MUHIMBILI UNIVERSITY OF HEALTH AND ALLIED SCIENCES.

SCHOOL OF NURSING.DERPARTMENT OF CLINICAL NURSING

PEDIATRIC NURSING( PD300)PRESENTATION:TOPIC - TRACHEO ESOPHAGEAL FISTULA

PRESENTER:JOHN, Songoma .Reg NO 2009-04-01476SUPERVISOR :MR. MENTI NDILE

INTRODUCTION• Esophageal atresia (EA) is the congenital malformation that

represent the failure of the esophagus to develop a continuous passage up to the stomach

• Tracheo esophageal fistula (TEF) is the congenital malformation where the trachea and esophagus fails to separate into distinct structures and a passage is created between the two.

• Tracheoesophageal defect is a serious, congenital condition in which there is an abnormal connection between the trachea and the esophagus; the esophagus ends before reaching the stomach and/or the esophagus develops as a pouch connected to the trachea by a fistula.

Esophagus : tube that connects the mouth to the stomach

Trachea: "windpipe“ Atresia : absence of a normal opening

Congenital : found at birth. Fistula : abnormal passage from a body organ to

the body surface or between two internal body organs.

CLASSIFICATION OF TEF• Classified by American Academy of Pediatrics as• TYPE A : It consists of blind upper and blind lower esophageal

segment without any tracheo- esophageal fistula (3.7 to 7%).• TYPE B : It involves fistula from trachea to upper oesophageal

segment (0.8%). • TYPE C: It type in which proximal esophageal segment

terminates in a blind pouch and the distal esophageal segment is connected to trachea or primary bronchi by a short fistula at or near tracheal bifurcation (86%).

• TYPE D : It involves fistula from trachea to both upper and lower esophageal segments (0.7 to 6%).

• TYPE E : It refers to H type TEF which are having otherwise normal trachea and oesophagus that are connected by a fistula (4.4- 7%)

TYPES

INCIDENCE & EPIDEMIOLOGY

• Occurs in 1:3000 to 1:4500 live births. Equal gender incidence EA associated with prematurity. A history of maternal polyhydroamnios is present in approx. 50% of infants with the defects. Often present with VATER/VACTERL syndromes. (VATER/VACTERL is acronyms that describe the associated anomalies of vertebral, ano-rectal, cardiovascular, tracheo-esophageal, and renal and limb abnormalities). Possible influences Inherent genetic factor , teratogens Environment factor Prematurity & low birth weight.

PATHOPHYSIOLOGY

• Upper part of esophagus is developed from retropharyngeal segment and the lower part from pregastric segment of the first part of primitive gut. At 4- 5weeks of gestation the laryngo-tracheal groove is formed. Two longitudinal furrows develop and separate the respiratory premordium from esophagus. Deviation or altered cellular growth of the septum results in formation of fistula between esophagus and trachea. Successive stages in the development of the tracheoesophageal septum durin g embryologic development.

Causes

• Congenital TEF can arise due to failed fusion of the tracheoesophageal ridges during the third week of embryological development.TEF can also occur due to pressure necrosis by a tracheostomy tube in apposition to a nasogastric tube (NGT).

Environmental (Acquired) Causes

• Although exposure to certain medications and infections during pregnancy have been proposed as possible risk factors for development of esophageal atresia/tracheoesophageal fistula (EA/TEF), no external factor has been consistently linked to the development of EA/TEF

• Exposure to methimazole during pregnancy .• Maternal diabetes mellitus .

Heritable Causes

• Chromosome anomalies have been reported in approximately 6%-10% of individuals with EA/TEF . EA/TEF is found in the following aneuploidy syndromes :

• Trisomy 21 (~0.5%-1.0% of affected individuals)

• Trisomy 18 (~25% of affected individuals)• Trisomy 13 • (Mosaic) trisomy X

Signs and Symptoms • Excessive oral secretions

• Constant drooling or Excessive salivation.• Intolerance of feedings• Regurgitation of feedings• Periodic episodes of choking and cyanosis• When fed, infant swallows but coughs, gags, and returns feeding through the nose and mouth• Respiratory distress from aspiration of secretions• Abdominal distention occurring soon after birth when air from the trachea enters esophagus and stomach through the fistula

DiagnosisEA/TEF may be suspected prenatally if• ultrasound examination reveals polyhydramnios, absence of a

fluid-filled stomach, a small abdomen, lower-than-expected fetal weight, and a distended esophageal pouch

• Fetal MRI may be used to confirm the presence of EA/TEF TEF may be detected postnatally by• X-ray taken with radiopaque catheter placed in esophagus to

check for obstruction; standard chest X- ray shows a dilated air-filled upper esophageal pouch and can demonstrate pneumonia

• inability to pass a NG tube into stomach because it meets resistance; required

• bronchoscopy visualizes fistula between trachea and esophagus; abdominal ultrasound;

• and an echocardiogram to check for cardiac abnormalities.

