introduction, deinition, types, pathophysiology,clinical manifestation, management

2. TRACHEO ESOPHAGEAL
FISTULA & ESOPHAGEAL
ATRESIA
Jayasmini mohanty
Tutor, KINS, KIIT,
deemed to be
university , BBSR

3. Tracheo-oesophageal fistula and
Oesophageal Atresia are the
malformation of digestive system, in
which oesophagus does not develop
properly.
The oesophagus is a tube that normally
carries food from the mouth to stomach.

4.  ESOPHAGEAL ATRESIA
Esophageal Atresia (EA) is failure of esophagus to
form a continuous passage from the pharynx to
the stomach during embryonic development.
TRACHEO-ESOPHAGEAL FISTULA
Tracheo- esophageal fistula is an abnormal
connection between trachea and esophagus.

6.  The incidence of the various forms of EA in the
general population is approximately 1 in 4000 live
births or 1 in 3,500 live births.
 These disorders are commonly associated with
congenital malformation & found among
premature or LBW infants and mothers having
polyhydramnios.
 EA is similar to that of a TEF and can occur with
or without the presence of a fistula.

7. The exact cause is unknown.
 Some factors influencing the incidence of the
problems are
• heritable genetic factor,
•teratogenic stimuli and intra-uterine
environment,
• offspring’s of affected adults,
•sporadic response of twins,
• siblings.

8.  TE fistulas occur due to abnormal separation of the
caudal foregut during the fourth and
fifth weeks of embryonic development. Normally,
the trachea forms as a diverticulum of the foregut
and develops a complete septum that separates the
esophagus from the trachea.

9.  An abnormal posterior positioning of
the tracheoesophageal septum will result in
retained connection between the two
compartments, resulting in fistula formation and
atresia of the esophagus.
 Isolated esophageal atresia without TE fistula can
occur when the esophagus fails to recanalize during
week 8 of development.

12.  EA without fistula
(8%).
 It is second most
common type.
 There is no
connection of
esophagus to trachea.
 The upper(proximal)
segment and lower
(distal) segment of
esophagus are blind.

13. EA with TEF
(upper).
 It is rare and
found in less than
1% of all cases.
 Upper segment of
esophagus open
into trachea by a
fistula.
 The distal or lower
segment is blind.

14.  EA with TEF (80-90%).
 It is the most common
type.
 In this condition,
proximal or upper
segment of the esophagus
has blind end.
The distal lower segment
of esophagus connects
into trachea by a fistula.

15.  EA with TEF both
upper and lower
segment.
It is also rare (less
than 1%).
There is EA with
fistula between
both proximal and
distal ends of
trachea and
esophagus

16.  H- type TEF.
It is found in about 4%
of all cases and not
usually diagnosed at
birth.
 Both proximal/upper
and distal/lower
segments of
esophagus open into
trachea by a fistula.
No EA present.

17.  Excessive salivation (blowing
bubbles)
 Constant drooling
 Large amount of secretion from nose
 Coughing
 Chocking
 Cyanosis

18.  Gagging
 Unexplained saliva in blind pouch.
 On the very first feed, after first or
second swallow, the infant coughs,
chocks or fluid returns out through
nose and mouth.
The infant struggle for breath and
cyanosis occurs.

19.  plain catheter introduce to diagnose the condition
Antenatal diagnosis include
o USG may reveal the polyhydramnios,
o small abdomen,
odistended esophageal pouch.

20.  Postnatal diagnostic procedure include
 USG,
 plain X-ray abdomen,
 chest X-ray
 Passing of radio-opaque catheter through
esophagus and confirming the anomalies by X-
ray
 Flexible Bronchoscopy may be useful for
diagnosis of acquired TEF, to identify the level
of fistula.
 ECG and Echocardiogram can be done for
cardiac anomalies

21.  IMMEDIATE MANAGEMENT/MEDICAL
MANAGEMENT
 SURGICAL MANAGEMENT
 NURSING MANAGEMENT

23.  the infant should be managed with
propped up position(30o angle) to
prevent reflux of gastric secretion,
 NPO
 O2 therapy
 I/V fluid therapy
 Nasogastric tube aspiration
 The blind pouch to be washed with
normal saline to prevent blocking of tube
with thick mucus.

