Anesthesiology APPLIED Exam › Pediatric and neonatal

Tracheoesophageal fistula

Pediatric and neonatal·~5 min read· Physician-reviewed✓ Sourced · 2

Stem

A 1-day-old boy, 2.6 kg, born at 36 weeks, drools constantly and choked and turned blue with his first feed. An orogastric tube coils in the upper chest on radiograph, and there is gas in the stomach. He is breathing room air with SpO2 95%, has a soft murmur, and is booked for repair of esophageal atresia with a distal tracheoesophageal fistula.

Question

How will you prepare this neonate and manage the airway for the repair?

Ideal answer

HeadlineHe cannot protect his lungs, and positive pressure can go down the fistula: head-up, continuous upper-pouch suction, no mask ventilation, and an echo first.¹

Echocardiogram, then renal and spinal ultrasounds. Preterm with a murmur, and about half have other anomalies: cardiac disease drives mortality, and a right-sided arch changes the thoracotomy side.²
Keep him breathing spontaneously. Sevoflurane or a propofol infusion, no apnea-inducing boluses, while the surgeon bronchoscopes to locate the fistula.²
Tube below the fistula, above the carina, confirmed by left-chest auscultation and bronchoscope.²^,1
Arterial line, pre- and postductal oximeters,² as right lung and mediastinal retraction drops saturation and pressure.
No aggressive positive pressure until the fistula is ligated, because the stomach takes the gas.

Watch for: abdominal distension, rising airway pressure and falling end-tidal CO2: ventilating the stomach, or the tube has moved.

Breaking down the answer

Anomaly numbers — congenital heart disease in about 30%, at least three VACTERL lesions in 20–30%, a right arch in about 2.5%;² the surgeon approaches opposite the arch, so the echo sets up the whole case.
Why spontaneous ventilation — gas follows the path of least resistance, which can be the esophagus; gastric insufflation can force an emergency gastrostomy or rupture the stomach.²
Changes if — a fistula of 3 mm or less: positive pressure is reported safe.¹ A gastrostomy already in place can be vented or occluded, so I ask the surgeon's plan before I choose the induction.
Tube maneuver — into the right mainstem, then withdraw listening on the left until breath sounds appear, and secure,¹ bevel anterior to cover the posterior-wall fistula. A fistula near the carina cannot be isolated by any tube position: a 4 Fr Fogarty balloon occludes it.²
Why the line and blood — retracting the right lung and mediastinum causes hypoxemia and hypotension; azygos ligation sits near large vessels.² A precordial stethoscope over the left chest detects tube migration within a breath.
Thoracoscopic repair — CO2 insufflation at about 5 mmHg still causes hypercapnia and acidosis in a small neonate, so I follow blood gases closely.¹
Extubation — most stay intubated 24–48 hours, a long-gap repair longer to limit anastomotic tension.² Under about 2 kg, tracheomalacia or poor lung function usually means staying intubated.¹

Follow-up question

After the chest is open and the right lung retracted, the saturation falls to 78% and the peak airway pressure climbs. End-tidal CO2 is falling and the abdomen looks fuller.

What is happening and what do you do?

Follow-up answer

HeadlineTube migration into the fistula or massive gastric insufflation; I tell the surgeon now and ask for the retractor to be released.

I hand-ventilate with 100% oxygen and auscultate. Lost end-tidal CO2 with desaturation means I have intubated the fistula; a tense abdomen with poor breath sounds means gas is going to the stomach.² I pull back until breath sounds return, confirm with the fiberoptic scope, and vent a gastrostomy if present. A collapsed right lung: suction blood or secretions, check retractor kinking. Ligating the fistula first solves both problems. Once he is stable I accept an SpO2 above 88% with permissive hypercarbia.²

Pitfalls that cost points

Giving a relaxant and bag-mask ventilating with no plan for where the gas goes.
Describing extubation without the warning about the anastomosis and the limit on neck extension.

Rapid-fire

Q: Why does a right aortic arch matter? A: The surgeon approaches through the side opposite the arch, so a right arch can mean a left thoracotomy.¹

Q: Why avoid nitrous oxide? A: It expands the gas in the stomach and bowel and lowers the inspired oxygen in a baby with a retracted lung.

Q: Which type is most common? A: Gross type C, esophageal atresia with a distal fistula, in about 85%; the isolated H-type fistula is about 4% and presents later with coughing on feeds.¹

Q: The tube migrates through the suture line after repair. What do you do? A: Avoid manipulating it, withdraw slightly until breath sounds return, ideally under fiberoptic guidance, and have the most experienced provider reintubate.²

Numbers to know

Item	Value
Type C frequency	~85% of cases¹
Congenital heart disease	~30%²
Right aortic arch	~2.5%²
Thoracoscopic insufflation	~5 mmHg¹
Fogarty for fistula occlusion	4 Fr²
Postoperative ventilation	Most stay intubated 24–48 h²

Sources

1.Anesthetic management of tracheo-esophageal fistula · Current Challenges in Thoracic Surgery (AME) · ccts.amegroups.org
2.Tracheoesophageal Fistula (SPA Case Guide) · Society for Pediatric Anesthesia, 2025 · www2.pedsanesthesia.org

Facts on this page were checked against these sources on Oct 14, 2026. Guidelines change; confirm doses against current institutional protocols.