Iatrogenic Tracheoesophageal Fistula After Cardiopulmonary Resuscitation (CPR)

Abstract

Iatrogenic tracheoesophageal (TE) fistula is a rare diagnosis that has high morbidity and mortality and requires a high index of suspicion. We report the first case of TE fistula formed during cardiac resuscitation and traumatic endotracheal (ET) intubation. A 77-year-old man with hypertension and atrial fibrillation presented after aspirating steak resulting in cardiac arrest. He went into asystole after unsuccessful abdominal thrusts. After 20 minutes of CPR by EMS and ET tube placement, return of spontaneous circulation was achieved. In the ED, he was comatose, hypotensive, and hypoxic. Chest X-ray showed rib fractures with the ET tube in the right main stem bronchus. Despite repositioning the ET tube, he remained hypoxic. Bronchoscopy showed erythema, but no foreign body. CT scan suggested food in the esophagus. Endoscopy revealed food contents in the upper third of the esophagus. After removal of the food with forceps, the scope was advanced without resistance. At 25 cm from the incisors, the ET tube balloon was seen within the esophageal lumen, suggestive of a TE fistula. Given the patient's clinical status and poor prognosis, endoscopic placement of an esophageal stent and surgical repair were deferred. On day 6 of hospitalization, he was declared brain dead and expired. Iatrogenic TE fistula can occur as a complication of prolonged ET intubation or trauma, usually taking 21-30 and 5-15 days, respectively, to develop. This is the first report of a TE fistula as an immediate complication of CPR and ET tube insertion, occurring mainly due to two factors: manipulation of the airway in the presence of food and compression of mediastinal contents between the sternum and vertebrae. Other risk factors are high ET tube cuff pressure, high airway pressures, and excessive motion of the ET tube. Tachypnea, hypoxia, and gastric distention suggest a TE fistula. Outcomes may be good when TE fistulas are detected early with prompt treatment. However, TE fistula in our patient was not detected on CT and bronchoscopy, the standard diagnostic procedures for its diagnosis. Esophageal stent placement and endoscopic suturing are potential alternatives to invasive surgical options and have good outcomes by preventing hypoxia and aspiration. This case demonstrates that a TE fistula can be an immediate complication of CPR associated with ET intubation, and although rare, it is associated with a high morbidity and mortality.Figure: Image 1 and 2: Upper endoscopy showing food at the epiglottisFigure: Image 3 and 4: ETT and balloon at the mid-esophagus