Tracheoesophageal fistula presenting with ventilator air leaks and recurrent pneumonia.

We describe a patient who received tracheostomy but complicated with tracheoesophageal fistula, where the nasogastric tube was visible from the fistula under bronchoscopy. Tracheostomy tube was then replaced with an endotracheal tube to bypass the fistula.

CLINICAL IMAGE

An 86‐year‐old male with a history of stroke was mechanically ventilated for almost 1 year. He received tracheostomy 1 month after intubation, and was transferred to our ward several months later. On day 121, the ventilator sensed multiple air‐leak events in spite of the balloon being inflated with 20 ml air, with the pressure being kept around 35 cm H2O. He received antibiotics treatment for pneumonia and kept nil per os for concurrent gastrointestinal bleeding. After recovery, he started nasogastric tube feeding and had a fever. Milky fluid was aspirated from the tracheostomy. Bronchoscopy showed ischaemic change (Figure 1A), pressure necrosis and a tracheoesophageal fistula (TEF) with the visibility of the nasogastric tube (Figure 1B). His son refused further surgical repair for the patient. The tracheostomy was replaced with an endotracheal tube which was inserted deeper into the lower trachea (Figure 1C) to bypass the TEF. The air leakage decreased. The clinical course is presented in Figure 2. Late complications of tracheostomy include formation of granulation tissue, tracheal stenosis, tracheomalacia, tracheoinnominate‐artery fistula, TEF, ventilator‐associated pneumonia and aspiration. Tracheostomy‐related TEF is due to high cuff‐pressure or direct injury. The treatment options include positioning the cuffed balloon below the fistula and endotracheal stent to bypass the fistula, and surgical repair.

FIGURE 1

(A) Cuffed tracheostomy tube with ischaemic change (white arrow) of the upper tracheal wall. (B) After the balloon was deflated, there was pressure necrosis (white arrow) at the posterior wall of the trachea and a tracheoesophageal fistula (TEF) with the visibility of the nasogastric tube (black arrow). (C) Endotracheal tube (white arrow) inserted from tracheostomy cuffed below the TEF

FIGURE 2

Clinical course of the patient who received tracheostomy but complicated with tracheoesophageal fistula. The tracheostomy tube was then replaced with an endotracheal tube to bypass the fistula. ICU, intensive care unit; RCW, respiratory care unit

CONFLICT OF INTEREST

None declared.

AUTHOR CONTRIBUTION

Hwa‐Yen Chiu wrote the manuscript. Tsui‐Fen Hsu processed the image and manuscript review.

ETHICS STATEMENT

The authors declare that appropriate written informed consent was obtained for the publication of this manuscript and accompanying images.