Correspondence to: Professor Vijay Naraynsingh, c/o Medical Associates, Cor. Albert and Abercromy Streets, St. Joseph, Trinidad, West Indies
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.1–2 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
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