Posttracheostomy tracheoesophageal fistula

Abstract

A 47-year-old diabetic and hypertensive woman was hospitalized with respiratory distress and right hemiparesis following a stroke. Magnetic resonance imaging (MRI) revealed right cerebellar and medullary infarcts. She was put on ventilator support, and anticipating prolonged ventilation, a tracheostomy was done. Multiple complications further extended her ventilation; her tracheostomy and nasogastric tubes were eventually removed after 5 months. At this time she was conscious, though weak, with normal hemodynamics and respiration. However, the patient continued to have episodes of respiratory distress and hypoxia and had to be reventilated twice; her chest X- ray also showed pneumonic patches in the left middle and lower lung zones. We noticed that each time oral feeding was initiated the patient would cough vigorously and complain of breathing difficulty. She was apprehensive of eating, drinking, and even swallowing her saliva, which she would frequently spit out. Possibility of a tracheoesophageal fistula (TEF) was considered. A barium swallow confirmed the presence of a fistulous connection between the left bronchus and esophagus at T-4 level [Figure 1]. Esophagoscopy however failed to demonstrate the TEF, which was probably small-sized. The patient was nursed semiupright, oral feeding was stopped, and small enteral feeds through a nasogastric tube started; she had no more respiratory problems and her condition gradually stabilized. Definitive management of the TEF was deferred to allow time for spontaneous fistula closure and to build up her nutrition; she was discharged on request and advised to return for a review after a month. However, she did not report back and was lost to further follow-up.Figure 1: Barium-swallow with a water soluble contrast showing selective opacification of the left lower lobe bronchus (arrow) suggestive of a tracheoesophageal fistulaTEF is a rare but serious complication of tracheostomy (incidence ≤ 1%)[1] caused by mucosal ischemia/abrasion secondary to prolonged intubation, use of high cuff pressures (≥ 30 cm H2O) and movement of the tube tip during frequent dressing changes and suctioning; concomitant use of a rigid, wide-bore nasogastric tube aggravates injury of the sandwiched mucosa.[2] Poor nutrition, airway infection, hypotension, hypoxemia, anemia, diabetes, and steroid therapy are the predisposing factors. TEFs secondary to tracheal cuff related injuries usually become symptomatic within 4 weeks.[2] Usual manifestations in nonventilated patients include uncontrolled coughing after swallowing (Ono's sign), breathing difficulty, repeated pneumonia, and unexplained weight loss.[3] A barium swallow demonstrates the defect in 70% of lesions. Endoscopy is the best diagnostic method, though small TEFs may be missed in the esophageal folds; bronchoscopy with methylene blue instillation identifies the defect better. Computed tomography (CT) and MRI chest are preferred in ventilator-dependent patients; chest X-ray demonstrates the effects of repeated soiling. Management of a TEF includes supportive therapy to improve the patient's condition followed by definitive intervention. While smaller fistulae may heal spontaneously, large TEFs are treated surgically with a single-staged fistula repair, or with tracheal reconstruction. Patients incapable of tolerating surgery are managed with esophageal or double (tracheal and esophageal) stenting using self-expanding metallic stents.[24] Close monitoring of the cuff pressure and volume (avoid pressure ≥ 20 cmH2O and volume ≥ 6–8 ml) can help reduce the risk of tracheal injury. Deflating the cuff every few hours does not decrease injury but may increase the risk of aspiration.[5] Our patient unfortunately suffered from recurring respiratory complications that were attributed to her underlying neurological condition, and despite obvious predisposing factors, TEF was thought of much later. This case reinforces the need for a high index of clinical suspicion for an early diagnosis and treatment of a TEF.