Tracheo-esophageal fistula

1. TRACHEO-ESOPHAGEAL
FISTULA
Nidhi chauhan
M.Sc nursing final year
GCON.Jodhpur

2. Introduction
Tracheo esophageal fistula occurs in
one of 3000 to 5000 births. Before the
performance of the first successful
repair in 1939, this condition was fatal
over the post 50 years. Estimates today
suggest that in the absence of other
severe anomalies, survival rate in these
infants approach 100%.

3. DEFINITION
Tracheo esophageal fistula is an
abnormal connection between
trachea and oesophagus .These
disorder commonly found among
premature and low birth weight
neonate and mother’s having
polyhydramnias

5. RISK FACTORS OF TEF-
The exact cause of these anomalies
is not known in most cases. But
these anomalies develop due to
deviation of septum between the
oesophagus and trachea or altered
growth of septum between them.
It mostly occurs during fourth and
fifth week of gestational life.

6. • Heritable genetic factor
• Intrauterine environment
• Teratogenic stimuli

7. CLASSIFICATION
 Type I - EA without fistula (8%). There
is no connection of esophagus to
trachea. The upper (proximal) segment
and lower (distal) segment of
esophagus are blind.

9.  Type II - EA with TEF (upper). It is
rare and found in less than 1%of all
cases. Upper segment of esophagus
open into trachea by a fistula. The distal
or lower segment is blind.
 Type III -EA with Fistula (80-90%). It is
the most common type. In this
condition, proximal and upper segment
of the esophagus has blind end. The
distal lower segment of esophagus
connects into trachea by a fistula.

10.  Type IV –EA with TEF both upper and
lower segment. It is also rare, less than
1%. There is with fistula between both
proximal and distal ends of trachea and
esophagus.
 Type V-H shape type of TEF. It is
found in about 4% of all cases and not
usually diagnosed at birth. Both
proximal /upper and distal/lower
segments of esophagus open into
trachea by a fistula. No EA present

12. PATHOPHYSIOLOGY

13. • Respiratory distress may develop due to
gastric distension and elevation of
diaphragm.

14. CLINICAL MANIFESTATION
OF TEF-
The clinical feature appears soon
after birth.
 The baby presents with excessive
salivation, constant drooling, large
amount of secretions form nose, and
also shown 3 “C” signs .
coughing, chocking and cyanosis,
 gagging.

16. Intermittent unexplained cyanosis
occurs due to laryngospasm caused by
aspiration of accumulated saliva in blind
pouch.
On the very first feed, after first and
second swallow, the infant coughs,
chokes or fluid returns out through nose
and mouth. The infant struggle for
breath and cyanosis occurs.
Only abdominal distension and poor
feeding may found in some infants.

17. SOME OTHER ANOMALIES PRESENT
IN CLIENT WITH TEF.
LIKE - VACTERL
V- vertebral anomalies
A- anal atresia
C- cardiac malformation
T- tracheo esophageal fistula
R- renal anomalies
L- limb anomalies and hydrocephalus.

18. DIAGNOSIS OF TEF-
Clinical presentations arouse a strong
suspicious.
 Simple technique can be done to
diagnosis the condition with plain
catheter. Inability to pass catheter
through nose or mouth into the stomach
indicate blind pouch or atresia.

20. Antenatal diagnosis of the condition can
be done by USG.
Postnatal diagnostic procedures include
USG, plain X-ray of abdomen, chest X-
ray or passing of radio-opaque catheter
through esophagus and confirming the
anomalies by X-ray.
Bronchoscopy also help to confirm the
diagnosis.
ECG can be done to detect associated
cardiac anomalies

21. MANAGEMENT OF TEF-
a. Immediate management –
Immediately after diagnosis, the infant
should be managed with propped up
position(30 angle) to prevent reflux of
gastric secretion, and nothing per mouth,
oxygen therapy, I/V fluid therapy.

