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LETTER TO EDITOR Table of Contents  
Ahead of print publication
Usefulness of flexible bronchoscopy for securing the airway in traumatic tracheal perforation during tracheostomy with development of tracheo-esophageal fistula

 Department of Anaesthesiology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

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Date of Submission21-Apr-2020
Date of Decision15-May-2020
Date of Acceptance25-May-2020
Date of Web Publication23-Jul-2020

How to cite this URL:
Rajan S, Mathew J, Babu KC, Daniel D. Usefulness of flexible bronchoscopy for securing the airway in traumatic tracheal perforation during tracheostomy with development of tracheo-esophageal fistula. Bali J Anaesthesiol [Epub ahead of print] [cited 2021 Apr 22]. Available from: https://www.bjoaonline.com/preprintarticle.asp?id=290531


The passage of the tube into a false track during tracheostomy can be fatal if not detected on time. Recently, we managed a 57-year-old woman with carcinoma of the hard palate, who underwent maxillectomy with free-flap reconstruction. Tracheostomy was attempted at the end of surgery for postoperative ventilation. During tracheostomy, the oral endotracheal tube (ETT) was partially withdrawn, and a tracheostomy tube was placed under direct vision, but without end-tidal carbon dioxide (EtCO2) tracing or breath sounds while ventilating through the tracheostomy tube.

We removed the tracheostomy tube and re-introduced the ETT with EtCO2 confirmation. However, absence of EtCO2 despite two subsequent reinsertion attempts of tracheostomy tube, led to suspicion of a false passage. Then, we loaded the tracheostomy tube onto a fiberoptic bronchoscope (FOB), and after identifying carina, it was railroaded into the trachea with the confirmation of EtCO2 readings and breath sounds upon positive pressure ventilation. The patient was ventilated postoperatively using volume-control mode with the following settings: tidal volume (TV) 400 ml, respiration rate 16/min, and positive-end expiratory pressure 5 cmH2O. However, expired TV remained 250–300 ml, and oxygen saturation remained 85%–90%. On examination, the patient was able to phonate, and a leak sound was noted from the mouth with the presence of abdominal distension. A chest X-ray showed pleural effusion, and ultrasound showed fluid in the lung.

Repeat flexible bronchoscopy through tracheostomy was essentially normal. We suspected a rent on the posterior tracheal wall located above the tip of the tracheostomy tube and below the lower part of the cuff. Then, the FOB was introduced up to the carina, and then we temporarily withdrew the tracheostomy tube over the FOB. On inspection, rent on the posterior tracheal wall was identified, and tracheoesophageal fistula (TEF) was diagnosed. The tracheostomy tube was changed to Shiley extended-length tube, keeping the cuff inflated just above the carina but below the fistula so that no gas leaks into the esophagus, enabling ventilation. The patient was weaned off the ventilator after 2 weeks, and bronchoscopy showed no fistula. She was decannulated later and had an uneventful recovery.

Postintubation TEF is a rare complication of prolonged mechanical ventilation but can happen during tracheostomy as well. Posterior tracheal perforation is considered a catastrophic event with the potential for esophageal injury and TEF.[1] The membranous portion of the posterior tracheal wall is susceptible to injury, especially in the elderly and short-statured. Overinflation of the cuff or direct trauma during the insertion of tracheostomy with the obturator in place may cause injury to an already-vulnerable posterior wall.[2] TEF following prolonged ventilation has been a well-reported complication of tracheostomy with an incidence of ≤1%.[3] This is usually caused by mucosal ischemia secondary to prolonged intubation and the use of high cuff pressures (≥30 cmH2O). Frequent movement of the tube tip, simultaneous use of the large and rigid nasogastric tube, hypotension, hypoxemia, anemia, and poor nutrition aggravate the mucosal injury.[4] Bronchoscopy is useful in detecting TEF after extubating susceptible patients.[5] Usually, smaller fistulae heal spontaneously, but large TEFs require surgical intervention.

The possibility of tracheal perforation during tracheostomy should be kept in mind. In doubtful cases, identifying the trachea with an FOB and railroading the tracheostomy tube over it will help to correctly place a tracheostomy tube, especially when a false passage has already been created.

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

Cipriano A, Mao ML, Hon HH, Vazquez D, Stawicki SP, Sharpe RP, et al. An overview of complications associated with open and percutaneous tracheostomy procedures. Int J Critical Illness Injury Sci 2015;5:179-88.  Back to cited text no. 1
Deganello A, Sofra MC, Facciolo F, Spriano G. Tracheotomy-related posterior tracheal wall rupture, trans-tracheal repair. Acta Otorhinolaryngol Ital 2007;27:258-62.  Back to cited text no. 2
Saputra DJ, Senapathi TG, Aribawa IG, Ryalino C. Awake intubation fiberoptic bronchoscope on pregnancy patient undergo decompression laminectomy and cervical fusion stabilization. Bali J Anesthesiol 2019;3:140-2.  Back to cited text no. 3
Diddee R, Shaw IH. Acquired tracheo-oesophageal fistula in adults. Continuing Education in Anaesthesia. Crit Care Pain 2006;6:105-8.  Back to cited text no. 4
Green MS, J Mathew J, J Michos L, Green P, M Aman M. Using bronchoscopy to detect acquired tracheoesophageal fistula in mechanically ventilated patients. Anesth Pain Med 2017;7:e57801.  Back to cited text no. 5

Correspondence Address:
Sunil Rajan,
Department of Anaesthesiology, Amrita Institute of Medical Sciences, Kochi, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/BJOA.BJOA_55_20


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