CME information and disclosures
To see contributor disclosures related to this article, click on this reference: [1]
Physicians can earn CME/MOC credit by using this article to address a clinical question and completing a brief evaluation about how they applied the information in their practice.
AMBOSS designates this internet point-of-care activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
For answers to questions about AMBOSS CME, including how to redeem CME/MOC credit, see “Tips and links” at the bottom of this article.
Summary
Acquired tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus caused by another condition (e.g., malignancy, trauma). Acquired TEF typically manifests with cough, dysphagia, dyspnea, and/or recurrent lung infections. Barium esophagogram and/or endoscopy confirm the diagnosis. Treatment involves a multidisciplinary team focusing on preventing aspiration, managing the underlying cause, and closing the fistula via surgery or endoscopy.
See also “Congenital tracheoesophageal fistula.”
Etiology
-
Malignancy [2]
- Esophageal cancer (most common malignant cause) [2]
- Lung cancer
- Prolonged endotracheal intubation or tracheostomy
- Excessive cuff pressure of tracheostomy or endotracheal tube
- Mediastinal surgery (e.g., esophagectomy)
- Esophageal or airway stent erosion
- Trauma (e.g., penetrating neck injury)
- Infection (e.g., tuberculosis, histoplasmosis, actinomycosis) [3]
- Ingestion (e.g., foreign body ingestion, caustic ingestion)
- Inflammatory diseases (e.g., rheumatoid arthritis, inflammatory bowel disease) [3]
Clinical features
Clinical features vary based on size, location, and rate of formation of the fistula. [2]
- Nonventilated patients [3]
-
Ventilated patients [2]
- Air leak despite inflated cuff
- Inability to wean off ventilator
- Gastric distention
- Symptoms of underlying cause
-
Symptoms of complications [3]
- Recurrent aspiration pneumonia
- Malnutrition
Diagnosis
- Confirm the diagnosis with barium esophagram and/or endoscopy (i.e., esophagoscopy, bronchoscopy). [2]
- Obtain additional diagnostics under expert guidance to guide treatment, e.g.: [2]
- CT chest
- Esophagoscopy
- Bronchoscopy
Treatment
Treatment is guided by a multidisciplinary team, including gastroenterology, pulmonology, thoracic surgery, and oncology. [2]
Initial management [2][3][4]
- Prevent aspiration in acquired TEF.
- Remove nasogastric tubes and orogastric tubes to minimize further injury.
- Provide nutritional support via jejunostomy tube or parenteral feeding.
- Manage underlying cause (e.g., malignancy, infection).
- Determine definitive management in consultation with multidisciplinary team.
Acute respiratory distress
In patients with known acquired TEF presenting with respiratory distress signs or clinical features of airway obstruction:
- Consider intubation past the level of the TEF if airway compromise is present.
- Patients with tracheostomy: See “Tracheostomy complications.”
- Consider repeat diagnostics (e.g., endoscopy, CT chest) to assess for evolution of the TEF.
- Start treatment of pulmonary aspiration.
Aspiration prevention in acquired TEF [2][3]
- Establish NPO status.
- Elevate head of bed ≥ 45 degrees.
- Perform frequent oral suctioning.
- Administer acid suppression medications.
- Consider gastrostomy tube for gastric decompression.
- In ventilated patients, advance ETT below TEF.
Definitive management [2][3]
Spontaneous closure of acquired tracheoesophageal fistula is rare, and intervention is typically required. [3]
Complications
- Aspiration pneumonia [3]
- Malnutrition [3]
We list the most important complications. The selection is not exhaustive.
3 free articles left this month