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Table of Contents
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 108-111

Airway and ventilatory management in a premature neonate with congenital tracheoesophageal fistula

Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Indonesia

Date of Submission17-Sep-2020
Date of Decision10-Dec-2020
Date of Acceptance20-Dec-2020
Date of Web Publication16-Apr-2021

Correspondence Address:
Dr. Iwan Antara Suryadi
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. PB Sudirman, Denpasar 80232
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_193_20

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Esophageal atresia/tracheoesophageal fistula (TEF) is a congenital defect that often presents with respiratory distress in neonates. The anatomical defect in the form of connection between the esophagus and the trachea often affects respiratory function. Gastric distention often occurs due to large air leak into the stomach and may lead to respiratory distress. Surgical correction of the anatomical defect will improve the outcome in these patients. Preoperative preparation and intraoperative management is an essential point. Suboptimal preparation may lead to a life-threatening situation intraoperative. Focusing on airway and ventilatory management may help in reducing morbidity and mortality. We report a case of anesthesia management of TEF repair in a premature neonate with a complication during airway and ventilatory management.

Keywords: Airway management, esophageal atresia, tracheoesophageal fistula, ventilatory management

How to cite this article:
Kurniyanta P, Heryana Putra KA, Agung Senapathi TG, Suryadi IA. Airway and ventilatory management in a premature neonate with congenital tracheoesophageal fistula. Bali J Anaesthesiol 2021;5:108-11

How to cite this URL:
Kurniyanta P, Heryana Putra KA, Agung Senapathi TG, Suryadi IA. Airway and ventilatory management in a premature neonate with congenital tracheoesophageal fistula. Bali J Anaesthesiol [serial online] 2021 [cited 2021 Jun 23];5:108-11. Available from: https://www.bjoaonline.com/text.asp?2021/5/2/108/313878

  Introduction Top

Esophageal atresia (EA) is a congenital defect where there is an interruption of the lumen of the esophagus. About 92% of the patients with EA will have a tracheoesophageal fistula (TEF), a conduit between the esophagus and the trachea or right main bronchus. This defect is estimated to have an incidence rate of 1 in 2500–3000 live births and is more common in premature babies. More than 50% of the infants also have other birth defects and may affect morbidity and mortality.[1],[2] Other congenital anomalies that are often present are congenital heart defects and can affect the survival rate of the baby. Furthermore, it is necessary to evaluate phenotype variants associated with EA and TEF through the acronym vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb abnormalities.[3]

Infants with TEF often present with respiratory distress. Anatomical defect in the form of connection between the esophagus and the trachea can cause a large amount of air to enter the stomach. This can result in gastric distention and affect the ventilatory function of the baby. Gastric distention may also lead to aspiration of gastric contents through the fistula which causes aspiration pneumonitis. This event is also one of the factors that aggravate morbidity and mortality in 50% of this patient population. The surgical procedure to close the fistula is an important measure in preventing complications that can occur.[4]

  Case Report Top

A 15-day-old, 1720-g preterm male referred from a district hospital with signs of respiratory distress since birth. The patient was born prematurely, per vaginal in a district hospital with birthweight 2200 g, with low Apgar score, and appeared cyanosis. During treatment, the patient was tried to be given breast milk but always seemed regurgitated. With increasingly severe respiratory distress, the patient is intubated. The patient received milk, administered in small increments through the orogastric tube. The patient also received nutrition through intravenous fluids. The patient was diagnosed with EA and suspected TEF. The patient underwent a gastrostomy procedure at the age of 12 days. After surgery, the patient was extubated in the neonatal intensive care unit, and breathing is assisted with noninvasive ventilation (NIV).

