Critical Care Medicine-Neurologic Disorders>>>>>Airway Diseases
Question 1#

A 70-year-old female with a history of diabetes, coronary artery disease, and hypothyroidism was admitted to the intensive care unit (ICU) for pneumonia complicated by acute respiratory distress syndrome (ARDS). She was intubated on the day of admission. Her ICU course was complicated by shock, delirium, and recurrent aspiration. She was successfully extubated on ICU day 14. Following extubation, she was noted to have significant coughing that seemed worse with the consumption of liquids. A barium swallow demonstrated a spillage of contrast from the esophagus into the trachea.

Which of the following is a risk factor for this complication?

A. Delirium
B. Hypothryoidism
C. ARDS
D. Hypotension
E. Advanced age

Correct Answer is D

Comment:

Correct Answer: D

This patient has developed an acquired tracheoesophageal fistula (TEF). TEF is a rare but serious complication of prolonged mechanical ventilation. The most common etiology for acquired TEFs is malignancy, with esophageal malignancy as the most frequent cancer leading to TEF. Following malignancy, the most common cause of TEFs is endotracheal intubation. Endotracheal tube–related TEFs can occur in up to 3% of ventilated patients. Risk factors include prolonged intubation, diabetes, overinflation of the endotracheal cuff, hypotension leading to necrosis of the tracheal wall, and recurrent airway infections. In ventilated patients, TEFs can present with weight loss, recurrent infections or inability to liberate from the ventilator. In nonventilated patients, coughing is a common sign with a classic sign of coughing after consuming liquids (Ono’s sign), particularly carbonated liquids. TEFs can be diagnosed via barium swallow, endoscopy, or bronchoscopy. Treatment is typically surgical; however, for nonoperable, malignant cases, stenting is an option. Extubation following correction of the TEF is key as positive pressure ventilation has been associated with poor anastomotic breakdown and stenosis. 

Reference:

  1. Diddee R, Shaw IH. Acquired tracheo-oesophageal fistula in adults. Contin Educ Anaesth Criti Care Pain. 2006;6(3):105-108.