Seminars in Pediatric Surgery (2009) 18, 116-118

The pitfalls of endotracheal intubation beyond the fistula

in babies with type C esophageal atresia
Saleh I. Alabbad, MD,a Kenneth Shaw, MD,a
Pramod S. Puligandla, MD, MSc, FRCSC, FACS,a Rubin Carranza, MD,b
Chantal Bernard, MD,c Jean-Martin Laberge, MD, FRCSC, FACSa

From the Divisions of aPediatric Surgery, Montreal Children’s Hospital, McGill University Health Center, Montreal,
Quebec, Canada;
b
Anaesthesia, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada; and the
c
Pathology, Montreal Children’s Hospital, McGill University Health Center, Montreal, Quebec, Canada.

KEYWORDS The intraoperative management of a neonate with esophageal atresia (EA) and distal tracheoesophageal
Esophageal atresia; fistula (TEF) is a true anesthetic challenge. Pediatric anesthesia textbooks recommend a distal tracheal
Tracheoesophageal intubation beyond the fistula and spontaneous ventilation, if possible, until surgical control of the fistula
fistula; is achieved to minimize gastric distention. A full-term neonate with Trisomy 21 presented with an
Bronchoscopy; EATEF and was transferred to the operating theater for repair after appropriate evaluation. After
Complication induction of anesthesia, a size 3.0 endotracheal tube was inserted orally with confirmation of its position
by good air entry and chest movement bilaterally. After positioning for thoracotomy, the patient
desaturated and became bradycardic with abdominal distention. Despite reintubation, gastric needle
decompression, and bilateral pleural aspiration to exclude pneumothorax, cardiopulmonary resuscitation
was unsuccessful and the child died. Autopsy revealed the endotracheal tube in the trachea with its distal end
passing through a large distal TEF. Preoperative bronchoscopy may help the team to assess the size and
location of the distal TEF and plan for the best anesthetic strategy. It may also be useful to confirm tube
location after endotracheal intubation and intraoperatively in the event of cardiorespiratory instability.
© 2009 Elsevier Inc. All rights reserved.

The management of neonates with esophageal atresia
(EA) and tracheoesophageal fistula (TEF) has improved
significantly over the past few decades in terms of preop-
erative assessment and intraoperative techniques. Anesthetic
care has focused on minimizing ventilation through the fistula,
usually by placing the end of the endotracheal tube distal to
it, thus preventing gastric distension/perforation and/or ven-
tilatory compromise.1-4 Preoperative endoscopic airway
evaluation of patients with esophageal atresia and tracheo-
esophageal fistula (EATEF) is also an important aspect of
operative management because it provides information
about the exact size of the fistula, its location, and other
coexisting airway anomalies, including the presence of
proximal fistula.5-7 We report a neonate with EATEF type C
in which the endotracheal tube unknowingly passed into the
fistula, leading to the infant’s demise.

Address reprint requests and correspondence: Jean-Martin Laberge,

MD, FRCSC, FACS, Division of Pediatric Surgery, The Montreal Chil- Case report
dren’s Hospital, 2300, rue Tupper, Room C-820, Montréal (Québec), H3H
1P3. A full-term, 3.1-kg male neonate, with a prenatal ultrasound
E-mail address: jean-martin.laberge@muhc.mcgill.ca. showing polyhydramnios and right hydronephrosis was

1055-8586/$ -see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1053/j.sempedsurg.2009.02.011
Alabbad et al. Endotracheal Intubation Beyond the Fistula 117

