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To the Editor, A 25-year-old female presented to the author’s institution with complaints of dyspnea and cough after each meal. The patient gave history of corrosive poisoning 6 months earlier, for which she was tracheostomised and had long-term ventilation. She was now suspected to have iatrogenic tracheo-oesophageal fistula (TOF), and CT scan confirmed the presence of TOF at D2 level. Fibreoptic bronchoscopy showed granulation tissue at the level of the fistula causing stenosis of tracheal lumen. Preoperative feeding jejunostomy was done for improvement of the nutritional status. She was scheduled for repair of TOF. Intraoperatively, arterial blood pressure, arterial blood gas, and entropy along with standard ASA monitoring were done. After premedication with 0.2-mg glycopyrrolate, anaesthesia was induced with fentanyl (2 mcg/kg), midazolam 1 mg and titrated doses of propofol to achieve entropy value of 50–60. Intraoperative fibreoptic examination confirmed preoperative findings. The trachea was intubated with a cuffed 6.5-mm endotracheal tube (ETT), and its tip was placed above the narrowing. Gentle squeezes of the bag to confirm ventilation led to large leaks of air through TOF (as evident by gurgling sounds and leak through jejunostomy tube, which was intentionally kept open to vent excessive pressure). After suctioning out residual gastric content, Nasogastric tube was kept open to atmosphere. Anaesthesia was maintained with O2 in 50% air, propofol infusion at the rate of

ain shams journal of anesthesiology

Weaning modes in the anaesthesia machine ventilators: a novel way of managing ventilation in tracheo-oesophageal fistula patients undergoing corrective surgery under general anaesthesia