Early presentation of postintubation tracheoesophageal fistula: Perioperative anesthetic management.

Tracheoesophageal fistula (TEF) in adults occurs as a result of trauma, malignancy, cuff-induced tracheal necrosis from prolonged mechanical ventilation, traumatic endotracheal intubation, foreign body ingestion, prolonged presence of rigid nasogastric tube, and surgical complication. Anesthetic management for repair of TEF is a challenge. Challenges include difficulties in oxygenation or ventilation resulting from placement of endotracheal tube in or above the fistula; large fistula defect causing loss of tidal volume with subsequent gastric dilatation, atelactasis, and maintenance of one lung ventilation. The most common cause of acquired nonmalignant TEF is postintubation fistula, which develops after prolonged intubation for ventilatory support. Acquired TEF, which occurs after prolonged intubation, usually develops after 12-200 days of mechanical ventilation, with a mean of 42 days. We present a rare case of TEF that developed after 7 days of intubation. It was a difficult case to be diagnosed as patient had a history of polytrauma, followed by emergency intubation and both these conditions can contribute to tracheobronchial injury.

Introduction

Acquired tracheoesophageal fistula (TEF) most commonly occurred following prolonged intubation. TEF develops after 12-200 days of mechanical ventilation, with a mean of 42 days. We present a case of polytrauma who developed TEF 7 days following ventilator support.

Case Report

A 27-year-old man, with history of polytrauma, presented to the emergency department with the loss of consciousness followed by emergency tracheal intubation done for poor Glasgow Coma Score (GCS) coma. He had been operated for head injury (dural repair for CSF leak) and facial injury (fracture maxilla). After 7 days of ventilatory support, patient was extubated. After tracheal extubation, patient complained of coughing and choking while ingesting liquids. Magnetic resonance imaging (MRI) neck showed TEF at the level of T1-2. Fiberoptic bronchoscopy was done under LA which identified the orifice of TEF on smooth posterior membranous wall 3–4 cm from carina and measuring 1.5 × 2 cm in size, and circumferential injury of trachea was present. Feeding jejunostomy was also done under local anesthesia to start feeding. The patient was planned for anterolateral thoracotomy and retrosternal gastric pull-up, after 15 days after the patient had recovered nutritionally.

On the morning of surgery, intravenous (IV) glycopyrolate and IV midazolam were given. In addition to routine monitoring central venous and radial artery cannulation was done for central venous pressure and invasive blood pressure monitoring. Thoracic epidural catheter was placed through the T5-6 interspace and 1.5 mg morphine was given epidural as preemptive analgesia. General anesthesia was induced with propofol, morphine, and succinylcholine. The table was tilted to the right to keep fistula down and avoid aspiration during positive pressure ventilation. Endobronchial intubation was done with 32 FG left-sided double lumen tube. During the passage of the tube through the cords, a resistance was felt. A 2.7-mm fiberoptic bronchoscope (FOB) was inserted through the tube and tube end was visualized just at the junction of trachea and esophageal fistula. The tube was gently withdrawn and the FOB advanced beyond fistulous opening up to the left main bronchus and tube was railroaded over the FOB. At this position, the tracheal cuff was just blocking the fistula opening. Anesthesia was maintained with a mixture of oxygen, air, and isoflurane. Intraoperative analgesia was maintained with epidural and intravenous boluses of morphine.

The fistula was localized by the surgeon and the cuff of the tube was just blocking the fistula and its tip was beyond the fistula making it an ideal position. Distal end of esophagus closed and retrosternal gastric pull up done through a neck incision.

The immediate postoperative course was uneventful. Patient had excellent analgesia with bupivacaine 0.125% and fentanyl epidural infusion. The epidural catheter was removed on the 4th postoperative day. Patient was not administered oral fluids or solids until barium swallow demonstrated absence of extravasation. Patient was discharged on the 10th postoperative day.

Discussion

TEF occurs after prolonged ventilatory support as a result of pressure on the opposed walls of esophagus and trachea by the inflated tracheal cuff and the in-lying esophageal feeding tube. It can develop anytime from 12–200 days after intubation with a mean of 40 days.[1] Time taken for an acquired TEF to develop and become symptomatic is dependent on precipitating cause and is illustrated as [Table 1].[2]

Table 1

Time taken for acquired TEF to develop and become symptomatic, based on the causative factor

Traumatic tracheobronchial injury is usually the result of blunt chest trauma and appears as horizontal or irregularly shaped disruptions involving the carina and often extending into main bronchi. Iatrogenic tracheobronchial injury, which could be a cause in our case as patient was having history of emergency intubation, in contrast usually presents as longitudinal laceration of posterior tracheal wall either centrally or laterally. The exact mechanism remains uncertain, but the most probable explanation is direct laceration from endotracheal tube tip caught in the fold of flaccid posterior tracheal membrane, while advancing the tube. Since the inflammatory process is progressive, in case of cuff-induced tracheal injury, there is never leakage into mediastinum as is seen in a traumatic fistula.

Factors implicated in the development of postintubation TOF are high cuff pressure, high airway pressure, excessive motion of tracheal tube, prolonged duration of intubation, respiratory infections, esophageal infection, hypotension, steroids, nasogastric tube, and advanced age. High intracuff pressure is probably the single most important factor in the development of TEF.[34]

Total obstruction of tracheal blood flow occurs at pressure >50 cm H2O. In patients with hypotension, even a cuff pressure of 34 cm of H2O may cause signs of tracheal damage.

There is a linear relationship between peak inflation pressure and minimum occlusive pressure of high volume low pressure cuff that may promote tracheal ischemic complications under certain circumstances.[5]

Head position may change the amount and location of lateral wall pressure exerted by cuff. Flexion of head causes more pressure to be applied anteriorly on trachea, while extension of head results in more pressure on the posterior wall.[6] The concomitant occurrence of hypotension may compromise mucosal blood supply. Excessive movement of tube can occur while positioning, suctioning or by weighing down by the ventilator equipment. Presence of nasogastric tube reflects more pressure on posterior wall and it acts as an abrasive surface against anterior esophageal wall. Norwak et al. and Morris et al. demonstrated a significantly high incidence of laryngotracheal pathology in head injury patients.[7]

In the present case, fistula was located 3 cm above carina and it had a circumferential appearance on bronchoscopy with no sign of air leakage, gastric distension, or mediastinitis, even on positive pressure ventilation, indicating an early postintubation etiology. However, history of polytrauma, emergency intubation in unconscious patient, repeated episodes of hypotension, and infection due to repeated surgeries favors trauma as the causative factor.

A patient with acquired TEF should be preoperatively given good supportive therapy, measures taken to prevent aspiration and pulmonary infections aggressively managed. If a patient on ventilator, the TEF may fail to close. A spontaneously breathing and nutritionally fit patient is prerequisite for success of the therapy. The site and size of the lesion must be carefully noted as this may dictate the anesthetic approach. Rapid isolation of the TEF is mandatory for successful anesthetic management. Failure to ventilate, due to intubation of the lumen of large TEF, is a major concern.

Proper selection of an appropriate size endotracheal tube, frequent cuff pressure monitoring (keeping cuff pressure between 20 and 30 mm of H2O), minimal endotracheal tube movement on positioning/suctioning and using flexible nasogastric tube prevent the occurrence of TEF.