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Ventilator-dependent patients developing giant tracheoesophageal fistulae present formidable management problems. We describe a method of cervical esophageal exclusion that can expediently control the tracheoesophageal fistula and restore adequate ventilation for such critically ill patients. Case Report An endotracheal tube induced tracheoesophageal fistula in a 20-year-old home ventilator-dependent woman with progressive pulmonary insufficiency Idiopathic obliterative bronchiolitis had been diagnosed by open lung biopsy two years before this presentation. The day of this admission, the patient was unable to obtain an adequate tidal volume from the ventilator. An effective seal with the tracheostomy cuff was impossible despite position change and hyperinflation of the balhxm cuff A rush of air from the patients mouth and around the tracheostomy site was noted with each inspiratory phase of mechanical ventilation. The patient was ob-tunded and blood gas analysis demonstrated severe hypercarbia (Pco2 = 93), hypoxia (Po2 = 59) and acidosis (pH = 7.26) on 40 percent supplemental oxygen. The abdomen was markedly distended and tympanitic. Interestingly, six weeks earlier, the patient had developed recurring fever, an abdominal ileus requiring nasogastric intubation, and new pulmonary infiltrates with purulent bronchial secretions.