Universidad de La Laguna
Correspondence to: Nicholás Serrano, MD, FCCP, Hospital Universitario de Canarias, Universidad de La Laguna, Intensive Care Unit, 38320 La Laguna, Tenerife, Spain; e-mail: firstname.lastname@example.org
To the Editor:
We have read with interest the excellent letter of Dr. Rampaul
and colleagues (CHEST; July 1999)1 regarding
the “breathing bag” sign in the early diagnosis of
tracheoesophageal fistula (TEF) in patients receiving positive pressure
ventilation. The phasic inflation and deflation of the nasogastric bag
with respiratory excursions is reported by them as not previously
In our experience, we described in 1996 a preexisting unrecognized
TEF in an acute respiratory failure patient that was discovered at the
moment of starting positive pressure ventilation.2Only a
few cases of asymptomatic TEF presenting immediately for the first time
in patients receiving positive pressure ventilation have been
previously reported during surgical general
anesthesia,3–5 but not among adult ICU patients. We were
also able to see this breathing bag sign in our patient and were
tempted to describe it in the same way as Rampaul and
colleagues.1 However, we found in one of these previous
reports that Dakaraju and colleagues3 in 1974 had already
described how “the polythene bag, which had been placed over the end
of the nasogastric tube, ballooned out each time the lungs were
inflated” in a 20-year-old woman receiving mechanical ventilation
with a previously undiagnosed esophagobronchial fistula.3
TEF associated with mechanical ventilation is an uncommon clinical
problem, and making an early accurate diagnosis is quite difficult in
most cases. After intubation, clinical manifestations of TEF are
frequently air leak around the cuff and gastric
distention.2 Massive gastric distention in intubated
patients has been reported as an early marker for the defective
airway,6 and this finding should alert that a
communication may exist between the airway and the GI tract, and the
need for a prompt appropriate diagnostic evaluation. Auscultation over
the abdomen can reveal air movement synchronous with the respiratory
action. Synchronous gurgling in the trachea and stomach is often
present. In one patient reported by Ng et al,5 the left
upper quadrant of the abdomen was noticed to distend during the
application of positive pressure and to deflate during
expiration,5 in a similar way as the polythene bag at the
end of the nasogastric tube has been reported.1,3
Because abdominal distention is a common finding in as many as 50% of
patients placed on mechanical ventilation, comparative analysis of
gases from the stomach, ventilator, and room air have been also
proposed as a simple supporting tool for the bedside clinical diagnosis
of TEF in patients receiving mechanical ventilation who experience
marked abdominal distention.7 However, we would agree
along with Dr. Rampaul and coworkers that breathing bag sign might be
considered a simpler method, and also a clue to the early diagnosis of
TEF in patients receiving positive pressure ventilation.
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