Tracheal Placement Research Articles

Tracheal Stent Placement In A Difficult Airway In A Patient With Central Airway Obstruction With Anterior Mediastinal Mass –A Case Report

Central airway obstruction due to benign and malignant aetiologies can result in life-threatening airway emergencies. Tracheal stenting is one of the definitive approaches for symptomatic relief in inoperable case scenarios. We report a case of papillary thyroid carcinoma with an anterior mediastinal mass presenting with dyspnoea and stridor for emergency tracheal stent placement. Awake stent placement using a video laryngoscope was performed after adequate airway topicalisation, followed by fibreoptic bronchoscope (FOB)-guided negotiation. Although rigid bronchoscopy is the gold standard, it often requires general anaesthesia, which could predispose to complete airway collapse in this patient.

A Novel Imaging Device for Percutaneous Dilatational Tracheostomy.

Objective: The purpose of this article is to introduce a novel imaging device and technique for percutaneous dilatational tracheostomy (PDT) and evaluate its clinical application. Methods: We have modified the bronchoscope to generate a novel imaging device. The handle of the bronchoscope was removed and replaced with added fixation pieces to secure the new device to the endotracheal tube. Nine mechanically ventilated patients admitted to the intensive care department of Shandong Public Health Clinical Center who underwent PDT between July 2023 and January 2024 have been treated with this novel imaging device. The number of medical staff members needed for the operation, number of needle interventions, operation time, arterial blood gas analysis, and intraoperative complications were observed. Results: Three medical staff were involved in the procedure: an operator, an assistant, and a nurse. The first attempted needle intervention was successful in all patients, and no serious complications such as major bleeding, pneumothorax, mediastinal emphysema, accidental extubation, desaturation, hypercarbia, respiratory acidosis, hemodynamic abnormality, or posterior tracheal puncture occurred. The average time was 11.63 ± 1.56 minutes from skin incision to the needle insertion and 4.43 ± 1.99 minutes from needle insertion to tracheal placement. Conclusions: PDT guided by the novel device is safe, preserves human resources, saves operating space, keeps the view stable, and makes the procedure easy. It is worthy of further research and application.

Recurrence of Takotsubo Cardiomyopathy following Rigid Bronchoscopy: A Case Report

We report a case of a young male patient with a history of Takotsubo cardiomyopathy following polytrauma. On presentation, the patient had a tracheal stent placement for tracheal injury. The patient was again posted for removal of tracheal stent, by rigid bronchoscopy. During the procedure patient had a recurrence of cardiomyopathy, requiring inotropes and post-operative ventilatory support. 2D echo showed apical ballooning of the heart. The patient improved by inotropes and later on Lasix 10 mg IV. He was extubated after 2 days.

Analysis of the Application Effect of Tracheal Stent Placement in the Nutritional Support Treatment of Tracheoesophageal Fistula

Objective: To evaluate and analyze the application effect of tracheal stent placement in nutritional support therapy for tracheoesophageal fistula. Methods: Clinical data of 32 patients who underwent nutritional support therapy for tracheoesophageal fistula in our hospital from September 2021 to September 2022 were collected, and all patients underwent tracheal silicone stenting, comparing dyspnea classification and Karnofsky score before and after stenting, and conducting post-treatment follow-up. Results: In 32 patients with tracheoesophageal fistula, dyspnea grading improved from grades III and IV to grades 0 to II. Before treatment, 10 patients (31.06%) were in grade IV, 17 patients (53.12%) were in grade III, and five patients (15.62) were in grade II; after treatment, 13 patients (40.63%) were in grade I, 12 patients (37.50%) were in grade I, and seven patients (21.87%) were in grade 0 (P < 0.05); Karnofsky score (37.52 ± 4.86 before treatment) improved significantly to 71.39 ± 8.24 one week after treatment (P < 0.05). Nine patients with tracheoesophageal fistula were placed with silicone Y14-10-10 stent, 11 with silicone 18-14-14 stent, three with silicone Y15-12-12, and seven with silicone stent 16-13-13. Conclusion: Silicone tracheobronchial stent placement for the treatment of tracheoesophageal fistula is technically feasible, simple, and safe, with reliable near-term efficacy, and is worthy of popularization and application.

