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Communications to the Editor |

Tracheoesophageal Fistula Following Blunt Chest Trauma : Diagnosis in the ICU—the “Breathing Bag” Sign FREE TO VIEW

R. S. Rampaul, MD; V. Naraynsingh, MD; V. S. Dean, MD (Port of Spain General Hospital, Trinidad, West Indies)
Author and Funding Information

Correspondence to: Professor Vijay Naraynsingh, c/o Medical Associates, Cor. Albert and Abercromy Streets, St. Joseph, Trinidad, West Indies



Chest. 1999;116(1):267. doi:10.1378/chest.116.1.267
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To the Editor:

In the Intensive Care Unit (ICU), when patients are intubated and/or sedated, the diagnosis of many conditions often depends solely on the recognition of physical signs. Complications, such as an acquired tracheoesophageal fistula (TOF) in the critically ill, is one such condition, which may be difficult to diagnose and carries a high mortality.12 We wish to describe a new clinical sign that may be of value in the early diagnosis of this condition as it presents in patients in the ICU receiving positive-pressure ventilation: the“ breathing bag” sign.

A 43-year-old male victim of a road traffic accident was admitted with a flail chest and severe bilateral pulmonary contusions. Due to respiratory embarrassment and deteriorating blood gases, he was intubated and put on intermittent positive-pressure ventilation. Four days following injury and admission, abdominal distension was noted. Later that day, his nasogastric bag was observed to fully distend and deflate cyclically in phase with the ventilator. These movements reminded us of an anaesthetist’s breathing bag during spontaneous respiration. Tracheal tube placement was reconfirmed by auscultation and capnography. A TOF was diagnosed on the basis of the above observations and clinical findings. Inspection with a fiberoptic bronchoscope confirmed this at 2 cm above the carina.

TOF complicating blunt chest trauma is rare, and although it is difficult in this case to directly ascribe its etiology, either from blunt chest trauma, overinflation of the endotracheal cuff leading to tracheal necrosis, or both, early diagnosis and surgical intervention carry a good prognosis.1

Fitzpatrick et al1 described detection of an air leak through the nasogastric tube via an under water seal, in the inspiratory phase.1However, phasic inflation and deflation of the nasogastric bag with respiratory excursions have not been previously described as far as we are aware. We think that having confirmed tracheal tube placement, recognition of this sign might provide a clue to the early diagnosis of a condition that otherwise carries a high mortality rate.2

Fitzpatrick, BT, O’Grady, JF, Sayed, K, et al (1983) Acute tracheo-oesophageal communication: a diagnostic sign for an unusual injury.Ir Med J76,421-422. [PubMed]
 
Reed, WJ, Shannon, DE, Aprahamian, C Tracheo-oesophageal fistula after blunt chest trauma.Ann Thorac Surg1995;59,1251-1256. [PubMed] [CrossRef]
 

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References

Fitzpatrick, BT, O’Grady, JF, Sayed, K, et al (1983) Acute tracheo-oesophageal communication: a diagnostic sign for an unusual injury.Ir Med J76,421-422. [PubMed]
 
Reed, WJ, Shannon, DE, Aprahamian, C Tracheo-oesophageal fistula after blunt chest trauma.Ann Thorac Surg1995;59,1251-1256. [PubMed] [CrossRef]
 
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