Tracheoesophageal fistula for bsc nursing

bsc nursing students

1. TRACHEOESOPHAGEAL FISTULA JANNET MARIA ELIAS LECTURER COLLEGE OF NURSING NIRMALA MEDICAL CENTRE, MUVATTUPUZHA

2. INTRODUCTION Definition Tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus.

3. INCIDENCE It occur in 1 in 3,500 births, Slight male dominance. Prematurity is common with associated TEF, with 34% of these infants weighing less than 2500 gm.

4. Conti.. Approximately 50% of neonates with TEF have other anomalies Cardiac anomalies is the most common (14.7% to 28%) and life-threatening. Associated anomalies include defects of the vertebrae, anorectal malformations, cardiac defects, renal defects.

5. Conti… Cause unknown in most cases. Possible influences include : Inheritable genetic factor; Twin babies Siblings Offspring of affected adults Teratogenic stimuli Environmental factors Heredity Genetic factors

6. Conti… Failure of proper separation of the embryonic channel into the esophagus and trachea occurring during the fourth and fifth weeks of gestation.

7. CLASSIFICATION A- 3.7% to 7% B-0.8% C-86% D-0.6-0.7% E-4.4% -7%

8. Conti.. Type I (Type A) : Proximal and distal segments of esophagus are blind; there is no connection to trachea; accounts for 8% of cases; second most common . TRACHEA ESOPHAGUS

9. Conti.. Type II (Type B): proximal segment of esophagus opens into trachea by a fistula; distal segment is blind; rare, 3% of cases. TRACHEA ESOPHAGUS FISTULA

10. Conti.. Type III (Type C): proximal segment of esophagus has blind end; distal segment of esophagus connects into trachea by a fistula; most common, with 85% of cases TRACHEA ESOPHAGUS FISTULA

11. Conti.. Type IV (Type D): esophageal atresia with fistula between proximal and distal ends of trachea and esophagus; (rare 1% of cases).

12. Conti.. Type V (Type E) : proximal and distal segments of esophagus open into trachea by a fistula; no esophageal atresia but sometimes referred to as an H-type fistula; occurs in 4.4% to 7% of cases, not usually diagnosed at birth.

13. PATHOPHYSIOLOGY The baby with TEF is unable to swallow effectively which result in accumulation of saliva or feed in upper esophageal pouch and aspiration in respiratory passage. Gastric secretion may regurgitate through distal fistula.     Abdominal distension may occur due to air entering the lower esophagus through the fistula and passing into the stomach during crying.    respiratory distress may develop due to gastric distension and elevation of the diaphragm  

14. CLINICAL MANIFESTATIONS 3 cardinal signs – cough, choking and cyanosis Excessive secretions Intermittent unexplained cyanosis Laryngospasm Abdominal distention Violent response of baby Poor feeding Inability to pass catheter through nose or mouth into stomach

15. DIAGNOSTIC EVALUATION Assessment Ultrasound scanning techniques X-ray of abdomen and chest Barium x-ray Electrocardiogram and Echocardiogram

16. MANAGEMENT IMMEDIATE TREATMENT Propping infant at 30-degree angle to prevent reflux of gastric contents. Gastrostomy to decompress stomach and prevent aspiration Nil per oral (NPO) I.V. fluids

17. SUPPORTIVE THERAPY I.V. fluids, Antibiotics Respiratory support, Maintaining thermally neutral environment.

18. SURGERY Prompt primary repair ( anastomosis ) Anastomosis - a connection made surgically between adjacent blood vessels, parts of the intestine, or other channels of the body.

19. SURGERY

20. Gastrostomy A  gastrostomy  is a surgical procedure used to insert a tube, often referred to as a "G-tube", through the abdomen and into the stomach.  Gastrostomy  is used to provide a route for tube feeding if needed for four weeks or longer, and/or to vent the stomach for air or drainage.

21. Cervical esophagotomy Circular esophagomyotomy Esophagomyotomy involves splitting the muscular layers of the distal esophagus and proximal stomach while leaving the mucosa intact.

22. NURSING ASSESSMENT Preoperative Nursing Diagnoses 1)Nursing Diagnoses: Risk for Aspiration related to structural abnormality Expected outcome : Preventing Aspiration Intervention

23. Nursing Interventions Position the infant with head and chest elevated 20 to 30 degrees to prevent or decrease reflux of gastric juices into the tracheobronchial tree. This position may also ease respiratory effort by dropping the distended intestines away from the diaphragm. Prone position will allow gastric juices to pool anteriorly away from the esophagus. Turn frequently to prevent atelectasis and pneumonia

24. Nursing Interventions Maintain the infant's temperature in thermoneutral zone, and ensure environmental isolation to prevent infection by using Isolation. Administer oxygen as needed. Suction mouth to keep clear of secretions and prevent aspiration. Provide mouth care.

