Is It Time to Reevaluate the Airway Management of Tracheoesophageal Fistula?

Abstract

There have been several reports of the use of a Fogarty balloon catheter for temporary occlusion of a tracheoesophageal fistula (TEF) to allow recovery from respiratory insufficiency before any surgical correction of the esophageal atresia and/or TEF is undertaken [1-4]. Bronchoscopy has also been useful for confirming the diagnosis, identifying unusual variants and permitting the proper anatomic placement of the endotracheal tube [5,6]. At our institution, bronchoscopy and balloon occlusion of the TEF is used routinely as the initial step in airway management. We report on two neonates with esophageal atresia and distal TEF. Case Reports Case 1 The patient was a 41-wk gestational age, 2639-g male born by normal spontaneous vaginal delivery with Apgar scores of 8 and 9. The patient was noted to have respiratory distress when feeding. A nasogastric tube was placed, and it stopped in a proximal esophageal blind pouch. After transfer from an outside hospital, the patient was brought to the operating room on Day 2 of life and monitoring was established consisting of an electrocardiogram, a right-sided pulse oximeter, right radial arterial line, end-tidal CO2, and axillary temperature monitoring. The patient was preoxygenated with 100% oxygen and received 0.06 mg atropine, 5 mg ketamine, and 6 mg succinylcholine. After the induction of anesthesia, the patient underwent bronchoscopy and a 3 Fr Fogarty arterial embolectomy catheter (Baxter Healthcare Corporation, Santa Ana, CA) was inserted into the TEF under direct visualization via a 2.5- times 20-cm rigid Storz bronchoscope. After isolation of the TEF with the Fogarty catheter, a No. 3.0 endotracheal (ET) tube was inserted and positive pressure ventilation ensued. Less than 5 min were required to place the Fogarty catheter and there were no episodes of arterial desaturation, dysrhythmias, hypotension, or bradycardia associated with the procedure. The patient was then turned on his left side with a small roll under his left axilla. A right thoracotomy, TEF closure, and esophagoesophagostomy was performed without difficulty or complication. The trachea remained intubated due to the surgeon's desire to avoid potential pulmonary events and to have the ability to perform pulmonary toilet. The patient was taken to the neonatal intensive care unit in satisfactory condition and his trachea was extubated the following morning. Case 2 The patient was a 36-wk gestational age male born via spontaneous vaginal delivery with initial Apgar scores of 7 and 9 and a birth weight of 2.25 kg. Shortly after birth, the patient was noted to be dyspneic and mildly floppy, with evidence of cyanosis of the extremities and nasal flaring. Chest radiograph demonstrated right upper lobe atelectasis and a blind esophageal pouch. The patient went to the operating room for placement of a gastrostomy tube and umbilical artery catheter while awaiting improvement in his pulmonary status. Four days later, the patient returned to the operating room for definitive repair. After placement of monitoring consisting of an electrocardiogram, a right-sided pulse oximeter, end-tidal CO2, and axillary temperature monitoring, the patient underwent anesthesia induction with 6 mg ketamine and 5 mg succinylcholine. A 3- times 20-cm rigid Storz bronchoscope was placed without difficulty. The TEF entered the trachea adjacent to the right main stem bronchi at the level of the carina. A 2 Fr Fogarty arterial embolectomy catheter was advanced into the TEF, and the balloon was inflated. The bronchoscope was then removed, and the patient was intubated with a No. 3.0 ET tube and positive pressure ventilation was initiated. There were no episodes of desaturation or other hemodynamic sequela during the less than 5 min required to accomplish the Fogarty catheter procedure. A right thoracotomy, TEF closure, and esophagoesophagostomy were performed without difficulty or complication. The patient's trachea remained intubated, and the patient was taken to the neonatal intensive care unit in satisfactory condition. The trachea was extubated the following morning. Discussion Survival of the neonate with TEF without coexisting diseases and associated congenital anomalies is approaching 100%. This was confirmed recently by Spitz et al. [7] who studied 303 infants with esophageal atresia and/or TEF treated over a 10-yr period. Using a modified version of the Waterston's classification [8], Spitz et al. demonstrated a survival for patients in Groups A and B of more than 90% Table 1. Seventy-seven percent of these patients underwent primary anastomosis repair with good outcome. To reach a goal of 100% survival in patients with uncomplicated TEF, and to improve further the more dismal survival rates in patients with TEF and associated congenital anomalies, we must continue to look critically at our surgical and anesthetic management practices.Table 1: Waterston Group Classification and Survival RatesPerioperative morbidity and mortality in patients with TEF are most often caused when 1) ventilation is ineffective wherein respiratory gases are lost into the gastrointestinal (GI) tract via the TEF; 2) respiratory gases accumulate in the GI tract resulting in gastric distension and increased intraabdominal pressure and potentially cause decreased venous return and hemodynamic compromise or restriction of diaphragmatic excursion and respiratory embarrassment; or 3) gastric contents are aspirated via the TEF causing pneumonitis. Aspiration alone has accounted for up to 50% of the perioperative morbidity and mortality in this patient population [9]. Theoretically, the sooner the TEF is closed, the less likely are any of these three predictable complications. The morbidity and mortality is predictably much higher for the complicated TEF patient population. These complicated TEF patients include patients with TEF and associated