born by cesarean section due to fetal distress. On evaluation,

the infant was found to have phenotypic features of Trisomy
21, and the pediatrician was unable to pass a nasogastric
tube through the esophagus. Chest and abdominal radio-
graphs demonstrated that the tube was coiled in the upper
esophagus. Furthermore, significant gastric distension was
also noted together with air in distal bowel loops, thus
confirming a diagnosis of EATEF (type C). In the neonatal
intensive care unit, the baby was stabilized, and the nasoe-
sophageal tube was placed on suction. Examination re-
vealed that the baby was breathing spontaneously and had
no other malformations; cardiac echogram was normal.
At the age of 12 hours, the baby was taken to the
operating room for definitive management.
After induction of anesthesia and gentle ventilation, the
baby was intubated with a size 3.0 endotracheal tube (ETT),
and its position was confirmed clinically by bilateral chest
movement and breath sounds on auscultation.
Shortly after positioning for a right thoracotomy, the
infant began to desaturate and became bradycardic. Increas-
ing abdominal distension was also noted. Despite two at-
tempts at reintubation, bilateral chest aspiration to exclude
pneumothorax, and gastric decompression with needle punc-
ture, the infant went on to cardiopulmonary arrest. The baby
died after a prolonged but unsuccessful resuscitation. The
family consented to a postmortem examination. The autopsy
confirmed the preoperative diagnosis of an EATEF (type C).
Although the ETT was found passing through the vocal cords
into the trachea, its distal end passed through a large distal
tracheoesophageal fistula 1.5 cm above the carina (Figure 1).