25. Nursing Interventions Be alert for indications of respiratory distress. Retractions Circumoral cyanosis Restlessness Nasal flaring Increased respiration and heart rate Maintain NPO status. Administer antibiotics as ordered to prevent or treat associated pneumonitis .

26. Nursing Interventions Observe infant carefully for any change in condition; report changes immediately. Check vital signs, color and amount of secretions, abdominal distention, and respiratory distress. Evaluate for complications that can occur in any neonate or premature infant. Be available, and recognize need for emergency care or resuscitation. Have resuscitation equipment on hand.

27. Nursing Interventions Monitor for signs or symptoms that may indicate additional congenital anomalies or complications. Gastrostomy tube may be placed before definitive surgery to aid in gastric decompression and prevention of reflux. Maintain gastrostomy tube to straight gravity drainage, and do not irrigate before surgery.

28. 2)Nursing Diagnoses: Risk for Deficient Fluid Volume related to inability to take oral fluids Expected outcome : Preventing Dehydration Intervention

29. Nursing Interventions Administer parenteral fluids and electrolytes as prescribed. Monitor vital signs frequently for changes in blood pressure (BP) and pulse, which may indicate dehydration or fluid volume overload. Record intake and output, including gastric drainage (if gastrostomy tube for decompression is present) and weight of diapers. Checked weight daily.

30. 3)Nursing Diagnoses: Anxiety of parents related to critical situation of neonate Expected outcome : Reducing Parental Anxiety Intervention

31. Nursing Interventions Explain procedures and necessary events to parents as soon as possible. Orient parents to hospital and intensive care nursery environment. Allow family to hold and assist in caring for infant. Offer reassurance and encouragement to family frequently. Provide for additional support by social worker, and counselor as needed.

32. Postoperative 1)Nursing Diagnosis: Ineffective Airway Clearance related to surgical intervention Expected outcome : Maintaining Patent Airway Intervention

33. Nursing Interventions Keep endotracheal (ET) tube patent by frequent lavage and suction. Note: Reintubation could damage the anastomosis . Suction frequently; every 5 to 10 minutes may be necessary, but at least every 1 to 2 hours. Observe for signs of obstructed airway. Ventilatory support is continued until clinically stable (usually 24 to 48 hours)

34. Nursing Interventions Request that the surgeon mark a suction catheter, indicating how far the catheter can be safely inserted without disturbing the anastomosis (usually 1 inch [2 to 3 cm]). Administer chest physiotherapy as prescribed. Change the infant's position by turning; stimulate crying to promote full expansion of lungs. Elevate head and shoulders 20 to 30 degrees. Use mechanical vibrator 2 to 3 days postoperatively (to minimize trauma to anastomosis ), followed by more vigorous physical therapy after the 3rd day. Continue use of Isolette or radiant warmer with humidity

35. 2) Nursing Diagnoses: Ineffective Infant Feeding Pattern related to defect Expected outcome : providing adequate nutrition Intervention

36. 3) Nursing Diagnoses : Acute Pain related to surgical procedure Expected outcome : Providing Comfort Measures Intervention

37. 4) Nursing Diagnoses: Impaired Tissue Integrity related to postoperative drainage Expected outcome : Maintaining Chest Drainage Intervention

38. 5) Nursing Diagnoses: Risk for Injury related to complex surgery Expected outcome : Observing for Complications Intervention

39. 6) Nursing Diagnoses: Risk for Impaired Parent/Infant Attachment related to prolonged hospitalization Expected outcome : Stimulating Parent-Infant Attachment Intervention

40. COMPLICATIONS CONGENITAL AND ACQUIRED TEF Recurrent pneumonia, Acute lung injury, Acute respiratory distress syndrome, Lung abscess, Poor nutrition, Bronchiectasis from recurrent aspiration Respiratory failure, and Death.

41. ESOPHAGEAL ATRESIA AND A TEF Esophagitis , Barrett esophagus Hiatal hernia.

42. POSTOPERATIVE COMPLICATIONS Tracheal stenosis and Recurrent fistula. Gastroesophageal reflux disease