H-type tracheo-oesophageal fistula in an infant4-month-old girl, 5.4 kg, for ligation of an H-type tracheo-oesophageal fistula through a neck incision

The patient

The examiner asks

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1. Consider

   What are the issues?

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   • A 4-month-old with an H-type fistula and repeated chest infections, for ligation through the neck. Patient
   • As an infant she loses heat fast and desaturates quickly; theatre is warmed first.
   • Repeated aspiration has injured her lungs; her chest must be at its best. Disease
   • VACTERL screen: spine, anus, kidneys, limbs and especially her heart.
   • Shared airway at bronchoscopy, a fistula that steals ventilation, and neck surgery near both laryngeal nerves. Surgery

2. Prepare

   How do you get her ready?

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   • Echo before surgery; in the EA/TEF group about a fifth have a major heart defect. Disease
   • Nil by mouth on tube feeds, nursed head-up to limit soiling through the fistula.
   • Chest clear now; arterial line if her gas exchange worsens.
   • Plan with the surgeon: bronchoscopy first, a wire through the fistula, then the neck approach. Surgery

3. Plan

   How do you manage her airway?

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   • Gas induction, keeping her breathing on her own until the fistula is tied. Airway
   • Topical lidocaine to her cords; the surgeon bronchoscopes and passes a wire through the fistula.
   • Tube then passed so its tip lies past the fistula but short of the carina.
   • Only small, low-pressure breaths; relaxant avoided or delayed.
   • Nasogastric tube left open to air to vent any gas that crosses.
   • After positioning for the neck incision, I recheck tube position. Surgery

4. Crisis

   After positioning, ventilation becomes hard, her abdomen distends, SpO2 85% and ETCO2 falls. What do you do?

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   • Tube in the fistula or gas into her stomach: tell the surgeon to stop. (Crisis)
   • Hand-ventilate on 100% oxygen with small breaths; check tube depth and both sides.
   • The surgeon can feel whether the tip sits in the fistula; I reposition it.
   • Aspirate her stomach through the nasogastric tube to relieve splinting.
   • Back to spontaneous breathing where possible until the fistula is tied.

5. Crisis

   After extubation she has stridor and a hoarse cry; SpO2 93%. What do you do?

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   • Oxygen, upright, kept calm; I watch her work of breathing. Crisis
   • Causes: recurrent laryngeal nerve injury from the neck dissection, tube oedema, or tracheomalacia.
   • Hoarseness suggests one nerve; both nerves injured can close her glottis.
   • Nebulised adrenaline and dexamethasone treat oedema, not a nerve palsy.
   • Worsening obstruction: reintubate and ventilate her in PICU; ENT to look at her cords. After surgery