VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

15 Early Development of Acquired Tracheoesophageal Fistula in a Ventilator Dependent ICU Patient With Atypical Risk Factors

Stecker Pierson, MD; Fahid Alghanim, MD Corresponding author: Stecker.pierson@lpnt.net

SOVAH Health Internal Medicine Residency Program

in place with Vaseline gauze under the flange, no bleeding or signs of infection. Pertinent Labs: Leukocytes 13.67, pH 7.35, pCO2 45.3, pO2 96.5 on ACVC 400/24/+10/40% Imaging: CT chest demonstrated tracheal esophageal communication at the left posterior aspect of the trachea. Diagnosis: Acquired tracheoesophageal fistula secondary to mucosal abrasion and multifactorial cuff agitation Treatment: ENT exchanged the endotracheal tube for a tracheostomy tube due to ventilator dependence. Tracheotomy was complicated by posterior tracheal wall abrasion. On post-tracheotomy day 2, ENT was consulted for persistent ventilator alarms of high circuit leak. A flexible laryngoscope examination showed a stable posterior wall abrasion. Fiberoptic bronchoscopy on post-tracheotomy day 5 demonstrated a posterior tracheal wall defect leading to a large secondary vertically oblong mucosal space with increased secretions. Anesthesia was consulted for re-intubation. A multidisciplinary team removed the tracheostomy tube, re-intubated from above, and confirmed endotracheal tube cuff placement below

the inferior edge of the tracheal defect via fiberoptic bronchoscopy through the endotracheal tube. The patient was determined to be a poor candidate for definitive surgical correction and was transitioned by family to comfort measures only shortly after. Comments: We herein report a case of ATEF with early development between post-tracheotomy days 2 and 5, intending to draw attention to additional risk factors that can accelerate ATEF formation. Three commonly cited ATEF risk factors were absent in this clinical case: prolonged tracheal cuff presence, high pressure >30 mmHg tracheal cuff inflation, and tandem rigid nasogastric tube. Three major contributors to this patient’s early ATEF development are suspected to be: intra-tracheotomy mucosal injury, significant risk factors for non healing (tobacco dependence, severe protein-calorie malnutrition, DM, renal failure), and multifactorial cuff agitation (tracheostomy repositioning, bag ventilation during intra-facility transport, vocalization attempts). Identification of these risk factors could lead to improved outcomes through early diagnosis or prevention of ATEF.

Context: Acquired tracheoesophageal fistula (ATEF) is a rare and severe complication of endotracheal intubation commonly cited as arising from local vascular compression due to high cuff pressures >30 mmHg. With a reported incidence of 0.3-3.0%, ATEF can lead to recurrent pneumonia and low tidal volume delivery. Case Report: A 59-year-old female ventilator-dependent ICU patient is evaluated for persistent ventilator alarms due to high circuit leak and low tidal volume delivery on volume control settings. Medical History: Class 3 obesity, ventral hernia, OSA/OHS not using CPAP, NIDDM, HTN, HLD, diastolic heart failure, COPD on 3 L supplemental oxygen via nasal cannula, tobacco dependence. Family History: Sister with unspecified cancer, mother with COPD, father with CAD. Social History: Independent with ADLs and ambulatory at baseline, 47 pack years. Pertinent Review of Systems: Unable to obtain. Pertinent Physical Exam: BP 118/57, HR 83, RR 24, T 97.7 F, 99% on ventilator. Tracheostomy

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