Discussion
The main goals of EA/TEF management are timely recognition of underlying
malformation and reduction of associated complications. To our knowledge
this is the first study concerning preoperative management of neonates
with EA/TEF and moderate respiratory distress; where we utilized the
novel FE-NIV-SPI approach to make accurate diagnosis, insert NTFG tube
and subsequent management to stabilize condition before surgical
intervention.
Shunting of ventilation through the fistula presents a major challenge
in managing neonates of EA/TEF with respiratory distress requiring PPV
support. Placing the ETT tip distal to the fistula is the principle key
to minimize ventilation loss through fistula. However, majority of the
TEFs reported are located within 1.0 cm from carina or even at the level
of carina, making this distal placement of ETT
difficult.17 Routine preoperative endoscopy in
neonates with EA/TEF remains inconsistent, but several studies
highlighted its usefulness in locating the fistula and associated airway
anomalies for deciding operating approach.6,7,18–21Previous literatures described using Fogarty catheter6or a semi-rigid umbilical catheter7 either to directly
balloon-occlude the fistula or prevent gastric distention, respectively,
for improving lung ventilation. This case series demonstrated that the
FE-NIV offered a practical and effective benefits in both pre- and
post-operative clinical management.
This FE-NIV-SPI technique provides several advantages especially in
high-risk neonates. 1) In our previous study11 of same
setting, the SPI with duration of 0 to 5 seconds could create well
correlated positive pressure levels of 4.1±3.3 to 65.5±18.5
cmH2O in laryngopharyngeal space. This transient,
dynamic and controllable positive pressure is safe and enough to expand
the collapsed aeroesophageal lumens in case of EA/TEF. 2) Oxygen
insufflation through the nasopharyngeal catheter can directly flush
upper airway dead space, as the effects of “apneic
oxygenation”,22-26 which may significantly prolong
onset of desaturation. 3) Both assist inspiration and expiration can be
optionally achieved by this simple maneuver to provide enough
oxygenation and ventilation. 4) No instruments such as mask, ETT,
ventilation bag or mechanical ventilator are needed, hence eliminate
preparation time and provide an unobstructed and unimpeded viewing field
for FE assessment and manipulation. 5) With improved PPV and visual
field, that facilitates accurate FE assessment of aeroesophageal tracks
such as length of TM, orifice diameter of TEF, distance between TEF and
carina, depth of the blind esophageal pouch; and consequent
interventions such as precise insertion of NTFG tube, ETT intubation,
laser and balloon measurement and even stent implantation in these
compromised neonates.
The NTFG tube placement has the following advantages. 1) Early occlusion
of the fistula prevents PPV loss that eliminate distension of stomach or
intestine, as the Case 1 with duodenal atresia (DA), and allows for
gastric feeding. 2) It facilitates effective lung ventilation, even in
neonates who require ETT PPV. 3) It offers stabilizing option that can
avert the need for emergent gastrostomy. 4) It preserves intact
peritoneal cavity and provides future benefits for intra-abdomen
procedures. 5) During surgical repair of EA/TEF, NTFG tube decompression
declines risk of surgical field contamination by gastric contents. 6)
NTFG tube can also act as a guide for locating the fistula during
operation. For patients similar to Case 1, staged repair consisting of
gastrostomy and fistula ligation followed by DA repair one week later
had been reported.27 This approach could allow for a
less hurried and well-prepared simultaneous surgical correction of both
EA/TEF and DA lesions in one session. Nevertheless, cannulation of NTFG
tube or concurrent ETT intubation require skillful technique of FE-NIV,
especially when performed in small neonates with multiple comorbidities.
Further large studies are required for validation and widespread
application.