracheoesophageal fistula (TEF) is a rare condition that can impair respiratory and digestive functions. Morbidity and mortality is high with malignancy being the most common etiology. Other less common etiologies occur secondary to infection, ruptured diverticula and trauma. Methods: 85-year-old female with extensive medical history presented to the hospital from a rehabilitation facility secondary to respiratory distress. She recently had an extensive admission at a different institution secondary to a stroke that required ventilator support with percutaneous endocscopic gastrostomy (PEG) tube placement due to dysphagia. Upon evaluation, she required intubation due to tachypnea at 44 breaths per minute and accessory muscle use. She was diagnosed with respiratory failure secondary to Methicillin Resistant Staphlococcus Aureus pneumonia along with pulmonary congestion. She was treated with Vancomycin and aggressively diuresed. Nutritional support was started via PEG the subsequent day. Results: After multiple attempts she was unable to be weaned from the ventilator and required tracheostomy tube placement. The patient tolerated the transition between complete continuous mandatory ventilator (CMV) support at night to continuous positive airway pressure support during the day. Shortly, she again went into respiratory distress and required CMV support. Repeat chest radiograph revealed new moderate vascular congestion. After diuresis, she could not be weaned; a computed tomography of the thorax was obtained, revealing bilateral aspiration pneumonia, with a TEF in the proximal third of the esophagus and trachea just above the level of the aortic arch. Confirmed with bronchoscopy. Tube feeds were discontinued and she was evaluated by gastroenterology for stent placement. Due to multiple occasions of hemodynamic instability it was decided she would not tolerate the procedure. Interventional radiology was able to place a gastrojejunostomy tube and she was discharged to a longterm care facility. Conclusion: Recurrent gastric content aspiration from the tube feeds did not allow our patient to be successfully weaned. It is unclear the exact timeframe when she acquired the TEF, most likely secondary to prolonged intubation at multiple institutions. A high index of suspicion is needed for acquired TEF in patients with recent history of prolonged intubation who acquire recurrent pneumonias or develop respiratory distress after medical optimization.