24. Gastrostomy to be done:-
 To decompress the stomach
 To prevent aspiration and
 To feed the infant

25. Supportive treatment should include:-
 Maintain of nutritional requirements and
warmth
 Prevention of infections
 Antibiotic therapy
 Respiratory support
 Detection and treatment of complications
 Continuous monitoring of patients condition
 Chest physiotherapy and
 Postural drainage by continue suction with
Replogle’s catheter every 5mins gently with

27.  Surgery depend upon child’s condition:-
• If the distance between the upper and
lower esophageal segment is less than
2.5c.m, weight of the infant in more than
2kg and the condition of the infant is
clinuicallygood
• primary repair is done by division and
ligation of fistula along with end to end
anastomosis of proximal and distal
segment of the esophagus.

28. Staging the surgery:-
When the distance between the two
esophageal segments is large and
condition of the infant is poor, a two
stage procedure may be required:
 Initially in the First stage, the tracheo-
esophageal fistula is ligated and
gastrostomy done to reduce the risk of
reflux and to provide feeding.

29.  In the second stage, both proximal and
distal esophageal segments are
anastomosed. If the segment is too large,
a segment of colon is used for the
reconstruction of the esophagus. This is
done at about 18 to 24 months.
Other surgical interventions include
cervical esophagostomy,
esophago-coloplasty, and
esophago-gastroplasty.

30.  The EAT Program at Boston Children's is the only
center in the world dedicated to using a highly
advanced surgical technique, known as the Foker
process, to treat cases of long-gap esophageal
atresia (EA).
 The Foker process can be performed on children as
small as 7 pounds (3.5 kg), and it takes anywhere
from several weeks to several months to complete,
depending on the severity of the condition.

31.  place small sutures in the disconnected or damaged
ends of the esophagus and add small amounts of
tension to those sutures daily.
 Over time, the tension stimulates the esophageal
ends to grow longer and the two ends eventually
grow closer together.
 The ends are then surgically connected to restore
esophageal continuity.
 Though the esophageal muscle may not contract
normally, the native esophagus may serve a child
better long term than other organs or parts of
organs that are sometimes used to replace the
esophagus, such as the stomach, intestine or colon.

33. a)Assessment:-
Nursing assessment is very important to
detect the condition immediate after birth or
at first feed.
 Detailed history of the child’s condition
 Clinical features and problems of the child
 Proper physical examination

34. Pre operative Nursing diagnosis
Post- operative nursing diagnosis

35. NURSING DIAGNOSIS NURSING INTERVENTION
1. Risk for aspiration
related to
esophageal
abnormality
Preventing
aspiration by
 Proper positing in
propped up position
 Carefully suctioning
 Nothing per mouth,
thus reducing the
chance of infection

36. NURSING DIAGNOSIS NURSING INTERVENTION
Preventing the
dehydration
 By giving I/V fluid as
prescribed by
physician
 Daily input and
output recording
 Monitoring of vital
signs and child’s
general health
2.Risk for fluid
volume deficit
related to
inadequate oral
intake.

37. NURSING DIAGNOSIS NURSING INTERVEWNTION
 3.
3. Parenteral
anxiety related to
congenital
anomalies of the
neonate.
Parent’s Anxiety
reduced by
 Giving
psychological
support
 Emotional support
 Health education

38. NURSING DIAGNOSIS NURSING INTERVENTION
1. Ineffective
airway clearance
related to surgical
interventions
 Maintaining airway
clearance by doing
the suctioning
 Maintaining Proper
positioning of the
patient
 Proper observation to
prevent the chocking
of the patient

39. NURSING DIAGNOSIS NURSING INTERVENTION
2. Pain related to
surgical interventions
 Reducing the pain
by giving
analgesic
 Maintaining the
comfort measures
 By giving
psychological
support

40. NURSING DIAGNOSIS NURSING INTERVENTION
3. Altered nutrition,
less than body
requirements related
to inadequate oral
intake.
 Providing adequate
feeding by I/V fluid
 Giving gastrostomy
feeding
 Measuring the weight
and input and output
chart

