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.