Post-intubation Tracheoesophageal Fistula In Severe Sars-cov-2 Covid-19 Patient: An Unexpected Finding During Swallowing Test

Abstract

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov2) has cause the COVID-19 pandemic that had led to an increase in intensive care unit admission for massive interstitial pneumonia. Many patients underwent mechanical ventilation and endotracheal intubation for a prolonged period of time followed by a subsequent tracheostomy. The most common complications related to these maneuvers are stenosis, malacia, laryngotracheal granulomas, webs. The least common complications are tracheal necrosis due to tracheo-arterial or trachea-esophageal fistulas, caused by compression between the nasogastric tube and the orotracheal tube cuff. A case of 58-year-old female COVID-19 patient with severe pneumonia who underwent prolonged mechanical ventilation and intubation and for two months with unexplained episodes of food inhalation. During the swallowing test, it was observed inhalation, without natural passage of food from the glottic plane. Therefore, ENT specialist in swallowing, suspecting the feared tracheo-esophageal fistula, requested a double contrast esophageal x-ray that confirmed the diagnostic hypothesis. Thoracic surgery team performed surgical correction by resection and tracheal anastomosis with esophagoraffia. TEF is a very rare, but potentially fatal, complication of invasive VM. Predisposing factors are prolonged periods of invasive VM, elevated cuff pressures, oversized endotracheal tubes, patient comorbidities, local and general infections, use of a nasogastric tube. The endoscopic swallow test is a relatively simple test, performed at the patient's bed, that can identify oropharyngeal swallowing disorders and esophageal changes, such as tracheoesophageal fistula.