Tracheoesophageal Fistula (Case 34)

Chapter 75 Tracheoesophageal Fistula (Case 34)



Veniamin Ratner, MD




Case


An apparently healthy term newborn with an unremarkable prenatal course is delivered. Prenatal ultrasound was significant only for mild polyhydramnios and a small stomach. Within the first few hours after birth, the infant develops copious oral secretions and is unable to tolerate oral feedings. Attempts at passing a feeding tube fail. Eventually, an increased respiratory rate and respiratory distress develop.




Differential Diagnosis













Esophageal atresia VACTERL CHARGE
Tracheoesophageal fistula (TEF) Vertebral anomalies
Anal atresia
Cardiac anomaly
Tracheo-
Esophageal fistula or atresia
Renal and Limb abnormalities		 Coloboma
Heartdefects, choanal
Atresia
Retardation of growth and development
Genital and
Ear anomalies


Speaking Intelligently


When I suspect a patient has a tracheoesophageal fistula, my first thought is to quickly verify my suspicion by attempting to pass a nasogastric tube to the stomach and confirm its position by chest radiography. Once the diagnosis of esophageal atresia has been established, my next step is to provide continuous suction of the proximal esophageal pouch to minimize the degree of lung aspiration-related injury. Next, I position the infant with its head elevated to minimize reflux of gastric secretions into the lungs. Early involvement of the pediatric surgical team is necessary. If there is rapid progression of respiratory distress, I intubate the patient and provide mechanical ventilatory support. If there is a fistula between the trachea and the distal portion of the esophagus, the patient may develop marked abdominal distention, requiring urgent surgical intervention. When the patient’s condition is stable, I evaluate for possible associated congenital defects (VACTERL, CHARGE). Laboratory work is rarely a priority; however, echocardiography is essential for identifying aortic arch anatomy and position to determine the appropriate surgical approach.



Patient Care



Clinical Thinking



• Provide continuous suction of the secretions from the esophageal pouch and mouth to prevent significant aspiration lung injury.

• Spontaneous breathing is preferable, but if respiratory support is necessary, avoid nasal canula or continuous positive airway pressure.

• Early evaluation for possible associated congenital anomalies is essential for comprehensive appropriate management.


History



• Polyhydramnios and an absent or small stomach bubble on prenatal ultrasound should raise suspicion of esophageal atresia.

• A history of inability to swallow oral secretions and excessive drooling must be followed with an attempt to pass a tube into the stomach. Failure to pass the tube is considered diagnostic for esophageal atresia.

• Inability to tolerate feeding due to development of respiratory distress or cyanosis since the first day of life should prompt evaluation for tracheoesophageal fistula.


Physical Examination



• Vital signs: Increased respiratory rate may be the first sign of the development of lung injury. Intermittent oxygen desaturation early in the disease may progress to significant constant oxygen desaturation with clinically obvious cyanosis.

• Classically, the neonate with esophageal atresia has copious, white, frothy bubbles of mucus in the mouth and sometimes the nose.

• The infant may have noisy breathing and episodes of coughing and cyanosis. These episodes may be exaggerated during feeding if a fistula between the esophagus and the trachea is present.

• Abdominal distention develops as air builds up in the stomach. The abdomen will be scaphoid in the absence of a fistula.


Tests for Consideration



• Chest and abdomen radiography with orogastric tube in place: To visualize the position of the esophageal pouch, degree of lung involvement, and degree of stomach distention $75 and $45
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Tracheoesophageal Fistula (Case 34)

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