Severe necrotising pneumonia complicating COVID-19 infection in an adolescent boy

We present a case of an early adolescent boy with respiratory insufficiency due to COVID-19 pneumonia with pulmonary embolisms, treated with corticosteroids, antibiotics, low molecular weight heparin and tocilizumab. His course was complicated by necrotising pneumonia with need for pleural drainage, tracheal cannula placement and antibiotics. We believe immunosuppressive medication potentially played a role in this course of disease.

Subcutaneous Emphysema Following Laser Assisted Dilation of Subglottic Stenosis: A Case Report

Introduction: Subcutaneous emphysema is characterized by the accumulation of air beneath the dermal layers of the skin. We present a case of extensive subcutaneous emphysema of the neck, face and arms in a patient who was two days post operative from laser assisted dilation of subglottic stenosis. Materials and Methods: We present a case of subcutaneous emphysema in a patient who presented to the emergency department. As this is a case report, no additional materials or specific methods were required. Case Presentation: A 71-year-old man with history of tracheal stenosis status post laser assisted subglottic dilation presented to the emergency department two days post-operatively for progressively worsening swelling of the face, neck and arms. Physical exam was notable for crepitus of the face, neck and arms. Oropharyngeal exam showed no edema to the posterior oropharynx or tongue. Breathing was non-labored without stridor. Imaging revealed extensive subcutaneous emphysema without any obvious source. The otolaryngology (ENT) service evaluated the patient and admitted him to their service. Initially he was managed conservatively via observation and supportive care however, on day two of hospitalization his respiratory status worsened. He required intubation and tracheal stent placement. The tracheal defect was never found on exploration in the operating room, suggesting the defect was sub-centimeter in size. He was extubated on hospital day four and discharged with a plan to have the tracheal stent in place for three months. Conclusion: Subcutaneous emphysema secondary to a tracheobronchial tree defect is a known complication of laser dilatation of subglottic stenosis. Most cases resolve spontaneously and can be managed conservatively. However, patients require close airway monitoring as some may require emergent airway management. Clinicians should be aware of this complication and subsequent management.

Diagnostic Accuracy Of Ultrasound For Confirmation Of Endotracheal Tube Placement Taking Capnography As A Gold Standard

Introduction: Accurate placement of an endotracheal tube (ETT) is critical for patient safety during medical procedures. The research explores the potential of ultrasound technology to provide a reliable alternative for ETT confirmation, offering insights into its diagnostic performance and the implications for enhancing patient care in surgical settings.
 Aims & Objectives: To determine the diagnostic accuracy of ultrasound for the confirmation of endotracheal tube keeping Capnography as a Gold standard.
 Place and Duration of Study: It is a Cross Sectional study and the study was carried out in Operation Theater Shaikh Zayed Hospital Lahore, within 6 months after approval of synopsis i.e. from 5th May, 2020 till 4th November, 2021.
 Material & Methods:Total 219 patients who fulfilled the inclusion criteria were enrolled. After standardization of anesthetic measures all patients were intubated by direct laryngoscopy. ETT placement was assessed by capnometry and by ultrasonography. Endotracheal tube placement was labeled (as per operational definition) on both the techniques.The analysis of the data was conducted using SPSS version 21.0, a p-value of ?0.05 was considered significant.
 Results: The mean age, BMI, neck circumference and thyromental distance of the patients was 39±8.15 years, 27±3.42 Kg/m 2, 29.5±4.63cm and 6.9±0.50cm. There were 58% males and 42% females in the study. Ultrasonography exhibited sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy rates of 98.5%, 90.6%, 98.9%, 86.1%, and 97.7%, respectively, in its ability to detect the accurate placement of endotracheal tubes (ETT).
 Conclusion: The sensitivity, specificity, diagnostic accuracy and promptness of recognition for confirmation of tracheal placement of ETT is higher withultrasonography compared to the gold standardcapnography in patients undergoing elective surgery under general anesthesia.