anomalies, prematurity, or neonates who have low birth weights. The incidence of associated anomalies in patients with TEF remains clinically significant (as high as 50%) [8,10,11]. One significant issue in the premature neonate with a TEF is the potential for the development of respiratory distress syndrome. The possibility of increasing ventilatory pressure requirements with consequent venting of air into the low resistance GI tract and subsequent hypoventilation, hemodynamic compromise, gastric distention, or aspiration has resulted in the consideration for early surgical correction within 12 h of life in this patient population [12,13]. Perioperative administration of surfactant decreases ventilatory pressure requirements and improves clinical outcome in some patients [14]. Such a preventive approach to TEF repair has moved the surgical community toward earlier surgical correction by primary anastomosis, or at least by ligation of the TEF and delayed anastomosis in most of the TEF patient population [12-19]. A similar preventive approach to the anesthetic management of TEF repair is presented in these cases and supports the temporary separation of the GI and respiratory tracts via bronchoscopy and occlusion of the TEF with a Fogarty catheter at the beginning of the operation. After the published experience of Kosloske et al. [5] in 1988, we also began routine bronchoscopy just prior to thoracotomy to evaluate the level of the fistula and the presence of unusual variants. At that time, our patients had a gastrostomy tube placed first. However, one of the authors quickly realized that the fistula tract could be occluded easily with the placement of a Fogarty arterial embolectomy catheter at the time of bronchoscopy. This change in our patient management has virtually eliminated intraoperative desaturation in these patients, which we thought was secondary to alveolar hypoventilation due to ventilatory gases escaping from the gastrostomy tube. The procedure entails direct laryngoscopy, with the placement of a Fogarty arterial embolectomy catheter through the vocal cords. The Storz bronchoscope is then placed through the cords, and the Fogarty catheter is visualized and advanced into the TEF. The Fogarty catheter often preferentially passes into the TEF because of the dependent position of the TEF Figure 1. The Storz scope is removed, and the trachea is intubated with an oral ET tube in the standard fashion Figure 2. Our experience has been that the procedure is easy to perform if the surgeon is an experienced bronchoscopist. This technique is the fastest means of separating the two tracts.Figure 1: An artist's rendition of a cut-away view of the trachea demonstrating the visualization of the tracheoesophageal fistula (TEF) with a Storz bronchoscope. The TEF is isolated with a Fogarty arterial embolectomy catheter, and the balloon is inflated.Figure 2: An artist's rendition demonstrating the Fogarty arterial embolectomy catheter isolating the tracheoesophageal fistula with the endotracheal tube in place.Proceeding to thoracotomy without first separating the two tracts exposes the patient to the risk of aspiration or ventilatory mishap by migration of the ET tube or loss of ventilatory gases into the GI tract until the surgeon has identified and ligated the TEF. In our experience, the time required to ligate the TEF from surgical skin incision is approximately 45 min--much longer than the time necessary to complete the Fogarty arterial embolectomy catheter placement as described above. In addition, the elimination of intraoperative desaturation episodes has made surgical management easier. Placement of a Fogarty catheter through the TEF by the oral transtracheal route is often considered in the sicker neonates with TEF [2]. This option for airway management should be considered routinely by the surgical and anesthesia teams. Block and Filston [1] presented some theoretical issues of concern with transtracheal placement of the Fogarty catheter in favor of placing this catheter through the gastrostomy site instead. However, the placement of a gastrostomy, and then the advancement of a Fogarty catheter through the gastrostomy with tethering of this Fogarty catheter by suture, which is then pulled proximally to exit the upper airway, is complicated in itself. For TEF patients in the operating room for reparative procedures, the theoretical concerns of the complex process of oral transtracheal bronchoscopy, the need to interrupt ventilation, and the possibility of pressure necrosis at the cricoid level are not supported by our clinical experience. The brief time required to use the transtracheal Fogarty catheter further justifies this simple approach. Furthermore, gastrostomy tubes no longer need to be routinely used on patients with TEF prior to definitive repair of the lesion [20,21]. In conclusion, neonates with uncomplicated TEF have an extremely low mortality rate. If significant comorbidity is present, then the mortality and morbidity increases. For the patient with complicated TEF, medical management, including the use of surfactant in neonates with respiratory distress syndrome and high ventilatory pressures, has increased the survival and decreased the morbidity rates and surgical management, with advances in technique and earlier operation, has resulted in decrease in morbidity and mortality. Advances in airway management could further improve results in patients with uncomplicated TEF and the unfavorable statistics associated with complicated TEF. We propose that one advancement in airway management would be to occlude the TEF by placement of a Fogarty arterial embolectomy catheter before beginning the surgical procedure, minimizing the time during which there is a conduit between the GI and respiratory tracts. Eliminating such a conduit may minimize the risks of aspiration, gastric distention, hemodynamic compromise, and hypoventilation which continue until the lesion is ligated surgically.