A Fatal, Post-Intubation, Tracheoesophageal Fistula

Despite the use of safer tubes with high-volume, low-pressure cuffs, post-intubation injury is still the leading cause of benign, acquired, tracheoesophageal fistula (TEF). Cuff pressure, which is their primary pathogenetic driver, is not routinely monitored as a quality metric. To highlight the devastating consequences, we report this case of a fatal, iatrogenic fistula in a 64-year-old Asian male. He had undergone tracheostomy due to amyotrophic lateral sclerosis (ALS) and had a series of hospitalizations due to recurrent episodes of pneumonia. A TEF was eventually diagnosed to be the underlying cause. Esophageal stenting was ineffective. We intend to present teaching points aimed at reducing the risk of TEF in ventilator-dependent patients.