Recent Patents on Intervention Auxiliary Device of Tracheal Stent

Background: The trachea is an essential part of the respiratory system. Lesions such as inflammatory granulomas cause Bronchial stenosis, which may be life-threatening. Tracheal stent placement is vital for treating airway stenosis, relieving dyspnea, and improving symptoms. Objective: This paper reviews the patents of tracheal stent placement and removal and auxiliary devices for diagnosis in recent years (from 2007 to the present) and introduces the characteristics and development of tracheal stent implantation, treatment, and assistive removal devices. In order to meet the need for more rapid operation and cause less harm to the human trachea, the structure of the tracheal stent surgical device needs to be improved continuously. Methods: This paper summarizes the research status of tracheal stent placement and removal and auxiliary devices for diagnosis and treatment in recent years and discusses the structural types and applications of tracheal stent auxiliary devices. Results: This paper summarizes the patent application of tracheal stent placement and removal and auxiliary devices for diagnosis and treatment at the present stage. This paper analyzes the main problems in its development and discusses the solutions to the problems and the future research direction. Conclusion: Tracheal stent surgical devices need further improvement in mechanical design, control strategy, etc. Tracheal stent surgical devices should be developed into universal, semi-automatic, and multi-functional machines. The relevant patents of the auxiliary device of the tracheal stent need to be developed.

SAT486 A Case of Superior Vena Cava Syndrome Caused by Untreated Multinodular Goiter

Abstract Disclosure: K. Blanchard: None. C. Musurakis: None. A. Ojha: None. C.P. Barsano: None. A. Havrylyan: None. A 92-year-old female with heart failure, COPD, obstructive sleep apnea, longstanding exertional dyspnea, and a 15-year history of a toxic multinodular thyroid on methimazole presented to our emergency department with one week of right arm swelling. Physical exam showed a 4 cm midline goiter with right-sided jugular venous distention and right upper extremity pitting edema. On admission, TSH, free T4 and free T3 levels were within normal limits on methimazole 5 mg daily. PTT, PT and INR were normal. Thyroglobulin antibodies and TSI measured two years prior were normal. Right arm venous duplex was negative for acute deep venous thrombosis (DVT) but showed heterogenous structures in the right neck with collateral vessels, likely related to a large multinodular thyroid gland with substernal extension. Left arm venous duplex showed chronic sequela of DVT in the left central subclavian vein. Chest x-ray revealed right-sided tracheal deviation due to goiter. A CT chest performed 6 months prior revealed a massive multinodular goiter with mass effect on the trachea, narrowing the tracheal opening to only 7 mm (ref 10-21 mm in females) and significant mass effect upon adjacent venous structures with resultant collateralized flow. Of note, the patient has a 15-year documented history of this goiter and repeatedly declined aggressive surgical intervention. We recommended ENT consultation for minimally invasive treatment options. ENT recommended thoracic surgery evaluation at a tertiary center and suggested tracheal stenting as a possible solution. Regarding the chronic left subclavian vein thrombosis, the patient opted to forego anticoagulation therapy after discussion of risk versus benefit. She again declined surgical evaluation and was discharged home with primary care and Endocrinology outpatient follow-up. Superior vena cava (SVC) syndrome is the result of either a partial or complete obstruction of the SVC, resulting in symptoms such as upper extremity swelling, dyspnea, cough, face or neck swelling, and dilated venous collaterals in the chest. Compression of the SVC by a mediastinal malignancy is the most common cause of SVC syndrome. However, retrosternal goiter as a cause is extremely rare, with only a few cases previously reported in the literature. Interestingly, the incidence of malignancy in retrosternal goiters is reported to be as high as 35 percent. Large intrathoracic goiters are primarily seen in long periods of neglected disease, as in our patient. The presence of a substernal goiter, regardless of symptoms, is an indication for thyroidectomy, as this is the only way to prevent mediastinal enlargement of the goiter. Non-surgical treatment options documented in the literature include temporary tracheal stent placement followed by radiofrequency thyroid ablation and ultrasound-guided needle aspiration of a dominant thyroid cyst. Presentation Date: Saturday, June 17, 2023

