Hammer, Jürg

Lücking-Famira, Klaus

Schulzke, Sven

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TEF. Despite surfactant application and a trial of high frequency oscillatory venti-lation, assisted ventilation became progres-sively difficult due to increasing abdominaldistension. Respiratory function was fur-ther impaired by the presence of a patentductus arteriosus (PDA). Decompressivegastrostomy on day 3 failed to improvepulmonary gas exchange because persistentair shunt resulted in increasing pneumo-peritoneum and further clinical deteriora-tion. On day 5, non-invasive TEF occlu-sion was therefore attempted by re-intubat-ing the infant with an ETT featuring a micro-thin high-volume-low-pressurepolyurethane cuff located very close to thetip (Microcuff; ID 3.0 mm). Correct place-ment was confirmed by flexible bronchos-copy: the TEF was visualized 5–10 mmabove the carina and the ETT advanced un-til complete covering of the fistula wasachieved. Cuff inflation to less than15 cmH2O successfully occluded the airshunt, while single deflation led to imme-diate recurrence of air leakage into theperitoneal cavity. Secondary TEF repair,anastomosis of both oesophageal pouches,and PDA ligation were performed on day10. Following surgery, the infant was re-intubated with an uncuffed (ID 2.5 mm)ETT. Rigid bronchoscopy after surgical repair and a subsequent flexible bronchos-copy prior to successful extubation on day27 of life did not reveal any signs of tra-cheal mucosal damage.Various modes of temporary TEF oc-clusion (besides emergency fistula repair)have been advocated in infants sufferingfrom respiratory instability due to “low-resistance” TEF, namely transtracheal ortransabdominal TEF occlusion using anembolectomy Fogarty catheter, ligation of the lower esophageal pouch or, most recently, TEF occlusion using a cuffedETT in a term infant [1, 2, 3]. Our casehighlights that even in the smallest prema-ture infants, cuffed ETT can be safely usedfor at least several days to occlude TEF after fiberendoscopic visualization [4] andfacilitate respiratory support prior to defi-nite surgical repair. However, the appropri-ate ETT size for the intended airway is crucial in order to minimize the risk of tra-cheal injury. It seems noteworthy that theMicrocuff ID 3.0 mm ETT’s outer diame-ter (OD) of 4.1 mm exceeds the uncuffedPortex ID 2.5 mm ETT’s OD of 3.7 mmand even the smallest manufactured cuffedETT (Ruesch; ID 2.5 mm/OD 4.0 mm) byjust 0.4 and 0.1 mm, respectively. The newhigh-volume-low-pressure cuffs allow tra-cheal sealing at fairly low cuff pressures[5]. Cuff pressures should be meticulouslymonitored to remain at “just seal” or, atleast, below the capillary perfusion pres-sure (<20 cmH2O). Despite concerns re-garding cuffed ETT in premature infants,tracheal damage was ruled out in our patient by serial bronchoscopies and thelong-term absence of clinical signs of airway obstruction after extubation.References1. Andropoulos DB, Rowe RW, Betts JM(1998) Anaesthetic and surgical airwaymanagement during tracheo-oe-sophageal fistula repair. Pediatr Anaesth8:313–3192. Richenbacher WE, Ballantine T (1990)Esophageal atresia, distal tracheoesoph-ageal fistula and an air shunt that com-promises mechanical ventilation. J PedSurg 25:1216–12183. Greemberg L, Fisher A, Katz A (1999)Novel use of neonatal cuffed trachealtube to occlude tracheo-oesophageal fistula. Pediatr Anaesth 9:339–3414. Holski J (2000) Novel use of neonatalcuffed tracheal tube to occlude tracheo-oesophageal fistula. Pediatr Anaesth10:571–5725. Dullenkopf A, Gerber A, Weiss M(2003) Fluid leakage past tracheal tubecuffs: evaluation of the new Microcuffendotracheal tube. Intensive Care Med 29:1849–1853K. M. Lücking-Famira (✉) · S. SchulzkeJ. HammerDivision of Neonatal and Pediatric Intensive Care,University Children’s Hospital Basel,PO Box 4005, Basel, SwitzerlandIntensive Care Med (2004) 30:1249DOI 10.1007/s00134-004-2249-x C O R R E S P O N D E N C EKlaus Michael Lücking-FamiraSven SchulzkeJürg HammerCuffed endotracheal tube for occlusion of a tracheo-oesophageal fistula in an extremely low birth-weight infantReceived: 2 December 2003Accepted: 17 February 2004Published online: 15 April 2004© Springer-Verlag 2004Sir: Large distal tracheo-oesophageal fistu-las (TEF) in type C oesophageal atresiamay compromise respiratory support inpremature infants suffering from severerespiratory distress syndrome (RDS), dueto an air shunt through the fistula leadingto abdominal distension, subsequent intes-tinal rupture, and peritonitis. We report onthe successful temporary TEF occlusion byusing a newly designed cuffed endotrache-al tube avoiding emergency surgical TEFligation in an extremely low birth-weightinfant. Traditional teaching prohibits theuse of cuffed endotracheal tubes (ETT) inchildren below 8 years of age. Our reportchallenges this dictum in critical situationseven for very premature infants.A male infant (birth weight 770 g) wasdelivered by caesarian section after abrup-tio placentae at 27 weeks of gestation. Fol-lowing immediate intubation with an un-cuffed ETT [Portex; 2.5 mm internal diam-eter (ID)] due to severe respiratory distress,an unsuccessful attempt was made to passa nasogastric tube into the stomach. X-raysshowed signs consistent with significantRDS and a nasogastric tube coiled in theproximal oesophageal pouch; air-filledstomach and bowel loops supported the diagnosis of oesophageal atresia with distal

Cuffed endotracheal tube for occlusion of a tracheo-oesophageal fistula in an extremely low birth-weight infant

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Cuffed endotracheal tube for occlusion of a tracheo-oesophageal fistula in an extremely low birth-weight infant

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