Respiratory examination showed respiratory rate 50 times/min, bronchovesicular in both lungs, decreased in the right lung, minimal rhonchi on the right and left lower lungs, peripheral oxygen saturation 90%–94% with NIV mode: pressure control, FiO2 35%, inspiration pressure (Pinsp) 16, respiration rate 50, and positive-end expiration pressure 7 mmHg. Complete blood count showed leukocytosis (21 × 103/μL), normal hemoglobin (16.36 g/dL), and normal hematocrit (50.01%). Hemostatic profile, blood chemistry, and the electrolyte were within normal limit. Blood gas analysis result showed compensated respiratory acidosis with pH 7.36, pCO2 58 mmHg, pO2 89.9 mmHg, BE 6.4 mmol/L, and HCO3 31.9 mmol/L. Radiographic examination showed a gastric tube that does not reach the stomach with a sign of intestinal air, suggesting TEF type C/D, and pneumonia with right upper lobe lung atelectasis [Figure 1]. The results of echocardiography are mild tricuspid regurgitation and patent foramen ovale diameter 1.5 mm with a left-to-right shunt.
Figure 1: The radiograph showed gastric tube that does not reach the stomach and a sign of intestinal air, suggesting tracheoesophageal fistula type C/D

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Anesthesia induction was performed with O2 and sevoflurane, with analgesic fentanyl 3 mcg for intubation facilitation, and muscle relaxant atracurium 1 mg. During induction, hemodynamic was stable with heart rate 158 times/min and SpO2 100%. After 3 min, the patient was intubated with endotracheal tube (ETT) size 3 without a cuff with depth 10 cm, and bilateral auscultation was performed. From auscultation, bilateral breath sound was unclear, and gastric breath sound was heard suggesting an inaccurate ETT position. Afterward, desaturation occurred with SpO2 reaching 80%. It was decided to reintubate due to suspicion of ETT entering the stomach.

In the second attempt, a gastrostomy tube was connected to an infusion bottle filled with fluid to evaluate the gastric ventilation/bubbling technique. With face mask ventilation, SpO2 returned to 97%. Intubation was performed with ETT size 3 without cuff with depth 14 cm. Right endobronchial intubation was deliberately performed. From auscultation, right breath sound was heard and no breath sound on the left lung and stomach. A bubbling sign was not visible from the gastrostomy tube. Adjustment of the ETT was carried to a depth of 11 cm slowly, and the bubbling sign appeared from the gastrostomy tube. After the adjustment, the patient had another episode of desaturation. SpO2 reached 70%, with cyanosis sign on the lip and extremities, and bradycardia occurred. We concluded that the diameter of the fistula is quite large, so the ETT in the airway was misplaced into the fistula. Atropine sulfate 0.1 mg was given, and it was decided to withdraw the ETT. Then, we performed face mask ventilation and SpO2 returned to 97% with heart rate 140 times/min. Afterward, we decided to reintubate the patient.

In the third attempt, intubation was performed with ETT size 3 without cuff with depth 14 cm. After the confirmation of the ETT position in the airway (positive right breath sound and no gastrostomy bubbling leak), adjustment of the ETT depth was performed slowly until depth 12.5 cm. The bevel of the ETT directed anteriorly away from the fistula. From the evaluation of the ETT position, bilateral breath sound was heard and gastrostomy leak was visible once again (positive bubbling sign). From clinical evaluation, hemodynamic was stable with heart rate 158 times/min and SpO2 95%–98%. The patient was concluded to have a fairly large size TEF type C and the exact location on the carina, so the gastrostomy leak will continue to occur. The patient was then decided to continue to undergo surgery with close monitoring of lung ventilation and oxygenation. Afterward, the surgery proceeded uneventfully and a TEF with a diameter 3 mm was found, nearly the size of the trachea.

  Discussion Top

Knowledge of the anatomy of the airway and the physiology of ventilation-oxygenation in newborns is important in pediatric anesthesia. Problems on the manipulation of the newborn airway are one of the factors that affect morbidity, the incidence of oxygen desaturation, and hypoxia. Newborns have different physiology where oxygen consumption is higher and lower oxygen reserves so that episodes of apnea will be difficult to tolerate. Hypoxia in newborns will cause bradycardia and cardiac arrest.[5]