Treatment of Manifestations• Initial postnatal intervention, aimed at minimizing

the risk of aspiration pneumonia, typically includes the elimination of oral feeds, placement of a suction catheter to allow continuous drainage of secretions, and elevation of the head of the bed to minimize reflux .

• Intravenous (IV) glucose and fluids should be provided; supplemental oxygen should be administered as needed.

• When intubation cannot be avoided, a possible complication is the collection of air in the stomach, which in severe cases can only be removed by gastrostomy

Treatment of Manifestations

• Surgical repair consists of closure of the TEF and anastomosis of the esophageal segments .

• Surgical repair may need to be delayed in infants with low birth weight, pneumonia, or other major congenital anomalies.

• When surgical repair is delayed, infants may be treated with parenteral nutrition, gastrostomy tube placement, and upper pouch suctioning until they become surgical candidates.

• The most common complications after surgical repair include leakage at the site of the anastomosis, recurrent fistula, structure formation, and gastroesophageal reflux

Treatment of Manifestations

Surgery:• Usually an emergency, is performed as soon as infant is stable.• Involves ligation of fistulas and anastamosis of esophagus to stomach.• Completed in one procedure if possible or done as a staged repair. Supportive care until surgery; IV antibiotics; GT inserted before surgery to decompress stomach.

NURSING MANAGEMENT.• Assess for symptoms immediately after birth

• Assess patency of esophagus before feeding or putting to breast• Evaluate difficulty feeding, respiratory distress, excess drooling, choking, and coughing• Assess lung sounds• Use semi-Fowler’s position to prevent reflux of gastric contents into trachea and to ease respiratory effort• Monitor respiratory status closely• Prevent aspiration• Maintain fluid and electrolyte balance

NURSING MANAGEMENT • Administer IV fluids to prevent dehydration

• Provide emotional support and reassurance to parents• Encourage parents to spend as much time with infant as possible• Place in warm, humidified environment

• The infant is immediately deprived of oral intake (NPO) Start IV fluids.

• Removal of secretions from the mouth and upper pouch requires frequent or continuous suction with Replogle’s catheter every 5 min gently with pressure of 50 cm of H₂O.

• Broad spectrum antibiotic therapy is often instituted.

CLIENT TEACHING FOR SELF-CARE

• Involve parents in care of infant to facilitate bonding by means of touch and eye contact• Offer information to parents about the defect, surgical repair, pre- and postoperative care and prognosis, and need for possible further surgery• Teach parents how to administer gastrostomy feedings until esophagus heals

COMPLICATIONS

• Tracheomalacia (weakness of tracheal wall) Anastomotic leak (tension) Strictures (narrowing, esophageal dilation) Dysphagia (esophageal motility disorder) Respiratory distress Gastroesophageal reflux (positioning, semisolids, fundoplication).

reference• www.cincinnatichildrens.org/health/info/ent/diagnose/trach-

fistular.htm• Boxwell, G. (Ed), (2000). Neonatal intensive care nursing.

London: Routledge; Chapter 15, Surgical Aspects; pp 347 - 352 • Chambers MA, & Jones, S. (eds).2007. Surgical nursing of

children, Edinburgh: Butterworth Heinemann Elsevier, Chapter 9, Neonatal Nursing.

• Ghai OP, Paul K Paul, Bagga Arvind. Essential Pediatrics . CBS publishers. 17 th edition. Pp 151 Meharban singh . Care of newborn. 6 th edition. Sagar publications. Pp 138 Marilyn J. Hockenberry , Wilson, Essentials of Pediatric Nursing, Elsevier, 8 th edition. 465-473.

• www. Wikipedia . Com/ tracheoesophageal atresia/