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Using Bronchoscopy to Detect Acquired Tracheoesophageal Fistula in Mechanically Ventilated Patients
Journal article   Open access

Using Bronchoscopy to Detect Acquired Tracheoesophageal Fistula in Mechanically Ventilated Patients

Michael S Green, Johann J Mathew, Lia J Michos, Parmis Green and Mansoor M Aman
Anesthesiology and pain medicine, v 7(4), pe57801
Aug 2017
DOI: https://doi.org/10.5812/aapm.57801
PMID: 29430408
url
https://doi.org/10.5812/aapm.57801View
Published, Version of Record (VoR)CC BY-NC V4.0,  Open

Abstract

Manometry Intubation Tracheal Diseases Tracheoesophageal Fistula Angioedema
An acquired Tracheoesophageal fistula (TEF) is commonly caused by a malignancy or trauma, with pulmonary infection or aspiration being the presenting symptom. However, in the critical care setting the presentation can be subtle and may present with difficult ventilation. High endotracheal tube cuff pressures can lead to tracheal erosions and thus increasing the chances for developing a TEF. Prolonged intubation in the presence of other risk factors like poor general state of health, episodic hypotension, nasogastric tubes, and repeated intubations can increase the likelihood of developing an acquired TEF. Angioedema of the airway is a rare but potentially devastating complication of angiotensin converting enzyme inhibitors (ACE-I) that could further add insult to the tracheal mucosa, predisposing to an acquired TEF. An elderly woman with multiple comorbidities and requiring mechanical ventilation, developed angioedema following intake of ACE inhibitor for hypertension. The ensuing airway edema made weaning off mechanical ventilation difficult. After repeated attempts at extubation, tracheostomy was performed. With the loss of airway after tracheostomy, the possibility of TEF was considered given her multiple risk factors and intra-operative findings of the tracheal mucosa. While it may be difficult to predict who will actually develop a TEF, it is prudent to identify those at risk and take precautionary measures to prevent one. Emphasis should be placed on daily endotracheal cuff manometric pressure check to prevent ischemic changes of the tracheal mucosa resulting from high cuff pressures. Also, bronchoscopy could be used after extubating susceptible patients to detect an acquired TEF.

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