Discussion
The unrecognized intubation of a TEF at the time of oper-
ative repair is a potentially devastating complication. In this
report, we present such a complication that could have been
prevented by performing a preoperative bronchoscopy to
identify the location and size of the fistula for a safe and
successful intubation during operative repair. Furthermore,
flexible bronchoscopy through the endotracheal tube could
have helped to verify tube position.
Several authors have suggested that preoperative bron-
choscopic assessment is a critical step in the surgical repair
of an EATEF, and part of the anesthetic strategy. For ex-
ample, Holzki6 noted the location of the TEF in 113 patients
in his series. Eleven percent had a fistula below the carina,
22% were within 1 cm of the carina, and 67% were above.
Furthermore, he was able to identify other congenital anom-
alies requiring additional intervention, such as tracheomalacia
and vascular rings. The use of routine preoperative bronchos-
copy by Kosloske and coworkers and Atzori and coworkers5,7
has modified the operative approach for EATEF in 57% and
24% of their patients, respectively. Currently, many tertiary
institutions perform routine preoperative rigid bronchos-
copy, ventilating through the bronchoscope with low in-
Figure 1 (A) The blind upper pouch is seen with a probe, and
the endotracheal tube is visible passing through the vocal cords. It
was found to be passing through a large TEF 1.5 cm above the
carina, better seen in (B) after the distal esophagus and trachea
were opened. (Color version of figure is available online.)
spiratory pressure after induction of general anesthesia.
Once the position of the fistula is documented, one can
achieve a desirable endotracheal tube position and pre-
vent intraoperative ventilatory difficulties.1,8-10 Deanovic
and coworkers,9 in their 10-year experience with fiberoptic
tracheoscopy with intermittent positive pressure ventilation,
concluded that it did expedite and facilitate surgery and did
not cause clinically relevant impairment of ventilation.
The ideal anesthetic care for infants with EATEF is to
place the tip of the endotracheal tube below the level of the
fistula. The problem is that it is not always feasible as
discussed above. When possible (with a high distal fistula),
this maneuver will maintain adequate ventilation while also
decreasing the amount of air passing into the stomach.
Gastric distention may complicate the ventilation of patients
with large TEFs. Gastric distension may also result in the
aspiration of gastric contents, or the elevation of the dia-
phragm, leading to decreased tidal volumes, decreased ve-
nous return, and cardiovascular collapse. Patients who de-
saturate must be quickly and efficiently evaluated. One of
118
the most important aspects of this evaluation is to determine
the location of the ETT.1,2,4-6 One must realize that it is
difficult to definitively confirm the location of the tip of the
ETT exclusively by direct laryngoscopy or auscultation. A
common pitfall is to assume proper placement of the ETT
because it is seen to pass through the vocal cords. Indeed, a
properly placed ETT at the beginning of the case may slip
into a large fistula. This is particularly true during patient
positioning for thoracotomy or thoracoscopy. Flexible bron-
choscopy may be used to confirm proper placement of the
ETT with position changes. However, patients with persis-
tent desaturation need expedient bronchoscopic evaluation
and removal of the ETT, even if this occurs during the
thoracotomy. The rigid bronchoscope offers the possibility
to ventilate the patient while also visualizing the airway.
Other adjuncts in case of continued cardiorespiratory insta-
bility include needle decompression of the stomach and
pleura as well as occlusion of the fistula with a balloon via
emergent gastrostomy or via bronchoscopy.11-15
We conclude that, for optimum surgical management, a
preoperative bronchoscopy for patients undergoing EATEF
repair is a useful procedure that helps the team to identify
the number, size, and location of any TEF and plan for
anesthetic and operative strategy. Flexible and rigid bron-
choscopy are also useful intraoperatively in situations where
cardiopulmonary instability may occur. Both surgeon and
anesthesiologist should be familiar with these techniques
and have the instruments readily available throughout the
operation.
References
1. Ulma G, Geiduschek JM, Zimmerman AA, et al. Anesthesia for
thoracic surgery. In: Gregory GA, ed. Pediatric Anesthesia. Philadel-
phia, PA: Churchill Livingstone, 2002:441-2.
Seminars in Pediatric Surgery, Vol 18, No 2, May 2009
2. Ramos CT, Kim PCW. Management of the neonate: surgical consid-
erations. In: B Bissonnette, BJ Dalens, eds. Pediatric Anesthesia:
Principles and Practice. New York, NY: McGraw-Hill, 2002:985-7.
3. Greemberg L, Fisher A, Katz A. Novel use of neonatal cuffed tracheal
tube to occlude tracheo-oesophageal fistula. Paediatr Anaesth 1999;9:
339-41.
4. Reeves ST, Burt N, Smith CD. Is it time to reevaluate the airway
management of tracheoesophageal fistula? Anesth Analg 1995;81:
866-9.
5. Kosloske AM, Lewell PF, Cartwright KC. Crucial bronchoscopic
findings in esophageal atresia and tracheoesophageal fistula. J Pediatr
Surg 1988;5:466-70.
6. Holzki J. Bronchoscopic findings and treatment in congenital tracheo-
oesophageal fistula. Paediatr Anaesth 1992;2:297-303.
7. Atzori P, Iacobellia BD, Bottero S, et al. Preoperative tracheobron-
choscopy in newborns with esophageal atresia: does it matter? J Pe-
diatr Surg 2006;41:1054-7.
8. Andropoulos DB, Rowe RW, Betts JM. Anaesthetic and surgical
airway management during tracheo-oesophageal fistula repair. Paedi-
atr Anaesth 1998;8:313-19.
9. Deanovic D, Gerber AC, Dodge-Khatami A, et al. Tracheoscopy
assisted repair of tracheoesophageal fistula (TARTEF): a 10-year ex-
perience. Pediatr Anesth 2007;17:557-62.
10. Richenbacher WE, Ballantine T. Esophageal atresia, distal tracheo-
esophageal fistula, and an air shunt that compromised mechanical
ventilation. J Pediatr Surg 1990;25:1216-18.
11. Filston HC, Chitwood WR, Schkolne B. The Fogarty balloon catheter
as an aid to management of the infant with esophageal atresia and
tracheoesophageal fistula complicated by severe RDS or pneumonia.
J Pediatr Surg 1982;17:149-51.
12. Jones TB, Kirchner SG, Lee FA, et al. Stomach rupture associated with
oesophageal atresia, tracheoesophageal fistula, and ventilatoty assis-
tance. AJR Am J Roentgenol 1980;134:675-7.
13. Salem MR, Wong AY, Lin HV, et al. Prevention of gastric distention
during anesthesia for newborns with tracheoesophageal fistulas. An-
esthesiology 1973;38:82-3.
14. Maoate K, Myers NA, Beasley SW. Gastric perforation in infants with
oesophageal atresia and distal tracheo-oesophageal fistula. Pediatr
Surg Int 1999;15:24-7.
15. Bordet F, Combet S, Basset T, et al. Distension gastrique aigue
nécessitant une gastrostomie après induction anesthésique pour cor-
rection chirurgicale d’une atrésie de l’æsophage de type III. Ann Fr
Anesth Réanim 1998;17:1136-9.