Bronchoesophageal fistula

Excerpt

A 57-yr-old woman with a history of radiation to the neck and mediastinum for Hodgkin’s lymphoma years prior presented with coughing during eating, dysphagia, and unintentional weight loss. Her investigation revealed a bronchoesophageal fistula (Figure), and she was referred for surgery. Airway management with preservation of spontaneous ventilation and flexible bronchoscopic (FB) intubation was considered to avoid positive-pressure ventilation and iatrogenic injury during intubation to the area involving the fistula. However, given a reassuring upper airway examination and potential difficulty associated with awake intubation with a double-lumen endotracheal tube (DL-ETT), the decision was made to proceed otherwise. Following induction of general anesthesia and administration of succinylcholine, the trachea was intubated via direct laryngoscopy followed immediately by further FB-guided advancement of the left-sided DL-ETT into the appropriate position. Positive-pressure ventilation was thus avoided in the right lung entirely. Following successful repair of the fistula, expeditious extubation was performed to avoid positive-pressure ventilation of the surgically repaired bronchus.

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