TE fistula: ETT positioning


A tracheo-esophageal fistula (TEF) is a congenital defect that is thought to be a result of a foregut malformation of uncertain etiology around the 4th to 5th week of gestation age. This malformation can be present in various anatomic formations and are categorized as Type A-E. Ninety-percent of TEFs are Type C, which consists of a fistula between the trachea and lower esophageal segment in conjunction with upper esophageal atresia. Due to this connection between the trachea and the gastric tract, both intubation and mechanical ventilation during surgical intervention can pose a challenge to the anesthesiologist (Davis, et al.)

In regards to airway management in TEF, one of the foremost concerns is the avoidance of ventilation through the fistula with resultant gastric distention and inadequate pulmonary ventilation. A hallmark in the airway management of these patients is to maintain spontaneous ventilation until the fistula tract is ligated. A variety of techniques have been described to minimize this complication. The conservative approach involves an awake intubation to avoid positive pressure mask ventilation. Alternatively, some practitioners have employed an inhalation induction of anesthesia with spontaneous ventilation and gentle positive pressure ventilation as needed (Knottenbelt, 2012).

If two-lung ventilation is desired, it has been historical practice to attempt to position the endotracheal tube (ETT) bevel anteriorly in order to avoid ventilation of the fistula through the Murphey’s eye (Salem, 1973). However, practically speaking maintaining this ETT position throughout an extended surgery with potential repositioning is difficult. If the fistula tract is above the carina a cuffed ETT can be placed at the carina and the cuff can be inflated to isolate the fistula tract from the distal airway. While ideally the ETT should be positioned below the fistula, often TEF’s are located close to, or at, the carina, thus predisposing to mainstem intubation, unintentional fistula tract ventilation, or inadvertent cephalad movement of the ETT above the fistula. Some institutions employ placement of a Fogarty catheter through larger, high-risk fistulas via a bronchoscope in order to occlude the fistula until surgical visualization has been achieved (Andropoulos, 1998). However, this approach may be impractical in neonates and may lead to further airway complications (Davis, et al). Finally, bronchoscopy may be performed to guide the placement of the endotracheal tube into the left bronchus to provide one lung ventilation. Fiberoptic bronchoscopy can also be used to rule out inadvertent passage into the fistula tract.


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  1. D B Andropoulos, R W Rowe, J M Betts Anaesthetic and surgical airway management during tracheo-oesophageal fistula repair. Paediatr Anaesth: 1998, 8(4);313-9

  2. Graham Knottenbelt, David Costi, Philip Stephens, Richard Beringer, Andrew Davidson An audit of anesthetic management and complications of tracheo-esophageal fistula and esophageal atresia repair. Paediatr Anaesth: 2012, 22(3);268-74

  3. M R Salem, A Y Wong, Y H Lin, H V Firor, E J Bennett Prevention of gastric distention during anesthesia for newborns with tracheoesophageal fistulas. Anesthesiology: 1973, 38(1);82-3