Overcoming Complex Airway Obstruction: Utilizing VV ECMO for Successful Procedure and Post-Operative Management in A Mediastinal Mass Patient

This case report presents a unique application of venovenous extracorporeal membrane oxygenation (VV ECMO) therapy in a 30-year-old female patient with a massive mediastinal mass suspected to be adenocarcinoma. The mass had severely compromised the patient’s airway, making her unable to lie flat. The tumor’s location posed challenges for conventional treatments, and after unsuccessful attempts with chemotherapy, a multidisciplinary decision was made to proceed with tracheal stent placement. During the procedure, VV ECMO was utilised to ensure hemodynamic stability and oxygenation. Subsequently, the patient was transported on ECMO for three consecutive days to another hospital to receive radiotherapy. This report emphasizes the critical role of ECMO in facilitating complex interventions and post-operative management in patients with compromised airways and highlights its potential as a bridge to further treatments.

Early Diagnosis of Esophageal Intubation: Primary Auscultation of the Armpits Versus Epigastrum

Esophageal intubation is a common accident and failure to detect it can result in fatality. The objective of this study is to suggest the primary the auscultation of the epigastric area as mean of rapid diagnosis of esophageal intubation. A cross sectional study was carried out at the N’djili hospital in Kinshasa from June to September 2020. The sampling was randomly made and two groups of the population were selected. In the study group, the endotracheal intubation was indirectly confirmed by the absence of borborygmi on auscultation of the of epigastric area whereas in the control group, it was confirmed by the presence of vesicular murmur in armpits. After intubation, the investigator counted the time from the moment the chest piece of the stethoscope was placed in the armpit to confirm tracheal intubation or on the epigastric area to rule out esophageal intubation. The chest compression was also performed to check fogging of endotracheal tube. The time counted was the time between the placement of the chest piece of the stethoscope and the diagnosis of esophageal intubation. Seven cases of esophageal intubation were recorded out of sixty-two patients intubated. The average time for diagnosing esophageal intubation was 15 ± 5.6 seconds in the study group and 24 ± 3.2 seconds in the control group (Z= 8.035; p < 0.0001). Based on the time recorded, the primary auscultation of the epigastric area can quickly detect esophageal intubation as opposed to the auscultation of the armpit. “The sign the cross” could be used as chronogram to confirm tracheal placement of the tube.

External airway splint placement for severe pediatric tracheobronchomalacia

ObjectiveTo present external airway splinting with bioabsorbable airway supportive devices (ASD) for severe, life-threatening cases of pediatric tracheomalacia (TM) or tracheobronchomalacia (TBM). MethodsA retrospective cohort was performed for 5 pediatric patients with severe TM or TBM who underwent ASD placement. Devices were designed and 3D-printed from a bioabsorbable material, polycaprolactone (PCL). Pre-operative planning included 3-dimensional airway modeling of tracheal collapse and tracheal suture placement using nonlinear finite element (FE) methods. Pre-operative modeling revealed that triads along the ASD open edges and center were the most effective suture locations for optimizing airway patency. Pediatric cardiothoracic surgery and otolaryngology applied the ASDs by suspending the trachea to the ASD with synchronous bronchoscopy. Respiratory needs were trended for all cases. Data from pediatric patients with tracheostomy and diagnosis of TM or TBM, but without ASD, were included for discussion. ResultsFive patients (2 Females, 3 Males, ages 2–9 months at time of ASD) were included. Three patients were unable to wean from respiratory support after vascular ring division; all three weaned to room air post-ASD. Two patients received tracheostomies prior to ASD placement, but continued to experience apparent life-threatening events (ALTE) and required ventilation with supraphysiologic ventilator settings. One patient weaned respiratory support successfully after ASD placement. The last patient died post-ASD due to significant respiratory co-morbidity. ConclusionASD can significantly benefit patients with severe, unrelenting tracheomalacia or tracheobronchomalacia. Proper multidisciplinary case deliberation and selection are key to success with ASD. Pre-operative airway modeling allows proper suture placement to optimally address the underlying airway collapse.