In patients with TEF who will undergo surgery, there are several considerations related to the anatomy and physiology of the patient [Figure 2]. One of the main considerations in the perioperative management of patients with TEF is good lung ventilation and avoidance of ventilation through the fistula. One of the first steps in the anesthesia management before surgery is intubation to secure the airway. In these patients, intubation is of particular concern where spontaneous ventilation of the patient will be replaced by artificial ventilation through ETT. In conditions of spontaneous ventilation, air entering through the airway will be divided into the lungs and stomach, while in the condition of artificial ventilation, the incoming air will be very dependent on the position of the tip of the ETT. For adequate ventilation, the tip of the ETT should be in a position distal to the fistula but proximal to the carina. If the tip of the ETT is proximal to or right at the fistula, ventilation provided through ETT will be divided into the lungs and stomach. In an extreme condition where the tip of the ETT enters the fistula, all of the ventilation will enter the stomach and hypoxia will occur.
Figure 2: Anatomical classification of tracheoesophageal fistula and incidences[1]

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Anatomically, the internal diameter of the trachea for a preterm newborn is 2–4 mm. The size of a fistula in a case of TEF varies from a small punctum to the size of the trachea. Chest auscultation for bilateral air entry after intubation may give a false-positive result, as air inflation in the stomach can easily be transmitted to the chest and be mistakenly identified as chest inflation, particularly in preterm infants. In the case of a fairly large fistula, it was difficult to avoid the fistula and insert the tube in the trachea.[5],[6]

There are several ways to secure the airway in these patients. The traditional technique most commonly used involves deliberate deep endobronchial intubation followed by adjustment of the ETT depth until the tip of the ETT is just above the carina and bilateral equal breath sounds are heard on auscultation of the chest. In addition, the ETT is rotated, so the bevel faces anteriorly and away from the fistula which is most commonly located on the posterior wall.[4] Alternative methods to confirm the placement of the ETT in a good position just distal to the fistula are by chest radiograph, ultrasound, or using the gastrostomy.

Bubbling versus lack of bubbling via gastrostomy can present when the tube is above or below the fistula.[3] In this case, we performed the traditional technique with deep endobronchial intubation followed by adjustment of the ETT depth and observation of the gastrostomy leak via bubbling sign. Due to the large size of the fistula and the exact position is in the carina, it was difficult to avoid the fistula. In the first and second attempts to intubate, the ETT was placed into the fistula, and desaturation happened. In the third attempt, the ETT is well placed in the airway, but there was some leak to the fistula. Ventilation was divided into the lung and the stomach with acceptable oxygenation of the patient.

Ventilatory management of these patients is often difficult if there is no gastrostomy due to gastric distention. Anesthetic management in this condition focuses on ventilating the lungs without ventilating the fistula. This requires maintenance of spontaneous breathing, with avoidance of neuromuscular blocking agents and excessive positive pressure, until the fistula is closed.[6] In the case of extreme gastric distention, ventilation can be difficult to maintain and can also lead to hemodynamic collapse. In a patient without a gastrostomy, a conservative approach with awake intubation can be performed to avoid positive pressure mask ventilation. However, this approach has the possibility of increased intracranial pressure and intraventricular hemorrhage in the premature infant. An alternative for ventilatory management is to perform anesthesia induction with volatile agents while maintaining spontaneous ventilation and then have the surgeon to perform rigid bronchoscopy. The role of the bronchoscopy is to determine the exact location and size of the fistula and to assist with placement of the ETT distally to the fistula but above the carina.[3] In our patient, the gastrostomy has been performed, so the ventilation can be managed without concern of gastric distention.

Other modalities can help in the airway management of patients. Flexible bronchoscopy (FOB) can also assist in airway evaluation and assist with placement of the ETT. Correct positioning of the ETT may require the use of a small, flexible bronchoscope introduced through the tube. The carina is identified and then the ETT is pulled back (with FOB inside ETT) until the fistula is visualized and then the ETT is advanced just distal to the fistula.[3],[7]

The use of a Fogarty balloon catheter or ETT with a cuff can also be considered for temporary fistula occlusion. Fogarty catheters can be placed postinduction of anesthesia anterograde via direct laryngoscopy or rigid bronchoscopy or retrograde via gastrostomy. In the anterograde technique, the Fogarty catheter is directed toward the fistula via rigid bronchoscopy. After the catheter is in the fistula, the balloon is inflated for fistula occlusion. Then, the bronchoscopy is removed, and intubation with ETT is performed. ETT is placed together with a Fogarty catheter in the trachea.[1],[3] There are drawbacks to this technique. First, from a technical perspective, this technique is a complex procedure and may not be effective. At the time of insertion, interruption of the ventilation is needed which is sometimes difficult for preterm babies to tolerate. Difficulties to find the size of the bronchoscopy corresponding to the size of the airway can also complicate the use of this technique. Furthermore, in cases where the Fogarty catheter is displaced intraoperatively, this catheter can cause tracheal occlusion and make ventilation impossible. Moreover, the balloon on the catheter can cause injury to the esophageal mucosa.[1]

