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Torqueing of tracheostomy tubes from malpositioned ventilator circuits should also be avoided. Prolonged nasogastric intubation with standard sump drainage systems is a serious management error of patients requiring extended endotracheal intubation. Soft, small diameter nasoenteral feeding tubes should be used in lieu of the larger and harder sump tubes. If an intermittent abdominal ileus is a problem, we recommend performing percutaneous or standard surgical gastrostomy to provide gastrointestinal access or decompression. We conclude that cervical esophageal exclusion to control tracheoesophageal fistulae occurring in the ventilator-dependent patient may be prudent. This procedure allows definitive control of the fistula with less extensive surgery. The new back wall of trachea established with this small excluded esophageal segment can withstand elevated mean inspiratory pressures without apparent difficulty. Total fistula control is also achieved prior to laparotomy for access to the gastrointestinal tract. A new posterior wall of trachea is established that precludes creation of an esophageal pouch or significant dead space ventilation. This approach avoids violation of the chronic inflammatory wall controlling the fistula in the critically ill, ventilator-dependent patient. Finally, delayed reconstruction of the trachea and cervical esophagus is still possible by a variety of well described methods.