Tracheo-esophageal Fistula (TEF)
Oesophageal Atresia
Failure of oesophagus to continuous passage from pharynx to stomach.
Tracheo-esophageal fistula (TEF)
TEF is congenital abnormalities, commonly found in premature or low birth weight infant.
It is abnormal connection (fistula) between trachea and oesophagus.
Etiology
1. History of maternal with polyhydramnios.
2. TEF present with VACTERL Syndrome.
V - Vertebral Column defecs
A - Anorectal malformation
C - Cardiac defects
TE- Tracheo-esophageal fistula
R - Renal anomalies
L- Limb anomalies
3. Teratogenic stimuli
4. Genetic factor
Classification of TEF
1. Type I
2. Type ll
3. Type lll
4. Type lV
5. Type V
1. Type 1
Esophageal atresia without fistula.
The upper segment of esophagus and lower segment of esophagus are blind.
There are no connection of esophagus to trachea.
2. Type ll
Esophageal atresia (EA) with TEF. Upper segment of esophagus is open into trachea by fistula. Distal or lower segment of esophagus is blind.
3. Type lll
Esophageal atresia with TEF. Upper segment of oesophagus has blind end. Distal or lower segment of esophagus connects into trachea by fistula.
4. Type lV
Esophageal atresia with double fistula. Both upper and lower segment ends of esophagus have fistula with trachea.
5. Type V
H type TEF.
Both upper and lower segment of esophagus open into trachea by fistula.
No esophageal atresia present.
Pathophysiology
In Intrauterine life, during 4th and 5th week of gestation failure of trachea and oesophagus.
The abnormality of tracheo esophagus occurs due to defective separation, incomplete fusion of the tracheal folds.
Clinical manifestations
1. Excessive salivation
2. Constant drooling
3. Large amount of secretions from mouth
4. Coughing and chocking and gagging
5. Cyanosis and laryngospasm
Caused by aspiration of accumulated saliva in blind esophageal pouch.
6. Abdominal distension incase of type lll, type lV and type V fistula.
7. Apnea
8. Pneumonia
Due to overflow of milk and saliva from oesophagus through fistula into lungs.
9. After first feed, infant cough, choked, or fluid return through nose and mouth.
Diagnostic Evaluation
1. Ultrasound of Pregnant women; Polyhydraminos
2. Chest X ray; air filled esophageal pouch and air in stomach.
If feeding tube inserted; appear coiled up in upper esophageal pouch.
3. Bronchoscopy
4. Ultrasound
Identification of type of tracheo-esophageal fistula.
5. Diagnosis suspected; attempt is made to pass feeding tube through nose or mouth into stomach. If not pass into stomach; baby with oesophageal atresia.
Management
1. If distance between upper and lower esophageal segment is less than 2.5cm; primary repair done by division and ligation of fistula along with and to end anastomosis proximal and distal segments of oesophagus.
2. Staging surgery
When distance between two oesophageal segment is large;
1. Initial first stage;
Tracheo esophageal fistula is ligated and gastrostomy done (Surgical opening through skin of abdomen to stomach; reduce risk of reflux and to provide feeding).
2. Cervical oesophagostomy
Drain out saliva from proximal blind oesophageal pouch
3. Inter costal chest drainage, posterolateral thoracostomy.
4. In second stage;
Both proximal and distal oesophageal segment anastomosed.
If gap is to large segment of colon used for reconstruction of oesophagus (done at 18-24months of age).
After repairs, oesophagostomy and gastrostomy are closed.
Nursing Diagnose
Preoperative;
1. Risk of aspiration related to structural abnormality.
2. Risk of deficient volume related to inability to take oral feeds.
3. Ineffective airway clearance related to frequent laryngospasm and excessive secretion of trachea.
Post operative
1. Ineffective airway clearance related to disease process evidence by surgery.
2. Risk of infection related to surgical incision and longer stay in hospital as evidence by surgical incision.
3. Fluid volume deficit as evidence by nil oral intake and less output.
4. Anxiety related to disease process and care of baby after discharge.
Management
Immediate management
1. NPO
2. Head elevated 30 degree Celsius; to prevent reflux of gastric secretion.
3. Nasogastric tube aspiration
4. Oxygen therapy
5. IV fluid therapy
6. Blind pauch to washed with NS
7. Antibiotic therapy
8. Respiratory support
9. Chest physiotherapy
10. Continuous monitoring of patient
11. Postural drainage
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