Capnography for catheter location confirmation in minimally invasive surfactant administration.

Minimally Invasive Surfactant Treatment (MIST) is a common method for administering surfactant as a treatment for respiratory distress syndrome. However, tracheal catheter placement can be difficult to confirm. We assessed the presence of carbon dioxide (CO2) in tracheal and esophageal gas aspirated using CO2 detector. Retrospective arm: 20 infants, MIST catheter placement was assessed with a CO2 detector in two techniques and confirmed with clinical response. Prospective arm-10 infants, aimed to check for CO2 presence in aspirated esophageal gas during routine nasogastric tube insertion. Retrospective arm: All infants had positive capnography. One infant that had no clinical response to MIST was diagnosed with total anomalous pulmonary venous return. All 10 infants of the prospective arm had a Negative capnography (P < 0.001, Fisher's exact test). Readily available CO2 detectors can distinguish between tracheal and esophageal placement of MIST catheters prior to MIST.

Enhancing the Performance of Two Different Commercial CO2 Indicators Using Digital Colourimetric Analysis, DCA

Two different, commercial colourimetric CO2 indicators are made in the lab, namely one based on an indicator in solution for monitoring the level of dissolved CO2 in an aquarium, i.e., a drop check indicator, and another based on an ink, for monitoring the level of CO2 in breath (capnography), i.e., a correct tracheal placement indicator. The selected commercial indicators are limited currently in terms of the analytical information they provide (qualitative) as they are normally assessed by eye. Thus, in each case, for both the lab-made and commercial indicators, colour photography coupled with digital image analysis, i.e., digital colour analysis (DCA), is used to convert the colour data from the indicator into a quantitative measure of CO2 and so markedly improve the quality of the analytical information provided by original indicator. This is the first time either indicator has been studied as a quantitative analytical system. The CO2 sensitivity of each of the lab-made indicators is found to match well that of its commercial counterpart. A simple program is provided to help non-experts and experts alike to apply DCA in this way. The potential of DCA to enhance the performance of other commercial indicators is discussed briefly.

PITFALLS OF PERCUTANEOUS TRACHEOSTOMY PLACEMENT

PITFALLS OF PERCUTANEOUS TRACHEOSTOMY PLACEMENT

Iatrogenic Tracheal Injury During Endotracheal Tube Exchange in a COVID-19 Patient: A Case Report

The coronavirus disease 2019 (COVID-19) pandemic has increased the need for prolonged intubation and mechanical ventilation. Though a rare complication of mechanical intubation, tracheoesophageal fistulas (TEFs) are severe and life-threatening. We present a patient with COVID-19 pneumonia who developed an iatrogenic TEF suspected to have been acquired during traumatic reintubation. After optimizing her for surgery, management of the TEF included tracheostomy tube placement at the distal end of the tracheal injury and placement of a stent over the defect. CT scan later showed migration of the stent into the esophagus that required removal. Despite receiving supportive therapy, the patients’ status declined and the patient shortly expired. By increasing demand for prolonged mechanical ventilation, complicating intubations amid fears of transmission, and potentially causing inflammatory tracheal damage, COVID-19 creates heightened obstacles to intubation that may put patients at risk of acquiring tracheal injuries. Increased awareness of possible tracheal injuries should be made by considering the many risk factors.

Prognostic Factors for Tracheal Restenosis after Stent Removal in Patients with Post-Intubation and Post-Tracheostomy Tracheal Stenosis.

