Published online Oct 26, 2022. doi: 10.12998/wjcc.v10.i30.11198
Peer-review started: August 1, 2022
First decision: August 22, 2022
Revised: August 30, 2022
Accepted: September 19, 2022
Article in press: September 19, 2022
Published online: October 26, 2022
Tracheoesophageal fistula (TEF) is a congenital anomaly characterized by interruptions in esophageal continuity with or without fistulous communication to the trachea. Anesthetic management during TEF repair is challenging because of the difficulty of perioperative airway management. It is important to determine the appropriate position of the endotracheal tube (ETT) for proper ventilation and to prevent excessive gastric dilatation. Therefore, the tip of the ETT should be placed immediately below the fistula and above the carina.
A full-term, one-day-old, 2.4 kg, 50 cm male neonate was diagnosed with TEF type C. During induction, an ETT was inserted using video laryngoscope and advanced deeply to ensure that the tip passed over the fistula, according to known strategies. The passage of the ETT through the vocal cords was confirmed via video laryngoscope. However, after inflating the ETT cuff, breath sounds were not heard on bilateral lung auscultation. Instead, gastric sounds were heard. Considering that a large fistula (approximately 6.60 mm × 4.54 mm) located 10.2 mm above the carina was confirmed on preoperative tracheal computed tomography, the possibility of unintentional esophageal intubation was highly suspected. Therefore, we decided to uncuff and withdraw the ETT carefully for repositioning, while monitoring auscultation and end-tidal CO2 simultaneously. At a certain point (9.5 cm from the lip), clear breath sounds and proper end-tidal CO2 readings were suddenly achieved, and adequate ventilation was possible.
Preanesthetic anatomical evaluation with imaging studies in TEF is necessary to minimize complications related to airway management.
Core Tip: Anesthetic management in tracheoesophageal fistula (TEF) repair is challenging for anesthesiologists because of the difficulty in airway management. Unexpected events during airway management can occur, resulting in catastrophic outcomes, such as desaturation, hypoxic damage, and even death. In our case, esophageal intubation was unintentionally performed because of the large fistula. We predicted the possibility of this event based on the preceding tracheal computed tomography, which helped us to obtain a better clinical outcome. Evaluating the anatomy of each patient with TEF using imaging studies before induction is essential to minimize complications and facilitate prompt management as necessary.