23. b. Nasogastric tube aspiration-
Nasogastric tube to be kept in situ and
suctioning to be done frequently to
prevent aspiration.
c. The blind pouch to be washed with
normal saline to prevent blocking of
tube with thick mucus.
d. Gastrostomy is done to decompress
the stomach and to prevent aspiration
and afterwards to feed the infant

25. e. Supportive care should include
maintenance of nutritional requirement
and warmth, prevention of infection,
antibiotic therapy, respiratory support,
detection and treatment of
complications, continuous monitoring of
patient condition, chest physiotherapy
and postural drainage.

26. SURGICAL MANAGEMENT
 The surgical correction of defect is done
by end to end anastomosis with
excision of the fistula by right
posterolateral thoracotomy followed by
intercostals chest drainage. This is done
when the infant has more than 2kg body
weight and no pneumonia present and
the baby is clinically stable.

27.  Surgical correction can be done in
stages with division of fistula.
Gastrostomy is performed in initial stage
followed by esophageal or colonic
transplant after 1year.
 Other surgical intervention includes
 Cervical esophagostomy, esophago-
coloplasty and esophago-gastroplasty

28. NURSING MANAGEMENT –
• Nursing management is very important
to detect the condition immediate after
birth or at first feed.
• Clinical features and problems to be
assessed promptly for lifesaving
measures.

29. The important nursing diagnosis
is include –
I. Preoperative-
• Risk for aspiration related to
esophageal abnormality.
• Risk for fluid volume deficit related to
inadequate oral intake.
• Parental anxiety related to congenital
anomalies of the neonate.

30. II. Postoperative –
• Ineffective airway clearance related to
surgical interventions.
• Altered nutrition, less than body
requirement related to inadequate oral
intake.
• Pain related to surgical intervention.
• Risk for infection related to hospital
procedures.
• Knowledge deficit related to home
based long term care.

31. NURSING INTERVENTION-
Nursing intervention are
performed based on nursing
diagnosis.
Preoperative intervention-
• Preventing aspiration by positioning,
suctioning and nothing by mouth, thus
reducing chance of respiratory
infections.

32. • Preventing dehydration by I/V fluid,
intake and output recording, monitoring
of vital signs and child’s general health.
• Preventing infections by infection
control measures.
• Reducing parental anxiety by emotional
support.

33. Postoperative intervention-
• Maintaining clear airway
• Providing adequate feeding by I/V fluid
and gastrostomy feeding.
• Reducing pain by analgesics and
comfort measures.
• Maintaining chest tube drainage with
necessary precautions.

34. • Preventing infection by general
cleanliness, hygienic measures and
administrating antibiotics.
• Improving knowledge by necessary
health education, encourage questions
and explaining the answers.

35. SUMMARY
Esophageal atresia is a failure of the
esophagus to form a continue passage
from the pharynx to the stomach during
embryonic development. These
anomalies develop due to deviation of
septum between the oesophagus and
trachea or altered growth of septum
between them.
It mostly occurs during fourth and fifth
week of gestational life.

36. • Simple technique can be done to
diagnosis the condition with plain
catheter.
• Postnatal diagnostic procedures include
USG, plain X-ray abdomen, chest X-ray
or passing of radio-opaque catheter
through esophagus and confirming the
anomalies by X-ray. Bronchoscopy
also help to confirm the diagnosis.

37. • Immediately after diagnosis, the infant
should be managed with propped up
position(30 angle) to prevent reflux of
gastric secretion, and nothing per
mouth, oxygen therapy, I/V fluid
therapy.
• Nasogastric tube aspiration nasogastric
tube to be kept in situ and suctioning to
be done frequently to prevent
aspiration.
• The blind pouch to be washed with
normal saline to prevent blocking of
tube with thick mucus

38. conclusion
• Most neonate who undergo repair of
TEF have some degree of esophageal
dysmotility. The extent of the repair
dictates the severity of subsequent
complication strictures at the site of the
anastomosis are common and may
subsequently require dilation.
• Serial esophagraphy should be
performed at two months, six months
and one year of age or whenever
swallowing difficulties occur