PurposeLong-term tracheal stent placement can increase the risk of stent-related complications; hence, removal of the stent after stabilization is attempted. However, little evidence has been established regarding the risk factors for tracheal restenosis. We aimed to identify the risk factors for tracheal restenosis in patients with post-intubation tracheal stenosis (PITS) and post-tracheostomy tracheal stenosis (PTTS).Materials and MethodsWe retrospectively analyzed patients with PITS and PTTS between January 2004 and December 2019. Patients were classified into a success or failure group according to treatment outcomes. Patients with successful stent removal were defined as patients who did not require additional intervention after stent removal during the follow-up period. Multiple logistic regression analysis was performed to identify the factors associated with tracheal restenosis.ResultsAmong 269 stented patients, 130 patients who had removed the stent were enrolled in this study. During the follow-up period, 73 (56.2%) patients had a stable clinical course; however, 57 (43.8%) patients had restenosis. The proportion of trauma-induced intubation was higher in the success group than in the failure group (p=0.026), and the median stent length was shorter in the success group (45 mm) than in the failure group (50 mm, p=0.001). On multivariate analysis, trauma-induced intubation [adjusted odds ratio (aOR), 0.329; 95% confidence interval (CI), 0.117–0.927; p=0.036], and stent length <50 mm (aOR, 0.274; 95% CI, 0.130–0.578; p=0.001) were associated with a decreased risk of restenosis.ConclusionTrauma-induced intubation and stent length were associated with successful stent removal.

Surgical tracheoplasty for children with congenital tracheal stenosis undergoing previous balloon dilatation or tracheal metal stent placement: a series of 9 cases

Objective: To examine the outcomes of Slide tracheoplasty for the children with severe congenital tracheal stenosis received previous repeated balloon dilatation or metal stent placement under endoscopy. Methods: A retrospective study was conducted in 9 children with congenital tracheal stenosis undergoing previous interventional therapy under tracheoscopy and later received Slide tracheoplasty due to obvious respiratory symptoms at Department of Cardiac Surgery, Qilu Children's Hospital of Shandong University between February 2017 and July 2021. There were 7 males and 2 females with a median age at operation of 72.4 months (range: 13.3 to 98.9 months), and the median weight was 19.0 kg (range: 9.0 to 33.0 kg). Among the 9 patients, 2 patients began to receive repeated balloon dilatation (more than 3 times) 17.8 and 51.8 months ago respectively. One patient received metal stents placement into the trachea for 4 days and the other 6 children for median 56.8 months (range: 21.6 to 74.2 months). Complete tracheal cartilage rings and long segmental stenosis were present. in all 9 children. Operative details and outcome measures, including the need for endoscopic airway intervention and mortality, were collected. Results: Slide tracheoplasty was performed in all cases. Two patients with repeated balloon dilatation had different thickness of tracheal wall, local scar hyperplasia and irregular lumen. Among them, 1 case had obvious local calcification of tracheal wall, which was difficult to suture. The metal stent in one patient with short time of placement was completely removed. However, only part of the metal stents could be removed due to the long placement time in the other 6 cases. There was no operative death in the 9 children. The median postoperative tracheal intubation time was 25.3 hours (range: 17.4 to 74.5 hours). A silicone stent was placed in the trachea of 1 child due to obvious respiratory symptoms. Follow-up of median 11 months (range: 1 to 23 months) showed that no death occurred after discharge and all children had basically normal activity tolerance with no obvious respiratory symptoms. Conclusions: Slide tracheoplasty is feasible for children undergoing prior balloon dilatation or metal stents placement. Previously repeated balloon dilatation or metal stent placement under endoscopy increased the difficulty of slide tracheoplasty, the metal stent could not be completely removed after a long time.

Airway stent placement for direct cricothyroid membrane puncture anesthesia with airway stricture or fistula.

Tracheal stent implantation with bronchoscope has become one of the main methods for the treatment of airway stenosis. Bronchoscopy is usually performed under local or general anesthesia. The aim of this study is to report our experience with direct cricothyroid membrane puncture anesthesia for airway stent placement. The medical records of 48 consecutive patients who underwent direct cricothyroid membrane puncture anesthesia for tracheal or bronchial stent placement were reviewed. The puncture site was chosen as the interspace between the thyroid cartilage and cricoid cartilage. Through the cricothyroid membrane, lidocaine was injected into the trachea to suppress the cough reflex. The airway stent was placed fluoroscopically at 48 patients at the trachea or bronchus. The success rate and complications of cricothyroid membrane puncture anesthesia were assessed. Anesthesia was successfully performed in all 48 patients. Six patients needed 2-4 mL supplementary lidocaine by injection from the catheter or stent delivery system. Technical success of the stent insertion was achieved in all 48 cases. Small asymptomatic subcutaneous hemorrhage occurred at the puncture site in two patients, which disappeared 1 or 2 days after stent placement. Direct cricothyroid membrane puncture anesthesia for airway metal stent insertion is safe and effective.

