SESSION TITLE: Bronchology/Interventional Student/Resident Case Report Posters I
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM
INTRODUCTION: Tracheoesophageal Fistula (TEF) is a rare (≤ 1%) but serious complication of tracheostomy caused by mucosal ischemia/abrasion secondary to prolonged intubation and use of high tracheal cuff pressures (≥ 30 cm H2O). We describe a challenging case of a patient on chronic ventilator support who presents with, multiple admissions for ventilator associated pneumonia (VAP), associated with gaseous bowel distention, was eventually found to have TEF on flexible bronchoscopy.
CASE PRESENTATION: A 31 y/o man on chronic ventilator support was brought to the ICU for worsening hypoxemia and hypotension. He had h/o quadriplegia secondary to a gunshot wound, chronic ventilator dependent respiratory failure with established tracheostomy and PEG for past 5 years. Patient was diagnosed with severe sepsis secondary to VAP after chest X-ray and CT scan showed increased bibasilar infiltrates. This presentation was similar to one of his multiple previous admissions. Patient was found to have worsening abdominal distention, with bubbling from the PEG site. CT scan of the abdomen and pelvis without contrast showed distention of multiple loops of small bowel and proximal colon, suggestive of an ileus pattern, with no evidence of obstruction (see images). Abdominal X-rays from the prior 8 months showed continued distention of the intestinal loops without focal mechanical obstruction. His tracheal cuff pressures from last 6 months ranged from 24-30 cm H2O. Subsequently, a diagnosis of TEF was considered, but CT scan of the neck failed to show TEF. Flexible bronchoscopy, showed two small indentations on the posterior tracheal wall at the site of the tracheostomy cuff with intermittent drainage (see images). Patient was diagnosed with TEF. Considering patient being a poor surgical candidate, a longer tracheostomy tube was inserted to bypass the fistulae and tracheal cuff pressure to be maintained at < 25 cm H2O.
DISCUSSION: This case illustrates challenges related to the diagnosis of TEF. Abdominal gaseous distension is a known clinical manifestation of TEF with esophageal atresia in the neonatal period, due to airflow through the fistula into the esophagus. However, while reported in neonates, it has not been reported as a clue in diagnosing TEF in older populations.
CONCLUSIONS: With increasing use of tracheostomy in recent times, awareness of potential complications and their management is needed. TEF is primarily managed surgically or by stent placement, however, placement of a longer tracheostomy tube to bypass TEF with use of total parenteral nutrition (TPN) may be an option in certain patient populations.
Reference #1: Intermmittent Gaseous Bowel Distention: Atypical Sign of Congenital Tracheoesophageal Fistula. Pediatric Pulmonology 44:244-248
Reference #2: Acquired Tracheo-oesophageal fistula in adults. Continuing Education in Anaesthesia : Critical Care and pain. Volume 6 November 3 2006
DISCLOSURE: The following authors have nothing to disclose: Karan Mahajan, Sameer Patel, Sanjay Shah
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