41. NURSING DIAGNOSIS NURSING INTERVENTION
4. Risk for infection
related to hospital
procedure
 Preventing infection
by maintaining
general cleanliness
 Maintaining hygienic
measures
 Administering
antibiotic as
prescribed by
physician

42. NURSING DIAGNOSIS NURSING INTERVENTION
5. Knowledge deficit
related to home based
long term care.
 Improving knowledge by
necessary health
education
 Encouraging the question
and explaining the
answering
 Practicing the procedure
to the patient and the
relatives in hospital for
doing in home.

43. 1. Esophageal stricture- 40%
2. Anastomotic leak- 14-21%
3. Fistula reoccurrence
Other post-operative complication include
4. Gastroesophagal Reflux Disease: Very common
(40-70%)
 GERD is managed with upright positioning
 Thickened feedings and
 Administration of prokinetic agents like
Domperidone

44. 5. Tracheomalacia:
 The diagnosis may be best made by
bronchoscopy
 The typical finding is “fish mouthing” or
tracheal collapse during inspiration at
the level of aortic arch.
6. Disturbed mobility of the esophagus and
stomach.

45. Is guarded. I t is not just a anatomical
aberration.
• Recurrent fistulas are a major concern.
• High incidence of restrictive and
obstructive lung disease has been
recorded.

48.  The best therapeutic approach for acquired
tracheoesophageal fistula can be determined with
careful consideration of relevant parameters on
admission, including medical history, presenting
findings, etiology, and characteristics of the fistula,
in addition to the clinical evaluation in the follow-
up period. In general, conservative management
should precede definitive surgical intervention both
to allow for possible spontaneous closure and also
to achieve optimal preoperative status. Primary
repair or a staged surgical approach can be best
selected by giving priority to the patient's airway
security.

49.  An infant admitted in M.K.C.G. Medical with
complain of coughing, cyanosis and chocking
when feed, Write down what may be the
diagnosis and treatment with nursing
management

50. 1. What is the most common type of neonatal
tracheo esophageal fistula?
2. The common complications following repair of
esophageal atresia and tracheo esophageal
fistula?
3. The most common cause of duodenal obstruction
is
4. An 8 hour old new born has mild respiratory
distress and excessive drooling. An abdominal
radiograph shows complete lack of air in the
gastrointestinal tract. What is the most likely
diagnosis?
5. The vacterl association most commonly including
which of the condition?

51. 1.Dutta parul, Pediatric Nursing, 2nd edition, Jaypee
brothers Medical publishers (p) Ltd. (2010), PP- 301-
305.
2. Wong’s, Essentials of pediatric Nursing, 8th Edition,
2009, Marilgn Hopckenberry, PP-854-855.
3. En.wikipedia.org/wiki Tracheo-esophageal fistula.
4. Varghese Susamma, Susmitha Anupama, Text book of
Pediatric Nursing, 1st Edition (2015), The health science
publishers (p) Ltd, New
Delhi/London/Philadelphia/panama, Pp-301-304.

54. Remember Embryology:
The esophagus and trachea both develop from
the primitive foregut. In a 4- to 6-week-old
embryo, the caudal part of the foregut forms
a ventral diverticulum that evolves into the
trachea

55.  The longitudinal tracheoesophageal fold fuses to
form a septum that divides the foregut into a
ventral laryngotracheal tube and a dorsal
esophagus. The posterior deviation of the
tracheoesophageal septum causes incomplete
separation of the esophagus from the
laryngotracheal tube and results in a TEF.

56. Syndrome that can be associated with it 
VACTERL including:
Vertebral anomalies
Anorectal anomalies
Cardiovascular anomalies
TrachoEsophagial fistula
Renal anomalies
Limb anomalies

57.  should be performed
by an experienced
pediatric radiologist,
or after transfer to
the tertiary
institution, and with
the use of a small
amount (0.5 to 1 mL)
of water-soluble
contrast. Care must
be taken to avoid
aspiration.