The use of microcuff ETT (METT) in TEF patients is shown in one case report in China. In this case, repeated attempts to secure the airway with traditional techniques show large air leaks to the stomach. Using METT to occlude the fistula helps improve ventilation in this case. METT has an ultrathin polyurethane cuff (10 μm) which is distally placed along the shaft and provides an effective tracheal seal at low pressures. METT with a cuff pressure of <15 cm H2O showed no damage to the tracheal mucosa.[8]

Occasionally, when the TEF is at the carina or more distally, it is necessary to perform bronchial intubation and one-lung ventilation until the TEF is ligated. One-lung ventilation may improve ventilation by bypassing air leaks to the stomach. One-lung ventilation also improves surgical conditions for right-sided thoracotomy. However, to perform left endobronchial intubation, flexible fiber-optic bronchoscopy is needed. Due to the use of only left lung for ventilation; this technique may lead to hypoxemia, hypercarbia, and an increase in pulmonary vascular resistance.[1],[7],[8]

One case report also shows the effectiveness of the use of a specially modified bifurcated tracheal tube. In this technique, a longitudinal cut is made at the distal end of ETT so that the tip becomes branched with two half lumens measuring half the normal ETT size. Insertion of this tube uses FOB with the aim of each lumen entering the right and left bronchi so that it passes through the fistula.[9]

  Conclusion Top

EA/TEF is a complex anomaly that affects the baby's airway and also ventilation and oxygenation. Airway and ventilatory management are essential in reducing morbidity and mortality in these patients. Knowledge of the anatomy of the airway in the neonate and evaluating the shape of the anatomic anomaly can help in determining anesthesia management, especially airway management. Several approaches can be selected to secure the airway either using a traditional approach or using other modalities such as bronchoscopy, the use of special ETT, or attempt to occlude the fistula. After the airway is secured, the next step is to ensure adequate ventilation and oxygenation in anesthesia management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Broemling N, Campbell F. Anesthetic management of congenital tracheoesophageal fistula. Paediatr Anaesth 2011;21:1092-9.  Back to cited text no. 1
Edelman B, Selvaraj BJ, Joshi M, Patil U, Yarmush J. Anesthesia practice: Review of perioperative management of H-type tracheoesophageal fistula. Anesthesiol Res Pract 2019;2019:8621801.  Back to cited text no. 2
Choumanova I, Sanusi A. Anaesthetic Management of Oesophageal Atresia. Publisher location: Nigeria: Published Online; 2017. p. 1-5.  Back to cited text no. 3
Taneja B, Saxena KN. Endotracheal intubation in a neonate with esophageal atresia and trachea-esophageal fistula: Pitfalls and techniques. J Neonatal Surg 2014;3:18.  Back to cited text no. 4
Hernández-Cortez E. Airway in the newborn patient. J Anesth Crit Care Open Access 2016;5:1-7.  Back to cited text no. 5
Goswami D, Kachru N, Pant N. Difficult ventilation in a wide congenital tracheoesophageal fistula. Can J Anaesth 2012;59:118-9.  Back to cited text no. 6
Al-Rawi O, Booker PD. Oesophageal atresia and tracheo-oesophageal fistula. Contin Educ Anaesth Crit Care Pain 2007;7:15-9.  Back to cited text no. 7
Gupta A, Gupta N. Ineffective ventilation in a neonate with A large pre-carinal tracheoesophageal fistula and bilateral pneumonitis-microcuff endotracheal tube to our rescue! J Neonatal Surg 2016;6:14.  Back to cited text no. 8
Miyamoto Y, Kinouchi K, Taniguchi A, Kitamura S. A bifurcated tracheal tube for a neonate with tracheoesophageal fistula. Anesthesiology 2004;100:733-6.  Back to cited text no. 9


  [Figure 1], [Figure 2]


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