INTRODUCTION: The development of a tracheoesophageal fistula in a chronic ventilator patient is a rare occurrence. It can be associated with gastric distension and prior studies have suggested the use of a “breathing bag” sign and gastric air analysis to further suggest the diagnosis and prompt further invasive workup.
CASE PRESENTATION: A 58-year-old veteran with a past medical history of non-Hodgkins lymphoma and epilepsy was admitted to the ICU after an elective right upper and middle lobectomy for a pleomorphic carcinoma. The patients post operative course was complicated by gram negative pneumonia with sepsis and ARDS. The patient also had prolonged neutrapenia. Due to significant lung damage related to fibroproliferative ARDS and critical illness polyneuropathy the patient underwent tracheostomy and PEG placement early in his hospitalization. The patients recovery was further impeded by multiple hospital acquired infections. Approximately 3 months post tracheostomy the patient developed a global ileus which was thought at the time to be due to electrolyte abnormalities, narcotics, and critical illness. Obstruction was ruled out and TPN was initiated. After 2 weeks of continued failed attempts to restart enteral feeding a new finding of massive gastric dilation and the patients PEG drainage bag inflating like a balloon was noted. The patient was placed on 100% oxygen and a new PEG bag was placed which inflated in a few minutes. A syringe was used to draw air from the bag which was then run on an ABG machine with a resulting pO2 of 688mmHg. This then prompted an EGD and bronchoscopy which demonstrated a tracheoesophageal fistula at the point of contact with the cuff and posterior tracheal wall. A soft foam trach was then placed beyond the fistula which resulted in resolution of the ileus and restoration of enteral feedings. Three weeks later the patient died from a MRSA pneumonia as the family did not wish to pursue further aggressive treatments at that point in time.
DISCUSSIONS: Tracheoesophageal fistula is a known but rare complication of tracheostomy occurring in less than 1% of cases. Previous authors have suggested several different clues to help clinicians think of this diagnosis. One suggestion has been to observe for the phasic respiratory variation of a bag hooked to a patients NG tube. In this case our patient developed a similar finding where a PEG drainage bag inflated with respiration. Additionally, there has been the suggestion to use gastric air analysis to confirm the diagnosis. In our patient by using 100% oxygen a large gradient was created to confirm the diagnosis and suggest further testing.
CONCLUSION: The clinical techniques of gastric air analysis and observation for the “breathing bag” sign are both useful non-invasive measures to evaluate for tracheoesophageal fistula. It is also a rare cause of global ileus and gastric distention that should be considered in the differential diagnosis of a tracheostomy patient.
DISCLOSURE: David Hasselbacher, None.