Tracheoesophageal Fistula (TEF)

Tracheoesophageal Fistula (TEF)

  • In the setting of the most common anatomy of TEF (esophageal atresia with the fistula between the trachea and the distal segment of the esophagus) the key is minimizing positive pressure ventilation. Due to the TEF, gas that delivered via positive pressure passes into the esophagus instead of the lungs (the path of least resistance), especially in the setting of pulmonary disease (e.g., prematurity or aspiration pneumonia).
  • To minimize gastric distension, an inhalational induction during spontaneous ventilation is preferred.
  • If pulmonary compliance is poor, a gastrostomy can be placed with local anesthesia to ensure easy decompression of the stomach/abdominal distension.
  • In some cases, the surgeon elects to perform a rigid bronchoscopy to evaluate the location of the fistula prior to surgical repair.
  • After the bronchoscopy, the trachea is intubated, aiming to position the endotracheal tube to avoid ventilating the fistula. Usually, this requires intentionally main-stemming and then slowly withdrawing to the position where until bilateral breath sounds are initially heard. Ideally, spontaneous ventilation is maintained until the fistula is ligated. In practice, however this can be difficult, and if the ETT adequately bypasses the fistula, gentle positive pressure ventilation can be maintained.
  • Surgical repair can be completed via an open or minimally invasive approach. If the distance between the 2 segments of esophagus is greater than 4-5 vertebral bodies, the repair is usually staged. During the initial surgery, the fistula is ligated and a gastrotomy inserted; at a later date, the esophagus is re-anastamosed.
  • In most cases, but especially after a primary re-anastomosis of the esophagus, the trachea remains intubated (to avoid any positive pressure ventilation via mask postoperatively), and the infant is transported to the intensive care nursery directly from the operating room.
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This information is meant to serve as an educational resource. Clinicians should use their own professional judgment in the care of any individual patient as the guidance contained in this document may not be appropriate for all patients or all situations.