Acute respiratory failure from esophageal dilatation

Excerpt

A 44-year-old woman with a history of asthma was intubated for severe acute respiratory failure with stridor, not responding to bronchodilators and steroids. In ICU, passive respiratory mechanics under volume-controlled-ventilation excluded both peripheral obstructive disease (airways resistance 13 cm H₂O/l/s) and restrictive disease (respiratory system compliance 50 ml/cm H₂O), with rapid normalization of gas exchange. An upper airways obstruction was suspected, consistent with no air leak at the endotracheal tube’s cuff deflation test. A chest x-ray (Fig. 1a) showed a mid-proximal esophageal kinking and important dilatation, with large amounts of air and ingested food and thickened esophageal walls. This orients to extrinsic tracheal compression as the cause of acute respiratory failure related to a sudden pressure increase in the esophagus due to food ingestion. Recognition of esophageal dilatation redirected therapeutic management. Esophageal emptying by esophagogastroduodenoscopy is the key treatment to allow restoration of tracheal patency and therefore weaning from mechanical ventilation; nasogastric tube placement is crucial to prevent subsequent postprandial relapses. If a partial tracheal compression is visualized by CT-scan (Fig. 1b), despite esophageal emptying, the patient should be oriented to surgical treatment (Heller myotomy).

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