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.

Tracheoesophageal fistula is a connection between the esophagus and the trachea.

The esophagus is the tube that connects the throat to the stomach. The trachea is the
tube that connects the throat to the windpipe and lungs. 

TE fistula is an abnormal connection between the esophagus and the trachea.

Risk Factors

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.
• Heritable genetic factor
• Intrauterine environment
• Teratogenic stimuli

PATHOPHYSIOLOGY
 The newborn with TEF is unable to swallow effectively which results in
accumulation of saliva and feed in upper oesophageal pouch and aspration in
respiratory passage.
 Abdominal distension occurs due to air entering the lower oesophagus through
the fistula and passing into the stomach during crying
 Respiratory distress may develop due to gastric distension and elevation of
diaphragm
  Upper part of esophagus is developed from retropharyngeal segment and the lower part
of the first part of primitive gut.
  At 4-5 weeks of gestation the laryngeal-tracheal groove is formed.
  Two longitudinal furrows develop and separate the respiratory tract permordium from
esophagus.
  Deviation cellular growth of the septum results in formation of fistula between esophagus
and trachea.


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

 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.

 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

 type A: isolated esophageal atresia (8%)

 type B: proximal fistula with distal atresia (1%)
 type C: proximal atresia with distal fistula (85% - most common)
 type D: double fistula with intervening atresia (1%)
 type E: isolated fistula (H-type) (4%)
 A fetus with esophageal atresia cannot effectively swallow amniotic fluid,
especially when TEF is absent; in a fetus with esophageal atresia and a distal
TEF, some amniotic fluid presumably flows through the trachea and down the
fistula to the gut.
 The neonate with esophageal atresia cannot swallow and drools copious
amounts of saliva.
 Also, air from the trachea can pass down the distal fistula when the baby cries,
strains, or receives ventilation; this condition can lead to an acute gastric
perforation, which is often lethal.
  Prerepair esophageal manometric studies have revealed that the distal
esophagus in esophageal atresia is essentially dysmotile, with poor or absent
propagating peristaltic waves.

Clinical Manifestation

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,

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.

Nursing Management

1. Physical exam. The acronym VACTERL (vertebral defects, anorectal

malformations, cardiovascular defects, tracheoesophageal defects, renal
anomalies, and limb deformities)

2. 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.
3. 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
4. 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.

Nursing Diagnosis
1. 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.
2. 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.
NURSING INTERVENTION
Preoperative intervention-
• Preventing aspiration by positioning, suctioning and nothing by mouth, thus reducing chance of
respiratory infections.
• 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.
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.
• Preventing infection by general cleanliness, hygienic measures and administrating antibiotics. •
Improving knowledge by necessary health education, encourage questions and explaining the
answers.