NOT ALL THE ASPIRATIONS ARE COMING FROM THE OROPHARYNX

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Aspiration is the entry of oral or gastric materials into the lungs leading to chemical pneumonitis, bacterial infection, or airway obstruction. Frequent conditions that predispose aspiration result from reduced level of consciousness without airway protection, neurologic disorders, or dysphagia from gastrointestinal tract disorders. While the most common route of aspiration is oropharyngeal, tracheoesophageal fistula (TEF) may initially present in the same manner. We present a middle-aged male with repeated aspiration pneumonia and pneumonitis secondary to TEF. CASE PRESENTATION: A 58-year-old male with history of squamous cell lung carcinoma stage IIIa in remission after chemoradiation and recurrent aspiration pneumonia with gastrostomy tube. Presented to the hospital in hypoxic respiratory failure due to sudden onset of dyspnea after attempting tube feeds. Initial evaluation was significant for leukocytosis and normal procalcitonin level. A CT of the chest showed ground glass opacities with consolidation in bilateral upper and lower lobes and tree-in-bud pattern. A bronchoscopy revealed tracheobronchial erythema with multilobar exudate and large tracheal fistula. An Upper GI series identified aspiration coating the trachea and left main bronchus. The patient was diagnosed with chemical pneumonitis and aspiration pneumonia secondary to tracheoesophageal fistula most likely from recurrent infections and radiation. He was transferred to a tertiary care center for esophageal and tracheal stent placement. DISCUSSION: TEF is an abnormal connection between the trachea and the esophagus that is mostly congenital, and in rare occasions can be acquired most commonly through esophageal malignancy, trauma, and chemoradiation. TEF is often associated with abnormal esophageal motility causing recurrent pneumonia and acute lung injury from chemical pneumonitis. Diagnosis of TEF as a result of these conditions can be challenging, but the preferred diagnosis method is direct visualization with esophagoscopy or bronchoscopy. Treatment consists of interventional procedures including airway and/or esophageal stent placement. It is the most common approach to prevent liquid leakage and help with the healing. Biological glue or thermal ablation can also be performed, as well as surgical intervention or conservative management. CONCLUSIONS: The patient presented with respiratory failure secondary to recurrent aspiration pneumonia and chemical pneumonitis who failed therapy with gastrostomy tube placement, due to tracheoesophageal fistula. TEF is a rare complication of chemoradiation that increases morbidity and mortality. It can be treated with airway/esophageal stent placement or more invasive surgical intervention. It is important to expand work up and differential diagnosis in patients with aspiration who continue failing therapy to include endoscopy for direct visualization of anatomical abnormalities. REFERENCE #1: Ke M, Wu X, Zeng J. The treatment strategy for tracheoesophageal fistula. J Thorac Dis. 2015;7(Suppl 4):S389-S397. doi:10.3978/j.issn.2072-1439.2015.12.11 REFERENCE #2: Abugroun A, Ahmed F, Singh N, Nadiri M. Late Onset Chemo/Radiation Induced Tracheoesophageal Fistula in Squamous Cell Cancer of the Lung. World J Oncol. 2017;8(5):171-173. REFERENCE #3: Lo WL, Leu HB, Yang MC, et al. Dysphagia and risk of aspiration pneumonia: A nonrandomized, pair-matched cohort study. J Dent Sci 2019; 14:241. DISCLOSURES: No relevant relationships by Nehal Bhatt, source=Web Response No relevant relationships by Joshuam Ruiz Vega, source=Web Response