Tracheo-oesophageal fistula and oesophagal atresia are birth defects where the esophagus does not form properly, either failing to connect to the stomach or connecting abnormally to the trachea. They occur in about 1 in 3500 births. Surgical intervention is required to divide any abnormal connections or perform anastomosis to reconnect the esophagus. Nursing care focuses on preventing aspiration, maintaining nutrition via feeding tubes, and managing pain and comfort after surgery. Complications can include tracheomalacia, anastomotic leaks, strictures, and reflux.

2. Introduction
• Tracheo-oesophageal fistula and
Oesophagal 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.

3. DEFINITION
Oesophagal Atresia
Oesophagal Atresia is the failure of
oesophagus to form a continuous
passage from the pharynx to the
stomach.
Tracheo-oesophageal fistula
Tracheo-oesophageal fistula is an
abnormal connection between the
trachea and the oesophagus.

4. EPIDEMIOLOGY
• Tracheo-oesophageal fistula occurs in 1 in 3500
births, with slight male dominance. Oesophagus
atresia with or without Tracheo-oesophageal
fistula is common in prematurity, with 34% of
cases weighing less than 2500 grams.
• Approximately 50% of neonates with oesophagus
atresia or Tracheo-oesophageal fistula have other
anomalies also. Usually cardiac anomalies are
seen in 14.7 – 28 % cases of TEF.

5. ETIOLOGY
• The cause of Tracheo-
oesophageal fistula and
Oesophagal Atresia is still
unknown.

6. PATHOPHYSIOLOGY
• The upper part of oesophagus is developed from
the retropharyngeal segment and lower part from
the pregastric segment of foregut. At about 4
weeks of gestation, a laryngo-tracheal groove is
formed which divides the foregut into two
longitudinal tubes, which further develop into the
respiratory tract and the digestive tract. Defective
separation due to deviated or incomplete septum
or incomplete fusion of tracheal fold results in
malformation of trachea and oesophagus.

7. TYPES OF TEF
Type A:
In this type, there is Oesophagal Atresia
and proximal and distal segments of
oesophagus are blind. There is no
communication between trachea and
oesophagus. This type is present in 3-7
% of cases.

8. Types B:
In this type, Oesophagal Atresia is
present and the blind proximal segment
of oesophagus connects with trachea by
a fistula. The distal end of oesophagus is
blind. This type is present in 0.8 %
cases.

9. Type C:
In this type, Oesophagal Atresia is
present. The proximal end of oesophagus
is a blind pouch and distal segment of
oesophagus is connected by fistula to
trachea. This is the commonest type,
present in about 87 % cases.

10. Type D:
It is the rarest type that occurs in 0.7 %
cases. In this type, both upper and
lower segments of oesophagus
communicate with trachea.

11. Type E:
In this type, oesophagus and trachea
are normal and completely formed but
are connected by a fistula. This type is
also known as ‘H’ type and is present in
4.2% cases.

12. CLINICAL MANIFESTATIONS
The disorder is usually detected soon after
birth when feeding is attempted on the
basis of following :
1. Violent response occurs on feeding
 Infant coughs and chokes
 Fluid returns through nose and mouth.
 Cyanosis occur
 The infant struggles

13. Cont.… coming out of nose and constant
2. Excessive secretions
drooling of saliva.
3. Saliva is frothy.
4. Abdominal distension occurs in presence of type III, IV
and V fistula.
5. Intermittent unexplained cyanosis and laryngospasm,
caused by aspiration of accumulated saliva in blind
oesophageal pouch.
6. Pneumonia may occur due to overflow of milk and
saliva from oesophagus through fistula into the lungs.

14. DIAGNOSTIC EVLUATION
The EA/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

15. 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:;
 Bronchoscopy visualizes fistula between trachea
and esophagus;
 Abdominal ultrasound and echocardiogram to
check for cardiac abnormalities.

16. TREATMENT
• The management of trachea-
oesophageal fistula is mainly surgical.
Surgical intervention depends on the
distance between proximal and distal
pouch of oesophagus, type of defect,
condition of neonate and his weight.

17. If distance between upper and lower
oesophageal segments is less than 2.5
cm and if the condition of infant is
good, primary repair is done by
division and ligation of the fistula
along with end-to-end anastomosis of
proximal and distal segments of
oesophagus.

18.  Staging Surgery: When the distance between the two
oesophageal segments is large and condition of the
infant is poor, a two- stage procedure may be
required:
 Initially in the first stage, the trachea-oesophageal
fistula is ligated and gastrostomy done to reduce the
risk of reflux and to provide feeding.
 In the second stage, both proximal and distal
oesophageal segments are anastomosed. If the gap is
too large, a segment of colon is used for
reconstruction of the oesophagus. This is done at
about 18-24 months.

19. NURSING DIAGNOSIS
Pre-Operative
Risk for aspiration related to
structural abnormality.
Risk for deficient fluid volume related
to inability to take oral feeds.
Impaired breathing related to
frequent laryngospasm and excessive
secretions in the trachea.

20. Post-Operative
Ineffective airway clearance related
to disease process.
Impaired nutrition related to surgery.
Altered comfort related to surgical
process.

21. NURSING INTERVENTION
A nasogastric tube is put in the upper
oesophageal segment and is aspirated
frequently, to prevent collection and
aspiration of secretion into the trachea.
Intravenous fluids are administered to
maintain the hydration status of infant.
Place the infant in semi-upright position
and administer oxygen if cyanosis is
present.

22. A cervical oesophagostomy is made
to drain out secretions from blind
oesophageal pouch and administer
oxygen to infant.
Feed the infant orally or by
gastrostomy.
Position the baby comfortably in
semi-fowler’s position and administer
analgesics.

23. COMPLICATION
Tracheomalacia (weakness of tracheal wall)
Anastomotic leak (tension)
Strictures (narrowing, esophageal dilation)
Dysphagia (esophageal motility disorder)
Respiratory distress
Gastro-esophageal reflux.