Diagnosis of inadvertent oesophageal intubation with H-type tracheo-oesophageal fistula

Editor—Tracheo-oesophageal fistula is a common congenital paediatric surgical condition with an incidence of 1 in 3500 to 1 in 4500 live births; it is usually diagnosed immediately after birth because of its association with oesophageal atresia.¹ The isolated tracheo-oesophageal fistula, without oesophageal atresia, termed H-type tracheo-oesophageal fistula, is uncommon with an incidence of 4–5% of all cases of tracheo-oesophageal fistula.² The common presenting feature is repeated respiratory tract infection and chronic cough or choking on feeding,² which usually escapes early diagnosis and is often confused with gastro-oesophageal reflux disease.2, 3 Airway management in these patients can be challenging, with possible inadvertent oesophageal intubation.

As an example, we report a case of a 1.5-yr-old 7 kg male child with a history of repeated lower respiratory tract infections since birth, failure to thrive, and delayed developmental milestones admitted for further evaluation (written consent for this report was obtained from the parents). There was a history of choking episodes on oral ingestion of liquids; CT imaging was inconclusive for diagnosis of tracheo-oesophageal fistula, and no other congenital anomalies were detected. Bronchoscopic evaluation of the trachea was performed to confirm the diagnosis, exclude gastro-oesophageal reflux disease, localise the fistula, and rule out associated laryngo-tracheal abnormalities. In the theatre, the child developed severe bronchospasm on being induced by mask with sevoflurane. As mask ventilation was difficult, anaesthesia was deepened, and atracurium bromide 5 mg and fentanyl 15 μg were administered i.v. to facilitate tracheal intubation; HR was 145–150 beats min⁻¹ with pulse oxygen saturation of 90–92%.

On direct laryngoscopy, only the epiglottis could be seen and a 4.5 mm uncuffed tracheal tube was inserted with bilateral chest rise and breath sounds. The tracheal tube was fixed at 10 cm at the angle of the mouth, and volume controlled ventilation with sevoflurane 1.5–2 vol% in 50% air:oxygen initiated. End-tidal carbon dioxide (ETCO₂) was ∼1.5 kPa. A leak was evident with set tidal volume =70 ml, delivered tidal volume =40 ml; as this was a diagnostic procedure, the leak was accepted without changing to a larger tracheal tube. A neonatal flexible bronchoscope (2.8 mm outer diameter) (Karl Storz, Tuttlingen, Germany) was introduced into the tube to locate the fistula, but once it crossed the distal end of the tube, the trachea could not be identified, while muscular folds of the oesophagus and the nasogastric tube could be seen. The bronchoscope was removed and repeat laryngoscopy was performed with cricoid pressure, which showed that the tube was in the oesophagus. Another 4.5 mm uncuffed tracheal tube was introduced into the trachea, followed by a sharp increase in ETCO₂ (>6 kPa) and oxygen saturation improvement to 96–97%. Repeat bronchoscopy showed the fistula 2.5–3 cm from the carina in the posterior tracheal wall (Fig. 1). The child was extubated upon completion of the procedure and made an uneventful recovery with definitive surgery planned 1 month later.

Fig 1.

A patent fistula (arrow) is seen in the posterior tracheal wall 2.5–3 cm from the carina.

In children, tracheal intubation can be difficult because of a large epiglottis, big tongue, and a relatively bigger head compared with the thorax,⁴ with a possibility of oesophageal intubation. Oesophageal intubation is quickly recognised however, as it leads to stomach distention, absence of capnogram, and immediate desaturation and hypoxaemia.⁵

There were several reasons oesophageal intubation was not suspected immediately in this patient, as the fistula was large enough (>2.8 mm) to allow adequate ventilation and signs of tracheal intubation without stomach distention. Nevertheless, vigilance is necessary in cases of suspected oesophageal fistula.

Declaration of interest

The authors declare that they have no conflicts of interest.