RECOGNITION OF A TRACHEOESOPHAGEAL FISTULA IN A MECHANICALLY VENTILATED PATIENT

SESSION TITLE: Fellows Critical Care Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Tracheoesophageal fistula (TEF) can present as either congenital or acquired abnormality Acquired TEF is usually secondary to malignant tumors Prolonged mechanical ventilation with cuff related injury leading to a non-malignant TEF usually presents post extubation although it has become rare with the introduction of high-volume low-pressure cuffs(1) Occurrence of TEF & its early identification in a mechanically ventilated patient is of critical importance to prevent severe ventilator inefficiency, sepsis and compromised nutrition Here we present a case of TEF presenting in a ventilator dependent patient CASE PRESENTATION: A 69 year old female with past medical history of diabetes and hypertension presented with hypoxemic respiratory failure due to COVID-19 pneumonia requiring mechanical ventilation Course was complicated by methicillin resistant Staphylococcus aureus (MRSA) bacteremia treated with intravenous Vancomycin After 3 weeks of mechanical ventilation, surgical tracheostomy was performed One week later, she developed tracheostomy site MRSA infection Two weeks later, the patient developed sudden severe abdominal distension and tachypnea with higher oxygen requirements Abdominal x-ray showed severely distended bowel loops which improved with orogastric (OG) tube suctioning but recurred when it was turned off (fig 1) The ventilator volume graphs revealed a large air leak despite an adequately inflated cuff and the external tip of the OG tube under water showed continuous bubbling Above findings raised suspicion of TEF which was confirmed by CT imaging (fig 2) As patient was unstable for surgical intervention, the regular tracheostomy tube replaced with an extended length (XLT) tracheostomy tube which led to resolution of air leak DISCUSSION: Acquired TEF can occur in the setting of prolonged mechanical ventilation, indwelling tracheal or esophageal stents, mediastinal infections and trauma or iatrogenic injuries Common presenting complaint is persistent cough upon food consumption post extubation It is a rare complication occurring in less than 1% of patients undergoing tracheostomy In ventilator dependent patients, presenting signs include persistent air leak even with a fully inflated cuff, abdominal distension and airway contamination with gastric contents(2) Endoscopy is considered the best diagnostic method, though small TEFs may be missed in the esophageal folds Bronchoscopy with methylene blue installation identifies the defect better Imaging with CT/MRI is preferred in ventilator dependent patients The mainstay of treatment of TEF in ventilated patients is usually conservative management with XLT tracheostomy tube or esophageal stenting CONCLUSIONS: TEF is a rare complication Acute bowel distension with a large continuous air leak on the ventilator & through OG tube (bubbling underwater), despite a fully inflated cuff should raise clinical suspicion Reference #1: 1 Reed MF, Mathisen DJ Tracheoesophageal fistula Chest Surg Clin N Am 2003;13(2):271-289 doi:10 1016/s1052-3359(03)00030-9 Reference #2: 2 Paraschiv M Tracheoesophageal fistula–a complication of prolonged tracheal intubation J Med Life 2014;7(4):516-521 DISCLOSURES: No relevant relationships by padmanabhan krishnan, source=Web Response No relevant relationships by Chetana Pendkar, source=Web Response No relevant relationships by Sumedha Sonde, source=Web Response No relevant relationships by Nishanth Vallumsetla, source=Web Response