Tracheo-esophageal fistula


  • the most important cause of an inspiratory air leak in an intubated / tracheostomsied patient


  • congenital
  • surgical or percutaneously inserted tracheostomy
  • traumatic insertion of tubes
  • hyper-inflated cuffs
  • penetrating trauma


Other causes of an inspiratory air leak in an intubated / tracheostomized patient:

  • cuff leak
  • malposition of the cuff
  • cuffless tube
  • undersized tube for the patient’s trachea


  • inspiratory air leak
  • inability to generate set tidal volumes
  • aspiration pneumonitis
  • enteral feed suctioned from the endotracheal tube


  • bronchoscopy
  • water soluble contrast radiology studies

However, the presence of a tracheal tube can obscure the leak from a TOF


Correct air leak due to other causes

  • ensure cuff inflated and monitor cuff pressures to assess for deflation
  • exchange tube if significant and persistent leak
  • consider an adjustable flange tracheostomy to optimise tube position if position is contributing to the leak

Acquired TOF

  • unlikely to spontaneously close, usually managed surgically
  • if too unstable for surgery, manage conservatively with gastric decompression and jejunal feeding pending delayed surgery
CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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